ASGE EndoVators Summit: Defining the role and value of endoscopic therapies in obesity management

Abstract

On November 20 and 21, 2016, the American Society for Gastrointestinal Endoscopy (ASGE) and the Association for Bariatric Endoscopy (ABE) hosted the EndoVators Summit at the Institute for Training and Technology in Downers Grove, Illinois to define the role and value of endoscopic therapies in obesity management. Nearly 100 obesity management experts, innovators, and key decision makers from industry, insurers, and regulatory agencies gathered to review the current state of the obesity epidemic in America and the role that endoscopic bariatric and metabolic therapies (EBMTs) could play in the management of this chronic disease. Additionally, ASGE invited leaders of societies with an interest in EBMTs to participate in an exchange of ideas related to the training, research, and education in EBMTs with the goal of identifying areas of cooperation and coordination. The following societies were represented:American Society for Gastrointestinal EndoscopyThe Association for Bariatric EndoscopyAmerican Society for Metabolic and Bariatric SurgeryInternational Federation for the Surgery of Obesity and Metabolic DisordersThe Obesity SocietyAmerican Association for the Study of Liver DiseasesAmerican Society of TransplantationAmerican College of GastroenterologyAcademy of Nutrition and DieteticsNorth American Society for Pediatric Gastroenterology, Hepatology, and NutritionSociety of American Gastrointestinal and Endoscopic Surgeons The Summit program was organized into 4 general sessions, with each session comprising 3 to 5 lectures from domain experts. The sessions were:1.Overview of the obesity problem: epidemiology, etiology, and impact on public health2.How should we treat obesity? Components of a successful program3.Endoscopic treatment of obesity4.The nuts and bolts of reimbursement This white paper summarizes the individual lectures for each session and outlines actionable items or areas of consensus reached by society leadership pertinent to that session. Obesity is a chronic relapsing disease with staggering prevalence worldwide. In the United States, over 37% of the adult population is obese [[1]Flegal K.M. Kruszon-Moran D. Carroll M.D. et al.Trends in obesity among adults in the United States, 2005 to 2014.JAMA. 2016; 315: 2284-2291Crossref PubMed Scopus (2049) Google Scholar]. After decades of growth, there have been some signs of stabilization in the obesity epidemic, which may be attributable to preventive efforts. However, the prevalence of severe obesity (body mass index [BMI] >40) continues to grow (10% in women, 6% in men) [[2]Centers for Disease Control and Prevention NHANES 2013–2014 demographic data.https://wwwn.cdc.gov/nchs/nhanes/search/datapage.aspx?Component=Demographics&CycleBeginYear=2013Date accessed: July 2, 2017Google Scholar]. Additionally, about 50% of obesity in adults began when they were aged between 20 and 39 years [[3]Ogden C.L. Carroll M.D. Fryar C.D. et al.Prevalence of obesity among adults and youth: United States, 2011–2014.NCHS Data Brief. 2015; 219: 1-8PubMed Google Scholar], which may represent an important target for preventive efforts because of a halo effect (the phenomenon of an individual's weight loss efforts positively influencing the weight loss efforts of family and friends). There are substantial ethnic differences in the distribution of obesity. Lower socioeconomic status has a clear impact on rates of obesity in white women but not in other groups [[4]Ogden C.L. Lamb M. Carroll M. et al.Obesity and socioeconomic status in adults: United States, 2005–2008.NCHS Data Brief. 