This document summarizes a lecture on the medical and endoscopic management of obesity. It discusses why obesity should be treated, noting its high prevalence and costs. The initial approach involves comprehensive assessment and lifestyle modification through diet and exercise. However, lifestyle changes alone are often ineffective long-term. Therefore, there may be a role for pharmacotherapy or endoscopic therapies to promote greater weight loss. The document reviews considerations for obesity drug treatment and barriers related to past drug withdrawals.

1. Edwin
McDonald,
MD
Associate
Director
Adult
Nutri0on
Medical
and
Endoscopic
Management
of
Obesity

2. Disclosures:
I
have
no
rela9onships
to
disclose
I
will
not
discuss
off
label
interven7ons
or
medica7ons
Image
by
bells
design
retrieved
from
h=p://www.gra7sography.com/pictures/299_1.jpg

3. Lecture
Goals
1. Why
should
we
treat
obesity?
2. What’s
the
ini9al
approach
to
trea9ng
obesity?
3. Is
there
a
role
for
pharmacotherapy?
4. Are
endoscopic
therapies
viable
op9ons?
Image:
Goals
by
Florian
Christoph
Retrieved
from
Flickr
crea7ve
commons

4. Why
should
we
treat
obesity?

5. Obesity
is
a
huge
public
health
issue

6. Prevalence
Prevalence
69%
BMI
≥
25
35%
BMI
≥
30
Image:
City
Lights
of
US
2012
Retrieved
from
Flickr
Crea7ve
Commons
Overweight
Obese
(Ogden,
Carroll,
Kit,
&
Flegal,
2014)

7. Obesity is
costly

8.
$147
billion
annually
Image:
Money
by
Andrew
Magil
h=ps://www.flickr.com/photos/amagill/
3367543094
(Finkelstein,
Trogdon,
Cohen,
&
Dietz,
2009)

9. Obesity affects
na9onal
and
local
security

10. 1/3
of
Americans
ages
17–24
are
too
overweight
to
join
the
military
h=p://healthyamericans.org/reports/obesity2011/Obesity2011Report.pdf
Image
h=p://www.thecypriotpuzzle.org/

11. A
third
of
our
firefighters
are
obese
Heart
A3acks
are
the
most
common
cause
of
death
on
the
job
mage:
Wikimedia
Commons
(Tsismenakis
et
al.,
2009)
(Berryman,
Lukes,
Drew-­‐Nord,
Hong,
&
Froelicher,
2009)

12. Image:
Thomas
Lefebrve
Retrieved
from
Unsplash.com
Paved
the
road
to
recent
guidelines
• BMI
>
30
• BMI
25-­‐30
plus
1
obesity
related
comorbidity
2013
AHA/ACC/TOS
Guidelines
(Na7onal
Heart,
Lung,
and
Blood
Ins7tute,
2013)

13. Who
should
we
treat?
YES
–
BMI
>30
or
BMI
25<30
with
addi9onal
risk
factor(s):
Weight
loss
treatment
is
indicated
for
1)
obese
individuals
and
2)
overweight
individuals
with
1
or
more
indicators
of
increased
CVD
risk
(e.g.,
diabetes,
prediabetes,
hypertension,
dyslipidemia,
elevated
waist
circumference)
or
other
obesity
related
comorbidi7es.
140
million
es9mated
candidates
for
weight
loss
treatment
(Na7onal
Heart,
Lung,
and
Blood
Ins7tute,
2013)
Dayyeh
et
al.,
2015)

14. What’s
the
ini9al
approach
for
trea9ng
obesity?

15. It
starts
with
an
assessment
and
lifestyle
modifica9on

16. More
than
just
a
scale
Image:
Bathroom
Scale
By
Magnus
D
Retrieved
from
Flickr
Crea7ve
Commons

17. Diet
Mental Health Behaviors Environment
Family
History
Prior
Attempts
Physical
Activity
Identifying the determinants of weight gain
(Kushner,
2012)

18. Obesity
assessment
Mnemonic
• Mechanical
• Metabolic
• Mental
• Monetary
4M
(Sharma,
2010)
A
Quick
Tool
for
Iden7fying
Complica7ons/
Biopsychosocial
Determinants
of
Obesity

19. Categorize
the
obese
pa9ent
Size
Severity
Edmonton
Obesity
Staging
System
(EOSS)
WHO
classifica7on

20. Lifestyle
modifica9on
is
the
founda9on
of
trea9ng
obesity
Image:
Blue
Metal
Bridge
by
Ghost
Presenter
Retrieved
from
Pexels.com

