An Approach to Obesity Management for Gastroenterologists and Hepatologists

  • Jessica BriscoeEmail author
  • Monica Saumoy
  • Octavia Pickett-Blakely
Obesity and Nutrition (O Pickett-Blakely, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Obesity and Nutrition


Purpose of Review

Obesity is associated with multiple gastrointestinal and liver diseases such as gastroesophageal reflux disease, Barrett’s esophagus, esophageal adenocarcinoma, cholelithiasis, colon polyps, and fatty liver disease. To effectively manage obesity, it is imperative to understand current and emerging therapies and procedures.


Obesity is becoming increasingly prevalent and is associated with a growing monetary health care burden. Cardiac disease, cerebrovascular disease, and diabetes are among the leading causes of preventable and premature death of Americans related to obesity. In addition to behavioral modification (diet and exercise) and bariatric surgery, multiple pharmacotherapies and endoscopic procedures are newly approved and available for the management of obesity.


This paper reviews the current literature on the treatments available for the management of obesity including behavior modification, pharmacotherapy, endoscopic weight loss procedures (endobariatrics), and bariatric surgery.


Obesity Diet Pharmacotherapy Endobariatrics Bariatric surgery 


Compliance with Ethical Standards

Conflict of Interest

Jessica Briscoe declares that she has no conflict of interest. Monica Saumoy declares that she has no conflict of interest. Octavia Pickett-Blakely declares that she has no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

References and Recommended Reading

Papers of particular interest, published recently, have been highlighted as:• Of importance

