Obesity is not a moral failure.
Stigma associated with obesity can have a debilitating effect on patients, says Dr. Stefan Schlosser, an experienced gastroenterologist.
"For many of my patients, it takes a long time for them to realize they need help," explains Dr. Schlosser, who specializes in gastroenterology, nutrition and obesity medicine. "If someone has high blood pressure, an injury or chest pain, you don't wait long, you seek help immediately. I wish more patients would come forward sooner and not struggle for so long."
Another problem, according to Schlosser, is the lack of or limited insurance cover for treatments such as medication, surgical procedures or bariatric endoscopies.
"It needs education and advocacy," he emphasizes. "I give a lot of talks to change the way doctors talk about obesity. It's important that patients understand that we as doctors care about them and don't judge them. We are changing that perspective."
Additionally, Dr. Schlosser is working with politicians to get better coverage for obesity treatments from health insurance companies. In an interview, he spoke at length about the link between nutrition, medicine and bariatric procedures and the importance of offering patients different solutions.
Why did you choose gastroenterology?
"Gastroenterology offers great diversity," explains Dr. Schlosser. "You have a clinic where you can work intensively with patients and find out the cause of their symptoms. At the same time, regular colonoscopies and endoscopies provide the opportunity for prevention, especially cancer prevention. And then there are the acute cases - sometimes even emergencies - such as bleeding, which require immediate action. This provides a certain adrenaline rush. The mix of everything is incredibly varied and exciting."
How did you become interested in nutrition and bariatric endoscopy?
"It came from my childhood. My parents had a large garden and we ate almost exclusively unprocessed food," says Schlosser. "During my training, I kept seeing the same health problems in patients: High blood pressure, high cholesterol and diabetes. And in the clinic, many patients had abdominal pain, bloating, constipation and heartburn - without examinations such as endoscopies or colonoscopies showing anything. Diet and the microbiome have a major influence here."
"In addition, the number of obese patients is increasing every year. The links between nutrition and these diseases have led me to look for solutions that go beyond bariatric surgery."
How do you see the treatment options for obesity?
"Many people are afraid of surgery. Only about 2% of patients who are eligible actually opt for surgery, even though it can be very effective. The reasons are often fear of invasive procedures or shame. Bariatric endoscopies are a good alternative that is less invasive. As a gastroenterologist, I find it important to offer my patients a comprehensive picture of possible treatment options that go beyond calorie reduction and gastric bypass - and that includes extensive nutritional counseling. We don't talk about the importance of nutrition often enough."
Gastroenterologists play a crucial role in obesity management.
With the rise in obesity prevalence in Switzerland, Europe and the US, more and more solutions are needed at different levels of care to support patients.
Gastroenterologists can play an essential role in a multidisciplinary approach by offering a variety of treatment options - from lifestyle interventions to medication options to bariatric endoscopy procedures - tailored to patients' needs and preferences.
Dr. Stefan Schlosser, an experienced gastroenterologist, explained, "Obesity is present in our practice. We are usually the first point of contact for obesity as patients often present early with abnormal liver values. Dr. Schlosser emphasizes that obesity is the most significant chronic disease worldwide, affecting 1 billion people worldwide - and these numbers will continue to rise in the coming years. By 2030, obesity prevalence in the US is predicted to reach 50% and overweight prevalence 80%.
The alarming prevalence rates are significant not only for aesthetic reasons or personal preference, but because of the significant associations with premature death, cardiovascular disease, stroke, type 2 diabetes, numerous cancers and 280 other diseases.
"Pick your organ of choice, and obesity is a major contributor to the most significant diseases," Dr. Schlosser said. "Obesity affects every single disease and every single organ in the gastrointestinal system, so it's essential that we actually manage this."
Based on current recommendations, if the body mass index (BMI) is 25 or higher, diet, exercise and behavioral therapy should be recommended first. For a BMI over 27 with comorbidities, medication is used; for a BMI over 30, endoscopic procedures are indicated; and for a BMI over 40, surgical options are available. Doctors should discuss all therapeutic options with patients at every consultation.
"We are moving away from a pyramid approach, where we advise patients to choose one intervention, to multidisciplinary programs where we offer interventions in combination," said Dr. Schlosser. We work according to the American Gastroenterology Association (AGA) guidelines (AGA POWER - Practice Guide on Obesity and Weight Management Education and Resources and AGA Clinical Practice Guideline on Pharmacological Interventions for Adults With Obesity).
