Last, but not least, I'm very honored to introduce our last speaker, Dr. Anthony Millard, who's the Assistant Medical Director of the Weight Loss Clinic and an obesity medicine specialist at the University of Colorado. The title of Dr. Millard's talk is Developing Collaboration between Endoscopists and Obesity Medicine. So, just to sum up our theme of the talk today, Dr. Millard, thank you very much for being with us. So just to summarize, the three areas that we're going to focus on are my role as an obesity medicine physician, and then in terms of endoscopy and how we collaborate with our endoscopy colleagues for both new patients who are interested in primary weight loss and then for post-surgical patients. So first, we'll talk a little bit about my role as an obesity medicine physician. Just briefly to summarize kind of what we go over during our first visit for weight management, from a health history perspective, we go over all the standard history markers. In terms of medications, we're thinking specifically about medications that can cause weight change, both ones that can increase weight, but also ones for diabetes or migraines, such as topiramate, that may be helpful in terms of weight loss. We want to think about when the first onset of weight gain occurred, if it was at a really young age, maybe we're thinking more about the monogenic or syndromic forms of obesity and things we need to investigate there, but also key triggers for weight gain along the way. In terms of weight loss history, we want to know what they've tried in the past as far as diet, exercise, and activity, medications, and certainly prior surgeries. We focus extensively on nutrition and activity, and then think a lot about what I like to call the four S's, sleep, stress, support, and socioeconomics. Think a little bit about a review of systems, including a brief depression screen, and then do our exam. As we think about an assessment and plan, we kind of go over several of those areas in detail, and obviously we think about medications that we may be able to start, anti-obesity medications or others for diabetes where there is other overlap. We're fortunate at CU to have a number of weight loss programs, a big research element as well, and then certainly today we'll think more about our procedural aspects as well. Now I want to spend just a second talking about kind of the role of an obesity medicine physician. I grew up playing sports, and I think there's a lot of overlap in terms of thinking about the role of an obesity medicine physician, either as, say, a point guard in basketball or since the Super Bowl is tomorrow, we'll talk about it from the perspective of a quarterback in football. Now, I don't in any way mean to trivialize the pursuit of weight loss and weight management, and I also don't mean to overrepresent my abilities as an obesity medicine physician. The quarterback in this picture was the most valuable player in the NFL in 2019, Lamar Jackson. But as we think about our very first visit with the patient, there really is some overlap. We think about the score like a quarterback would. We think about a patient's weight, how much weight they're interested in losing. We think about the timeframe that they're interested in losing it in. Is there a specific medical indication that's coming up like a surgical procedure for which they need to lose weight? Is there a milestone such as a birthday or pregnancy or wedding or something like that that's coming up? We think about context, not only in terms of comorbidities, places maybe you will overlap in terms of medication, but context like those four S's that I mentioned, their sleep, their stress, their support system at home, and then financial situation as well. Most importantly, in terms of this talk, we think about our teammates. As I mentioned, you may not have heard me say at the beginning at the University of Colorado, obviously we're very fortunate to have a superstar teammate like Dr. Sullivan. But we also think about our dieticians who do one-on-one consultations. They run some of our group weight loss programs. We have a meal replacement program, behavior change program, small group program. We think about our friends in psychology who assist in a number of different ways, but then also our friends in sleep medicine, the folks who run our fatty liver clinic, and then certainly our proceduralists, both the surgeons at the main university hospital, and then our endoscopy team led by Dr. Sullivan. And then finally, as the quarterback comes to the line and looks at what the defense is presenting, quarterback sometimes thinks back to what has worked previously in terms of maybe audible and do a different play. Here we think about what's worked for the patient in the past, in terms of medications, in terms of dietary strategies, but then certainly in terms of endoscopy, thinking about a balloon and whether we might repeat a balloon procedure at some point down the road. This is kind of a different schematic way to think about the relationship between primary care that may be doing weight management or an obesity medicine physician and their proceduralist. The key points are that you can really enter the circle from either perspective being referred to a weight management