Communication

from the ASGE

Training CORE CURRICULUM
Committee

Obesity core curriculum

Prepared by: ASGE TRAINING COMMITTEE
Rahul Pannala, MB BS, MPH, Reem Z. Sharaiha, MD, MSc, Shelby A. Sullivan, MD, Mihir S. Wagh, MD,
Jonathan Cohen, MD, Chair, ASGE Training Committee, Christopher C. Thompson, MD, MHES, Chair,
Association for Bariatric Endoscopy
This document is a product of the ASGE Training Committee and the Association of Bariatric Endoscopy. This document
was reviewed and approved by the Governing Board of the American Society for Gastrointestinal Endoscopy.

This is a document prepared by the Association for
Bariatric Endoscopy, a division of the American Society
for Gastrointestinal Endoscopy (ASGE), and the ASGE
Training Committee. This curriculum document contains
recommendations for training and is intended for use by
gastroenterology program directors and faculty,
including those involved in teaching endoscopy, and
trainees in gastroenterology. Although only a small pro-
portion of gastroenterologists currently treat obesity,
given the burden of disease, an urgent need exists for
greater involvement of physicians from multiple spe-
cialties, including gastroenterology, to be actively
involved in the care of patients with obesity. This curric-
ulum was developed to provide an overview of the cogni-
tive and technical content areas that gastroenterology
fellows should learn pertaining to the evaluation and
management of patients with obesity and to serve as a
guide to published references, videos, and other available
resources. Specifically, this document addresses the core
concepts that all general gastroenterology fellows should
acquire about lifestyle intervention; pharmacologic,
endoscopic, and surgical treatments for obesity; evalua-
tion and management of GI comorbidities in patients
with obesity; challenges associated with sedation in pa-
tients with obesity; endoscopic evaluation of post–
bariatric surgical anatomy; and the management of
selected adverse events in patients who have had bariat-
ric surgery. The document also suggests recommenda-
tions for those fellows who are interested in acquiring
further skills in the treatment of obesity such as incorpo-
rating medical treatment of obesity in their practice or
Abbreviations: ASGE, American Society for Gastrointestinal Endoscopy;
EBT, endoscopic bariatric therapy.
Copyright ª 2020 by the American Society for Gastrointestinal Endoscopy
0016-5107/$36.00
https://doi.org/10.1016/j.gie.2019.07.007
Received July 6, 2019. Accepted July 6, 2019.
those interested in offering endoscopic bariatric thera-
pies, treatment of more complex bariatric surgical
adverse events, or endoscopic treatment of weight regain
after Roux-en-Y gastric bypass. By providing this frame-
work to trainers and trainees, the ASGE hopes to facilitate
the incorporation of this important material into training
programs to ensure that trainees are adequately pre-
pared for future professional responsibilities in this area.
INTRODUCTION AND IMPORTANCE
The epidemic of obesity is a major public health chal-
lenge nationally and globally. In the United States the
self-reported, age-adjusted prevalence of obesity (defined
as body mass index 30 kg/m2) between 2013 and 2014
was 35% in men and 40% in women.1 Obesity is a risk
factor for several diseases across various organ systems;
major obesity-associated comorbidities include type 2 dia-
betes, coronary artery disease, stroke, nonalcoholic fatty
liver disease, GERD, Barrett’s esophagus, obstructive sleep
apnea, and several malignancies.2 Given the multisystem
effects of obesity and the varied and complex factors
that determine the success of the initial weight loss and
the maintenance of weight loss, patients with obesity
should ideally be treated in the framework of a
comprehensive, multidisciplinary approach. Further, it is
also important that these patients have access to various
treatment options including lifestyle intervention,
medical therapy, and endoscopic and surgical bariatric
therapies. In this context, gastroenterologists increasingly
need to become involved in the care of patients with
obesity. All gastroenterology fellows should acquire
several core skills pertaining to obesity during their
training. These include the evaluation and management
of obesity-related GI comorbidities such as nonalcoholic
fatty liver disease, Barrett’s esophagus, and GERD; assess-
ing and addressing periprocedure risk in the performance
of standard endoscopic procedures in patients with
obesity; appropriate preoperative evaluation for bariatric

