Official journal of the American College of Gastroenterology


Obesity affects 1 in 8 adults worldwide and is increasing among children and adolescents (1) The economic impact is anticipated to rival most other non-communicable diseases and is an urgent clinical and public health problem (2,3). This immense burden has the potential to impact clinical care and policy decisions with important caveats pertaining to social determinants of health, disparities, and availability of therapeutic options.

The current issue of The American Journal of Gastroenterology was imagined as a crossroads between the multiple specialties involved in studying obesity pathogenesis. We also aimed to highlight the burden, treatment, and challenges in implementation of programs aimed at obesity reduction. An exciting development is the emergence of GI specialists as a major hub in the management of obesity. This rapidly changing role of GI practitioners in obesity management ranges from medication utilization, to endoscopic management, to writing exercise prescriptions (4,5). Our collection of articles emphasizes the multidisciplinary management of obesity via collaboration amongst primary care physicians, gastroenterologists, endocrinologists, nutritionists, and surgeons. The frameshift in obesity management is exciting and has the potential to reach patients who would not otherwise have access to this expertise across numerous provider types.

The most worrisome trend in obesity is the current and future epidemic in children and adolescents. The issue amply portrays this in the context of steatotic liver disease, esophageal diseases, and even the role of food insecurity (6–8). This looming trend underscores the need to address obesity as early in life as possible. The far-reaching impact of obesity, and co-factors such as ultra-processed foods and dietary additives, on GI cancers, inflammatory bowel disease (IBD) and liver disease are also highlighted in this issue (9–11).

The multi-factorial pathogenesis of obesity from the gut-brain axis, and gut-liver axis are explored in this issue. A complex interplay of biological, psychological, and social cues contributes to food-related behavior (12). Clinicians managing obesity need to be sensitive towards the stigmas that can be associated with obesity. Providers can address the negative cues that could exacerbate obesogenic behaviors (13). An in-depth review by Busch and colleagues (14) sheds light on the role of the gut microbiome in obesity, while an original study of the small bowel microbiome (15) in obese individuals sheds light on novel microbial targets. The modulation of the microbiome and the gut-brain axis is an interesting aspect of obesity management that could provide future treatment targets.

While obesity can directly impact cardiovascular and endocrinological outcomes, it can also modulate treatment response to conventional therapies in chronic GI and liver diseases. This issue highlights several novel aspects of fat deposition overall and around the viscera in gastroesophageal reflux disease, IBD, and pancreatic disorders. Body composition and visceral fat changes can affect both predisposition to these disease and response to therapies (16–19). Obesity should be considered as an important factor when selecting appropriate pharmacologic therapy (20) and when determining response to therapies for chronic GI and liver diseases.

In keeping with the evolving role of GI specialists as hubs for obesity management, we need knowledge regarding surgical, endoscopic, and medical options. The current issue focuses on the optimal use of these modalities as well as the complications and consequences of obesity management (21–23). Endoscopic treatments have blurred the lines between surgical and non-surgical therapies for obesity (24,25). The status of endoscopic obesity treatments is evolving in light of pre-existing surgical techniques and the ever-increasing array of effective weight-loss medications such as GLP-1 agonists. Specifically, the contentious issue of potential pulmonary aspiration associated with GLP-1 agonists during endoscopy as well as proper preparation for colonoscopy has been highlighted. These complications directly affect patients, GI providers, and clinicians providing sedation or anesthesia (26–28) The data are in their early stages but point towards a need to carefully weigh the risks and benefits of these medications around endoscopies. The effectiveness and safety of weight loss treatments in GI and liver diseases has also been explored (29,30).

This special issue of The American Journal of Gastroenterology on obesity in GI disorders provides many unique, multi-faceted insights into one of the defining disorders of our age. GI providers have the capability and resources to reduce the major burden of obesity.

CONFLICTS OF INTEREST

Guarantor of the article: Jasmohan S Bajaj, MD, MS, FACG

Specific author contributions: Authors contributed equally to this article.

Financial support: None to report.

Potential competing interests: None to report.

REFERENCES

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2. World Health Organization. Obesity and overweight. 2024. Accessed April 25, 2024. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

3. GBD 2019 Risk Factors Collaborators. Global burden of 87 risk factors in 204 countries and territories, 1990-2019: A systematic analysis for the global burden of disease study 2019. Lancet 2020;396(10258):1223–49.

4. Gold SL, Kornbluth A. The role of the gastroenterologist in obesity management: Now is the right time for our involvement. Am J Gastroenterol 2024;119(6):1001–6.

5. Stine JG, Henry ZH. How to write an exercise prescription to treat MASLD for the busy clinician. Am J Gastroenterol 2024;119(6):1007–10.

6. Paik JM, Duong S, Zelber-Sagi S, et al. Food insecurity, low household income, and low education level increase the risk of having metabolic dysfunction-associated fatty liver disease among adolescents in the United States. Am J Gastroenterol 2024;119(6):1089–1101.

7. Kennedy KV, Umeweni CN, Alston M, et al. Esophageal remodeling correlates with eating behaviors in pediatric eosinophilic esophagitis. Am J Gastroenterol 2024;119(6):1167–76.

