Obesity is a chronic, progressive and relapsing medical condition characterized by the accumulation of abnormal or excessive body fat that impairs health.
Causes of obesity are multifactorial with complex interactions.
Treatment goals include addressing the principal cause of weight gain and focusing management on both weight loss and patient-centered health outcomes.
A multidisciplinary approach, that is a combination of dietary change, physical activity and behavioral modification, is recommended.

Surgical Intervention

Bariatric and Metabolic Surgery

  • Most effective method to reduce and maintain weight in severely obese patients
  • Associated with average weight losses of between 16-35% in up to 8 years depending on type of surgical procedure
    • Laparoscopic approach is the first treatment of choice
  • Based on long-term data, surgery has been shown to reduce overall mortality over a 15-year period compared to conservative medical treatment
    • Surgery improves ORCs and quality of life and decreases CV mortality and morbidity
  • Metabolic surgery should be done in high-volume centers with well-informed and experienced multidisciplinary teams; strict selection criteria should be applied 
  • May have partial weight regain in up to 35% of patients after 5 years in patients with BMI >35 kg/m2
  • According to the 2016 American Association of Clinical Endocrinologists (AACE) and American College of Endocrinology (ACE) guidelines, it is indicated in patients with BMI ≥40 kg/m2 or BMI 35-39.9 kg/m2 with comorbidities in whom weight loss through surgery is expected to improve the disorder (eg DM and other metabolic disorders, CVD, severe joint disease, and obesity-related severe psychological disorders)
  • The 2nd Diabetes Surgery Summit (DSS-II):
    • Recommends metabolic surgery for the treatment of T2DM Asian patients with class III obesity (BMI ≥37.5 kg/m2) and class II obesity (BMI 32.5-37.4 kg/m2) when optimal lifestyle and medical treatment are inadequate to control hyperglycemia
    • Considers metabolic surgery for patients with class II obesity with adequate glycemic control and class I obesity (BMI 27.5-32.4 kg/m2) with poor glycemic control despite optimal lifestyle and medical treatment (including injectable medications and insulin)
  • The International Federation for the Surgery of Obesity and Metabolic Disorders - Asia Pacific Chapter (IFSO-APC) consensus statements in 2011 recommend bariatric surgery in the following Asian patients with:
    • BMI ≥35 kg/m2 with or without comorbidities
    • BMI ≥30 kg/m2 inadequately controlled by lifestyle changes or medical therapy for the treatment of T2DM or metabolic syndrome
    • BMI ≥27.5 kg/m2 as non-primary treatment alternative for inadequately controlled T2DM or metabolic syndrome
  • Contraindications:
    • Current alcohol/substance abuse
    • Unstable psychological conditions
    • Esophageal dysmotility, inflammatory bowel disease, chronic pancreatitis, bile duct pathology
    • Portal hypertension, active malignancy
    • Regular use of NSAIDs
    • History of gastric cancer
    • Relative contraindication includes inability to comply with postoperative nutritional changes or follow-ups
  • Commonly performed bariatric surgery procedures in Asia include sleeve gastrectomy, Roux-en-Y gastric bypass (RYGB), adjustable gastric band (AGB) and biliopancreatic diversion with duodenal switch (BPD-DS) 
  • Endoscopic bariatric procedures include intragastric balloon and endoscopic sleeve gastroplasty (ESG); ESG results in about 15-20% weight loss at 12-24 months when combined with lifestyle modification
  • Medical follow-up at 1, 3, 6 and 12 months then annually is advised
  • Complications may include dumping syndrome, hypoglycemia, malnutrition including mineral and vitamin deficiencies, anemia, osteoporosis, regain of weight, or need for revisional surgery
  • Long-term lifestyle support and micronutrient and nutritional status monitoring (eg mineral and multivitamin supplementation) are mandatory post-surgery
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