  1. 1.
  2. 2.
    Hales CM, Fryar CD, Carroll MD, Freedman DS, Ogden CL. Trends in obesity and severe obesity prevalence in US youth and adults by sex and age, 2007-2008 to 2015-2016. JAMA. 2018;319(16):1723–5. Scholar
  3. 3.
    Adult Obesity Facts | Overweight & obesity | CDC. Published January 31, 2019. Accessed February 25, 2019.
  4. 4.
    2013 AHA/ACC/TOS Guideline for the management of overweight and obesity in adults. :37.Google Scholar
  5. 5.
    Chalasani N, Younossi Z, Lavine JE, et al. The diagnosis and management of non-alcoholic fatty liver disease: Practice Guideline by the American Association for the Study of Liver Diseases, American College of Gastroenterology, and the American Gastroenterological Association. Hepatology. 2012;55(6):2005–23. Scholar
  6. 6.
    Sullivan S, Kumar N, Edmundowicz SA, et al. ASGE position statement on endoscopic bariatric therapies in clinical practice. Gastrointest Endosc. 2015;82(5):767–72. Scholar
  7. 7.
    • Acosta A, Streett S, Kroh MD, et al. White Paper AGA: POWER — Practice guide on obesity and weight management, education, and resources. Clin Gastroenterol Hepatol. 2017;15(5):631–649.e10. This study provides a comprehensive weight management guide for physicians.CrossRefGoogle Scholar
  8. 8.
    Negro F, Clément S. Impact of obesity, steatosis and insulin resistance on progression and response to therapy of hepatitis C. J Viral Hepat. 2009;16(10):681–8. Scholar
  9. 9.
    Frezza EE, Wachtel MS, Chiriva-Internati M. Influence of obesity on the risk of developing colon cancer. Gut. 2006;55(2):285–91. Scholar
  10. 10.
    Low AK, Bouldin MJ, Sumrall CD, Loustalot FV, Land KK. A Clinician’s Approach to medical management of obesity. Am J Med Sci. 2006;331(4):175–82. Scholar
  11. 11.
    Sacks FM, Bray GA, Carey VJ, et al. Comparison of weight-loss diets with different compositions of fat, protein, and carbohydrates. N Engl J Med. 2009;360(9):859–73. Scholar
  12. 12.
    Dansinger ML, Gleason JA, Griffith JL, Selker HP, Schaefer EJ. Comparison of the Atkins, Ornish, Weight Watchers, and Zone Diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005;293(1):43–53. Scholar
  13. 13.
    Zone diet: what to know | US News Best Diets. Accessed March 17, 2019.
  14. 14.
    Gudzune KA, Doshi RS, Mehta AK, et al. Efficacy of commercial weight loss programs: an updated systematic review. Ann Intern Med. 2015;162(7):501–12. Scholar
  15. 15.
    Dashti HM, Al-Zaid NS, Mathew TC, et al. Long term effects of Ketogenic diet in obese subjects with high cholesterol level. Mol Cell Biochem. 2006;286(1-2):1–9. Scholar
  16. 16.
    Bueno NB, Melo ISV. de, Oliveira SL de, Ataide T da R. Very-low-carbohydrate ketogenic diet v. low-fat diet for long-term weight loss: a meta-analysis of randomised controlled trials. Br J Nutr. 2013;110(7):1178–87. Scholar
  17. 17.
    Westman EC, Yancy WS, Mavropoulos JC, Marquart M, McDuffie JR. The effect of a low-carbohydrate, ketogenic diet versus a low-glycemic index diet on glycemic control in type 2 diabetes mellitus. Nutr Metab. 2008;5(1):36. Scholar
  18. 18.
    Gasior M, Rogawski MA, Hartman AL. Neuroprotective and disease-modifying effects of the ketogenic diet. Behav Pharmacol. 2006;17(5-6):431–9.CrossRefGoogle Scholar
  19. 19.
    Moreno B, Bellido D, Sajoux I, et al. Comparison of a very low-calorie-ketogenic diet with a standard low-calorie diet in the treatment of obesity. Endocrine. 2014;47(3):793–805. Scholar
  20. 20.
    Wheless JW. The Ketogenic diet: an effective medical therapy with side effects. J Child Neurol. 2001;16(9):633–5. Scholar
  21. 21.
    Wing RR, Vazquez JA, Ryan CM. Cognitive effects of ketogenic weight-reducing diets. Int J Obes Relat Metab Disord J Int Assoc Study Obes. 1995;19(11):811–6.Google Scholar
  22. 22.
    Ballaban-Gil K, Callahan C, O’Dell C, Pappo M, Moshé S, Shinnar S. Complications of the Ketogenic diet. Epilepsia. 1998;39(7):744–8. Scholar