21.
Mul7disciplinary
Team
Approach
Physician
(endoscopist)
Health
Coach
Dietician
Exercise
Physiologist
Psychiatrist
Social
Worker
Bariatric
Surgeon

22. Even
with
all
of
these
pieces…

23.
Lifestyle
change
alone
is
o_en
ineffec9ve
Image:
Empty
Gym
on
4th
July
Weekend
By
Jeffery
Zeldman
Retrieved
from
Flickr
Crea7ve
Commons

24. Mean
percentage
of
total
weight
loss:
11
studies
of
lifestyle
interven7ons
(n=6,754)
Control
n=2,711
High
CHO
n=320
Low
Fat
n=188
High
MUFA
n=62
6
mo
12
mo
18
mo
2
yr
3
yr
4
yr
0
-­‐2
-­‐4
-­‐6
-­‐8
-­‐10
%
(Franz,
Boucher,
Ru=en-­‐Ramos,
&
VanWormer,
2015)

25. Burning
off
excess
calories
is
hard

26. Energy
Expenditure
(kcal/h)
1200
1000
800
600
400
200
Chewing
gum
Walking
2
mph
All
out
compe77ve
sports
Running
10
mph
Running
6
mph
Climbing
Stairs
Sexual
Intercourse
Gardening
Walking
4
mph
Bicycling
Energy
Expenditure
of
Physical
Ac9vity
Per
Hour
(Russell,
1985)

27. Addi9onal
tools
are
o_en
needed
Image
by
Todd
Quackenbush
Retrieved
from
unsplash.com

28. Evalua7ng
weight
loss
adjuncts
Total
Body
Weight
Loss
%
(TBWL)
Excess
Weight
Loss
%
(EWL)
Weight
Loss
Ini7al
Weight
X
100
Weight
Loss
Ini7al
Weight
–
Ideal
Body
Weight
X
100

29. Is
there
a
role
for
pharmacotherapy
in
managing
obesity?

30. Yes,
but
it’s
complicated

31. Many
physicians
avoid
using
weight
loss
medica9ons

32. Hesita9on
fueled
by
drug
withdrawals
Image:
Gas
Pump
by
Endless
Studio
Retrieved
from
Flickr
Crea7ve
Commons

33. Obesity
drug
withdrawals
since
1996
Dintrophenol
• Hyperthermia
related
deaths
Amphetamines
• Dependency
• Cardiovascular
side
effects
Aminorex
• Pulmonary
HTN
Mazindol
• Valvular
Abnormali7es
Fenfluramine
and
dexfenfluramine
• Pulmonary
HTN
• Valvular
abnormali7es
Sibutramine
• Cardiovascular
Events
Rimonabant
• Cardiovascular
events
• Depression,
Anxiety,
Suicidal
Idea7on
(Kakkar
&
Dahiya,
2015)

34. Should
we
avoid
using
the
currently
FDA
approved
drugs
en9rely?
{Kumar:2015jp}
Image:
Retrieved
from
Wikimedia
Commons

35. Pharmacotherapy
is
indicated
in…
{Apovian:2015kz}
)
BMI
≥
30
No
comorbidi7es
BMI
≥
27
+1
comorbidi7es
2015
Endocrine
Society
Guidelines
+
Image:
Pills
by
Victor
Retrieved
From
Flickr
Crea7ve
Commons
(Apovian
et
al.,
2015)

36. Five
FDA
approved
medica9ons
Orlistat
• 1999
• Lipase
inhibitor
• Fat
malabsorp7on
Lorcaserin
• 2012
• selec7ve
serotonin
2C
receptor
agonist
• Appe7te
reduc7on
Phentermine/
Topiramate
• 2012
• Adrenergic
agonist
• Taste
aversion/appe7te
reduc7on/increased
REE
Bupropion/Naltrexone
• 2014
• Dopaminergic/
noradrenergic
s7mula7on
• Decreases
reward
pathway
Liraglu9de
• 2014
• GLP-­‐1
receptor
agonist
• Decreases
appe7te
{Kumar:2015jp}

37. Siddarth
Singh,
MD
–
UCSD
Compara9ve
Efficacy
and
Tolerability
of
Long-­‐term
Pharmacological
Interven9ons
for
Obesity
A
Systemic
Review
and
Network
Meta-­‐Analysis
DDW
2016

