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IFSO Consensus on definitions and clinical practice guidelines (part 1)

In March 2023, the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) organised a Delphi consensus meeting on definitions and clinical practice guidelines with world-renowned adult and paediatric bariatric surgeons, obesity medicine physicians, endoscopists and integrated health professionals including dietitians, psychologists and exercise physicians. The consensus conference was held at the Johnson & Johnson Institute in Norderstedt, Germany, and was supported by Johnson & Johnson by means of an educational. The sessions featured presentations that examined the evidence and results for a range of obesity treatments including diet, lifestyle, exercise, medical treatment, endoscopy and metabolic/bariatric surgery (MBS). The outcomes from the meeting will be published at the IFSO World Congress in Naples, Italy (30 August – 2 September). The following are the brief highlights from the presentations.

The response to anti-obesity treatment for non-responders/suboptimal weight loss

The first presentation by Professor Lee M Kaplan (The Obesity and Metabolism Institute Boston, MA) examined the response to anti-obesity treatment for non -responders/ suboptimal weight loss, including MBS and anti-obesity medications (AOMs). He started by stressing that the magnitude of weight loss is important with clear evidence that the 10-15% weight loss results in improvements in numerous of conditions [type 2 diabetes (T2DM), hypertension, dyslipidaemia, fatty liver disease (NAFLD), obstructive sleep apnoea (OSA), osteoarthritis, stress incontinence, gastroesophageal reflux (GERD), polycystic ovary syndrome (PCOS)].

More recently, weight loss induced by MBS has been shown to reduce cancer incidence and mortality (Aminian A, Wilson R, Al-Kurd A, et al. Association of Bariatric Surgery With Cancer Risk and Mortality in Adults With Obesity. JAMA. 2022;327(24):2423–2433. doi:10.1001/ jama.2022.9009). Nevertheless, it is important to note that weight loss varies widely among patients depending on their obesity treatment pathway – the lowest weight loss is seen with diet/ lifestyle modifications, then AOMs (eg. (Liraglutide 3.0 mg), devices and endoscopic metabolic/bariatric therapies (such as duodenal liner) and unsurprisingly, MBS results in the greatest weight loss.

However, weight loss response after MBS including Roux-en-Y gastric bypass (RYGB) varies among different patients. Initially, it was perceived that mechanical factors (variation in surgical technique) or behavioural factors were thought to underlie this variation. It is now known that genetic factors strongly contribute to the degree of weight loss after RYGB.

To investigate these genetic factors, Hatoum et al (Heritability of the weight loss response to gastric bypass surgery. J. Clin. Endocrinol. Metab. doi:10.1210/ jc.2011-1130) identified 26 first-degree relatives (siblings or parent–child pairs) living apart who had undergone RYGB and compared their weight loss after surgery to that of 20 patients undergoing RYGB who were living together but were genetically unrelated. The researchers observed that weight loss in genetically related pairs was much more similar than in either group of pairs of genetically unrelated patients. Two years later, the same group reported that specific genetic mutations do correlate with weight loss (Hatoum IJ et al., Am J Hum Genet 2013) and underscore the biological nature of the response to RYGB. Kaplan said a combination of these clinical and genetic factors has the potential to predict weight loss success after gastric bypass. For patients who are non-responders/ have suboptimal outcomes after MBS, he added that there are a variety of options (reinvigorate lifestyle treatment, add one or more anti-obesity medications, bariatric endoscopic intervention, revisional/conversion MBS), and each one can be used alone or in combination with others, but each option has different benefit, risk and cost characteristics.

More recently, Kaplan explained, the 3rd generation of AOMs have shown to be truly effective anti-obesity medications (ie. Tirzepatide 10-15 mg and Semaglutide 2.4 mg) as they mimic the action of native GI and CNS peptides, offering average weight loss reduction of 14-24 kgs (Tirzepatide only, Jastreboff AM et al, NEJM 2022). On average, suboptimal initial weight loss (0-20% body weight change) occurs in some 15-20% of patients, with the maximum weight loss occurring approximately 18 months after surgery (Sanchez-Cordero et al., J Clin Med 2023).

For non-responders/suboptimal weight loss, Kaplan suggested there are several options using these new AOMs including pre-operative calorie restriction, pre-operative AOMs stopped at surgery, pre-operative AOMs then bariatric surgery with AOMs continued after surgery.