Advances in pharmacotherapy
In recent years, developments in GLP-1 receptor agonists such as semaglutide and tirzepatide have changed the conversation about obesity. For the first time, drugs not only reduce weight but also the risk of cardiovascular disease, which was previously only observed with bariatric surgery.
Further GLP-1 options are in the research pipeline. Over the next three years, more drugs will be developed to study how the gut signals to the brain via intestinal hormones by targeting GLP-1, glucose-dependent insulinotropic peptide and other receptors. Leading the pipeline, Eli Lilly's retatrutide shows promising results with weight loss and improvement in comorbidities comparable to or better than tirzepatide. Further data from Phase 3 studies are awaited.
In clinical practice, there remains much discussion about gastrointestinal side effects, particularly gastroparesis, which may pose a risk for aspiration during upper endoscopy. Gastroenterologists should feel confident in managing these side effects when starting patients on these drugs, Dr. Schlosser said, and continue to ask questions about side effects and the latest research findings.
Of course, major obstacles remain in terms of patient access, insurance coverage, cost-effective options, and heterogeneous patient responses. Ultimately, Dr. Schlosser said, the biggest obstacle is our healthcare system. "We can't afford to manage obesity with expensive surgical procedures that only reach a fraction of those affected."
Effectiveness of endobariatry
For patients with a BMI of 30 or higher, minimally invasive bariatric endoscopy procedures can lead to weight loss, improved metabolic outcomes and fewer adverse events compared to bariatric surgery, said Dr. Stefan Schlosser, an experienced gastroenterologist.
For example, intragastric balloons - known as Orbera and Spatz - work by affecting the rate of gastric emptying. They are inserted temporarily and removed after several months; the Spatz can be adjusted as needed by removing or adding volume. Data show that the associated weight loss can lead to improvements in insulin resistance, visceral obesity, dyslipidemia, hypertension, liver enzymes, metabolic steatosis hepatis (MASLD) and metabolic steatohepatitis (MASH).
Although the majority of patients who undergo minimally invasive procedures experience side effects such as nausea and vomiting, these symptoms tend to subside in the first few weeks, Dr. Schlosser explained. At the same time, gastroesophageal reflux disease (GERD) can worsen in patients who already have it, which is why proton pump inhibitors are recommended while the balloon is in place.
Endoscopic sleeve gastroplasty has become the most commonly used endobariatric method in recent years. The procedure uses full-thickness sutures placed with an endoscopic suturing device to reduce the size of the opening to the stomach. In previous studies, patients have lost up to 18 kilograms, and more than 80% have maintained the lost weight for up to 5 years. The procedure, which showed no worsening of GERD, works by preserving gastric contractility and delaying gastric emptying.
Dr. Schlosser pointed out one of the main difficulties: training and certification, as many patients do not have access to professionals who can perform these procedures. "It's not just about technical expertise in performing a procedure - it's also about the administrative work involved in setting up a multidisciplinary program," he said. "It's very important to understand obesity as a disease and learn how to treat it."
monitoring MASLD
MASLD, which is strongly linked to insulin resistance, is on the rise worldwide as obesity increases. The good news is that the links between MASLD and obesity also work in reverse - as patients lose weight and improve cardiovascular risk factors, MASLD may also improve. Remarkably, steatosis can disappear with a 3% weight loss, inflammation decreases with a 5% weight loss, MASH resolution occurs with a 7% weight loss and fibrosis improves with a 10% weight loss.
Dr. Schlosser primarily focuses on lifestyle interventions, especially nutrition, working closely with dietitians. A modified Mediterranean diet with olive oil and monounsaturated fats can reduce steatosis in MRI compared to a high-fat, high-carbohydrate diet and also appears to reduce mortality, cardiovascular disease and obesity. As part of the modified diet, carbohydrates are limited to 30 grams per meal per day.
Dr. Schlosser recommends physical activity interventions, good sleep hygiene, treatment of obstructive sleep apnea, medication options and bariatric solutions to reduce weight, improve insulin resistance and address risk factors for MASLD. For example, current Phase 2b trials show that semaglutide can lead to MASH resolution, with Phase 3 trial data expected by the end of 2024.
