Obesity and the gastroenterologist

Obesity (body mass index [BMI] ≥ 30 kg/m²) is a chronic, incurable and life-threatening disease of excess fat storage. The absolute and relative excess of adipose tissue and the visceral distribution of fat place the individual at risk of premature death and obesity-associated co-morbidities. A considerable decrease in life expectancy is associated with obesity. A very recent analysis of 57 prospective studies has assessed the associations of BMI with overall and cause-specific mortality [1]. In both sexes, mortality was lowest at about 22.5 – 25 kg/m². After adjustment for age, sex, smoking status, and after correction for reverse causality, the median survival at BMI 30 – 35 kg/m² was reduced by 2 – 4 years and at BMI 40 – 45 kg/m² by 8 – 10 years. Each 5 kg/m² higher BMI was associated with about 30 % higher overall mortality: 40 % for vascular mortality, 120 % for diabetic, 60 % for renal and 82 % for hepatic mortality, 10 % for neoplastic mortality, and 20 % for respiratory mortality. In the EPIC study (European Prospective Investigation into Cancer and Nutrition) both general adiposity and abdominal adiposity were associated with significant increased risks of death [2].

There are several reasons why gastroenterologists should take care of the obese patient. In the first place, the health implications are substantial; almost every organ system is affected by obesity and the digestive tract is involved as well. In the second place, the gastrointestinal tract is involved in the regulation of the energy balance and many treatments will concentrate on the digestive tract. The third reason is the burgeoning interest in bariatric surgery. Gastroenterologists should participate in the multidisciplinary treatment group; this implies a thorough knowledge of the surgically altered anatomy with its complications and side-effects which are different for each of the surgical interventions [3]. The gastroenterologist may be an indispensable link in solving postoperative problems and complications. The common indications for a gastroenterological consultation and for an endoscopy include the evaluation of symptoms because many of the complications and side-effects of weight-loss procedures are related to alterations in the gastrointestinal tract, the management of expected and unexpected complications, and the evaluation of failure of weight loss [4] [5].