  23. 23.
    Frassetto LA, Schloetter M, Mietus-Synder M, Morris RC Jr, Sebastian A. Metabolic and physiologic improvements from consuming a Paleolithic, hunter-gatherer type diet. Eur J Clin Nutr. 2009;63(8):947–55. Scholar
  24. 24.
    Mellberg C, Sandberg S, Ryberg M, et al. Long-term effects of a Palaeolithic-type diet in obese postmenopausal women: a 2-year randomized trial. Eur J Clin Nutr. 2014;68(3):350–7. Scholar
  25. 25.
    Genoni A, Lo J, Lyons-Wall P, Devine A. Compliance, palatability and feasibility of Paleolithic and Australian guide to healthy eating diets in healthy women: a 4-week dietary intervention. Nutrients. 2016;8(8):481. Scholar
  26. 26.
    Longo VD, Panda S. Fasting, circadian rhythms, and time-restricted feeding in healthy lifespan. Cell Metab. 2016;23(6):1048–59. Scholar
  27. 27.
    Patterson RE, Sears DD. Metabolic effects of intermittent fasting. Annu Rev Nutr. 2017;37(1):371–93. Scholar
  28. 28.
    Sutton EF, Beyl R, Early KS, Cefalu WT, Ravussin E, Peterson CM. Early time-restricted feeding improves insulin sensitivity, blood pressure, and oxidative stress even without weight loss in men with prediabetes. Cell Metab. 2018;27(6):1212–1221.e3. Scholar
  29. 29.
    Klempel MC, Kroeger CM, Varady KA. Alternate day fasting (ADF) with a high-fat diet produces similar weight loss and cardio-protection as ADF with a low-fat diet. Metabolism. 2013;62(1):137–43. Scholar
  30. 30.
    Trepanowski JF, Kroeger CM, Barnosky A, et al. Effect of alternate-day fasting on weight loss, weight maintenance, and cardioprotection among metabolically healthy obese adults: a randomized clinical trial. JAMA Intern Med. 2017;177(7):930–8. Scholar
  31. 31.
    American Heart Association recommendations for physical activity in adults and kids. Accessed March 22, 2019.
  32. 32.
    Jakicic JM, Marcus BH, Gallagher KI, Napolitano M, Lang W. Effect of exercise duration and intensity on weight loss in overweight, sedentary women: a randomized trial. JAMA. 2003;290(10):1323–30. Scholar
  33. 33.
    Jeffery RW, Wing RR, Sherwood NE, Tate DF. Physical activity and weight loss: does prescribing higher physical activity goals improve outcome? Am J Clin Nutr. 2003;78(4):684–9. Scholar
  34. 34.
    Current Guidelines - Accessed July 17, 2019.
  35. 35.
    Blumenthal JA, Sherwood A, Gullette ECD, et al. Exercise and weight loss reduce blood pressure in men and women with mild hypertension: effects on cardiovascular, metabolic, and hemodynamic functioning. Arch Intern Med. 2000;160(13):1947–58. Scholar
  36. 36.
    Goodpaster BH, DeLany JP, Otto AD, et al. Effects of diet and physical activity interventions on weight loss and cardiometabolic risk factors in severely obese adults: a randomized trial. JAMA. 2010;304(16):1795–802. Scholar
  37. 37.
    Hashida R, Kawaguchi T, Bekki M, et al. Aerobic vs. resistance exercise in non-alcoholic fatty liver disease: a systematic review. J Hepatol. 2017;66(1):142–52. Scholar
  38. 38.
    Lemes ÍR, Ferreira PH, Linares SN, Machado AF, Pastre CM, Netto J. Resistance training reduces systolic blood pressure in metabolic syndrome: a systematic review and meta-analysis of randomised controlled trials. Br J Sports Med. 2016;50(23):1438–42. Scholar
  39. 39.
    Cauza E, Hanusch-Enserer U, Strasser B, et al. The relative benefits of endurance and strength training on the metabolic factors and muscle function of people with type 2 diabetes mellitus. Arch Phys Med Rehabil. 2005;86(8):1527–33. Scholar
  40. 40.
    Hallsworth K, Fattakhova G, Hollingsworth KG, et al. Resistance exercise reduces liver fat and its mediators in non-alcoholic fatty liver disease independent of weight loss. Gut. 2011;60(9):1278–83. Scholar
  41. 41.
