Obesity is a chronic disease that’s misunderstood. What roles do different treatment options play today?

With the rise in popularity of GLP-1 drugs and a shift in the conversation about obesity as a disease, two experts weigh in on combination therapy and opportunities for treatments to evolve.  

The rise of GLP-1 agonist drugs used for weight loss has shifted the conversation about obesity care. Despite their popularity, these drugs aren’t a one-size-fits-all solution to treating obesity. Recent studies indicate that they don’t work for everyone, evidence of the fact that obesity is still a chronic disease without a cure, and that is not fully understood. 

Indeed, “the meteoric rise in the popularity of GLP-1 agonist drugs is a sign that there is a lack of proper treatment and care for people living with obesity,” says Jörg Tomaszewski, M.D., a bariatric surgeon and Global Medical Director, Johnson & Johnson MedTech Surgery. 

“Any form of treatment must be tailored to the individual patient,” he continues. “Contrary to popular belief, diet and exercise are not considered a standalone treatment for obesity. Most of the time, combination therapy, which includes these traditional lifestyle changes but also things like metabolic surgery, endoscopic procedures and pharmacology, are needed for successful treatment.”  

In determining proper obesity and metabolic patient pathways, healthcare leaders have yet to come to a clear-cut consensus. "The clinical community is struggling to come to a common view on what the role of obesity management, medications, surgery and other interventions should be,” says Sandeep Makkar, Global President, Endomechanical and Energy, Johnson & Johnson MedTech. 

The encouraging news: The fact that there are now effective pharmacological treatments that work for some people has helped change the way people think about the disease, opening up avenues to discuss and research obesity in a less stigmatized way, paving the way to better options for patients and increasing understanding in the medical community.  

Gaining insights into obesity causes—and treatment options 

There are three main reasons for the lack of proper obesity care and treatment options, according Tomaszewski. First, many people aren’t aware that obesity is a chronic disease that requires treatment. The second is stigma in the general public and within the healthcare system. And the third is that in some regions in the world, there is a lack of reimbursement for treatments for obesity, which can be because of a lack of acknowledgement of obesity as a disease or financial constraints within a healthcare system.  

Gaining more insight into the causes and varying patient pathways of obesity is crucial for finding and defining treatments, both Makkar and Tomaszewski agree.  

Right now, body mass index (BMI) is the standard for how physicians diagnose someone with obesity. But many emerging scientific theories show that most harmful comorbidities of obesity derive from visceral fat, Tomaszewski says. Other diagnostic assessments, such as the Edmonton Obesity Staging System (EOSS) or including measures like waist-hip ratio, might be a better way to think about and diagnose phenotypes or stages of obesity. For example, an obese person with cardiovascular disease might need a different weight loss goal to regain health than someone with osteoarthritis, according to Tomaszewski. In short, “different complications of obesity might need different treatments and treatment goals, and in order to even examine that in studies, you need a different form of staging,” he says.  

More clinical studies are needed to better understand these different patient populations. “There were major changes in the way we treat cancer over the last 20 years, because we started to understand the disease better than we did before,” Tomaszewski says. "That’s a learning that we have to gain with obesity as well.” 

One suggestion from Makkar is for the industry to work with medical and obesity societies to establish registries for patient data. “We lack longitudinal tracking of a patient as the patient is navigating the journey of trying different options,” he says. While registries of bariatric surgery data exist, we need to establish registries with metabolic centers that capture patients when they first are diagnosed with obesity or seek care to get the full picture of the lifecycle of obesity, Makkar says. The number of patients who are eligible for bariatric surgery is around 300 million worldwide, but those populations are much larger when we look at the complete picture of obesity.

“The opportunity we have is to expand our impact beyond the surgically eligible obese patients and look at reaching close to a billion obese patients worldwide who are looking for a solution to treat obesity as a disease,” Makkar says.  

