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Dr. Jeffrey Mechanick Part 6, Bariatric Surgery and Obesity Treatment

Dr. Jeffrey Mechanick talks with Diabetes in Control Publisher Steve Freed at the 2016 AACE Meeting. In part 6 of this Exclusive Interview, Dr. Mechanick explains the changes to the AACE obesity treatment guidelines and how they impact current healthcare behavior.

Dr. Jeffrey Mechanick, MD, FACP, FACE, FNLA is the Clinical Professor of Medicine and Director of Metabolic Support in the Division of Endocrinology, Diabetes and Bone Disease at the Icahn School of Medicine at Mount Sinai, NY. Dr. Mechanick was chosen president of the American College of Endocrinology (ACE) in May 2016, an office he will hold for one year. His current research interests are in nutrition and metabolic support, lifestyle and obesity medicine, and network analysis of complex systems.


Transcript of this video segment:

Steve Freed: One of the major changes that I’ve seen here and I’m sure that we’ll see at ADA and that’s basically more information about obesity, because now we have more tools to treat obesity. I noticed that recently they’ve just come out with new guidelines for treating obesity and bariatric surgery. So far what I’ve read about bariatric surgery is that a lot of the patients lose the weight initially but eventually gain that weight back. They just went through a major surgical operation to get to the same result. What are your thoughts and where does it fit in in this whole paradigm?

Dr. Mechanick: You bring up several points. I’ll start with the last because I remember it the best. Most patients who have bariatric surgery are not going to regain the weight all the way back to baseline. However you’re correct that some patients will regain too much weight and it’s a problem and it highlights the need for what I said before, which is not only concurrent lifestyle change, but we need more education, more research, more knowledge, more experience, about implementing lifestyle change. As far as bariatric surgery as well having a therapeutic effect, you may have seen the recent report in Diabetes Care from the Diabetes Care Summit from Francesca Rubino. AACE was fortunate enough to be part of that. I was a representative at that diabetes surgery summit. AACE endorsed the findings. Although I’m not sure whether these findings are going to be static, I expect they’re going to be changing these recommendations over time. I think they’re very important findings and they illustrate the effects in these patients who really are at the extreme of the spectrum, where lifestyle and pharmacotherapy are not having a sufficient effect on halting or abrogating these very detrimental effects with diabetes in the natural history of diabetes that you really find yourself in a place where you need to call in bariatric surgery. Let’s move on to the obesity guidelines by AACE. I was privileged to work with Tim Garvey, who was the chair and with the other members of the writing group and the reviewers and this was a project that we were really able to complete within a year. It’s a very large, long comprehensive guidelines. Hundreds of pages for 1000 references, all evidenced-based, in strict adherence with our AACE protocol for guidelines with guidelines. Very transparent in terms of the methods. Here’s how it differs and here’s how it impacts the obesity space. First of all, it’s comprehensive, it’s not just talking about drugs. It’s not just focusing on weight loss, though weight loss obviously is very important. It’s not just focusing on BMI as the target. It really is emphasizing complications. Weight loss or weight related complications. Weight gain or weight loss. Weight related complications. It’s those complications which are the biological relevance of the anthropometric changes and we talk about different anthropometric changes, whether it’s BMI or waist circumference in different ethnicities. How in an individual, they are translated to affect different organs and cause organ dysfunction. We focus on the lifestyle changes. We focus on a broad array of pharmacotherapy that must be available. This is really a call to action for our American health care system that we need to have all of these various weight loss drugs available so that individual physicians can individualize for their individual patients. That’s what’s necessary, not just have one type of treatment for every type of patient who has obesity or preobesity, which is being overweight. So, these guidelines are really moving the needle forward and advancing the care. One other thing that’s in these guidelines as you thumb through them and you go to the appendix, is we offer an AACE care model, a chronic care model for obesity, really serving to anchor and provide context for these guidelines so the recommendations truly are actionable and they have relevance for today. The components of that care model are first, that you have an activated patient. The patient wants to lose weight. The patient understands the benefits. The health benefits, reducing the risk for complications, or reducing the progression of complications that may already exist, with a comprehensive program for obesity. Second, preparedness of the clinical practice. The physician needs to be well-informed. The physician needs to have access to these guidelines. The physician needs to have the proper equipment in their office, proper training.  Sensitivity to obesity as a disease. Third, community engagement, the schools, houses of worship, the workplace, community meeting places, that the whole system is involved in a sensitivity and a desire and a diligence to combat obesity. Lastly, a health care system that can receive these components of a chronic care model and make them work. We need better reimbursement strategies for drugs for bariatric surgery. We need training for lifestyle, we need reimbursement for lifestyle change, reimbursement for nutritionists, and reimbursement for those who can teach physical fitness, reimbursement for sleep studies, reimbursement for behavioral medicine. These things, not only did they not exist before, but in the current health care economic climate, they are few and far between and there is really a schism between what we need and what we have.

To view other segments in this video series:

Part 1: Nutrition and Lifestyle
Part 2: Effective Diet Discussions
Part 3: Simplifying Aspects of Diabetes Care
Part 4: Influx of Prediabetes Patients
Part 5: Tips to Alter Lifestyle