References

• 1 Prospective Studies Collaboration . Body-mass index and cause-specific mortality in 900 000 adults: collaborative analyses of 57 prospective studies.  Lancet. 2009;  373 1083-1096
• 2 Pischon T, Boeing H, Hoffmann K. et al . General and abdominal adiposity and risk of death in Europe.  N Engl J Med. 2008;  359 2105-2120
• 3 Mathus-Vliegen E M. The role of endoscopy in bariatric surgery.  Best Pract Res Clin Gastroenterol. 2008;  22 839-864
• 4 Christou N V, Sampalis J S, Liberman M. et al . Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients.  Ann Surg. 2004;  240 416-423
• 5 Stellato T A, Crouse C, Hallowell P T. Bariatric surgery: Creating new challenges for the endoscopist.  Gastrointest Endosc. 2003;  57 86-94
• 6 El-Serag H B. Obesity and disease of the esophagus and colon.  Gastroenterol Clin N Am. 2005;  34 63-82
• 7 Hampel H, Abraham N S, El-Serag H B. Meta-analysis: obesity and the risk for gastroesophageal reflux disease and its complications.  Ann Intern Med. 2005;  143 199-211
• 8 Sjostrom L, Larsson B, Backman L. et al . Swedish obese subjects (SOS). Recruitment for an intervention study and a selected description of the obese state.  Int J Obes Relat Metab Disord. 1992;  16 465-479
• 9 Weinsier R L, Wilson L J, Lee J. Medically safe rate of weight loss for the treatment of obesity: a guideline based on risk of gallstone formation.  Am J Med. 1995;  98 115-117
• 10 Tsai C J, Leitzmann M F, Willett W C, Giovannucci E L. Prospective study of abdominal adiposity and gallstone disease in US men.  Am J Clin Nutr. 2004;  80 38-44
• 11 Tsai C J, Leitzmann M F, Willett W C, Giovannucci E L. Weight cycling and risk of gallstone disease in men.  Arch Intern Med. 2006;  166 2369-2374
• 12 Martinez J, Sanchez-Paya J, Palazon J M. et al . Is obesity a risk factor in acute pancreatitis? A meta-analysis.  Pancreatology. 2004;  4 42-48
• 13 Calle E E. Obesity and cancer.  BMJ. 2007;  335 1107-1108
• 14 Bergstrom A, Pisani P, Tenet V. et al . Overweight as an avoidable cause of cancer in Europe.  Int J Cancer. 2001;  91 421-430
• 15 Corley D A. Obesity and the rising incidence of oesophageal and gastric adenocarcinoma: what is the link?.  Gut. 2007;  56 1493-1494
• 16 Kubo A, Corley D A. Body mass index and adenocarcinomas of the esophagus or gastric cardia: a systematic review and meta-analysis.  Cancer Epidemiol Biomarkers Prev. 2006;  15 872-878
• 17 Giovannucci E, Michaud D. The role of obesity and related metabolic disturbances in cancers of the colon, prostate, and pancreas.  Gastroenterology. 2007;  132 2208-2225
• 18 Berrington de G A, Sweetland S, Spencer E. A meta-analysis of obesity and the risk of pancreatic cancer.  Br J Cancer. 2003;  89 519-523
• 19 Renehan A G, Tyson M, Egger M. et al . Body-mass index and incidence of cancer: a systematic review and meta-analysis of prospective observational studies.  Lancet. 2008;  371 569-578
• 20 Corley D A, Kubo A, Levin T R. et al . Abdominal obesity and body mass index as risk factors for Barrett’s esophagus.  Gastroenterology. 2007;  133 34-41
• 21 Pischon T, Lahmann P H, Boeing H. et al . Body size and risk of colon and rectal cancer in the European prospective investigation into cancer and nutrition (EPIC).  J Natl Cancer Inst. 2006;  98 920-931
• 22 Patel A V, Rodriguez C, Bernstein L. et al . Obesity, recreational physical activity, and risk of pancreatic cancer in a large US cohort.  Cancer Epidemiol Biomarkers Prev. 2005;  14 459-466
• 23 Giovannucci E. Obesity, gender, and colon cancer.  Gut. 2002;  51 147
• 24 Terry P D, Miller A B, Rohan T E. Obesity and colorectal cancer risk in women.  Gut. 2002;  51 191-194
• 25 Korner J, Leibel R L. To eat or not to eat – how the gut talks to the brain.  N Engl J Med. 2003;  349 926-928
• 26 Blundell J E. Perspective on the central control of appetite.  Obesity (Silver Spring). 2006;  14 Suppl 4 160S-163S
• 27 Wren A M, Bloom S R. Gut hormones and appetite control.  Gastroenterology. 2007;  132 2116-2130
• 28 Monteleone P, Bencivenga R, Longobardi N. et al . Differential responses of circulating ghrelin to high-fat or high-carbohydrate meal in healthy women.  J Clin Endocrinol Metab. 2003;  88 5510-5514
• 29 Batterham R L, Heffron H, Kapoor S. et al . Critical role for peptide YY in protein-mediated satiation and body weight regulation.  Cell Metab. 2006;  4 223-233
• 30 Cummings D E, Shannon M H. Ghrelin and gastric bypass: is there a hormonal contribution to surgical weight loss?.  J Clin Endocrin Metab. 2003;  88 2999-3002
• 31 Le Roux C W, Aylwin S J, Batterham R L. et al . Gut hormone profiles following bariatric surgery favor an anorectic state, facilitate weight loss, and improve metabolic parameters.  Ann Surg. 2006;  243 108-114
• 32 Batterham R L, Cohen M A, Ellis S M. et al . Inhibition of food intake in obese subjects by peptide YY3–36.  N Engl J Med. 2003;  349 941-948
• 33 Batterham R L, Le R oux, Cohen M A. et al . Pancreatic polypeptide reduces appetite and food intake in humans.  J Clin Endocrinol Metab. 2003;  88 3989-3992
• 34 World Health Organization .Obesity: preventing and managing the global epidemic. Report of a WHO Consultation on Obesity, Geneva, 3 – 5 June 1997. Report No.: WHO/NUT/NCD/98.1 
• 35 National Institutes of Health, National Heart, Lung and Blood Institute . Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults – The evidence report.  Obes Res. 1998;  6 Suppl 2 1S-209S
• 36 National Institute of Clinical Excellence .Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children, 2006. http://Available at: www.NICE.org.uk/CG43
• 37 Glenny A M, O’Meara S, Melville A. et al . The treatment and prevention of obesity: a systematic review of the literature.  Int J Obes Relat Metab Disord. 1997;  21 715-737
• 38 de Goederen-van der Meij S, Pierik R GJM, OudkerkPool M. et al . Six months of balloon treatment does not predict the success of gastric banding.  Obes Surg. 2007;  17 88-94
• 39 Schapiro M, Benjamin S, Blackburn G. et al . Obesity and the gastric balloon: a comprehensive workshop. Tarpon Springs, Florida, March 19 – 21, 1987.  Gastrointest Endosc. 1987;  33 323-327
• 40 Fernandes M, Atallah A N, Soares B G. et al . Intragastric balloon for obesity.  Cochrane Database Syst Rev. 2007;  1 CD004931
• 41 Mathus-Vliegen E M. Intragastric balloon treatment for obesity: what does it really offer?.  Dig Dis. 2008;  26 40-44
• 42 Dumonceau J M. Evidence-based review of the Bioenterics intragastric balloon for weight loss.  Obes Surg. 2008;  18 1611-1617
• 43 Negrin Dastis S, Francois E, Deviere J. et al . Intragastric balloon for weight loss: results in 100 individuals followed for at least 2.5 years.  Endoscopy. 2009;  41 575-580
• 44 Melissas J, Mouzas J, Filis D. et al . The intragastric balloon – smoothing the path to bariatric surgery.  Obes Surg. 2006;  16 897-902
• 45 Rucker D, Padwal R, Li S K. et al . Long term pharmacotherapy for obesity and overweight: updated meta-analysis.  BMJ. 2007;  335 1194-1199
• 46 Christensen R, Kristensen P K, Bartels E M. et al . Efficacy and safety of the weight-loss drug rimonabant: a meta-analysis of randomised trials.  Lancet. 2007;  370 1706-1713
• 47 Mathus-Vliegen E M, Tytgat G N. Intragastric balloon for treatment-resistant obesity: safety, tolerance, and efficacy of 1-year balloon treatment followed by a 1-year balloon-free follow-up.  Gastrointest Endosc. 2005;  61 19-27
• 48 Rutten S JE, de Goederen-van der Meij S, Pierik R GJM, Mathus-Vliegen E MH. Changes in quality of life after balloon treatment followed by gastric banding in severely obese patients – the use of two different quality of life questionnaires.  Obes Surg. 2009 ;  DOI: DOI 10.1007/s11695-008-9732-3