2010; 50: 1-8PubMed Google Scholar]. Obesity has been linked to over 260 medical comorbidities, including cardiovascular disease, diabetes, and cancer [[5]Centers for Disease Control and Prevention Rudd center for food policy and obesity.https://www.cdc.gov/vitalsigns/adultobesity/infographic.htmlDate accessed: July 1, 2017Google Scholar]. Medical costs associated with obesity have been climbing. In 2008, the total cost of obesity was approximately $147 billion [[6]Finkelstein E. Trogdon J. Cohen J. et al.Annual medical spending attributable to obesity: payer- and service-specific estimates.Health Aff. 2009; 28: w822-w831Crossref PubMed Scopus (1996) Google Scholar]. Rising costs are due mainly to the increasing frequency of multiple comorbidities among adults with obesity [[7]Arterburn D.E. Maciejewski M. Tsevat J. Impact of morbid obesity on medical expenditures in adults.Int J Obes. 2005; 29: 334-339Crossref PubMed Scopus (199) Google Scholar]. Primary prevention is key. Education is paramount. Treatment needs to focus on widespread, scalable strategies. Specific efforts should focus on combating the bias and stigma of obesity that exist in the public, among patients, and even among healthcare providers. Other areas of focus include reducing energy intake (sugary drinks, high-energy dense foods), increasing daily physical activity and decreasing television time, pregnancy care (focusing on before-pregnancy weight, weight gain during pregnancy, diabetes, and smoking), breastfeeding, and sleep. Adverse childhood experiences [[8]Centers for Disease Control and Prevention (CDC) Adverse childhood experiences reported by adults—five states, 2009.MMWR Morb Mortal Wkly Rep. 2010; 59: 1609-1613PubMed Google Scholar] contribute to chronic diseases like obesity and may predict responses to treatment and relapses [9Fellitti V.J. Anda R.F. Nordenberg D. et al.Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) study.Am J Prev Med. 1998; 14: 245-258Abstract Full Text Full Text PDF PubMed Scopus (9786) Google Scholar, 10Lodhia N.A. Rosas U. Moore M. et al.Do adverse childhood experiences affect surgical weight loss outcomes?.J Gastrointest Surg. 2015; 19: 993-998Crossref PubMed Scopus (26) Google Scholar]. Certainly there are genetic contributions to obesity. However, with the exception of certain rare monogenic causes of obesity [[11]Bray G.A. Obesity illustrated.in: An atlas of obesity and weight control. Parthenon Publishing, New York2003: 79Google Scholar], the vast majority of obesity cases have polygenic contributors [[12]Hinney A. Vogel C. Hebebrand J. From monogenic to polygenic obesity: recent advances.Eur Child Adolesc Psychiatry. 2010; 19: 297-310Crossref PubMed Scopus (163) Google Scholar]. A current research focus is epigenetics—the concept of stably heritable phenotypes that result from chromosomal changes without alterations in the DNA sequence. Environmental factors important in the pathogenesis of obesity include increase in portion sizes [[13]Nielsen S.J. Popkin B.M. Patterns and trends in food portion sizes, 1977–1998.JAMA. 2003; 189: 450-453Crossref Scopus (802) Google Scholar], increasing energy intake from selected food items, increased sugar consumption [[14]Powell E. Recent trends in added sugar intake among U.S. children and adults from 1977 to 2010.in: Poster abstract presented at: The Obesity Society Annual Meeting at Obesity Week 2014; November 2–7, 2014; Boston, MA. 2014Google Scholar], television watching [[15]Hu F.B. Lee T.Y. Colditz G.A. et al.Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women.JAMA. 2003; 289: 1785-1791Crossref PubMed Scopus (1340) Google Scholar], and sedentary lifestyle [[16]Ladabaum U. Mannalithara A. Myer P.A. et al.Obesity, abdominal obesity, physical activity, and caloric intake in US adults: 1988 to 2010.Am J Med. 2014; 127: 717-727Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar]. There is a significant biological underpinning to obesity. Adipose tissue is an endocrine organ that secretes leptin to the brain, altering energy expenditure and food intake [[17]Badman M.K. Flier J.S. The gut and energy balance: visceral allies in the obesity wars.Science. 2005; 307: 1909-1914Crossref PubMed Scopus (391) Google Scholar]. Hormones (insulin, leptin, ghrelin, peptide YY, glucagon-like peptide-1) secreted by the stomach, colon, adipose tissue, and small intestine affect the hypothalamus, reward centers in the brain, and higher centers in the central nervous system [[18]Korner J. Leibel R.L. To eat or not to eat—how the gut talks to the brain.N Engl J Med. 2003; 349: 926-928Crossref PubMed Scopus (179) Google Scholar]. New medications target the hormones identified to play a role in the pathogenesis of obesity (e.g., liraglutide, a glucagon-like peptide-1 analogue) [[19]Drucker D.J. Nauck M.A. The incretin system: glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase-4 inhibitors in type 2 diabetes.Lancet. 