Recurrent weight gain

Next, Professor Gerhard Prager (Medical University of Vienna, Vienna, Austria) looked at the reporting standards for recurrent weight gain (RWG – formerly “weight recurrence” or “weight regain”) and stated that it was important to remember that all procedures show a certain extent of RWG with time.

A review of the literature in SOARD (Majid et al. The current state of the definition and terminology related to RWG after metabolic surgery: review by the POWER Task Force of the American Society for Metabolic and Bariatric Surgery, SOARD;18;7;2022’957-963) reported that there are a variety of WR definitions. Indeed, RWG can occur after primary MBS with an estimated incidence of 9%–91% depending on the definition. Although, this paper determined that total weight loss (TWL) as the accepted definition and research endpoint for describing the response to therapy (in line with the nonoperative weight loss literature), Prager added that a standard definition for RWG is needed to streamline the discussion.

RWG can be defined as a percentage of maximum weight loss (weight recurrence/maximum weight loss) x 100). For example, if a patient loses 100 kg and regains 30 kg their RWG is 30%, the advantage of defining RWG is this way means it is not so dependent on the patient’s initial (pre-operative) BMI (Grover BT, et al. Defining Weight Loss After Bariatric Surgery: a Call for Standardization. Obes Surg. 2019 Nov;29(11):3493-3499). Furthermore, King et al (Comparison of the Performance of Common Measures of Weight Regain After Bariatric Surgery for Association With Clinical Outcomes. JAMA. 2018 Oct 16;320(15):1560-1569) among a large cohort of adults who underwent RYGB surgery, weight regain quantified as a percentage of maximum weight lost performed better for association with most clinical outcomes than the alternatives examined.

Interestingly, he noted that >20%TWL correlates best with the recurrence of diseases such as hyperlipidaemia (after 10 kg of weight) and hypertension (after 10% of maximum weight lost), but 50-70% of patients will have RWG according to this definition.

“In general, a late post-operative clinical deterioration after metabolic/ bariatric surgery is demonstrated either by an RWG of more than 30% of the initial surgical weight loss or by worsening of an obesity complication that was a significant indication for surgery and that occurs after an initially adequate post-operative clinical response,” he explained, “In general, a suboptimal initial clinical response to metabolic/bariatric surgery is demonstrated either by a total body weight or BMI loss of less than 20% OR by an inadequate improvement in an obesity complication that was a significant indication for surgery.”

He concluded his presentation by citing M. Nedelcu et al (Surgery for Obesity and Related Diseases 12 (2016) 1129–1130: “It is unacceptable that in the bariatric community there is no consistent definition for recurrent weight gain exists. We emphasize the dire need for standardization of definitions for failure post metabolic/bariatric surgery.”

Non-surgical treatment of postoperative recurrent weight gain

There are several variables that contribute to suboptimal postoperative outcomes, explained Dr David Sarwer (College of Public Health Temple University, Philadelphia, PA). RWG after MBS is often attributed to behavioural factors, including dietary intake, loss of control over eating, disordered eating, low physical activity and loss of follow-up. Although success following surgery requires chronic adherence to a rigorous, reduced-calorie diet, many patients exhibit poor dietary compliance and a failure to increase physical activity after surgery. Challenges underscore that postoperative behaviour change is imperative for sustained success.

He stated that postoperative interventions to reverse postoperative RWG emphasising caloric restriction and increased physical activity are the cornerstone of obesity treatment. The literature shows that they typically produce a 5-10% weight loss in a period of six months.

Acceptance-based behavioural treatment (ABT) emphasises engaging in goal-directed behaviours and has been shown to be efficacious for weight loss in persons with obesity who have not undergone bariatric surgery. A small number of studies have investigated the use of ABT in patients who have undergone MBS. While they provided some support for a post-surgical role of ABT, they had significant methodological limitations (including small sample sizes and uncontrolled design), and Sarwer added, there has yet to be a large RCT investigating the efficacy of this approach.

It is well documented that more frequent postoperative follow-up and/or attendance at support groups is associated with greater weight loss. However, only 40% of patients return for their first year’s follow-up visits; support group attendance is low and decreases over time. Following the pandemic, many bariatric programmes have seen the value of telehealth medical appointments in bariatric care, where care can be delivered efficiently and effectively without requiring the time and expense of an in-person appointment. He said that such remote/online delivery of interventions appears to be well-suited to address these issues. Such programmes are particularly desirable, reduced participant burden and are cost effective, and have been shown to result in clinically meaningful weight losses.

“The worldwide growth in rates of clinically severe obesity and utilization of MBS necessitates the development of novel strategies to promote lifelong success” he concluded.

