BAROCRINOLOGY The Bariatric Pyramid: A framework for therapeutic targets

The Bariatric Pyramid is a model which serves to explain the goals of obesity management, act as a milestone for monitoring of therapy, and to benchmark the utility of various anti-obesity medications and interventions. Built upon a base of sustainability, it lists three more desired aspects of care: suﬃciency (suﬃcient strength) safety and security. Each of the four aspects of the pyramid: sustainability, suﬃciency safety and security have three angles, which allows the reader to understand them easily. The model that we propose is useful in training health care professionals, in therapeutic patient education, for assessing various anti-obesity therapies, and in reaching the right decision while managing obesity.


Introduction
The increasing number of options for management of obesity have increased the responsibility of health care providers who treat the condition. 1Each therapeutic modality, whether non-pharmacological or invasive, has its own strengths and limitations, caveats and contraindications.At the same time, each individual who seeks care for obesity has specific concerns and challenges which are unique to her or him.These have to be kept in mind while planning person-centred therapeutic strategies. 2 In this regard, obesity management is similar to that of other chronic diseases, including diabetes.Diabetes care professionals have evolved various models and rubrics, which help inform targets, strategies and tools for treatment. 3Similar developments in the field of obesity have focussed on the pathophysiology (the Ominous Octet) 4 and the choice of therapy of obesity.We posit a Bariatric Pyramid, similar to the glycaemic pyramid described earlier, which places diabetes care in perspective (Figure).

The Bariatric Pyramid
The pyramid is perhaps the most stable architectural shape developed and widely used in medical parlance. 5This is reflected in the base of the bariatric pyramid, which stands for sustainability.The aim of weight management is to achieve sustained weight loss, without weight cycling (yo yo phenomenon) or weight rebound. 6The three surfaces of the bariatric pyramid stand for sufficiency, safety and security in the process of achieving optimal weight.Sufficiency can be measured by body mass index reduction, and also by reduction in central fat/visceral fat/body fat percentage, as well as ectopic fat deposition.Safety implies that bariatric therapy should not cause malnutrition, metabolic diseases (hypoglycaemia, ketoacidosis, hyperuricaemia, dyslipidaemia), or gastrointestinal / gall bladder disturbances.The third aspect of the pyramid, security, reminds us that weight loss therapies should ensure not only short-term cardiovascular (e.g, avoidance of cardiac arrhythmias) and long term cardiovascular(avoidance of major adverse cardiovascular outcomes) security, but also psychological security, including avoidance of weight-related dysthymia, eating disorders, and other psychiatric diseases. 7

Pragmatic Usage Practical Utility
The bariatric pyramid offers a useful tool for training and education of obesity care professionals, and also for counselling of people living with obesity.It acts as an aid to clinical decision making by offering a reality check regarding targets of obesity care, and the relative strengths of various options available for intervention.The pyramid's base underscores the long term (and infinite) nature of weight management.The three surfaces-sufficiency, safety and security-reinforce the need to choose therapeutic tools, and follow sensible strategies, which are effective, safe and well-tolerated, not only in the short term, but the long term as well.
The bariatric pyramid kickstarts an interactive discussion between various stakeholders in obesity care (the person living with obesity, the physician, paramedical care providers, partners and peers (caregivers), and payers) which allows for informed and shared decision making.This ensures better understanding of obesity and its management and its management and promotes adherence.

The Way Forward
As we work to tackle the obesity pandemic, and navigate the increasing number of options for treatment, the bariatric pyramid offers much needed support.In a sustainable manner, it provides sufficient strength safety and security, by helping us plan optimal strategies, choose the right techniques, and target appropriate goals for management.All anti-obesity medications and procedures should be judged by the standards of the bariatric pyramid.