2006; 368: 1696-1705Abstract Full Text Full Text PDF PubMed Scopus (3061) Google Scholar]. Research in enhanced medication delivery may improve compliance, such as orally absorbable peptides or weekly and/or monthly depot injections. Likewise, new endoscopic therapies for obesity that alter anatomy or place barriers to absorption also alter hormonal mechanisms. Bariatric surgery also beneficially alters hormone levels, which may contribute to decreased body weight. Vulnerable populations are population subgroups that are exposed to a greater “risk of risks” because of social, economic, political, structural, and historical forces, and they thereby are at a disadvantage with respect to their health and healthcare. People who did not graduate from high school have a higher average BMI than college graduates, and similarly, the populations with the lowest income have a higher average BMI than those with the highest income. With regard to interactions between income and sex, one of the common myths is that all or virtually all low-income people are far more likely to be obese. In reality, research studies demonstrate that an increased risk of obesity is more consistent for female adults and children of low-income or low socioeconomic status than for men and boys. However, the interactional relationships among race and/or ethnicity, sex, income level, and obesity are more complex. For example, obesity prevalence is similar among men across income levels, but it is higher among non-Hispanic black and Mexican American men of higher income. Additionally, lower-income women have a higher prevalence of obesity, and the overall trend is similar across race and/or ethnicity but is not significant in Hispanic white women. Therefore, it is not accurate to say that virtually all low-income people are more likely to be obese. Obesity disproportionately impacts patients who have public insurance or are without insurance compared with those with private insurance. There are a host of mechanisms that link social vulnerability to obesity, including government policies, food insecurity, health literacy, sugar-sweetened beverages, and effects that occur at a neighborhood level. One quarter of appropriated funds goes to federal subsidies that finance the production of corn, soybeans, wheat, rice, dairy, and livestock (via subsidies on grains). More than half of all calories consumed by American adults during 2001 to 2006 originated from subsidized food commodities. A large proportion of these foodstuffs are converted into high-fat meat and dairy products, refined grains, high-calorie drinks, and processed foods. Three quarters of appropriated funds go to the Supplemental Nutrition Assistance Program, previously known as food stamps, which are disproportionately used to purchase these subsidized, less-expensive, calorie-dense foods [[20]Siegel K.R. McKeever B. Imperatore G. et al.Association of higher consumption of foods derived from subsidized commodities with adverse cardiometabolic risk among US adults.JAMA Intern Med. 2016; 176: 1124-1132Crossref PubMed Scopus (33) Google Scholar]. Food insecurity refers to the limited or uncertain availability of nutritionally adequate and safe foods or the limited ability to acquire acceptable foods in socially acceptable ways. Food insecurity affects 14% of U.S. adults and 35% to 40% of U.S. families at or below the poverty level. Food insecurity is linked to obesity because it leads to food overconsumption during times of food availability and/or adequacy in order to compensate for times in which food is unavailable or inadequate. Food insecurity leads to consumption of less-expensive, calorie-dense foods at the expense of more costly fresh fruits and vegetables [21Seligman H.K. Schillinger D. Hunger and socioeconomic disparities in chronic disease.N Engl J Med. 2010; 363: 6-9Crossref PubMed Scopus (298) Google Scholar, 22Seligman H.K. Laraia B.A. Kushel M.B. Food insecurity is associated with chronic disease among low-income NHANES participants.J Nutr. 2010; 140: 304-310Crossref PubMed Scopus (939) Google Scholar]. Liquid sugar intake through consumption of inexpensive sodas and fruit juices contributes to obesity because of its high calorie content and possibly by increasing lipogenesis [[23]Malik V.S. Hu F.B. Fructose and cardiometabolic health: what the evidence from sugar-sweetened beverages tells us.J Am Coll Cardiol. 