Nutritional considerations after MBS

Dr Violeta Moizé Arcone (Hospital Clinic Barcelona, Barcelona, Spain) then examined the nutritional considerations in the short- and long-term after MBS. She began by stating that risk assessments for medical and nutritional evaluation should be carried out before and after MBS to identify any nutrient deficiencies and subsequently corrected in candidates for surgery.

She recommended:

  • Post-operative vitamin and mineral supplements should be reviewed regularly and adjusted accordingly.

  • A complete multivitamin and mineral supplement (containing thiamine, iron, selenium, zinc and copper) should be taken daily after all bariatric procedures.

  • A low-fat, moderate carbohydrate and high-protein diet, and post-operative protein intake of 1.2-1.5 g/kg/day based on goal body weight (minimum of 60 g protein/day).

For older patients (>65a), sarcopenia may have profound implications for these patients and is associated with physical disability, reduced quality of life and death. Post-surgical changes in lean body mass range from 10%-25% and are often negatively correlated with weight loss. Indeed, such alterations in fat-free mass may impact disability, function and frailty. Therefore, a comprehensive geriatric pre-operative programme should prescribe individual protein intake along with strength training before undergoing MBS and during the follow-up to avoid sarcopenia-derived complications in older patients.

Adolescents should be monitored for dietary adherence and nutritional assessment on a regular basis due to changes in body composition, growth and sexual development after malabsorptive procedures. The evidence shows that this group has a higher prevalence of postsurgery nutritional deficiencies and care should remain with the specialist clinic.

“A specialised interdisciplinary care – including nutritional assessment, obesity medication assessment, psychological assessment and bariatric endoscopic assessment – are the key to achieving optimal long-term weight loss and maintenance goals following MBS,” she concluded.

Physical activity and sedentary behaviour

Dr Dale Bond (Hartford Hospital/ HealthCare, Hartford, CT) examined the importance of physical activity and sedentary behaviour in people living with obesity before and after MBS. He explained that research shows physical activity can confer numerous physical and psychological health benefits in the context of MBS including increased cardiovascular fitness, muscle strength, physical function, body composition, eating regulation, weight loss and energy, and decreased cardiometabolic risk, bone loss, and symptoms of depression.

However, the problem is that most patients engage in too little physical activity and too much sedentary time to attain these benefits. Specifically, patients on average perform low levels of moderate-to-vigorous intensity physical activity (MVPA) and high levels of sedentary time (ST) before MBS, when measured objectively. He further explained that studies show patients on average make only modest changes in MVPA and in ST during the initial year after MBS and that most patients do not make further changes beyond this point. Additionally, research shows that mean MVPA levels of MBS patients often fall below minimum guidelines to improve health (and definitely those for improved weight management).

Therefore, patients need some form of behavioural intervention to modify physical activity and sedentary behaviours, both before and after MBS. The published evidence from the few interventions available suggests that interventions can help patients achieve significant changes in their physical activity and sedentary behaviours. He said that there is a need to integrate some routine physical activity and sedentary behaviour assessment into MBS care and all MBS team members should encourage patients to engage in regular physical activity & limit the time they spend sedentary. Subsequently, there is a need to develop and empirically assess specific physical activity and sedentary behavioural guidelines/prescriptions for the MBS population.

“Therefore, MBS patients need pre- and postoperative interventions to make physical activity changes. However, there have been few interventions to help patients achieve changes in free-living physical activity, either by targeting increases in MVPA or decreases in ST,” he concluded. “Patients need behavioural interventions/support to achieve sustainable increases in physical activity for general health, to optimise short- and long-term MBS outcomes, and physical activity should become a larger component of multidisciplinary MBS pre- and post-operative care."

Prioritising patients for weight management pharmacotherapy

In his presentation, Professor Arya Sharma (University of Alberta, Edmonton, Canada) asked the question, who should be prioritised for obesity pharmacotherapy? He began by stating that there are levels of evidence (1a-5 grades) for nearly all obesity treatments (anti-obesity medications (AOMs), lifestyle interventions, MBS). In addition, with the latest generation of AOMs, there has been a convergence of medical and surgical treatment – ranging from lifestyle to several generations of AOMs to MBS.

He stated that the updated ‘Obesity Pharmacotherapy – Decision Tool (October 2022)’ presents healthcare practitioners (HCP) with a simple guideline when considering prescribing obesity pharmacology including access, goals of therapy (contraindications, patient values and preferences), assessment and alternative medication/s.