setting like mine or being referred directly to a proceduralist. And then there's really a symbiotic relationship that develops over time where both of us have the opportunity to escalate care as needed. Primary care, obesity medicine tend to manage more of the comorbidities. And then the end result really is that hopefully the patient has seen a better ability to maintain weight in the long run and we see increased patient volumes on both practice sides. Thinking about endoscopy for primary weight loss, there are a number of different characteristics that I think about when I'm thinking whether to refer someone to Dr. Sullivan. We'll go through each of these now. For BMI, obviously these have been laid out earlier today. Certainly it is important to remember that the upper end, you know, isn't hard and fast as Dr. Sullivan mentioned, you know, we do have patients with a BMI of 45, for instance, who may be interested in a gastric balloon. The real important thing is just to lay out and directly establish expectations. And maybe we'll work in an obesity medicine setting on additional weight loss to get them closer to that range. In terms of weight loss goals, this has obviously been reviewed in detail today. The main comment in terms of endoscopy is that it sort of fits nicely in that middle range between lifestyle and medication and surgery. And obviously we think about doing more than one of those at a given time. In terms of a patient's interest in endoscopy, we find that many patients who come and see me don't even really realize that endoscopy is an option. And there's some who are very interested when we talk about it. Some of the key cues that I'm looking for from patients to think about endoscopy as an option is when we talk over lifestyle or medication or surgery, they may have a specific reaction to those. Someone may say, I've tried diet and exercise a number of times in the past. I've been either unsuccessful in losing weight or unsuccessful in maintaining from that perspective. Maybe I'm on too many medications. I really want to limit how many I'm on. Something that I'm going to have to take forever or significant concern about side effects. And then from a surgical perspective, as has been discussed today, we have some who say, I really don't want to see any change to my body, any change to my GI tract. Some may not be able to stay in the hospital overnight or for a couple of nights or may be able to take the two weeks off either from a work standpoint or caregiving responsibilities at home. And then a lot of patients, unfortunately, come to us with preconceived notions about bariatric surgery. Obviously, it's on us to try to correct any misconceptions that are there, but some people feel very strongly based on a friend or family member or somebody else's prior experience that they're not interested. When any of these things do arise, that really gives us an entree to talk more about an alternative option like endoscopy. In terms of the timeframe, I touched on this briefly. We obviously want to think about the period of time over which a patient is going to reach their Nader weight with a balloon or with the Aspire Assist or an ESG. We want to try to match that up with the patient's timeline in terms of milestones, such as a birthday, a wedding, a pregnancy, medical concerns like a knee replacement surgery or another medical issue that requires weight loss. And then sometimes we think about it in matching up with patients who work seasonally, anything from someone who's a teacher to an accountant to an insurance agent who's doing open enrollment. We have some patients who say, I want to think about a procedure during my busiest time because that's the time that I really struggle and I feel like this is the type of thing that's going to help me maximize my progress during that time. There are others who say, like a teacher in the middle of the summer, I want to do a procedure at a time where I have the most time to dedicate to a full lifestyle and behavior change. We want to think about the dynamics there. In terms of cost and benefit, this is really unfortunately the cost is still the rate limiting step for a lot of our patients. It's really important to know that we do get an occasional coverage by insurance for a procedure like this. It's important to know if you're referring from my perspective, what your endoscopist has in terms of flexibility from a payment standpoint, does everything need to be prepaid? Can there be some pay as you go or installment plan? We also want to think about the cost of alternatives. Some of our medications can be very expensive when taken month after month, year after year. We want to think about the costs associated with a surgical intervention, but then really most importantly from an endoscopic perspective, I found it beneficial to talk with patients about the benefits. If they have comorbidities, is there something that we might see in terms of resolution? Might we be able to peel off a medication or more than one medication with a certain amount of weight loss? Then you almost can never put a dollar amount on quality of life. That can be a really important consideration for patients too. It's not just the costs, but also the benefits they get relative