2015; 66: 1615-1624Crossref PubMed Scopus (245) Google Scholar]. One third of the American adult population suffers from limited health literacy. Health illiteracy is more common among minority and low-income subgroups, and it is the strongest predictor of increased consumption of sugar-sweetened beverages [[24]Schillinger D. Grumbach K. Piette J. et al.Association of health literacy with diabetes outcomes.JAMA. 2002; 288: 475-482Crossref PubMed Scopus (1299) Google Scholar]. The neighborhood in which one lives also strongly impacts the risk of obesity. Those who live in economically deprived neighborhoods have higher BMIs, even after adjusting for individual socioeconomic status. Possible mechanisms include decreased exercise because of lack of walkable streets and increased violence, limited access to grocery stores and healthy foods, and peer and/or social networks that model unhealthy diets and lifestyles. Society leadership underscored obesity as a chronic, relapsing disease with a complex web of environmental and biological etiologies. Associated with over 200 comorbidities, obesity is a healthcare crisis. An effective strategy for combating this crisis must be predicated on public health education, preventive efforts, and development and/or implementation of scalable treatments. Within medical specialty societies, there exist pockets of interest in obesity research and treatment that must be identified and linked in a collaborative effort to speak with a more powerful, unified voice. Society leadership expressed enthusiasm in promoting intersociety dialogue, finding a commonality of goals, and uniting efforts to further obesity research through public and professional education. Given the predominance of lower socioeconomic status as a strong risk factor for obesity and given the fact that a majority of obese individuals in the United States are of lower socioeconomic status, new endoscopic and related innovative therapies must be accessible to those who are publicly insured (e.g., Medicaid populations) and of low income. In order to ensure the greatest population benefit to such new therapies, it is vital that reimbursement policies ensure that those who have the greatest need for these therapies are not left behind. Obesity is a patient-centered condition. Before seeking medical consultation, patients often consult self-help books and Internet and/or commercial weight-loss programs and try over-the-counter medications and dietary supplements [[25]Kushner R.F. Weight loss strategies for treatment of obesity.Prog Cardiovasc Dis. 2014; 56: 465-472Crossref PubMed Scopus (152) Google Scholar]. Both patients and providers need to recognize obesity as a chronic relapsing disease [26Price J.H. Desmond S.M. Krol R.A. et al.Family practice physicians' beliefs, attitudes, and practices regarding obesity.Am J Prev Med. 1987; 3: 339-345Abstract Full Text PDF PubMed Google Scholar, 27Hill J.O. Wyatt H. Outpatient management of obesity: a primary care perspective.Obes Res. 2002; 10: 124S-130SCrossref PubMed Scopus (50) Google Scholar]. As such, there needs to be a push by patients and providers alike to seek and provide care and counseling much earlier in the disease course. The U.S. Preventive Services Task Force recommends screening for and management of obesity in adults (B recommendation) [[28]Moyer V.A. U.S. Preventive Services Task Force Screening for and management of obesity in adults: U.S. Preventive Services Task Force recommendation statement.Ann Intern Med. 2012; 157 (378–8)Google Scholar] as well as behavioral counseling for obesity (B recommendation) [[29]Lefevre M.L. U.S. Preventive Services Task Force Behavioral counseling to promote a healthful diet and physical