In addition, the staging systems can be used as supplementary tools to identify patients at greatest risk, the Edmonton Obesity Staging System (EOSS) is one such tool, designed to allow clinicians to describe the health impact associated with excess weight and determine appropriate clinical management. This tool includes medical risk factors, psychological symptoms and functional limitations.

According to Sharma, the following could qualify an individual for obesity pharmacotherapy:

  • Individuals who meet criteria for MBS but are not suited for, do not have access to, or do not want MBS

  • Individuals who are too heavy/sick for MBS (pre-surgical weight loss)?

  • Individuals who regain weight after MBS

  • Individuals who require weight loss for other procedures (e.g. transplantation)

  • Individuals with poorly controlled comorbidities

  • Individuals with well controlled comorbidities

  • Individuals without comorbidities

  • Individuals post-weight loss at high risk of weight gain recurrence

He concluded by stating that there are three pillars of obesity management that support nutrition and physical activity – psychological intervention, pharmalogical therapy and MBS.

Weight management pharmacotherapy in children and adolescents

Dr Claudia Fox (University of Minnesota, MN) examined the evidence for anti-obesity medications (AOMs) in children and adolescents, and if AOMs are appropriate for long-term treatment of obesity in adolescents ages 12-18 years, whether AOMs can be offered to children ages 6-12 years for the long-term treatment of obesity, and whether adjuvant AOM should be offered to youth who require additional obesity treatment after MBS.

In 2017, the US Preventive Services Task Force (US Preventive Services Task Force. Screening for Obesity in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA. 2017 Jun 20;317(23):2417-2426) recommended that clinicians screen for obesity in children and adolescents 6 years and older and offer or refer them to comprehensive, intensive behavioural interventions to promote improvements in weight status (B recommendation), after noting a clinically significant 0.3 BMIz change between patients who did and did not receive intensive behavioural interventions. However, the dose of lifestyle therapy required to achieve this degree of BMI reduction was 52 hours of contact, which for most families is not feasible.

The outcomes of AOM use for paediatric obesity ≥12 years of age from four RCs and one systematic review of the RCT favours the use of liraglutide, semaglutide, phentermine/ topiramate, orlistat and metformin vs placebo. However, she noted the trials were relatively small compared to those in adults. Nonetheless, liraglutide, semaglutide, phentermine/topiramate and orlistat are approved by the US FDA and liraglutide is approved by the EMA for obesity in youth ≥12 years of age. Currently, there is very limited evidence (one study) to support the use of AOM (metformin) for obesity in youth 6-<12y. Finally, she said there are no data on AOM use post-MBS for the treatment of recurrent weight gain or insufficient weight loss in the paediatric population.

Compared to adults, adolescents with T2DM have hyper responsive beta cells, lower insulin sensitivity and more rapid deterioration of beta cell function. One study reported 50% of adolescents with T2DM treated with metformin ± LMT progressed to exogenous insulin dependence in one year ((TODAY Study Group. N Engl J Med. 2012 Jun 14;366(24):2247-56).

However, she concluded a second study found metformin does not slow beta cell deterioration in adolescents with impaired glucose tolerance or T2DM (RISE Consortium. Impact of Insulin and Metformin Versus Metformin Alone on β-Cell Function in Youth With Impaired Glucose Tolerance or Recently Diagnosed Type 2 Diabetes. Diabetes Care. 2018 Aug;41(8):1717-1725. While some of the same anti-obesity medications treat T2DM in youth, this comorbidity is an indication for MBS in youth.

Long-term use of pharmacotherapy

Dr Josep Vidal (Hospital Clínic Barcelona, Spain) discussed the evidence for the safety and efficacy supporting the long-term use of pharmacotherapy for obesity. He began by outlining that. Based on the time-frame definitions in the bariatric surgery literature, there is a lack of long-term data to determine whether AOMs are safe and efficacious. Thus far, only orlistat (XENDOS study) has reported follow-up data out to four years, liraglutide three years, Phen/Topiramate two years, Naltrexone/Bupropion one year, and more recently, semaglutide and tirzepatide, two years and one year, respectively.

Vidal defined efficacious as achieving WL>15% in at least 50% of patients, which he explained was not achieved by any of the 1st generation of AOMs. Although semaglutide and tirzepatide have achieved this degree of WL at two years and one year, respectively, it is still to be determined if this will be maintained over the long term. Nevertheless, the outcomes from the STEP 1 trial demonstrated the impact on recurrent weight gain when participants stopped taking semaglutide.

