Ali Tavakkoli, MD, Co-Director of the Center for Weight Management and Metabolic Surgery at Brigham and Women’s Hospital discusses medical weight loss options for patients including, medications, surgery and novel new therapies.
The Brigham and Women’s Hospital Center for Weight Management and Metabolic Surgery (CWMMS) is dedicated to helping our patients develop and maintain a healthy lifestyle by improving and preventing the medical conditions associated with excess weight.
ALI TAVAKKOLI: We are often asked, what are the implications of being overweight or obese and outside the healthy weight range? And this is a very topical and important issue in the US, because only a third of us currently live in a healthy weight range. And the majority of us are either obese and overweight. And this has significant implications. Being obese is associated with significant medical conditions and ill health. For example, a woman who has a BMI of 35 has about a 50-fold increase in risk of diabetes compared to a normal weight female. So increased weight and obesity is associated with increased mortality and morbidity. And in fact, for every five-unit increase in BMI, there is a 30% increased risk of mortality in the patient population, so that by the time an individual's weight reaches a BMI of 40, their life expectancy is reduced by about 8 to 10 years, which is equivalent to being a lifelong, heavy smoker. The treatment options currently fall into three main categories. The one that most of us are familiar with is this concept of dieting and exercise. And there are multiple diets out there. The other approach has been to give medications. And although there's been a lot of research and some new medications that are coming out, in the past the medications have not been very successful. And some have had some significant side effects. And as a result, what has really become the gold standard of therapy has been surgery. And there are certain criteria that patients need to meet before they can have surgery. Their BMIs need to be over 40, or they need to have a BMI between 35 and 40 and health-related issues related to their weight, for example, diabetes, hypertension, or sleep apnea. When you think about what happens to an individual currently who wants to seek advice for their management of the weight, they kind of really struggle. They usually are [INAUDIBLE] their PCPs. And then the PCP has a choice of referring patients. Some refer the patients to endocrinologists. Some refer them to dietitians. Some refer them to a weight loss program, such as Weight Watchers or even a hospital-based weight loss program. And sometimes they were referred to bariatric surgery. As you can see from this slide, it's very confusing for patients to make sense out of where they are along this treatment paradigm. And the other problem was that once patients entered a particular silo or a group, it was very difficult for them to transfer from one to the other. And I think this was really the main impetus for us to come together about a year ago and try to redesign the way we care for our obese and overweight patients to help streamline the process and help improve on the care that we are currently providing. So the new center that we have created, the Center for Weight Management and Metabolic Surgery, really brings in all the experts who are involved in this field together to assess the patients at the same time in the same geographical location to help enhance communication between the various groups that are involved, and also make the delivery of care for the patients easier and more seamless. And during their initial evaluation, they're seen by a weight management specialist, by a dietitian. And if we know that they have health-related comorbidities related to their weight and need input from other specialties, that can be arranged at the same time, such as they can be seen by a cardiologist or a pulmonologist. During this visit, we will also perform baseline evaluations as needed. And then depending on patients' weight, their wishes, they will then get allocated different treatment arms. So a patient may choose that they want to try some medications. A patient may realize that they qualify for bariatric surgery and actually that's something that they would like to learn more about. And in that case, they get referred to our bariatric program. And the arm, the treatment arm and the group that we are actually most excited about is these novel therapies and new treatments that are actually coming down the pipeline. And at the moment, no one knows how to gain access to them. And thanks to the expertise that we have at the Brigham, these patients will now be offered those treatment options as well. And if one person who is assigned to one arm ends up not being successful or not liking that arm, it will be easy for them to transfer to the other treatment groups, because everything is organized by the same Center staff. So one of the unique qualities about this integrated care concept is that the chances of patients falling through the cracks, not receiving appropriate follow-up, or being forgotten about is significantly less. And I think the way the field is evolving is rather than focusing on weight only, when we assess patients we're also going to take into account the severity and presence of any medical conditions they have, diabetes being one of them. And then taking into account degree of obesity, the severity of these health issues such as diabetes, then we will probably customize treatment for patients. So in patients who are not very obese, who have mild health problems related to their weight, medications may be offered. In patients who are very obese, BMIs are over 40, they have bad diabetes, I think surgery will continue to play a strong role. But then there is a large group of patients that fall between those two groups. These are patients whose weight is not very high and they have medical problems, but they're currently reasonably well controlled. And I think the way the field is evolving, there's going to be lots of novel therapies, new medications, new devices, less invasive surgeries that are going to come through. And we will be able to offer it to those patient population. And I think the way we've structured our Center helps us to be uniquely positioned to offer this.