38. Five
FDA
approved
medica9ons
28
trials
29,018
par7cipants
Secondary
Outcomes
≥
5%
weight
loss
≥
10%
weight
loss
Adverse
events
Primary
Outcome
(Khera
et
al.,
2016)

39. Efficacy
-­‐
Tolerability
Trade
Off
Placebo
Orlistat
Lorcaserin
Naltrexone
Bupropion
Liraglu7de
Phenteramine-­‐
Topiramate
0.2
0.6
0.6
1.0
0.8
0.8
0.2
0.4
0.4
0.0
Probability
of
Fewest
Adverse
Events
Probability
of
being
highest
ranked
in
achieving
≥5%
weight
loss
1.0
Least
Side
Effects
Best
Wt
Loss
(Khera
et
al.,
2016)

40. If
you
plan
on
using
these
medica9ons…

41. Know
the
contraindica9ons
Orlistat
Malabsorp7on;
gallbladder
disease
Phentermine/
Topiramate
ER
Glaucoma;
hyperthyroidism;
MAOIs;
pregnancy
Lorcaserin
MAOIs.
Cau7on
with
serotonergic
drugs;
pregnancy
Naltrexone/Bupropion
Seizure
disorder;
uncontrolled
HTN;
opioid
use;
suicidality;
MAOIs;
pregnancy
Liraglu7de
Personal
or
Family
history
of
medullary
thyroid
carcinoma;
MEN;
pregnancy
Data
from
drug
inserts

42. Is
endoscopy
a
viable
op7on
for
trea7ng
obesity?

43. Gastroenterologists
Image:
Yeah
by
Mark
Retrieved
from
Flickr
Crea7ve
Commons

44. Bariatric
surgery
is
the
most
effec9ve
interven9on
Common
license
Image
retrieved
wikimedia.org
50-­‐70%
excess
weight
loss
at
1
year
80-­‐90%
Improvement
in
comorbidi7es
(Buchwald
&
Oien,
2013)
(Buchwald
et
al.,
2009)

45. Only
1%
of
eligible
pa9ents
have
bariatric
surgery
{Mechanick:2013gx}
Image:
wikipedia

46. Obesity
treatment
gap
based
on…
Pharmacologic
Therapy
Bariatric
Surgery
Cost
Safety
Eligibility
Efficacy
Image:
Wikipedia
Commons

47. Endoscopic
bariatric
therapies
(EBT)
promise
to
fill
the
gap
Pharmacologic
Therapy
Bariatric
Surgery
Cost
Safety
Eligibility
Efficacy
Image:
Wikipedia
Commons
Endoscopic
Bariatric
Therapies

48. Endoscopic
Bariatric
Therapy:
Categories
Gastric
Space
Occupying
Aspira7on
Suturing/
Plica7on
Small
Bowel
Sleeves
Magnet
Anastomosis
Mucosal
Resurfacing
(Vargas
&
Dayyeh,
2016)

49. FDA
approved
EBTs
• Intra-­‐Gastric
Ballons
• Endoscopic
Sleeve
Focus:
FDA
approved
therapies
Image
by
Benjamin
Combs
Retrieved
from
Unsplash.com
With
common
license
a=ribu7o

50. Two
FDA
approved
intra-­‐gastric
balloons
ReShape
TM
Orbera
TM
BMI
30-­‐
40
plus
a
comorbidity
BMI
30-­‐
40
Credit:
reshape
medical
Credit:
Apollo
Endosurgery
6
months
Endoscopy
500-­‐750ml
32.1%
EWL
12.2%
TWL
900
ml
(Neylan,
Dempsey,
Tewksbury,
Williams,
&
Dumon,
2016)
27.9%
EWL
7.6%
TWL
(Goyal
&
Watson,
2016)

51. Weight
loss
axer
balloon
removal?

52. OrberaTM
vs
RYGB:
Weight
loss
at
5
yrs
3
2
1
10
20
70
30
40
50
60
61.9
80
%
Excess
Weight
Loss
65.1
69.5
61.1
58.1
39.2
25.1
17.1
Years
Orbera
n=122
RYGB
n=134
5
(Kotzampassi,
Grosomanidis,
Papakostas,
Penna,
&
Elexheriadis,
2012)

53. Orbera
adverse
events
n=8500
70
60
50
40
30
20
10
0
%
33.7
29
18.3
12
7.5
2
1.4
0.3
0.4
0.08
Pooled
rates
of
adverse
events
observed
with
the
Orbera
intra
gastric
balloon
(Dayyeh
et
al.,
2015)