To date, orlistat (XENDOS trial), liraglutide (SCALE re-diabetes study) and Phen/Topiramate (SEQUEL trial) reported no major safety concerns, although there was an increased incidence of gallbladder-related events with liraglutide at three years. Two-year outcomes from the STEP 5 trial (semaglutide) showed an improvement of cardiovascular risk factors with no major safety concerns.

He concluded that the data from five RCTs suggest that WL is maintained over time, with efficacy being larger with newer generation drugs, but discontinuation of the drugs is associated with recurrent weight gain. The data also indicates that WL is associated with improvement in cardiovascular risk factors and thus far, the ‘long-term’ use of current AOM’s does not appear to associate major safety concerns. However, more data is needed to confirm if the benefits of AOMs translate into a reduction of major cardiovascular events in the long term (five-years and more).

Personalisation of pharmacotherapy for obesity

According to Professor Alex Miras (Ulster University and Imperial College), whilst still in its infancy, we are now entering a new phase in pharmacotherapy for obesity: personalisation. The personalisation of pharmacotherapy for obesity could improve risk stratification and patient prioritisation, avoid exposure to side effects in non-responders, maximise the effect of the drug, make the drugs more cost-effective and result in better, cheaper and faster clinical trials.

Previous studies have demonstrated that using early response criterion is clinically useful to identify individuals – early responders vs. early non-responders – who achieved clinically meaningful weight loss with liraglutide (Fujioka K et al. Early Weight Loss with Liraglutide 3.0 mg Predicts 1-Year Weight Loss and is Associated with Improvements in Clinical Markers. Obesity. 2016 Nov;24(11):2278- 2288). In addition, tailoring medicines for specific conditions has been proven effective as reported by Carbone EA et al (An open-label trial on the efficacy and tolerability of naltrexone/bupropion SR for treating altered eating behaviours and weight loss in binge eating disorder. Eat Weight Disord. 2021 Apr;26(3):779-788), who noted Naltrexone/Bupropion reduced food cravings and addiction in patients with binge eating disorders.

Liraglutide used in combination with intensive behavioural treatment (IBT) has also been shown to result in greater improvements in hunger, fullness and food preoccupation than those assigned to IBT-alone (Tronieri JS et al. Effects of liraglutide on appetite, food preoccupation, and food liking: results of a randomized controlled trial. Int J Obes (Lond). 2020 Feb;44(2):353-361). Furthermore, the effects of liraglutide on weight loss have been associated with delay in gastric emptying of solids at five weeks, which correlated with weight loss at 16 weeks (Halawi H et al. Effects of liraglutide on weight, satiation, and gastric functions in obesity: a randomised, placebo-controlled pilot trial. Lancet Gastroenterol Hepatol. 2017 Dec;2(12):890-899). This suggests that subsequent gastric emptying may be a biomarker of responsiveness and may help to select individuals for prolonged treatment with drugs such as liraglutide.

Newer drugs, such as semaglutide, have not only shown to be highly effective for weight loss but also reduce food cravings. As reported by Wharton et al (Two-year effect of semaglutide 2.4 mg on control of eating in adults with overweight/obesity: STEP 5. Obesity (Silver Spring). 2023 Mar;31(3):703-715), at 104 weeks scores for a desire to eat salty and spicy food, cravings for dairy and starchy foods, difficulty in resisting cravings, and control of eating were significantly reduced with semaglutide versus placebo (all p<0.05).

Moreover, Gabery et al (Semaglutide lowers body weight in rodents via distributed neural pathways. JCI Insight. 2020 Mar 26;5(6):e133429) have suggested that semaglutide is so effective in lowering body weight by direct interacting with diverse GLP-1 receptors (GLP-1Rs) in the brain and by directly and indirectly affecting the activity of neural pathways involved in food intake, reward and energy expenditure.

According to Miras, a phenotype guided approach to weight loss has also been proven more effective vs non-phenotype-guided treatment group (Acosta A et al. Selection of Antiobesity Medications Based on Phenotypes Enhances Weight Loss: A Pragmatic Trial in an Obesity Clinic. Obesity (Silver Spring). 2021 Apr;29(4):662-671), and the potential of selecting obesity medications based on phenotypes could provide the framework for individualising treatment. However, he cautioned that this field is still in its infancy and phenotyping patients/assessing eating behaviour is challenging, but increasing medication choice will fuel future research in this field.