to those costs. In terms of comorbidities, this has been touched on elsewhere. We have some pretty good data to tell us if you're seeing 10 to 15% weight loss with an intragastric balloon, you're going to see some commensurate improvements in terms of comorbidities as well from diabetes, high blood pressure on down to sleep apnea. We also have some data in terms of comorbidity improvement related to ESG. Now thinking about contraindications, Dr. Sullivan showed you the really full and comprehensive list for each procedure, would ask you to think about those as well. But some of the key ones that I have my eye on when we're talking with patients, certainly prior GI or bariatric surgery, as Dr. Sullivan mentioned, is a full contraindications. Structural or inflammatory GI conditions can be an impediment too. Eating disorders, pregnancy, alcohol, and other drug addiction, mental health concerns are obviously a big player. Advanced medical disease can be a concern too. Anything that we worry about from a bleeding perspective is something that has to be very closely examined. And then for the Obalon, obviously, if you're unable to swallow the practice capsules, then that may reduce our ability to think about that as an option too. Post-procedure considerations, again, Dr. Sullivan talked about this in more detail, but some of the things that I think about with patients is as soon as you bring up endoscopy, they have questions about what may be involved. In terms of Orbera, you know, a seven to 10-day progression back to more regular foods. As she alluded to, Dr. Sullivan did, pain and nausea, we think somewhere in the neighborhood of four to seven days is about average. I know her procedure day is typically Tuesdays, so she encourages patients to take the rest of the week off from work. Sometimes that can be a limitation as a patient thinks about how much time they can get off work. From the perspective of Obalon, they can get back to work more quickly and resume regular eating patterns a bit more quickly. But obviously, in a place like Colorado where we're located, altitude is a very significant concern. Spending additional time at sea level, other pressure changes from scuba diving, from flying in an airplane, essentially, if your plan is to ride out the rest of the pandemic in the South Pacific scuba diving and flying on puddle jumpers, this might not be the best time to have the Obalon placed. In terms of the Aspire Assist, a number of things to think about here, too. I think the biggest limiting step for patients that I speak with is the after meal time. You have patients who are traveling for work or, for instance, who are in meetings consistently during the day, folks who work in a hospital, even, who may not be able to set aside time after a meal like this in order to be able to wait and then do the aspiration period. And then as far as things like an ESG go, there's an extended period of time needed to advance the diet. And for some patients, this is very similar to bariatric surgery for some patients. This really isn't an ideal option as well. Now we've also touched on side effects, procedural concerns, pain, nausea, vomiting are some of the biggest ones for us to consider, too. This usually isn't a very limiting factor for patients, but it's something it's good to be upfront about so that they have expectations set ahead of time. Now as we think about endoscopy for patients who've already had a surgical procedure, certainly we've heard a lot about this in the last two talks as it relates to complications and for weight loss. There are a number of things that we think about here as well. We'll go through each of these in detail. In terms of weight regain, this has been fleshed out. The graph on the left is from the Swedish Obesity Study. The graph on the right from the Labs Consortium. I think we all have established that there is fairly dramatic weight loss usually in the first year, 18 months to two years, and then some weight regain after that. Obviously the group in orange with the graph on the right, the 6% that lost weight initially and then kept losing, that isn't typically the norm. From this labs data, we can say for Roux-en-Y gastric bypass that about 75% of patients are able to maintain 25% of total body weight loss at seven years, which is really great, but obviously that means that there are some patients who may fall short of that expectation as well. Thinking about comorbidities, the Labs Consortium also gives us some good data here. We think about diabetes with Roux-en-Y gastric bypass, almost 70% see remission at year one, and then slowly that number starts to trickle down closer toward 60%. We see similar patterns with other comorbidities, but certainly patients who have seen weight regain over time after surgery or have seen a return of comorbidities have had to restart medications for diabetes, for high blood pressure, may be extra motivated to think about an endoscopic approach to restore that weight loss. In terms of what we think about with the patients, there are a number of post-surgical habits. Certainly protein goals are key, how we approach our food, chewing slowly and thoroughly, separating liquids and solids, are we limiting sweets, particularly as it relates to high calorie