54. ReShape
DuoTM-­‐
ReShape
Medical
Adverse
Events
Credit:
reshape
medical
Complica7ons
similar
to
Orbera
except
10%
ulcera7on
rate
(Goyal
&
Watson,
2016)

55. Apollo
Overs7tch
Image
by
apolloendo

56. Gontrand
Lopez
Nava,
MD
Endoscopic
Sleeve
Gastroplasty
for
Obesity:
A
Mul9center
Study
of
242
Pa9ents
with
18
Months
of
Follow-­‐up
DDW
2016

57. -­‐8
-­‐12
-­‐10
-­‐16
-­‐14
-­‐18
-­‐20
-­‐22
0
8
4
6
2
10
12
14
16
18
%
TBWL
19.8%
+/-­‐
11.6
at
18
mos
Months
Endoscopic
Sleeve
Gastroplasty:
Weight
Loss
at
18
mos
(Lopez-­‐Nava
et
al.,
2016)

58. 2%
had
serious
adverse
events
• PE
• Splenic
lacera7on
• Fluid
collec7on
• Pneumothorax

59. These
are
the
viable
and
available
op9ons,
but…
Pa9ents
pay
out
of
pocket

60. Notable
at
DDW,
awai7ng
FDA
approval

61. The
First
Procedure-­‐less
Gastric
Balloon
For
Weight
Loss
Ram
Chu=ani
Image:
Courtesy
of
Allurion
ElipseTM
(Chu=ani
et
al.,
2016)

62. Gelesis
Hydrogel
Capsules
Image
courtesy
of
gelesis

63. Image
courtesy
of
gelesis

64. AspireAssistTM
Connector
Companion
Reservoir
System
stores
away
in
compact
Carry
Bag
BMI:
35-­‐55
kg/m2
Pilot
Study:
49.0%
EWL
at
1
yr
(Sullivan,
Stein,
Jonnalagadda,
Mullady,
&
Edmundowicz,
2013)
Images:
Aspire
Bariatrics

66. Summary
1. Why
should
we
treat
obesity?
2. What’s
the
ini7al
approach
for
trea7ng
obesity?
3. Is
there
a
role
for
pharmacotherapy?
4. Are
endoscopic
bariatric
therapies
viable
op7ons?