activity for cardiovascular disease prevention in adults with cardiovascular risk factors: U.S. Preventive Services Task Force Recommendation Statement.Ann Intern Med. 2014; 161: 587-593Crossref PubMed Scopus (206) Google Scholar]. Multiple society guidelines provide a framework for learning about and treating obesity (American Association of Clinical Endocrinologists/American College of Endocrinology obesity guidelines 2016 [[30]Garvey W.T. Mechanick J.I. Brett E.M. et al.American Association of Clinical Endocrinologists and American College of Endocrinology Comprehensive clinical practice guidelines for medical care of patients with obesity: executive summary.Endocr Pract. 2016; 22: 842-884Crossref PubMed Scopus (106) Google Scholar], metabolic surgery guidelines 2016 [[31]Rubino F. Nathan D.M. Eckel R.H. et al.Metabolic surgery in the treatment algorithm for Type 2 diabetes: a joint statement by International Diabetes Organizations.Diabetes Care. 2016; 39: 861-877Crossref PubMed Scopus (556) Google Scholar], American College of Cardiology/American Heart Association/The Obesity Society obesity guidelines 2014 [[32]Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Crossref PubMed Scopus (1408) Google Scholar] ENDO Pharma Management 2015) [[33]Apovian C.M. Arrone L.J. Bessesen D.H. et al.Pharmacological management of obesity: an Endocrine Society clinical practice guideline.J Clin Endocrinol Metab. 2015; 100: 342-362Crossref PubMed Scopus (686) Google Scholar]. The current medical model for obesity management (BMI >25) includes [[34]National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdfDate accessed: February 21, 2014Google Scholar] (1) lifestyle modification (physical activity, diet, and behavioral changes) as a foundational treatment, (2) anti-obesity medications (BMI >27 with comorbidities or BMI >30), and (3) obesity surgery (BMI >35 with comorbidities or BMI >40) [[1]Flegal K.M. Kruszon-Moran D. Carroll M.D. et al.Trends in obesity among adults in the United States, 2005 to 2014.JAMA. 2016; 315: 2284-2291Crossref PubMed Scopus (2049) Google Scholar]. To be successful, any treatment for obesity (including medications, EBMTs, and surgery) should be built upon a firm foundation of lifestyle modifications. Five medications are U.S. Food and Drug Administration (FDA)–approved for obesity [[35]U.S. Food and Drug Administration http://www.accessdata.fda.gov/scripts/cder/drugsatfda/index.cfmDate accessed: April 15, 2016Google Scholar]: orlistat, lorcaserin (Belviq), phentermine/topiramate ER (Qsymia), naltrexone/bupropion SR (Contrave), and liraglutide (Saxenda). The rationale for medications is to help patients adhere to a lower-calorie diet more consistently to achieve sufficient weight loss and health improvements in combination with increased physical activity [[32]Jensen M.D. Ryan D.H. Apovian C.M. et al.2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the Obesity Society.J Am Coll Cardiol. 2014; 63: 2985-3023Crossref PubMed Scopus (1408) Google Scholar]. Medications may or may not be covered by insurance. Studies of medications for obesity have generally demonstrated weight loss of 5% to 12% of initial weight [[34]National Heart, Lung, and Blood Institute http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdfDate accessed: February 21, 2014Google Scholar]. Behavior modification provides patients with the tools to promote self-regulation, stress management, and habit modification to fight back against a toxic food environment. Behavior modification supports positive changes in diet and exercise through self-monitoring. Extensive contact with an interventionist familiar with weight management is crucial (at least 14 times over a 6-month period for initiation and at least monthly for maintenance) [[36]Wadden T.A. Webb V.L. Moran C.H. et al.Lifestyle modification for obesity: new developments in diet, physical activity, and behavior therapy.Circulation. 