Bariatric surgery and obesity medicine

Obesity treatment has been transformed by the introduction of GLP-1 weight loss medications. Yet obesity treatment is not one-size-fits all, said Lisa Dobruskin, MD, on a recent episode of the Penn Medicine Physician Interviews podcast. A bariatric surgeon and obesity medicine specialist, Dr. Dobruskin serves as Medical Director of the Center for Bariatric Surgery and Metabolic Medicine at Penn Medicine Princeton Health.

“The goal of our program is to provide multidisciplinary care for patients who are struggling with obesity,” said Dr. Dobruskin. “It’s a very complex disease that involves many organ systems and affects people for their whole lives.”

The Center for Bariatric Surgery and Metabolic Medicine offers a range of services, including:

• Robotic bariatric surgery (including sleeve gastrectomy and Roux-en-Y gastric bypass)
• Endoscopic procedures, such as endoscopic sleeve gastroplasty
• Revisional procedures
• Medications such as GLP-1s
• Nutrition counseling and behavioral health services

Advances in obesity medicine: GLP-1 inhibitors

The field of obesity medicine has evolved—not just with new weight loss medications, but also in its understanding of the disease.

“One of the things I’ve learned is that obesity is so much more than calories in and calories out,” Dr. Dobruskin says. “Because there’s such an imbalance and dysregulation of so many metabolic pathways that control eating and hunger, it’s not just a matter of telling a patient that they have to eat less. We have to help them by treating some of these abnormalities.”

Like many diseases, obesity exists on a spectrum. While some patients can achieve and maintain a healthy weight with diet and exercise counseling, others need medications and/or surgery to successfully address the metabolic dysfunction.

For patients with a body mass index of 40 or greater, medication alone is often not an adequate treatment. Early studies suggested the GLP-1 inhibitor semaglutide resulted in patients losing up to 15 percent of their total body weight, while patients taking tirzepatide lost up to 20 percent.

In newer real-world studies, however, the weight loss appears to be a bit more modest, around 13 percent for semaglutide and 18 percent for tirzepatide. “For somebody who has a hundred-plus pounds to lose, these medications alone are not an adequate treatment,” Dr. Dobruskin notes.

However, medications can be an excellent adjunct to surgery, she adds. “For patients who have a little bit of weight re-gain, or who don’t lose as much as they should after surgery, these medications work really well.”

Barriers to weight-loss medicine

The cost and insurance coverage of injectable weight-loss medications remains a barrier for many individuals.

“Patients are not getting the treatment they feel they need,” Dr. Dobruskin says. Recent large-scale studies suggest that at one year, more than 50 percent of patients have stopped taking the medications. The expense may be one reason why.

Other patients who can’t afford GLP-1 prescriptions may turn to online programs that sell compounded GLP-1 medications, which are not regulated by the FDA.

“I’m adamant with patients about the fact that using compounded medications is not safe,” Dr. Dobruskin says. What’s more, patients buying the drugs online may not receive the counseling and support that will help them lose weight successfully.

“Neither bariatric surgery nor medication on its own is going to work effectively without lifestyle modification,” she adds. “Offering patients resources like nutritional counseling, behavioral health, and support groups is crucial to helping patients achieve good results.”

Obesity treatment at Penn Medicine Princeton Health

Primary care providers can play an important role in helping patients address their weight—including referring patients for specialized obesity treatment when needed.

Patients are considered good candidates for bariatric surgery if they have a BMI over 40, or a BMI over 35 plus an obesity-related disease such as diabetes, hypertension, or sleep apnea. “Any patient who qualifies should be referred for a consultation to discuss their options,” Dr. Dobruskin says.

If patients aren’t ready for surgery, the clinic can manage their treatment with medications and lifestyle changes. They also see patients who don’t qualify for bariatric surgery but struggle with high body weight or obesity and are interested in medications and support from obesity specialists and a dedicated bariatric nurse navigator.

Obesity is a chronic illness, often involving periods of remission when patients maintain a healthy weight, followed by periods of relapse. The Center for Bariatric Surgery and Metabolic Medicine takes a long-term approach to caring for patients.

“We offer all of these services for the duration of the patient’s life, because we know that patients need a lifetime follow-up to treat this chronic disease,” Dr. Dobruskin says. “Depending on the stage of the disease process for that particular patient, we’re able to tailor the treatment to their needs.”

Clinical consult and patient referral

Board-certified surgeon Lisa Dobruskin, MD, sees patients at the Center for Bariatric Surgery and Metabolic Medicine in Princeton, NJ. For a provider-to-provider consultation with Dr. Dobruskin, please call 877-937-7366, or refer a patient online.