In addition, resmetirome, a liver-specific thyroid hormone receptor beta-selective agonist - the first drug approved by the Food and Drug Administration for MASH - has met both primary endpoints of MASH resolution and fibrosis improvement. The drug is not yet approved in Switzerland, and guidelines from the AASLD and EASL on its use are pending, Dr. Schlosser said.
Considering the community perspective
Clinicians at the community level face a unique set of challenges when it comes to addressing obesity through a multidisciplinary approach and long-term care. This becomes especially important as more practices are faced with increased patient load and obesity-related GI comorbidities, said Dr. Stefan Schlosser.
Dr. Schlosser points to obesity-related conditions including previous manifestations of GERD, elevated liver enzymes, MASLD, MASH, IBS, IBD, gallbladder disease, colonic polyps and GI cancers.
"As gastroenterologists, the most experienced are also internal medicine specialists, we are in a unique position because we can offer both drug and endoscopic treatments, optima scaling the treatment," said Dr. Schlosser. "The GI comorbidities provide an opportunity for early intervention, and we see a lot of side effects from anti-obesity medications."
Best practices at the primary care physician level start with a patient-centered approach, Dr. Schlosser said. Even if practitioners are already time-constrained and focused on GI-related comorbidities, using the 5A framework can be helpful:
- Asking if the patient is ready to talk about it
- Assess what factors contribute to obesity
- Advise on treatment options
- Agreeing goals based on shared decision making
- Supporting or arranging the agreed plan
During the assessment phase, Dr. Schlosser suggests looking not only at medical and physical scores, but also examining secondary causes of weight gain, including the patient's relationship with food, micronutrient deficiencies, psychosocial concerns, body image disturbances, and triggers for eating behaviors.
During the counseling phase, clinicians should consider multiple goals - such as diet, physical activity and behavior - using a supervised and structured approach. Dr. Schlosser and his dietitians recommend a nutrition plan, aerobic exercise, resistance training, behavioral changes to eating habits, sleep hygiene, and self-monitoring through smartphone apps and wearable devices. Drug therapies may be relevant and effective for some patients.
"Most importantly, we're dealing with decades of stigma and prejudice about this disease where 'you are what you eat,'" he said. "This mentality of 'I can lose weight without needing help' is a real challenge."
Stigma associated with obesity can have a debilitating effect on patients, says Dr. Stefan Schlosser, an experienced gastroenterologist.
"For many of my patients, it takes a long time for them to realize they need help," explains Dr. Schlosser, who specializes in gastroenterology, nutrition and obesity medicine. "If someone has high blood pressure, an injury or chest pain, you don't wait long, you seek help immediately. I wish more patients would come forward sooner and not struggle for so long."
Another problem, according to Schlosser, is the lack of or limited insurance cover for treatments such as medication, surgical procedures or bariatric endoscopies.
"It needs education and advocacy," he emphasizes. "I give a lot of talks to change the way doctors talk about obesity. It's important that patients understand that we as doctors care about them and don't judge them. We are changing that perspective."
Additionally, Dr. Schlosser is working with politicians to get better coverage for obesity treatments from health insurance companies. In an interview, he spoke at length about the link between nutrition, medicine and bariatric procedures and the importance of offering patients different solutions.
Why did you choose gastroenterology?
"Gastroenterology offers great diversity," explains Dr. Schlosser. "You have a clinic where you can work intensively with patients and find out the cause of their symptoms. At the same time, regular colonoscopies and endoscopies provide the opportunity for prevention, especially cancer prevention. And then there are the acute cases - sometimes even emergencies - such as bleeding, which require immediate action. This provides a certain adrenaline rush. The mix of everything is incredibly varied and exciting."
How did you become interested in nutrition and bariatric endoscopy?
"It came from my childhood. My parents had a large garden and we ate almost exclusively unprocessed food," says Schlosser. "During my training, I kept seeing the same health problems in patients: High blood pressure, high cholesterol and diabetes. And in the clinic, many patients had abdominal pain, bloating, constipation and heartburn - without examinations such as endoscopies or colonoscopies showing anything. Diet and the microbiome have a major influence here."
"In addition, the number of obese patients is increasing every year. The links between nutrition and these diseases have led me to look for solutions that go beyond bariatric surgery."