2012; 125: 1157-1170Crossref PubMed Scopus (380) Google Scholar]. Intensive behavioral weight management interventions have demonstrated strong efficacy for weight-loss initiation but a more modest impact on maintenance of weight loss [37Look AHEAD Research Group Cardiovascular effects of intensive lifestyle intervention in type 2 diabetes.N Engl J Med. 2013; 369: 145-154Crossref PubMed Scopus (1856) Google Scholar, 38Dombrowski S.U. Knittle K. Avenell A. et al.Long term maintenance of weight loss with non-surgical interventions in obese adults: systematic review and meta-analyses of randomized controlled trials.BMJ. 2014; 348: g2646Crossref PubMed Scopus (480) Google Scholar]. Self-monitoring of adherence to dietary intake restrictions is one of the most important behavioral factors for weight-loss initiation. It appears that increased moderate vigorous physical activity is required for successful weight-loss maintenance. The need for multiple sessions represents a major barrier for behavioral modification, although remote interventionist contact seems to be effective (Power trial). Newer technologies that include mobile apps for real-time decision support, self-monitoring, and remote coaching may expand the reach of behavioral interventions. Although technology is evolving rapidly, the underlying principles to promote behavioral modification remain unchanged. It is hoped that new research will lead to more efficient delivery of behavioral interventions and promote the adoption of a stepped-care algorithm when behavioral interventions are ineffective. Type 2 diabetes is closely linked to obesity. Approximately 80% to 85% of patients with Type 2 diabetes are obese. It is now recognized that a comprehensive lifestyle intervention program that is designed to promote long-term weight loss, like the Why WAIT program (Weight Achievement and Intensive Treatment) at the Joslin Diabetes Center, not only prevents or improves Type 2 diabetes but may reverse it [[39]Hamdy O. Carver C. The Why WAIT program: improving clinical outcomes through weight management in type 2 diabetes.Curr Diab Rep. 2008; 8: 413-420Crossref PubMed Scopus (56) Google Scholar]. Proper lifestyle-management programs can achieve long-term weight loss in many patients with diabetes without the need for surgery. The important components of such a program include structured nutrition therapy, an adequate variety of physical activity that maintains lean muscle mass, cognitive behavioral support, and group intervention and education. It also includes adjustment of diabetes medications to enhance weight reduction and prevent weight regain. Most recent data showed that the Why WAIT program results in maintenance of weight loss of 6.4% at 5 years with significant improvement in many cardiovascular risk factors [[40]Hamdy O. Mottalib A. Morsi A. et al.Long-term effect of intensive lifestyle intervention on cardiovascular risk factors in patients with diabetes in real-world clinical practice: a 5-year longitudinal study.BMJ Open Diabetes Res Care. 2017; 5e000259Crossref PubMed Scopus (65) Google Scholar]. Well-designed lifestyle-management programs can be a cost-effective intervention for the prevention and treatment of diabetes, as it reduces total healthcare costs by 27% and diabetes-related costs by 44% per year. Bariatric surgery has been shown, in multiple studies, to lead to significant and durable weight loss [[41]Sjostrom L. Lindroos A.K. Peltonen M. et al.Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery.N Engl J Med. 2004; 351: 2683-2693Crossref PubMed Scopus (3280) Google Scholar]. Currently, it is indicated for patients with a BMI >35 who have comorbidities or patients with a BMI >40. The most commonly performed bariatric surgeries worldwide are vertical sleeve gastrectomy and Roux-en-Y gastric bypass. The adjustable gastric band and biliopancreatic diversion are less frequently performed in the United States [[42]Angrisani L. Santonicola A. Iovino P. et al.Bariatric surgery worldwide 2013.Obes Surg. 2015; 25: 1822-1832Crossref PubMed Scopus (1070) Google Scholar]. The laparoscopic approach for these surgeries now is considered the standard of care. Sleeve gastrectomy, the most commonly performed bariatric surgery, results in as much as 70% excess weight loss (EWL) at weight nadir and long-term weight loss of 50% EWL [[43]Diamantis T. Apostolou K.G. Alexandrou A. et al.Review of long-term weight loss