For a long time, the relatively few people with deep commitment to obesity care knew that multimodal therapy was necessary. Bariatric surgery centers of excellence assembled teams to deliver nutrition, mental health, and physical therapy support. But persistence with follow-up was often disappointing. Now, though, something different is emerging.

Suddenly, multimodal therapy is the hot topic in obesity care.

What Is the Best Way?

Despite a long history with comprehensive care in some centers, these are early days for multimodal obesity therapy. Until now, obesity medicine and bariatric surgery have operated in largely separate silos. So rigorous evidence for the best protocols are lacking.

With the availability of advanced obesity medicines, the pressure to change all of that is tremendous. In the International Journal of Obesity, Nick Finer sums up what we know and the gaps that remain quite nicely:

“The role of these drugs before, after, or in combination with BMS requires further and better research but there is already sufficient evidence both to offer patients pharmacotherapy as an alternative to surgery, and to initiate pharmacotherapy when there has been an insufficient clinical response.”

Mixed Evidence on Neoadjuvant Drug Therapy

A recent study of semaglutide prior to surgery showed no real benefit in terms of outcomes for body weight. But a prior study showed just the opposite. Both of these studies are observational and thus have significant limitations. Hence the need for well-controlled research to define the best approach.

Trends Ahead of Protocols

Nonetheless, it is impossible to miss the rising trends in drug use both before and after surgery. Some are speculating that obesity medicines will largely displace metabolic surgery as there effectiveness continues to improve. Certainly many people are choosing to try the newer medicines well before they elect surgery. And after surgery, another recent study showed a rather dramatic increase in the use of these medicines starting in 2022. Researchers found a cumulative incidence of 20% of surgery patients having used obesity medicines after eight years of follow-up.

All of this makes one thing clear. Multimodal care is fast becoming the standard of care in obesity. But researchers have a lot of work to do. The data to support evidence-based approaches to this emerging standard of care needs to catch up with the reality of what patients need.

Click here for Finer’s editorial, here for the study of rising post-op use of obesity medicines, here and here for the studies of pre-operative use. For further perspective, click here, here, and here.

Night, painting by Henry Ossawa Tanner / WikiArt