67. All
images
in
the
presenta7on
were
obtained
via
common
license
use

68. • Apovian,
C.
M.,
Aronne,
L.
J.,
Bessesen,
D.
H.,
McDonnell,
M.
E.,
Murad,
M.
H.,
Pago=o,
U.,
et
al.
(2015).
Pharmacological
Management
of
Obesity:
An
Endocrine
Society
Clinical
Prac7ce
Guideline.
The
Journal
of
Clinical
Endocrinology
&
Metabolism,
100(2),
342–362.
h=p://doi.org/10.1210/jc.2014-­‐3415
• Berryman,
P.,
Lukes,
E.,
Drew-­‐Nord,
D.
C.,
Hong,
O.,
&
Froelicher,
E.
S.
(2009).
Cardiovascular
Risk
Factors
Among
Career
Firefighters.
AAOHN
Journal,
57(10),
415–422.
h=p://doi.org/10.3928/08910162-­‐20090916-­‐02
• Buchwald,
H.,
&
Oien,
D.
M.
(2013).
Metabolic/Bariatric
Surgery
Worldwide
2011.
Obesity
Surgery,
23(4),
427–436.
h=p://doi.org/10.1007/s11695-­‐012-­‐0864-­‐0
• Buchwald,
H.,
Estok,
R.,
Fahrbach,
K.,
Banel,
D.,
Jensen,
M.
D.,
Pories,
W.
J.,
et
al.
(2009).
Weight
and
Type
2
Diabetes
axer
Bariatric
Surgery:
Systema7c
Review
and
Meta-­‐analysis.
The
American
Journal
of
Medicine,
122(3),
248–256.e5.
h=p://doi.org/10.1016/j.amjmed.2008.09.041
• Chu=ani,
R.,
Machytka,
E.,
Raxopoulos,
I.,
Bojkova,
M.,
Kupka,
T.,
Buzga,
M.,
et
al.
(2016).
102
The
First
Procedureless
Gastric
Balloon
for
Weight
Loss:
Final
Results
From
a
Mul7-­‐Center,
Prospec7ve
Study
Evalua7ng
Safety,
Efficacy,
Metabolic
Parameters,
Quality
of
Life,
and
6-­‐Month
Follow-­‐Up.
Gastroenterology,
150(4),
S26.
h=p://doi.org/10.1016/
S0016-­‐5085(16)30213-­‐X
• Dayyeh,
B.
K.
A.,
Edmundowicz,
S.
A.,
Jonnalagadda,
S.,
Kumar,
N.,
Larsen,
M.,
Sullivan,
S.,
et
al.
(2015).
Endoscopic
bariatric
therapies.
Gastrointes0nal
Endoscopy,
81(5),
1073–1086.
h=p://doi.org/10.1016/j.gie.2015.02.023
• Finkelstein,
E.
A.,
Trogdon,
J.
G.,
Cohen,
J.
W.,
&
Dietz,
W.
(2009).
Annual
Medical
Spending
A=ributable
To
Obesity:
Payer-­‐And
Service-­‐Specific
Es7mates.
Health
Affairs,
28(5),
w822–w831.
h=p://doi.org/10.1377/hlthaff.28.5.w822
• Franz,
M.
J.,
Boucher,
J.
L.,
Ru=en-­‐Ramos,
S.,
&
VanWormer,
J.
J.
(2015).
Lifestyle
weight-­‐loss
interven7on
outcomes
in
overweight
and
obese
adults
with
type
2
diabetes:
a
systema7c
review
and
meta-­‐analysis
of
randomized
clinical
trials.
Journal
of
the
Academy
of
Nutri0on
and
Diete0cs,
115(9),
1447–1463.
h=p://doi.org/10.1016/j.jand.2015.02.031
• Franz,
M.
J.,
VanWormer,
J.
J.,
Crain,
A.
L.,
Boucher,
J.
L.,
Histon,
T.,
Caplan,
W.,
et
al.
(2007).
Weight-­‐Loss
Outcomes:
A
Systema7c
Review
and
Meta-­‐Analysis
of
Weight-­‐Loss
Clinical
Trials
with
a
Minimum
1-­‐Year
Follow-­‐Up.
Journal
of
the
American
Diete0c
Associa0on,
107(10),
1755–1767.
h=p://doi.org/10.1016/j.jada.2007.07.017
• Goyal,
D.,
&
Watson,
R.
R.
(2016).
Endoscopic
Bariatric
Therapies.
Current
Gastroenterology
Reports,
1–8.
h=p://
doi.org/10.1007/s11894-­‐016-­‐0501-­‐5
• Kakkar,
A.
K.,
&
Dahiya,
N.
(2015).
Drug
treatment
of
obesity:
Current
status
and
future
prospects.
European
Journal
of
Internal
Medicine,
26(2),
89–94.
h=p://doi.org/10.1016/j.ejim.2015.01.005
• Khera,
R.,
Murad,
M.
H.,
Chandar,
A.
K.,
Dulai,
P.
S.,
Wang,
Z.,
Prokop,
L.,
et
al.
(2016).
383
Compara7ve
Efficacy
and
Tolerability
of
Long-­‐Term
Pharmacological
Interven7ons
for
Obesity:
A
Systema7c
Review
and
Network
Meta-­‐Analysis.
Gastroenterology,
150(4),
S87.
h=p://doi.org/10.1016/S0016-­‐5085(16)30408-­‐5

