A personalized approach to treating obesity and related health conditions
Bariatric surgeon James Ku, MD, offers counsel to help patients understand their weight-loss goals and the capacity of each available option to meet them.
Minimally invasive bariatric surgery has a long track record as a safe and effective approach to helping patients with obesity achieve their long-term weight loss and health goals. FDA approval of GLP-1 receptor agonists for obesity treatment now offers people another effective medical option for achieving significant weight loss.
Helping patients understand all of their options—and how it is not always an either/or decision—requires a clear understanding of their weight-loss goals and the ability of each approach to meet them.
“There is no one-size-fits-all answer to addressing a disease as complex as obesity,” says James Ku, MD, a bariatric surgeon at Penn Medicine Lancaster General Health. “Successful weight loss requires a long-term commitment by both the patient and those supporting their healthy weight management journey.”
Dr. Ku explains that each patient brings a unique set of circumstances to the table. “Effective treatment begins with educating them on their condition, the options for its treatment, and my role as an obesity medicine specialist in helping guide them in their decision.”
Understanding a complex condition
Board certified as both a bariatric surgeon and obesity medicine specialist, Dr. Ku says that his role involves taking a comprehensive look at each patient and exploring all options to help them treat obesity, a chronic and largely misunderstood disease.
“There is no one-size-fits-all answer to addressing a disease as complex as obesity.”
“Obesity carries a stigma, where the public tends to think that those afflicted simply need to eat less, exercise more, or try harder to change a number on a scale,” explains Dr. Ku. He emphasizes that blaming people for the disease they’re facing isn’t an effective approach to addressing it. “I start with compassion, which involves establishing a baseline for where the patient’s life is when they arrive.”
Obesity is classified according to body mass index (BMI):
- Class I: BMI between 30 and 34.9
- Class II: BMI between 35 and 39.9
- Class III (morbid obesity): BMI of 40 or higher
Initial conversations focus on providing patients with a deeper understanding of what obesity is—a chronic relapsing medical condition that’s both complex and progressive, and that may recur or worsen despite treatment. Additionally, obesity has a trajectory significantly influenced for many people by genetic and biological factors, making it hard to treat with basic behavior changes. Finally, obesity presents differently for each person, adding to its complexity and resulting in the need for a personalized approach.
Obesity is also a heterogeneous condition and systemic disease characterized by chronic inflammation, which induces significant stress on organs and tissues. Moreover, it’s an endocrine disease through hormonal dysregulation of hunger and satiety and a driver of metabolic disruption. In these ways, obesity mirrors cancer’s effects on the body and mind.
Dr. Ku suggests that treatment for obesity is increasingly adapting paradigms common to cancer. Although mechanistically distinct, therapy for both cancer and obesity requires a multimodal approach focused on trying to down-stage the disease. The goal in either case is to avoid or address comorbidities and enhance or prolong treatment effect.
“The most effective approach to treating this disease is whatever combination of therapies works best for a given patient,” he advises. “We’re fortunate to have multiple options.”
Fitting the treatment to the patient
Medical and surgical interventions for obesity are designed to address health issues in patients for whom conservative therapy (e.g., diet and exercise) alone fails to achieve a resolution.
Because obesity can be a gateway to Type 2 diabetes, heart disease, and other secondary conditions, effective and timely treatment is essential. As a result, part of the decision on the best course of treatment should account for the speed and efficacy of the intervention.
Bariatric surgery remains the “gold standard” for treating morbidly obese patients, in that it offers a safe approach to rapidly removing excess weight detrimental to health. Current qualifications for bariatric surgery include:
- A BMI of 40 or higher (Class III obesity)
- A BMI of 35 or higher (Class II obesity) with one or more serious obesity-related health condition
“Surgery remains the most effective treatment for class III obesity, as well as class II obesity with certain comorbidities,” Dr. Ku says. With over 20 years as a bariatric surgeon and having performed thousands of procedures, his belief in surgery as a life-changing and sometimes life-saving option for these people is based on experience.
Evidence supports Dr. Ku, with surgical outcomes frequently including:
- Loss of up to 70% of excess weight within 1-year post-surgery
- Significant improvement or possible resolution of obesity-related health conditions
- Viability as a long-term weight loss solution
Nevertheless, Dr. Ku adds that surgery may not be right for everyone. This can be due to a number of factors ranging from personal preferences to health conditions. Thus, having this newer class of successful obesity medications as another tool is incredibly beneficial. However, it’s crucial that providers communicate the realistic outcomes of medications and surgery to inform patients of the potential differences in weight loss results.
Helping patients choose wisely
Dr. Ku says that establishing a patient’s expectations for weight loss, resolution of comorbidities, and other health goals sets the stage for all treatment decisions.
“There are absolutely situations when a medication might be selected as neoadjuvant therapy,” he explains. For instance, a GLP-1 receptor agonist may be used as a means of BMI reduction to mitigate risk of non-bariatric surgery, including organ transplants and joint replacements. In some circumstances, a period of time on obesity medication can also improve the outcomes of bariatric procedures.
Aside from medical necessity, choosing medication over surgery may also be a matter of psychological or emotional considerations, as well as personal preference. These might exclude surgery as an option (either permanently or for the present time) depending on the patient’s goals and response to the medication. In such cases, the patient’s expectations dictate the conversation.
Whether surgery, medication, or a combination of both, Dr. Ku emphasizes that they’re only the first step in what will be expected of patients during the process.
“My aim is to focus less on outcomes strictly confined to lower numbers on the scale and more on what the patient wants in terms of better overall health and quality of life,” says Dr. Ku. For some, success might simply mean a reduced risk of comorbidities and achieving some weight loss. Others’ experiences with medication may be less positive.
“Where BMI and total body weight are concerned, even highly responsive patients will be limited in how much they can lose on medication alone,” explains Dr. Ku. Time is also a factor, as loss of insurance coverage or other reasons for patients stopping the medication frequently results in weight regain.
“This reinforces the importance of not only setting realistic expectations, including goals for weight and health improvements, but also honestly evaluating benchmarks at regular intervals.”
The road to long-term success
Despite the substantial attention given to GLP-1 medications, Dr. Ku says that minimally invasive bariatric surgery remains a safe and effective approach to managing the disease and should not be dismissed. “It’s important that these patients are aware that surgery is still available to them as a therapeutic option.”
Whether surgery, medication, or a combination of both, Dr. Ku emphasizes that they’re only the first step in what will be expected of patients during the process.
“The bottom line is that neither medication nor surgery can force individuals to make the lifestyle changes necessary to realize long-term success,” he says. “Those commitments are personal choices that need to become lifelong habits.”
Clinical consult and patient referral
For clinical consult with Dr. Ku and bariatric team colleagues in Lancaster, please call 717-544-2935.
To refer a patient to Penn Medicine for obesity management, please call the 24/7 provider-only line at 877-937-7366 or submit a referral through our secure online referral form.