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Obesity core curriculum
surgical procedures; endoscopic evaluation and accurate
reporting of common post–bariatric surgical anatomy;
endoscopic management of selected adverse events
associated with bariatric surgery; and the long-term man-
agement of gastroenterology issues in this patient popula-
tion. Fellows who are interested in incorporating obesity
treatment into their practice should gain experience in
multidisciplinary collaborations and treatment through
comprehensive lifestyle intervention and adjunctive thera-
pies such as pharmacotherapy. Further, the advent of
several effective endoscopic bariatric therapies (EBTs) in
recent years has expanded the role of gastroenterologists
in the primary treatment of obesity. Fellows who are inter-
ested in performing EBTs require training in addition to
the skills detailed above. As such, establishing a broader
understanding of the evaluation and management of pa-
tients with obesity in the gastroenterology fellowship cur-
riculum and providing a framework for fellows who are
interested in acquiring further skills in treating patients
with obesity including medical management and EBTs
are critically needed.
Currently, content related to obesity is limited in the
gastroenterology core curriculum document,3 especially
relative to the burden of obesity as a public health problem.
The gastroenterology core curriculum document also
predates the advent of several EBTs and newer techniques
in the endoscopic management of bariatric surgical adverse
events; therefore, these content areas are not included
in the endoscopy section of the curriculum. Obesity is a
chronic disease with various endoscopic and medical
therapeutic options. Gastroenterology fellowship programs
should allocate sufficient time for clinical rotations and
didactic sessions to properly educate trainees in the
evaluation and management of patients with obesity.
Although the American Society for Gastrointestinal
Endoscopy (ASGE) has previously published a position
statement on EBTs in clinical practice4 and a systematic
review and meta-analysis assessing the preservation and
incorporation of valuable endoscopic innovation thresholds
for adopting EBTs,4 a curriculum document on the overall
evaluation and treatment of patients with obesity has not
been published.
The objectives of this document are to provide an
overview of the core concepts and suggested goals and
modes of training for general gastroenterology trainees
with regard to the evaluation and management of patients
with obesity. First, this includes medical and endoscopic
skills pertaining to the regular gastroenterology care of
patients with obesity and the evaluation and treatment
of obesity that all gastroenterology fellows should acquire.
Second, the document provides a framework for fellows
who are interested in acquiring further skills in the med-
ical management of patients with obesity and/or EBTs and
management of complex bariatric surgical adverse events.
Finally, this document provides a general listing of
training resources of benefit to trainers and trainees alike.
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Although the eventual update of the 2007 gastroenter-
ology core curriculum will require a multisociety effort,
this document is intended to help inform that process
and, in the interim, provide training programs with guid-
ance in this area.
GOALS OF TRAINING
Gastroenterology training programs should define spe-
cific goals for education and training in the management
of patients with obesity. Education in obesity physiology,
comorbidities related to obesity, knowledge of categories
and principles of medical management for weight loss,
and recognition of surgically altered anatomy should be
feasible during standard 3-year gastroenterology fellowship
training (Tables 1 and 2). Further, trainees should achieve
proficiency in understanding the complexities associated
with regular endoscopy in patients with obesity and be
able to recognize and accurately report the endoscopic
findings in patients who have undergone common
bariatric surgical procedures (Table 1). Trainees should
also be able to describe common pathology, such as
anastomotic ulceration, strictures, and bleeding, that can
be noted in bariatric surgical patients. Training in other
endoscopic interventions in the patient with obesity and
primary EBTs requires additional training. Depending on
the nature of the intervention, interested trainees can
acquire many of these skills through additional training
during the 3-year general gastroenterology fellowship or
as a component of postfellowship training (Table 3).
Evaluation of patients with obesity and obesity-
related diseases
General gastroenterology trainees should develop an
understanding of the pathophysiology of obesity. Further,
gastroenterology trainees should be able to obtain a
comprehensive medical history relevant to obesity and
recognize various obesity-related diseases (Table 2). For
gastroenterology disorders that are related to obesity
such as GERD, Barrett’s esophagus, nonalcoholic fatty
liver disease, and GI malignancies associated with
obesity, gastroenterology trainees should have a more
comprehensive understanding and be able to evaluate
these comorbidities and treat or refer for appropriate
care.
Endoscopy in patients with obesity
All gastroenterology trainees should recognize the spe-
cific challenges of performing endoscopic procedures in
patients with obesity, including the effect of related co-
morbidities on sedation and airway management in this
high-risk population. General gastroenterology trainees
should understand how to assess the proper setting for
performing endoscopy in obese patients based on both
patient-related factors and the complexity of the intended
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 Obesity core curriculum

TABLE 1. Suggested description of endoscopic procedural skills pertaining to patients with obesity or who have undergone bariatric surgical
procedures for all gastroenterology trainees and fellows interested in performing advanced endoscopic procedures

Endoscopic category General gastroenterology fellowship training Additional training*

Endoscopy in patients with Recognize the overall risks associated with
obesity. endoscopic procedures in patients with obesity.
Adequately assess risk of airway problems with sedation
in patients with obesity.
Select the appropriate setting for planned endoscopic
procedures.
Identify patients with obesity who require anesthesia
assistance to safely perform endoscopic procedures.
Upper endoscopy in patients after Assess and accurately report anatomy in common
bariatric surgery. bariatric surgical procedures (Roux-en-Y gastric
bypass and sleeve gastrectomy).
Assess and treat basic pathology in the gastric pouch
and at gastrojejunal anastomosis (ulcers, bleeding).
Push and device-assisted
enteroscopy in surgically
altered anatomy.
Device-assisted ERCP and interventional EUS-
*Additional training, defined as specific procedural training and other aspects of care of these patients, can be acquired either during the gastroenterology fellowship or as
dedicated further training based on available resources.
Provide recommendations and establish
policies for endoscopy units to appropriately
care for patients with obesity undergoing
endoscopy.
Accurately identify and report anatomy of
various bariatric surgical procedures.
Manage complex pathology (eg, refractory
bleeding) in the gastric pouch and
anastomosis.
Assessment and luminal therapeutic
interventions at jejunojejunal anastomosis,
Roux limb, and excluded stomach.
guided access procedures.