    Willis LH, Slentz CA, Bateman LA, et al. Effects of aerobic and/or resistance training on body mass and fat mass in overweight or obese adults. J Appl Physiol. 2012;113(12):1831–7. Scholar
  42. 42.
    Wycherley TP, Noakes M, Clifton PM, Cleanthous X, Keogh JB, Brinkworth GD. A high-protein diet with resistance exercise training improves weight loss and body composition in overweight and obese patients with type 2 diabetes. Diabetes Care. 2010;33(5):969–76. Scholar
  43. 43.
    Castelnuovo G, Pietrabissa G, Manzoni GM, et al. Cognitive behavioral therapy to aid weight loss in obese patients: current perspectives. Psychol Res Behav Manag. 2017;10:165–73. Scholar
  44. 44.
    Daubenmier J, Moran PJ, Kristeller J, et al. Effects of a mindfulness-based weight loss intervention in adults with obesity: a randomized clinical trial. Obesity. 2016;24(4):794–804. Scholar
  45. 45.
    Katterman SN, Kleinman BM, Hood MM, Nackers LM, Corsica JA. Mindfulness meditation as an intervention for binge eating, emotional eating, and weight loss: a systematic review. Eat Behav. 2014;15(2):197–204. Scholar
  46. 46.
    Kang JG, Park C-Y. Anti-obesity drugs: a review about their effects and safety. Diabetes Metab J. 2012;36(1):13–25. Scholar
  47. 47.
    Keith JN. Pharmacotherapy in treatment of obesity. Gastroenterol Clin North Am. 2016;45(4):663–72. Scholar
  48. 48.
    McMahon FG, Fujioka K, Singh BN, et al. Efficacy and safety of sibutramine in obese White and African American Patients with hypertension: a 1-year, double-blind, placebo-controlled, multicenter trial. Arch Intern Med. 2000;160(14):2185–91. Scholar
  49. 49.
    Yanovski SZ, Yanovski JA. Long-term drug treatment for obesity: a systematic and clinical review. JAMA. 2014;311(1):74–86. Scholar
  50. 50.
    Srivastava G, Apovian C. Future pharmacotherapy for obesity: new anti-obesity drugs on the horizon. Curr Obes Rep. 2018;7(2):147–61. Scholar
  51. 51.
    Gadde KM, Allison DB, Ryan DH, et al. Effects of low-dose, controlled-release, phentermine plus topiramate combination on weight and associated comorbidities in overweight and obese adults (CONQUER): a randomised, placebo-controlled, phase 3 trial. The Lancet. 2011;377(9774):1341–52. Scholar
  52. 52.
    Research C for DE and. FDA Drug Safety Communication: completed safety review of Xenical/Alli (orlistat) and severe liver injury. FDA. 2018. Accessed June 17, 2019.
  53. 53.
    Apovian CM, Aronne L, Rubino D, et al. A randomized, phase 3 trial of naltrexone SR/bupropion SR on weight and obesity-related risk factors (COR-II). Obesity. 2013;21(5):935–43. Scholar
  54. 54.
    Mehta A, Marso SP, Neeland IJ. Liraglutide for weight management: a critical review of the evidence. Obes Sci Pract. 2016;3(1):3–14. Scholar
  55. 55.
    Pi-Sunyer X, Astrup A, Fujioka K, et al. A randomized, controlled trial of 3.0 mg of liraglutide in weight management. N Engl J Med. 2015;373(1):11–22. Scholar
  56. 56.
  57. 57.
    Jirapinyo P, Thompson CC. Training in bariatric and metabolic endoscopic therapies. Clin Endosc. 2018;51(5):430–8. Scholar
  58. 58.
    Abu Dayyeh BK, Kumar N, Edmundowicz SA, et al. ASGE Bariatric Endoscopy Task Force systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting endoscopic bariatric therapies. Gastrointest Endosc. 2015;82(3):425–438.e5. Scholar
  59. 59.
    • Abu Dayyeh BK, Edmundowicz S, Thompson CC. Clinical practice update: expert review on endoscopic bariatric therapies. Gastroenterology. 2017;152(4):716–29. This study provides an expert review of available and emerging endoscopic weight loss therapies. Additionally, the authors provide best practice indications, contraindications, and ways to incorporate these procedures into clinical practice.CrossRefGoogle Scholar
  60. 60.
    Health C for D and R. Health Care Providers (Medical Devices) - The FDA alerts health care providers about potential risks with liquid-filled intragastric balloons. Accessed March 24, 2019.
