Extreme obesity is a challenging disease to manage and requires a multifactorial approach

Daniela Barros, postgraduate student of the Surgical Clinic Program at Ribeirão Preto Medical School, University of São Paulo (FMRP-USP), Ribeirão Preto, SP, Brazil.

Obesity is a complex and multifactorial disease that is common enough to constitute a serious medical and public health problem. Overwhelming evidence indicates that obesity carries excess risks. Indeed, mortality rises sharply when the body mass index (BMI) surpasses 30 kg/m², particularly with a concomitant central distribution of adipose tissue (STUMPF et al., 2023). Obesity has serious effects on respiratory, cardiovascular, digestive, and genitourinary systems, imposing barriers to progress in some diagnostic and therapeutic procedures (MANCINI, 2001).

In the article Challenges in the care and treatment of patients with extreme obesity, published in Archives of Endocrinology and Metabolism (vol. 68, 2024), Stumpf and Mancini, discuss the main challenges in the care of extreme obesity and review the literature on its treatment, focusing on drugs and surgical procedures. The authors, who are from the Unidade de Obesidade, Divisão de Endocrinologia e Metabolismo, Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo (Brazil), also provided their personal perspectives and experiences on these topics (STUMPF et al., 2024).

Individuals with obesity derive significant clinical benefits from a 5%-10% weight loss (HALPERN et al., 2022). However, this amount of weight loss is insufficient for people with extreme obesity. An increased weight loss achieved by these individuals results in a dose-dependent change in metabolic and mechanical comorbidities that leads to incremental clinical benefits. However, to date, there have been no randomized clinical trials specifically targeting the clinical treatment of individuals with extreme obesity alone (STUMPF et al., 2024).

Traditional anti-obesity medications (e.g., sibutramine, naltrexone plus bupropion, topiramate, orlistat) lack the potency of the more recent agonist drugs. However, due to their relatively low cost and extensive literature experience, off-label combinations of these traditional medications could lead to substantial weight loss (HALPERN et al., 2010), providing an option for adjuvant therapy in individuals with extreme obesity.

Image: jarmoluk via Pixabay.

In terms of the most modern anti-obesity drugs, we have retatrutide, a triple agonist of the glucose- dependent insulinotropic polypeptide (GIP), glucagon- like peptide-1 (GLP-1), and glucagon receptors, at a dose of 12 mg for 48 weeks has been recently associated with a remarkable 24.2% weight loss in adults with obesity. Interestingly, patients with BMI ≥ 35 kg/m² had an even greater weight loss (26.5%) (JASTREBOFF et al., 2023). Tirzepatide, a dual GIP and GLP-1 receptor agonist, at a dose of 15 mg for 72 weeks, has also been associated with important weight loss (20.9%) in people with obesity (JASTREBOFF et al., 2022). Semaglutide, another anti-obesity medication, is a GLP-1 receptor agonist administered subcutaneously once weekly at a 2.4 mg dose. This regimen achieves weight loss below 20%, comparable to the results obtained with a daily 50 mg oral dose (KNOP et al., 2023).

Due to its overall safety profile and strong association with weight loss, bariatric surgery should be considered the first-line treatment for people with extreme obesity. The authors here highlight some important issues that must be observed during the preoperative and perioperative care, which includes bridging procedures and anesthesia (STUMPF et al., 2024).

An important issue concerns the most suitable surgical procedure for patients with extreme obesity. Some experts recommend biliopancreatic diversion (BPD) with duodenal switch (DS), Roux-en-Y gastric bypass (RYGB), or OAGB for these patients, while others advise a two-stage procedure, with SG as the primary stage, followed by BPD/DS, RYGB, or OAGB (BHANDARI et al., 2019).

A retrospective review of 498 patients with extreme obesity who underwent SG, RYGB, or OAGB showed that SG and OAGB were safe and effective primary surgical procedures, and that weight loss was superior with OAGB and RYGB than SG (SOONG et al., 2021). On the other hand, a study comparing RYGB, LAGB, and SG (BETTENCOURT-SILVA et al., 2019) found percentages of total weight loss (TWL) during the first year of 36.3%, 31.6%, and 21.1% respectively, favoring nonrestrictive techniques as best candidates for treating extreme obesity concerning exclusively weight loss (BETTENCOURT-SILVA et al., 2019; SAMUEL et al., 2020).

In Brazil, only LAGB, SG, RYGB, and BPD (Scopinaro’s surgery or DS) are authorized by the Federal Council of Medicine (VALEZI et al., 2023). Other techniques could be used in the setting of clinical studies upon approval by ethics committees.

Stumpf and Mancini also reviewed the available data on failure after bariatric surgery, recurrent weight gain, and revisional operations. The criterion defining failure after bariatric surgery as a loss of less than 50% excess weight loss (EWL) after the procedure was proposed more than 40 years ago (REINHOLD, 1982). This definition remains widely used today, al- though bariatric procedures vary in terms of their effect on weight loss and comorbidity resolution. Many patients – especially those with extreme obesity – are unable to maintain an EWL of 50% or more in the long term and are thus considered to have a suboptimal clinical response (KOWALEWSKI et al., 2018).

No consensus has been established on the definition of recurrent weight gain after bariatric surgery. A recent position statement by the Brazilian Society of Bariatric and Metabolic Surgery classified recurrent weight gain as recidivism (when 50% of the weight lost is regained in the long term or 20% of the weight is regained in association with reappearance of comorbidities) or controlled recidivism (when 20%-50% of the weight lost is regained in the long term).

A long-term recurrent weight gain of less than 20% of the weight lost is expectable (BERTI et al., 2015). Therefore, it is very important to regularly reevaluate the patient’s diet, cognitive-behavioral therapy, and physical activity, along with conducting anatomical assessments through upper gastrointestinal endoscopy and/or a contrast x-ray study (NORIA et al., 2023).

Despite the large number of comorbidities presented by candidates for bariatric surgery, the procedure can still be considered overall safe, with a mortality risk of ap- proximately 0.8% (PORIES, 2008).

But it is noteworthy that bariatric surgery has the potential to trigger several complications, like rhabdomyolysis and venous thrombosis, which remains the main cause of readmission and mortality following bariatric surgery (DAIGLE et al., 2018).

In conclusion, extreme obesity is a challenging disease that can present with multiple comorbidities and high rates of mortality and complications following bariatric surgery. The flowchart here presented (Figure 2) summarizes some of the main recommendations for the care of individuals with extreme obesity, even though its management is still far from state of the art.

The authors recommend that more studies should be conducted specifically in patients with this degree of obesity, since their outcomes are expected to be distinct from those of people with lower BMI (STUMPF et al., 2024).

To read the article, access

STUMPF, M.A.M., et al. Challenges in the care and treatment of patients with extreme obesity. Archives of Endocrinology and Metabolism [online]. 2024, vol. 68,  e230335 [viewed 10 December 2024]. https://doi.org/10.20945/2359-4292-2023-0335. Available from: https://www.scielo.br/j/aem/a/Kc7Rpb9TjnJTmZHvx58VM7D/

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External links

Archives of Endocrinology and Metabolism – AEM

Orcid – Matheo A. M. Stumpf