8. Parashette KR, Coakley KE, Kong AS, et al. High prevalence of elevated alanine aminotransferase in american indian children seen in a pediatric weight management clinic. Am J Gastroenterol 2024;119(6):1201–4.

9. Vagianos K, Dolovich C, Witges K, et al. Ultra-processed food, disease activity and inflammation in ulcerative colitis: The Manitoba Living With IBD Study. Am J Gastroenterol 2024;119(6):1102–9.

10. Danpanichkul P, Auttapracha T, Sukphutanan B, et al. The burden of overweight and obesity-associated gastrointestinal cancers in low and lower-middle income countries: A global burden of disease 2019 analysis. Am J Gastroenterol 2024;119(6):1177–80.

11. Meine GC, da Veiga Picon R, Arruda do Espirito Santo P, et al. Ultra-processed food consumption and gastrointestinal cancer risk: A systematic review and meta-analysis. Am J Gastroenterol 2024;119(6):1056–65.

12. Moraes CHC, Alvarenga MDS, Moraes JMM, et al. Exploring psychosocial determinants of eating behavior: Fruit and vegetable intake among brazilian adolescents. Front Nutr 2021;8. doi: 10.3389/fnut.2021.796894

13. Papademetriou M, Riehl M, Schulman AR. Stigma, bias, and the shortfalls of body mass index: A reflection on the state of weight management. Am J Gastroenterol 2024;119(6):1023–7.

14. Busch CBE, Bergman JJGHM, Nieuwdorp M, et al. Role of the intestine and its gut microbiota in metabolic syndrome and obesity. Am J Gastroenterol 2024;119(6):1038–46.

15. Leite G, Barlow GM, Rashid M, et al. Characterization of the small bowel microbiome reveals different profiles in human subjects who are overweight or have obesity. Am J Gastroenterol 2024;119(6):1141–1153.

16. Dong X, Zhu Q, Yuan C, et al. Associations of intrapancreatic fat deposition with incident diseases of the exocrine and endocrine pancreas: A UK Biobank prospective cohort study. Am J Gastroenterol 2024;119(6):1158–66.

17. Ebach DR, Jester TW, Galanko JA, et al. High body mass index and response to anti-tumor necrosis factor therapy in pediatric Crohn’s disease. Am J Gastroenterol 2024;119(6):1110–16.

18. Han YM, Yoon JH, Yoo S, et al. Visceral adipose tissue reduction measured by deep neural network architecture improved reflux esophagitis endoscopic grade. Am J Gastroenterol 2024;119(6):1117–25.

19. Hiramoto B, McCarty TR, Lodhia N, et al. Quantified metrics of gastric emptying delay by glp-1 agonists: A systematic review and meta-analysis with insights for periprocedural management. Am J Gastroenterol 2024;119(6):1126–40.

20. Moy BM, Volk S, Richards B, et al. Use of postoperative opioid therapy following endoscopic sleeve gastroplasty. Am J Gastroenterol 2024;119(6):1186–91.

21. Evans G, Yu JX, Moy B, et al. Use of impedance planimetry in the diagnosis of gastric sleeve stenosis: The establishment of new benchmark values. Am J Gastroenterol 2024;119(6):1074–80.

22. Camilleri M, Lupianez-Merly C. Effects of GLP-1 and other gut hormone receptors on the gastrointestinal tract and implications in clinical practice. Am J Gastroenterol 2024;119(6):1028–37.

23. Maselli DB, Donnangelo LL, Jirapinyo P, et al. Transoral outlet reduction: Expert tips, tricks, and troubleshooting. Am J Gastroenterol 2024;119(6):1047–55.

24. Dayyeh BKA, Bazerbachi F, Vargas EJ, et al. Endoscopic sleeve gastroplasty for treatment of class 1 and 2 obesity (MERIT): A prospective, multicentre, randomised trial. Lancet 2022;400:441–51.

25. Dolan RD, Schulman AR. Endoscopic approaches to obesity management. Annu Rev Med 2022;73:423–38.

26. Garza K, Aminpour E, Shah J, et al. Glucagon-like peptide-1 receptor agonists increase solid gastric residue rates on upper endoscopy especially in complicated diabetic patients: A case control study. Am J Gastroenterol 2024;119(6):1081–8.

27. Yao R, Gala KS, Ghusn W, et al. Effect of glucagon-like peptide-1 receptor agonists on bowel preparation for colonoscopy. Am J Gastroenterol 2024;119(6):1154–7.

28. Flanagan R, Muftah M, Hiramoto B, et al. Impact of body composition on esophagogastric junction opening measures: Discordant flip and manometric findings are more common with increased body mass index. Am J Gastroenterol 2024;119(6):1181–5.

29. Pham JT, Ghusn W, Acosta A, et al. Effectiveness and safety of antiobesity medications in patients with obesity and inflammatory bowel disease. Am J Gastroenterol 2024;119(6):1197–1200.

30. Tang H, Kaplan DE, Mahmud N. The impact of weight loss programs on BMI trajectory in patients with metabolic dysfunction-associated steatotic liver disease: A Veterans health Administration study. Am J Gastroenterol 2024;119(6):1192–6.

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