  61. 61.
    Health C for D and R. UPDATE: potential risks with liquid-filled intragastric balloons - letter to health care providers. FDA. 2018. Accessed June 20, 2019.
  62. 62.
    Sullivan S, Swain JM, Woodman G, et al. 812d The Obalon swallowable 6-month balloon system is more effective than moderate intensity lifestyle therapy alone: results from a 6- month randomized sham controlled trial. Gastroenterology. 2016;150(4):S1267. Scholar
  63. 63.
    Sullivan S. Aspiration therapy for obesity. Gastrointest Endosc Clin N Am. 2017;27(2):277–88. Scholar
  64. 64.
    Thompson CC, Dayyeh BKA, Kushnir V, et al. Aspiration therapy for the treatment of obesity: 4-year results of a multicenter randomized controlled trial. Surg Obes Relat Dis. 2019;0(0). Scholar
  65. 65.
    Thompson CC, Abu Dayyeh BK, Kushner R, et al. Percutaneous gastrostomy device for the treatment of class II and class III obesity: results of a randomized controlled trial. Am J Gastroenterol. 2017;112(3):447–57. Scholar
  66. 66.
    Lopez-Nava G, Sharaiha RZ, Neto MG, et al. 101 endoscopic sleeve gastroplasty for obesity: a multicenter study of 242 patients with 18 months follow-up. Gastroenterology. 2016;150(4):S26. Scholar
  67. 67.
    Hajifathalian K, Ang B, Dawod QM, et al. 175 LONG-TERM FOLLOW UP AND OUTCOMES AFTER ENDOSCOPIC SLEEVE GASTROPLASTY FOR TREATMENT OF OBESITY (5 YEAR DATA). Gastrointest Endosc. 2019;89(6):AB58. Scholar
  68. 68.
    Novikov AA, Afaneh C, Saumoy M, et al. Endoscopic sleeve gastroplasty, laparoscopic sleeve gastrectomy, and laparoscopic band for weight loss: how do they compare? J Gastrointest Surg Off J Soc Surg Aliment Tract. 2018;22(2):267–73. Scholar
  69. 69.
    Fayad L, Cheskin LJ, Adam A, et al. Endoscopic sleeve gastroplasty versus intragastric balloon insertion: efficacy, durability, and safety. Endoscopy. 2019;51(6):532–9. Scholar
  70. 70.
    Gloy VL, Briel M, Bhatt DL, et al. Bariatric surgery versus non-surgical treatment for obesity: a systematic review and meta-analysis of randomised controlled trials. BMJ. 2013;347:f5934. Scholar
  71. 71.
    Celio AC, Pories WJ. A history of bariatric surgery: the maturation of a medical discipline. Surg Clin North Am. 2016;96(4):655–67. Scholar
  72. 72.
    Baker MT. The history and evolution of bariatric surgical procedures. Surg Clin North Am. 2011;91(6):1181–201. Scholar
  73. 73.
    English WJ, DeMaria EJ, Brethauer SA, Mattar SG, Rosenthal RJ, Morton JM. American Society for Metabolic and Bariatric Surgery estimation of metabolic and bariatric procedures performed in the United States in 2016. Surg Obes Relat Dis. 2018;14(3):259–63. Scholar
  74. 74.
    Karra E, Yousseif A, Batterham RL. Mechanisms facilitating weight loss and resolution of type 2 diabetes following bariatric surgery.Trends Endocrinol Metab. 2010;21(6):337-344. Scholar
  75. 75.
    Peterli R, Wölnerhanssen BK, Peters T, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss in patients with morbid obesity. JAMA. 2018;319(3):255–65. Scholar
  76. 76.
    Salminen P, Helmiö M, Ovaska J, et al. Effect of laparoscopic sleeve gastrectomy vs laparoscopic Roux-en-Y gastric bypass on weight loss at 5 years among patients with morbid obesity. JAMA. 2018;319(3):241–54. Scholar
  77. 77.
    Parrott J, Frank L, Rabena R, Craggs-Dino L, Isom KA, Greiman L. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727–41. Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019
corrected publication 2019

Authors and Affiliations

  • Jessica Briscoe
    • 1
    Email author
  • Monica Saumoy
    • 2
  • Octavia Pickett-Blakely
    • 2
  1. 1.Division of Gastroenterology and HepatologyTemple University HospitalPhiladelphiaUSA
  2. 2.Division of Gastroenterology and HepatologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaUSA

Personalised recommendations