69. • Kotzampassi,
K.,
Grosomanidis,
V.,
Papakostas,
P.,
Penna,
S.,
&
Elexheriadis,
E.
(2012).
500
Intragastric
Balloons:
What
Happens
5
Years
Thereaxer?
Obesity
Surgery,
22(6),
896–903.
h=p://doi.org/10.1007/s11695-­‐012-­‐0607-­‐2
• Kumar,
R.
B.,
&
Aronne,
L.
J.
(2015).
Efficacy
comparison
of
medica7ons
approved
for
chronic
weight
management.
Obesity
(Silver
Spring,
Md.),
23
Suppl
1,
S4–7.
h=p://doi.org/10.1002/oby.21093
• Kushner,
R.
F.
(2012).
Clinical
Assessment
and
Management
of
Adult
Obesity.
Circula0on,
126(24),
2870–2877.
h=p://
doi.org/10.1161/CIRCULATIONAHA.111.075424
• Lopez-­‐Nava,
G.,
Sharaiha,
R.
Z.,
Neto,
M.
G.,
Kumta,
N.
A.,
Topazian,
M.,
Shukla,
A.,
et
al.
(2016).
101
Endoscopic
Sleeve
Gastroplasty
for
Obesity:
A
Mul7center
Study
of
242
Pa7ents
With
18
Months
Follow-­‐Up.
Gastroenterology,
150(4),
S26.
h=p://doi.org/10.1016/S0016-­‐5085(16)30212-­‐8
• Mechanick,
J.
I.,
Youdim,
A.,
Jones,
D.
B.,
Garvey,
W.
T.,
Hurley,
D.
L.,
McMahon,
M.
M.,
et
al.
(2013).
Clinical
Prac7ce
Guidelines
for
the
Periopera7ve
Nutri7onal,
Metabolic,
and
Nonsurgical
Support
of
the
Bariatric
Surgery
Pa7ent—2013
Update:
Cosponsored
by
American
Associa7on
of
Clinical
Endocrinologists,
The
Obesity
Society,
and
American
Society
for
Metabolic
&
Bariatric
Surgery.
Surgery
for
Obesity
and
Related
Diseases,
9(2),
159–191.
h=p://doi.org/10.1016/
j.soard.2012.12.010
• Na7onal
Heart,
Lung,
and
Blood
Ins7tute.
(2013).
Management
of
Overweight
and
Obesity
in
Adults:
Guidelines
From
the
Expert
Panel,
2013,
1–70.
h=p://doi.org/10.1161/01.cir.0000437739.71477.ee/-­‐/DC1
• Neylan,
C.
J.,
Dempsey,
D.
T.,
Tewksbury,
C.
M.,
Williams,
N.
N.,
&
Dumon,
K.
R.
(2016).
Endoscopic
treatments
of
obesity_
a
comprehensive
review.
Surgery
for
Obesity
and
Related
Diseases,
1–8.
h=p://doi.org/10.1016/j.soard.
2016.02.006
• Ogden,
C.
L.,
Carroll,
M.
D.,
Kit,
B.
K.,
&
Flegal,
K.
M.
(2014).
Prevalence
of
Childhood
and
Adult
Obesity
in
the
United
States,
2011-­‐2012.
Jama,
311(8),
806–9.
h=p://doi.org/10.1001/jama.2014.732
• Russell,
R.
(1985).
Undergraduate
teaching
project.
Unit
13.A.
Nutri7on:
Energy
and
protein.
Gastroenterology,
88(6),
2018.
h=p://doi.org/10.1016/0016-­‐5085(85)90056-­‐3
• Sharma,
A.
M.
(2010).
M,
M,
M
&
M:
a
mnemonic
for
assessing
obesity.
Obesity
Reviews
:
an
Official
Journal
of
the
Interna0onal
Associa0on
for
the
Study
of
Obesity,
11(11),
808–809.
h=p://doi.org/10.1111/j.1467-­‐789X.2010.00766.x
• Sullivan,
S.,
Stein,
R.,
Jonnalagadda,
S.,
Mullady,
D.,
&
Edmundowicz,
S.
(2013).
Aspira7on
therapy
leads
to
weight
loss
in
obese
subjects:
a
pilot
study.
Gastroenterology,
145(6),
1245–52.e1–5.
h=p://doi.org/10.1053/j.gastro.2013.08.056
• Tsismenakis,
A.
J.,
Christophi,
C.
A.,
Burress,
J.
W.,
Kinney,
A.
M.,
Kim,
M.,
&
Kales,
S.
N.
(2009).
The
obesity
epidemic
and
future
emergency
responders.
Obesity
(Silver
Spring,
Md.),
17(8),
1648–1650.
h=p://doi.org/10.1038/oby.2009.63
• Vargas,
E.
J.,
&
Dayyeh,
B.
K.
A.
(2016).
Endoluminal
bariatric
and
metabolic
interven7ons.
Techniques
in
Gastrointes0nal
Endoscopy,
1–7.
h=p://doi.org/10.1016/j.tgie.2016.01.006

70. • Wadden,
T.
A.,
Webb,
V.
L.,
Moran,
C.
H.,
&
Bailer,
B.
A.
(2012).
Lifestyle
modifica7on
for
obesity:
new
developments
in
diet,
physical
ac7vity,
and
behavior
therapy.
Circula0on,
125(9),
1157–1170.
h=p://doi.org/10.1161/CIRCULATIONAHA.
111.039453