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STAT

An MUSC blog
Keyword: obesity

Overweight patients who have not been successful at losing weight through diet and exercise but are hesitant to undergo weight-loss surgery now have a new treatment option. An innovative nonsurgical obesity treatment can offer greater weight loss than lifestyle modifications alone, without the risks of major surgery.

Now available at MUSC Health, ReShape™ weight-loss treatment involves two outpatient endoscopic procedures along with one year of nutrition and behavioral counseling.

While bariatric surgery has a track record of offering patients significant weight loss, MUSC gastroenterologist Gregory Cote, M.D., says many people are understandably reluctant to undergo surgery. He’s excited about ReShape’s potential to reach more people who have struggled to lose weight on their own. In partnership with the experienced interdisciplinary team of experts at MUSC Health, the ReShape intragastric balloon is one of the latest nonsurgical approaches to managing excess weight.

“Roughly two-thirds of the people in the United States are overweight or obese, and most of those people want nonsurgical treatment solutions,” Dr. Cote says. “There is a tremendous demand for treatments that fall somewhere between diet and lifestyle modification and more intense surgical interventions.”

ReShape: A New Kind of Weight-Loss Plan

Historically, most obesity treatments have fallen under one of two categories:

  • Lifestyle interventions, such as diet, exercise, behavioral, and pharmaceutical modifications, tend to be minimally effective at achieving long-term weight loss and are often insufficient for those with morbid obesity.
  • Bariatric surgery, which is an effective treatment for obesity, exposes patients to the potential for surgery-related complications. Bariatric surgery is currently indicated for those with morbid obesity who have a BMI greater than 35 with comorbid health conditions.

ReShape and other intragastric balloon procedures represent a middle-ground treatment approach: a minimally invasive nonsurgical procedure paired with an intensive behavioral program. The intragastric balloon helps jump-start patients’ weight loss while MUSC’s nutrition experts help patients learn healthy habits to sustain them into the future. Endoscopic approaches like the intragastric balloon also serve as a treatment option for those in the so-called “treatment gap”: patients with a BMI between 30 and 40.

Patients receiving this treatment undergo two outpatient procedures, both under light sedation:

  • Placing the dual balloon system: Using an endoscope through a patient’s mouth, a gastroenterologist inserts two connected balloons in the stomach, inflating them once they are in place. This 20-minute procedure helps patients feel full faster and reduces appetite.
  • Removing the dual balloon system: Six months later, a patient undergoes another short endoscopic procedure, during which specialists remove the balloons from the stomach. This procedure returns a patient’s digestive system back to its normal function, requiring them to rely on healthy habits to maintain their new weight.

To help patients ensure long-term weight-loss success, patients receive one full year of regular health coaching from MUSC’s nutrition and other medical experts:

  • First week after surgery: After balloon placement, patients receive daily phone calls from care specialists, to ensure they are tolerating the treatment well.
  • Monthly meetings: Soon after the balloon-placement procedure, patients attend monthly sessions with MUSC’s registered dietitians and medical specialists to:
    • Assess progress on behavioral changes and weight-loss.
    • Tackle individual challenges and plan for success.
    • Ensure patients have the tools and know-how to maintain eating and behavior changes long term.

“Patients keep careful track of their food intake after the initial balloon placement procedure,” explains Dr. Cote, who says the diet recommendations for ReShape are similar to the guidelines patients follow after bariatric surgery. “After the balloon removal procedure, patients continue to have monthly visits with our nutrition experts for continued close monitoring of weight and additional coaching.”

A New Approach to Obesity Treatment

Unlike bariatric surgery, ReShape does not permanently modify a patient’s digestive organs. Dr. Cote has high hopes that this procedure, though temporary, will help patients achieve significant weight-loss goals in the short term and adopt healthier habits that will benefit them for years to come.

“This procedure works under the premise that after one year, patients have achieved a durable weight-loss goal and, more importantly, have adapted to a healthier lifestyle. Our bariatric experts coach patients to help them incorporate portion control, exercise, and other healthy habits into their lives. With this guidance and support, they will hopefully minimize weight regain later,” says Dr. Cote.

MUSC Health is currently one of the few centers in South Carolina offering this nonsurgical balloon procedure. While Dr. Cote notes that MUSC’s Metabolic and Bariatric Surgery Program offers a range of surgical and nonsurgical treatment options, he says ReShape is most suitable for patients who have less severe obesity (with a BMI between 30 and 40) and obesity-related complications, such as prediabetes.