results after laparoscopic sleeve gastrectomy.Surg Obes Relat Dis. 2014; 10: 177-183Abstract Full Text Full Text PDF PubMed Scopus (156) Google Scholar]. Vertical sleeve gastrectomy produces effective and sustained weight loss that is comparable with that seen after Roux-en-Y gastric bypass. The morbidity and mortality of bariatric surgery have improved significantly, with 30-day mortality rates of 0.1% for vertical sleeve gastrectomy and 0.15% for Roux-en-Y gastric bypass [[44]Young M.T. Gebhart A. Phelan M.J. et al.Use and outcomes of laparoscopic sleeve gastrectomy vs laparoscopic gastric bypass: analysis of the American College of Surgeons NSQIP.J Am Coll Surg. 2015; 220: 880-885Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar]. Rates of adverse events now approximate those of gallbladder surgery, and nutritional deficiencies can be corrected with proper monitoring. Notwithstanding its demonstrated efficacy and relative safety, only 1% to 2% of the eligible population with obesity undergo bariatric surgery. More recently, the goal of bariatric surgery has shifted from a primary focus on weight loss to improvement of metabolic comorbidities. In obese diabetics, bariatric surgery has been shown to be superior to intensive medical therapy for improving glycemic control, reducing cardiovascular risk, and reducing utilization of pharmacotherapy [[45]Schauer P.R. Bhatt D.L. Kirwan J.P. et al.Bariatric surgery versus intensive medical therapy for diabetes—3 year outcomes.N Engl J Med. 2014; 370: 2002-2013Crossref PubMed Scopus (1155) Google Scholar]. Because of its demonstrated efficacy, revised indications for bariatric surgery soon may include the treatment of patients who have Type II diabetes with Class 1 obesity (BMI 30–34.9)—or for Asian diabetics, an even lower BMI threshold [[46]National Institute for Health and Care Excellence Obesity: identification, assessment and management of overweight and obesity in children, young people and adults: partial update of CG43. National Clinical Guideline Centre, 2014Google Scholar]. Gastric banding, sleeve gastrectomy, and gastric bypass have been shown in randomized, controlled trials to be safe and effective treatment for patients with BMIs of 30 to 35 in the short and medium term [47Cohen R. Pinheiro J.C. Schiavon C.A. et al.Effects of gastric bypass surgery in patients with type 2 diabetes and only mild obesity.Diabetes Care. 2012; 35: 1420-1428Crossref PubMed Scopus (221) Google Scholar, 48Dixon J.B. O'Brien P.E. Playfair J. et al.Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial.JAMA. 2008; 299: 316-323Crossref PubMed Scopus (1163) Google Scholar]. The optimal multidisciplinary weight-management program should include an endoscopist who is experienced in bariatric treatments (who may be the bariatric surgeon, depending on expertise), a bariatric surgeon, an endocrinologist and/or obesity medicine physician, a registered dietitian, an exercise specialist, a behavior coach, a psychologist, and a nurse or physician extender. A variety of practitioners can perform behavior coaching provided that they have training in behavior coaching for weight loss. Collaboration among different obesity management specialists is crucial for optimal patient care in obesity, including initial weight loss and weight loss maintenance. The collaboration between the proceduralist and obesity medicine and/or endocrinologist is important for helping with weight-loss maintenance and for informed decisions regarding the escalation of care. Likewise, the collaboration between the surgeon and endoscopist is important and useful for the management of adverse events and the escalation to endoscopic or surgical therapy. Every team member is important for providing adjunctive lifestyle therapy. Obesity care should be optimized within a collaborative program. Specialists in obesity management may consider joining a pre-existing multidisciplinary group or building a virtual center with referrals to other obesity treatment practitioners. Society leadership recognized that there is a pervasive prejudice among the general population and healthcare providers alike that obesity is a lifestyle choice instea