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Obesity Primer for the Practicing Gastroenterologist

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Obesity Primer for the Practicing Gastroenterologist 918 REVIEW ARTICLE Obesity Primer for the Practicing Gastroenterologist Pichamol Jirapinyo, MD, MPH1,2 and Christopher C. Thompson, MD, MSc1,2 With worsening of the obesity pandemic, gastroenterologists will see more patients with this chronic disease. Given the association between obesity and several gastrointestinal conditions and the interplay between obesity pathophysiology and 05/09/2021 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= by http://journals.lww.com/ajg from Downloaded gut hormones, gastroenterologists can play an important role in the management of this disease. Furthermore, because more Downloaded patients undergo bariatric surgery, an understanding of postsurgical anatomy and medical and endoscopic management of bariatric surgical complications is essential. This article provides clinical tools for the assessment and management of from REVIEW ARTICLE http://journals.lww.com/ajg obesity for the general gastroenterologist. Tables containing high-yield practical information are also provided for quick reference. Am J Gastroenterol 2021;116:918–934. https://doi.org/10.14309/ajg.0000000000001200 by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= INTRODUCTION OBESITY-RELATED GASTROINTESTINAL CONDITIONS Obesity has become pandemic. It is estimated that more than 650 Obesity is associated with several gastrointestinal (GI) conditions million adults (13% worldwide) suffer from obesity (1). In the including various esophageal, gastric, small intestinal, colonic, United States, the prevalence is even higher with 42.4% of adults hepatobiliary, and pancreatic diseases (14–17). Specifically, obe- meeting criteria for obesity (2). As of 2013, the American Medical sity may result in a higher incidence, earlier presentation, and Association officially recognized obesity as a chronic disease (3). more severe clinical manifestations of these diseases. For exam- There are several ways to define and categorize obesity. Per the ple, obesity increases the risk of gastroesophageal reflux disease, Obesity Medicine Association, obesity is “a chronic, relapsing, esophagitis, and esophageal adenocarcinoma by 2-, 1.8-, and 2.8- multifactorial, and neurobehavioral disease, wherein an increase in fold, respectively (18). Similarly, the incidence of nonalcoholic body fat promotes adipose tissue dysfunction and abnormal fat fatty liver disease is approximately 90% in patients with obesity, mass physical forces, resulting in adverse metabolic, bio- compared with 25% in the general population (19), and obesity mechanical, and psychosocial health consequences (4).” Tradi- has been shown to hasten the progression from compensated to tionally, obesity has also been defined as a body mass index (BMI) decompensated cirrhosis (20). However, weight loss of at least of at least 30 kg/m2. It is further categorized into classI obesity (BMI 7%–10% total weight loss (TWL) has been shown to reverse 30–34.9 kg/m2), class II obesity (BMI 35–39.9 kg/m2), and class III histologic features of fatty liver (21). A more extensive list of obesity (BMI $40 kg/m2) (5). The use of BMI, however, is limited obesity-related GI conditions is summarized in Table 1 and can be in certain populations, such as the elderly, muscular, and sarco- more deeply explored in the work of Camilleri et al. (14). Given penic, because it does not distinguish between lean muscle and these associations, gastroenterologists should have an increased body fat or its location (6). Alternatively, waist circumference suspicion and low threshold to look for these illnesses in this (WC) may be used. Specifically, for patients with a BMI of 25–34.9 patient population. In addition, early diagnosis of obesity and kg/m2,WCof$40 inches (.102 cm) in men and $35 inches (.88 timely evaluation and management may help reduce the preva- cm) in women suggest central obesity, which is associated with lence and severity of such disorders. increased cardiometabolic risk (7–9). Finally, obesity may also be on fi $ 05/09/2021 de ned as body fat percentage of 25% in men and 35% in women OBESITY EVALUATION with the healthy body fat ranging from 8% to 19% in men and The obesity evaluation consists of several elements including 21%–35% in women (depending on age) (4,10,11). Nevertheless, medical, lifestyle, psychological, and endoscopic assessments. accurate body composition testing can be expensive with limited availability. Furthermore, it is important to note that these cutoffs vary based on ethnicity, such as a BMI of $25 and $27kg/m2 being Initial evaluation used to defineobesityinAsianandMiddleEastpopulations,re- During the initial