Setmelanotide for genetic obesity conditions

Next, Dr Caroline Apovian (Brigham and Women’s Hospital, Harvard Medical School) discussed rare genetic obesity conditions and outcomes for treating these conditions with setmelanotide. She began by stating there are three rare genetic conditions affect hunger, satiation and metabolism, namely, Proopiomelanocortin (POMC) deficiency, proprotein subtilisin/kexin type 1 (PCSK1) deficiency and leptin receptor (LEPR) deficiency.

People with obesity due to POMC, PCSK1 or LEPR deficiency are usually at normal weight at birth but gain excess weight and develop severe obesity at a young age because of a genetic defect that affects their level of hunger, ability to feel full or satiated and metabolism. The defect concerns the hypothalamic MC4R pathway. As MC4R are critical mediators of appetite, energy expenditure and body weight, in patients with POMC, PCSK1, LEPR, appetite and body weight increases, whilst energy expenditure decreases. These conditions are like syndromic obesities, such as Bardet Biedl Syndrome (BBS) and Alstrom Syndrome.

She then reported on the positive outcomes of setmelanotide (Imcivree) that demonstrated >10% weight loss in 80% of patients with POMC or PCSK1 at one year. Moreover, 45.5% of patients with LEPR achieved 10% weight loss at one year. Haqq et al (Lancet Diabetes Endocrinol. 2022 Dec;10(12):859-868), reported 32.3% (p=0·0006) of patients aged 12 years or older with BBS reached at least a 10% reduction in body weight after 52 weeks of setmelanotide. The most commonly reported treatmentemergent adverse events were skin hyperpigmentation (23 [61%] of 38) and injection site erythema (18 [48%]).

“While POMC, PCSK1 or LEPR deficiencies may occur only rarely, these conditions present enormous challenges for health care providers, parents, and patients. Thus, the primary users of setmelanotide are likely to be clinics where children with severe obesity are referred for evaluation,” she concluded. “Newer trials are showing meaningful weight loss at one year, including with BBS patients.”

Adjuvant pharmacotherapy pre- and post-MBS

Next, Professor Rachel Batterham (University College London) discussed the role of AOMs before and after MBS. She stated that AOMs can be used prior to surgery but that the timing needs to be aligned with the operation date as once discontinued people will regain weight. The next generation of GLP-1R (semaglutide) and GLP-1R/GIPR agonist (tirzepatide) have been shown to engender double-digit weight loss as an adjunct to a lifestyle intervention (Wilding J et al NEJM 2021 and Jastreboff NEJM 2022, respectively).

Previous studies have shown that topiramate (Zilber-Stein 2004), and phentermine (Schwartz 2016, Ard 2019 and Hanipah 2017) can improve post-surgical weight loss. In addition, observational studies by Suliman, Wharton (both 2019) and Lautenbach (2022) have all demonstrated liraglutide and semaglutide also aid post-surgical weight loss.

The GRAVITIS trial, which assessed adjunctive liraglutide treatment in patients with persistent or recurrent T2DM after metabolic surgery (Miras AD et al. Lancet Diabetes Endocrinol2019; 549-559) reported a significant change in HbA1c and weight loss in liraglutide patients, compared to placebo. In addition, the current BARI-STEP trial is investigating whether, and the extent to which, 68 weeks of subcutaneous semaglutide 2.4 mg/ml vs. placebo causes greater percentage weight loss in patients with poor weight loss following gastric bypass or sleeve gastrectomy.

She presented data from the BARIOPTIMISE trial, the first RCT to assess AOMs (in this case liraglutide 3 mg) on weight loss. People with <20% weight loss who were more than one year post-MBS were randomised to placebo or liraglutide 3 mg, both as an adjuvant to a lifestyle intervention for 24 weeks. The mean difference in percentage body weight change for liraglutide, 3.0 mg, vs placebo was -8.03 (95% CI, -10.39 to -5.66; P < .001). This trial has now been published Mok J et al JAMA Surgery, e232930. Advanced online publication. https:// In addition, Prof Batterham mentioned BARI-STEP RCT, which is investigating the efficacy of semaglutide 2.4 mg compared to placebo on percentage weight loss, in people with poor weight loss after sleeve gastrectomy or gastric bypass ( ct2/show/NCT05073835).

“The efficacy and safety of AOMs is similar in adults following MBS, compared to adults with obesity who have not undergone MBS,” she concluded. “New AOMs (semaglutide 2.4 mg and tirzepatide 10 mg/15 mg) are anticipated to offer similar weight loss and health benefits in people after MBS.”


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