How do you see the treatment options for obesity?
"Many people are afraid of surgery. Only about 2% of patients who are eligible actually opt for surgery, even though it can be very effective. The reasons are often fear of invasive procedures or shame. Bariatric endoscopies are a good alternative that is less invasive. As a gastroenterologist, I find it important to offer my patients a comprehensive picture of possible treatment options that go beyond calorie reduction and gastric bypass - and that includes extensive nutritional counseling. We don't talk about the importance of nutrition often enough."
Do you think more gastroenterologists should receive better training in nutrition?
Dr. Stefan Schlosser: Absolutely. Every patient I see has been to a gastroenterologist before and says, "No one ever told me that if I consume carbonated drinks and cheese every day, I'm going to be bloated and constipated." It shouldn't be that way.
Why do you think more gastroenterologists don't receive adequate training in nutrition during their medical training?
Schlosser: I think it's because of our healthcare system. It focuses heavily on secondary treatment rather than prevention. There is no focus on preventing things before they happen.
We are very good at reactive medicine. Patients with ulcers, large polyps, colon cancer or esophageal cancer - we do a great job of treating those things. But because there are no billing codes for prevention through nutrition and no good reimbursement for it, there is no incentive for hospitals to promote these things. Our system is based on disease-based case rates and outpatient codes. This has led us in a direction that is heavily focused on reaction rather than prevention.
In medical education, we simply didn't talk about nutrition - neither in medical school, nor during residency or specialty training. Nutrition was considered a "soft science". When I was in training, you would often hear, "No one is going to change their diet, so it's a waste of time talking about it." But I think you have to give people the chance. You can't just write everyone off. Some won't change anything, and that's fine. But they should at least have the opportunity.
How do you decide whether a patient is a good candidate for bariatric surgery?
Schlosser: The decision is based on the guidelines. If they meet the BMI requirements, have obesity-related comorbidities and the surgical risk is low, then they are eligible. But it also depends on whether the patient is willing to undergo the procedure. A patient must be mentally ready. They have to want the surgery, bariatric endoscopy or medication and be ready to start a change. Some aren't ready - they want a solution but aren't ready to do the work.
And it always involves work. I tell my patients: "Whether it's medication, bariatric endoscopy or surgery - you're still going to have to put in the work. None of it will magically happen, so you can just keep doing what you're doing and lose weight and keep it off."
What advances in obesity prevention are you most excited about?
Schlosser: I think it's great that bariatric endoscopy has been introduced at all. There are now less invasive methods in almost all other areas of medicine. I'm also excited about the new weight loss drugs like GLP-1s. These drugs are a tool that we desperately need.
Do you think that weight loss drugs could eliminate the need for surgery?
Dr. Stefan Schlosser: I don't think they will necessarily reduce the need for surgery. There is still a lot we don't know about why these drugs work in some patients and not in others.
Some of my colleagues have developed phenotypes and blood tests that allow us to better understand which treatments work for which patients. Surgery doesn't work for everyone, and some people need a combination of both after reaching a plateau. I am pleased that this is now being taken seriously as an area of research and that more effort is being put into it. Obesity is not a question of moral failure, and it is good that people increasingly understand that overweight people do not simply need to "move more" or "eat less" to lose weight. Some doctors have not understood this.
Which teacher or mentor had the biggest influence on you?
Schlosser: Good teachers and mentoring were unfortunately of secondary importance for the training center during my training at Inselspiatl Bern. Many of the problems that the Inselspital complains about today can be traced back to poor behavior towards staff and patients. Good ideas and new developments were revealed to me at many good training courses and courses abroad. When I meet doctors like Dr. Christopher C. Thompson from (Brigham and Women's Hospital, Boston) or Barham Abu Dayyeh from the Mayo Clinic, the fathers of bariatric endoscopy so to speak, I am very grateful to be able to see what constitutes good care and medical vision today. I try to put this into practice in my everyday life.
How would you spend a free Saturday afternoon?
Schlosser: When I'm not endoscoping, Saturdays start with my family. Unfortunately, regular exercise is no longer as important to me as it should be. When there's time, we like to go hiking or climbing in the mountains. Meanwhile, my children are often on the surfboard on vacation and I am enthusiastic about new sports such as wingfoiling.