With a better understanding of the lifecycle of obesity, patients can really think about which options are best for them, he says. A person with a 50+ BMI who comes in wanting 25% weight loss is not going to find that with an obesity medicine alone. It could be more of a situation in which this person is on an obesity medicine as a precursor to surgery, “but the primary therapy will still be bariatric surgery.”  

Bariatric surgeons are working to find their place in the new obesity conversation 

The initial surge in popularity of obesity medications has had some wondering about the future of bariatric surgery and noting some declines in surgical volumes. But in a recent survey of 119 US bariatric surgeons, Johnson & Johnson MedTech found many surgeons now say that these obesity medications have changed the way that they think and allowed them to expand their network in the interest of patients to work more toward a comprehensive care model. Makkar says that not only are bariatric surgeons becoming more aware of the efficacy and safety data of medicines, but primary care providers and endocrinologists are becoming more aware of outcomes on the surgery side.  

“When you have everyone understanding what works well for a given patient under certain conditions, it gives patients better outcomes,” Makkar says. “It's the same thing that happened in cancers. When you say 'multimodal care,' a medical oncologist knows the constraints and the limitations of a certain chemotherapy regimen or immunotherapy regimen. But they also understand the role  of surgery in the treatment process. We are in the early throes of this multimodal understanding when it comes to bariatric and metabolic disease management.” 

Most bariatric surgeons believe that bariatric procedure volume growth in the next 18 to 24 months will be driven by obesity medicine non-responders, according to the survey. “There's optimism that surgical procedures will increase as well because more and more patients will enter the conversation as stigma around treatment is reduced.” 

Even though overall declines in bariatric surgery have been reported at 15 to 25% on average, it really depends on the location and type of practice, Makkar says. Economically affluent markets like California that have more access to obesity management medications have seen more declines in surgery than markets such as West Virginia, especially as these medications must be taken long term for sustainable weight loss.   

Sustainability of results might also play a factor in stabilizing surgical volumes. “Metabolic bariatric surgery is still one of the key treatments for obesity when you look at safety and longterm effectiveness,” Tomaszewski says. Bypass surgery is still the most effective treatment for high BMIs, with long-term total weight loss in the 25-30% range of total body weight.  

The future of multimodal obesity care 

In terms of what a better future for obesity treatment looks like, Makkar says everyone has a part to play. Pharmaceutical companies are working on improving delivery mechanisms, safety and efficacy of obesity medications. Drugmakers are also looking at how obesity medicines tie into the resolution of comorbidities such as cardiovascular disease and diabetes, whereas, metabolic and bariatric surgery have already undergone impressive research and development over the past 60 years, Tomaszewski says. “Development and adoption of these surgeries were accelerated by the adoption of laparoscopic keyhole surgery,” he says. “We have accumulated a rich body of clinical evidence regarding bariatric surgery’s effectiveness, but also about the safety and improvement of body weight and complications of obesity, leading to an extension of life expectancy.” 

From a medical technology standpoint, Johnson & Johnson MedTech is continuously working on making surgery even safer and less invasive and finding ways to reduce both tissue-device and surgical team variability. “I think bariatric surgery would have never become so safe without the progresses in laparoscopic techniques and instruments including stapling and energy devices, that are used in these procedures,” Tomaszewski says. 

One of the biggest holdbacks of bariatric surgery for patients is the fear that it is too invasive, because it often requires an overnight hospital stay, Makkar says. “We’re continuously looking at ways to make it less invasive with new technologies and processes that reduce overall hospitalization stay.. In terms of knee surgery, this shift toward widespread adoption with minimally invasive surgeries has already happened with standardized processes in ambulatory surgical centers. It hopefully will for bariatric surgery one day, too.”  

"I get excited about these new patient pathways because it takes the blinders off us as well,” Makkar says. “The more we can open up the conversation about obesity, the more we will learn about the best treatment pathway for obesity. And sometimes the best treatment pathway in terms of safety, efficacy and expected weight loss is going to be surgery.” 

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