foods, but also in terms of thinking about a condition like dumping syndrome. We also want to understand several other key areas in terms of what patients are doing from an exercise and activity perspective. Have they gotten off track in certain areas that we may be able to help them get back on track? How things look from a sleep perspective and how things look from a stress perspective that could be factoring in as well. In terms of hunger and appetite specifically, I think the most common question we ask is about portion sizes, but sometimes portion sizes don't tell the whole story. Sometimes it can be helpful to sort of reframe this and ask a patient over a period of 24 hours, does it take you more food to feel full than it did say in the first year after surgery? Some patients are more grazers. They eat small portions, but they're eating more consistently throughout the day. And so sometimes that can be a key measure for us to think about in terms of weight regain. Are they having any new or different cravings? Certainly alcohol has been documented as a concern after bariatric surgery, even for some folks who weren't consumers of alcohol beforehand. And then we definitely want to get an understanding for binge eating history as this has been touched on in a number of areas as well. In terms of symptoms, obviously a lot of things to think about here. Dr. Shulman covered a number of these as well, but we want to get a sense from a patient, what is different now relative to where they were at the time of surgery and in the first year afterwards? Some of the biggest ones that we see, nausea, vomiting, abdominal pain can be some of the biggest cues and then issues related to swallowing. My job also is to check on vitamin related deficiencies, make sure that they're up to date in terms of vitamins and vitamin labs as well. In terms of what they've had done after surgery, unfortunately still in 2021, we see a number of patients who may have a bariatric surgery at a place where followup isn't as robust. Maybe they're short term followup, but now they're several years out and they've been lost to follow up. In terms of what they have followed up on with their surgeon, we want to understand as well. Have they tried weight loss medications and either found success there and had to come off them or not found success? What have they had done from an imaging and an endoscopy standpoint to explore what is going on structurally? And then obviously the vitamin labs as I touched on as well. Now in terms of outcomes, Dr. Kambari talked about this just in the last talk briefly. I'll spend a little more time on this slide because I think this can be an important inflection point in terms of our decision-making process. You've seen that for patients after Roux-en-Y gastric bypass who have the transoral outlet reduction procedure, a mean total weight loss of around 10 kilos, and that if we look out as far as five years, more than three-fifths of patients are able to maintain 5% total weight loss at five years. Now a handful of these patients I believe also did receive medications during that time, but we compare it to some of the limited data that was touched on earlier as well as it relates to medication use alone after sleeve or Roux-en-Y gastric bypass. I think the 2020 data tells us that for patients out five years, we probably see a little more robust response with the endoscopy plus weight loss than certainly we do at a shorter time period with a lower percentage able to maintain that with medications alone. So I think the answer really is if we can try to combine the two, an endoscopic revision and medication, we may see our best outcomes. Just a couple of closing thoughts here. Obviously, comprehensive care has been a theme today in weight management. There's so many different folks who have something to offer in the medical setting in terms of weight loss and weight management. From a primary care obesity medicine perspective, those who are performing weight management, I think it's helpful to establish relationship with someone who may be doing endoscopy, bariatric endoscopy in GI or in the general surgery setting. You want to know who in your area has that expertise already or who may be interested in developing it over time. That may be something that they can take on as a significant niche and you guys can develop a relationship there. You can find endoscopic providers through the device makers. Each of the device makers, particularly Orbera and the Obalon balloons, I think have directories of providers who are utilizing their products. That can be a way to find someone in your area. As has been discussed, we have established that primary endoscopy really is safe in a community setting, but that surgical revisions either for complications or weight loss really do need to be done in a comprehensive multidisciplinary setting. Lastly, as has been discussed today, the role of endoscopy really is going to evolve in the years ahead. Certainly, we welcome, from my perspective as a weight management physician, as many tools as we can have to help patients with weight loss. The more tools, the better. Thank you very much.

obesity medicine

collaboration

endoscopists

weight management

comprehensive care

primary care