encounter, physicians should assess patients’ spectively, because of their higher body fat at a lower BMI and readiness to change their health behavior using the “Stages of earlier appearance of comorbidities (12,13). Change” model (22,23). Specifically, the model consists of 5 This review is intended to serve as a clinical guide for the stages: (i) precontemplation: the individual is unaware of the general gastroenterologist on the assessment and management of consequences of their behavior and resistant to change, (ii) obesity. Tables containing high-yield information are also pro- contemplation: the individual is aware of the consequences and vided for quick reference. open to change, (iii) preparation: the individual shows 1Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Boston, Massachusetts, USA; 2Harvard Medical School, Boston, Massachusetts, USA. Correspondence: Christopher C. Thompson, MD, MSc. E-mail: [email protected]. Received June 4, 2020; accepted December 29, 2020; published online April 6, 2021 The American Journal of GASTROENTEROLOGY VOLUME 116 | MAY 2021 www.amjgastro.com Copyright © 2021 by The American College of Gastroenterology. Unauthorized reproduction of this article is prohibited. Obesity Primer 919 precontemplation stage, the goal is to help move them to the Table 1. Gastrointestinal conditions associated with obesity contemplation stage before referral to bariatric specialists. Mo- tivational interviewing techniques, such as the 5 A’s (Ask, Advise, Gastrointestinal Gastrointestinal conditions Assess, Assist, and Arrange) and OARS (Open-ended questions, organ associated with obesity Affirmations, Reflections, and Summaries), can help with this Esophagus •Abnormal esophageal peristalsis process to elicit and strengthen patient’s motivation along this •Isolated hypertensive LES pressure spectrum (24,25). •Isolated hypotensive LES pressure •GERD •Erosive esophagitis Medical evaluation •Barrett’s esophagus A weight-focused history, physical examination, and laboratory •Esophageal adenocarcinoma evaluation should be obtained. Weights at specific time points, ff Stomach •Dyspepsia including around the major life events, and the e ectiveness of •Erosive gastritis previous weight loss attempts should be reviewed. Certain med- •Gastric ulcer ications can cause weight gain and should be downtitrated or REVIEW ARTICLE •Gastric cancer substituted with weight neutral drugs (Table 2) (26,27). On •Greater fasting gastric volume physical examination, BMI, WC, waist-hip ratio, and percent •Decreased satiation body fat should be measured. Signs of obesity-associated medical conditions including hyperpigmented skin around the neck or • Small intestine Duodenal ulcer axilla (acanthosis nigricans associated with insulin resistance), • Small intestinal bacterial overgrowth hirsutism (polycystic ovarian syndrome), large neck circumfer- • Diarrhea (related to changes in bile acids, ence (.17 inches for men or .16 inches for women suggesting accelerated colonic transit, and increased mucosal increased risk of sleep apnea), and thin, atrophic skin (Cushing permeability) disease) should be looked for (28). Baseline laboratory should • Increased absorption of glucose (related to increased include electrolytes, renal function, fasting glucose, hemoglobin SGLT-1) A1c (HbA1c), liver enzymes, complete blood count, lipid panel, • Increased absorption of protein (specifically whey thyroid-stimulating hormone, vitamin D, and urine albumin. hydrolysate) •Increased absorption of long chain fatty acids (related to increased induction of lipid binding proteins) Lifestyle evaluation Colon •Diverticulosis Dietary and eating habits should be reviewed using a 24-hour diet •Diverticular bleeding recall, food frequency questionnaire, or food log. Dietary habits •Recurrent diverticulitis including eating patterns (skipping breakfast, eating one large •Clostridium difficile infection meal per day, emotional eating, and grazing), frequency of eating •Adenomatous polyps out, and grocery shopping details should be evaluated. Further- •Sessile serrated polyps more, onset of satiation (the point at which one becomes full •Colorectal cancer ending one’s desire to eat during a single meal) and period of •Dyssynergic defecation satiety (the state of being full and satisfied which regulates the •Incomplete rectal evacuation time elapsed between 2 meals) should be assessed. •Fecal incontinence Physical lifestyle should be assessed. It is important to un- •Crohn’s disease (conflicting data) derstand whether patients have an active or sedentary lifestyle •Earlier loss of response to biologics in IBD patients and details regarding exercise (types, duration, and frequency). Liver •Nonalcoholic fatty liver disease Total energy expenditure (TEE) is the amount
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