Because an endoscopic procedure has fewer risks than surgery, Dr. Cote hopes physicians will consider referring overweight and obese patients to MUSC’s Metabolic and Bariatric Surgery Program sooner.

“Determining the right type of weight-loss intervention for each patient is an individualized process. An intragastric balloon may not end up being the best fit for all patients. But by referring patients who could benefit from weight loss to our program, those patients can get connected to a comprehensive weight-loss program that offers the full spectrum of treatments for obesity,” says Dr. Cote.

For more information, contact Dr. Cote at cotea@musc.edu.

fatty liver disease image 3

In results published on October 19, 2015 in the Journal of Lipid Research (http://dx.doi.org/10.1194/jlr.M063511), a team of translational scientists at the Medical University of South Carolina (MUSC) report a new reason why non-alcoholic steatohepatitis (NASH) worsens in people who are obese. The results may help prevent cirrhosis and liver cancer, according to co-senior authors Kenneth D. Chavin, M.D., Ph.D., a transplant surgeon in the MUSC Health Department of Surgery, and Lauren Ashley Cowart, Ph.D., Associate Professor in the Department of Biochemistry and Molecular Biology and Co-Director of the MUSC Center of Biomedical Research Excellence in Lipidomics and Pathobiology.

 NASH (also called non-alcoholic fatty liver disease) has become a major cause of liver disease requiring transplant. “In my 17 years of doing liver transplants, it’s gone from 4% of patients to around 20% of patients who get transplants because of NASH,” says Chavin. “In 10-15 years, because of advances with Hepatitis C, it will probably become the number one reason why patients get transplants.”

When excess dietary fats are consumed over time, fat deposits form in the liver and NASH can develop. Early-stage NASH is typically not associated with any physical symptoms; nearly 30% of people in the U.S. have it. Though obesity is correlated with the development of NASH, the team wanted to know exactly why NASH worsens to a stage requiring transplant in certain obese people. “Obesity doesn’t cause disease in every obese person and we don’t understand why it does in some but not others,” explains Cowart.

The team suspected that inflammation stemming from a lipid molecule called sphingosine-1-phosphate (S1P) might be responsible. They’d previously discovered in other organs that S1P is increased by excess dietary saturated fat.

Chavin took biopsies from human livers during transplant surgery and supplied them to Cowart, who determined the levels of sphingosine kinase 1, the enzyme that makes S1P. They found double the normal amount of sphingosine kinase 1 in livers of obese people with non-alcoholic steatohepatitis.

The team wanted more understanding of why S1P causes inflammation, but NASH has previously been difficult to mimic in the laboratory setting. They developed a new and highly improved preclinical model of NASH, wherein mice were fed on custom-designed diets of either high saturated fat or high unsaturated fat. Curiously, mice on each type of diet became obese, but only mice on the saturated fat diet developed inflammation and NASH-like pathology stemming from S1P. Taking the human and pre-clinical studies together, it’s likely that saturated fat, but not unsaturated fat, raises S1P levels in obese people, and it’s S1P that unleashes the inflammation that characterizes NASH.

Performing lipid studies in the laboratory is not easy—most biochemistry is water-based, and fat and water don’t easily mix. The group relied on the MUSC Sphingolipidomics Core laboratory, one of only a handful of such facilities in the country capable of developing the new methods needed to examine S1P for their study. Without lipidomics, we never would have understood that saturated fats activate this pathway,” says Cowart. The team is working to identify the S1P receptors responsible for inflammation in NASH, with the ultimate goal of designing treatments to prevent the need for a liver transplant in obese patients with NASH.

Does this work support the idea that it’s the type of fat, but not all fat, that leads to health problems? After all, mice fed a high unsaturated fat diet still became obese but were metabolically healthy. “Because the unsaturated fat diet didn’t cause NASH, it may provide a clue as to what actually links obesity to disease,” says Cowart. “Even if it’s difficult to lose weight, dietary modifications might prevent some disease associated with obesity.”

 MUSC researchers Tuoyu Geng, Ph.D., Alton Sutter, M.D.,Ph.D., Arun Palanisamy Ph.D., and Michael D. Harland also contributed to this study.

 This work was supported by a Veterans Affairs Merit Award, National Institutes of Health Grants 1R01HL117233 and 5P30GM103339-03 (L.A.C.), and National Institutes of Health Grant 1R01DK069369 to K.D.C .

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