procedure. Because of the potentially increased peripro-
cedural risk and the need for therapeutic interventions,
endoscopic treatment of surgical adverse events in pa-
tients who have recently undergone bariatric surgery
should preferably be performed in the hospital setting
with anesthesia assistance. Most often, EBTs are per-
formed in the hospital setting with anesthesia, but certain
EBTs may be performed in ambulatory surgical centers af-
ter careful evaluation of cardiopulmonary and procedural
risks. In the subset of patients who have had bariatric sur-
gery and are undergoing endoscopy, gastroenterology
trainees should be able to recognize common surgical
anatomy and to report accurately the nature of the surgi-
cally altered anatomy and any associated endoscopic
findings.
Endoscopic bariatric and metabolic therapies
General gastroenterology trainees should possess
knowledge of the various approved EBTs, their indications,
and the commonly noted adverse events associated with
these EBTs. These trainees should also be able to identify
situations where patients with EBTs require consultation
with an EBT specialist or surgeon (Table 3).
For trainees to be able to perform EBTs themselves,
they will require additional training to learn both the tech-
nical aspects of performing the procedures and the effec-
tive care of patients after these procedures. Depending
on the nature of the EBT and intervention, this training
may be obtained by interested fellows within the standard
3-year fellowship program. For more technically complex
interventions and EBTs, such as primary endoscopic sleeve
gastroplasty and management of certain bariatric surgical
adverse events (postoperative strictures, fistulas, leaks),
interested trainees will need specific procedural training
by an experienced endoscopist either during the 3-year
fellowship or as dedicated postfellowship training in these
procedures.
Faculty
Endoscopic training should be provided by faculty with
expertise in treating patients with obesity and associated
GI comorbidities. In addition, trainees should have access
to faculty from other specialties with obesity-related
expertise such as endocrinologists, obesity medicine spe-
cialists, bariatric surgeons, dietitians, and psychiatrists.
When feasible, elective outpatient rotations with some
of these specialists may help trainees obtain adequate
exposure in these content areas. In programs where
appropriate faculty are not available, interested trainees
may also acquire knowledge in these areas from didactic
courses or workshops conducted by various professional
societies. Ideally, core curriculum lectures on the basic as-
pects of obesity pathophysiology and management are
offered to trainees in all programs. In programs that offer
training in EBTs, trainees should have access to faculty
with expertise in EBT and access to EBT cases. Regular
feedback should be provided to the trainee on both the
endoscopic aspects of the procedure and the overall
care of the patient with obesity. In programs where EBT
training is not available, interested trainees may also ac-
quire exposure to these procedural skills through
hands-on workshops and courses that include the partic-
ular EBT.

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Obesity core curriculum

TABLE 2. Obesity training matrix for all gastroenterology fellows and fellows interested in offering obesity treatment

Content area/skill(s) All gastroenterology fellows Additional training in obesity*

Pathophysiology of obesity Acquire an understanding of the pathophysiology of
obesity.
Epidemiology of obesity and Knowledge of the current rates of obesity and the
factors that influence obesity trends in adult, adolescent, and childhood obesity.
Recognize various environmental, cultural, genetic, and
behavioral factors that affect energy balance.
Evaluation of patients with Obtain a comprehensive medical history in patients
obesity with obesity including weight history, medications
(including those that can induce weight loss or gain),
previous weight loss attempts, weight-related
comorbidities, exercise, diet, and sleep patterns.
Screen for obesity-related GI comorbidities.
Assess readiness to change.
Comprehensive lifestyle Recognize the components of lifestyle intervention:
intervention diet, exercise, and behavior modification.
Define the correlation between intensity of therapy and
weight loss outcomes.
Identify lifestyle intervention as the foundation of
obesity treatment.
Pharmacotherapy Knowledge of the common categories of medications
that are associated with weight gain/weight loss as an
adjunctive effect in addition to their primary
indication.
Knowledge of medications used to treat obesity
including basic indications and contraindications.
*As with procedural training (see Table 1), additional training in medical aspects of obesity treatment can be acquired either during the gastroenterology fellowship or as
dedicated further training based on available resources. A training matrix for endoscopic skills (EBTs and management of bariatric surgical adverse events) is provided in Table 3.
Gut–brain–adipocyte regulation of energy intake
including hormonal and neurohormonal signals.
Gut microbial influence on food intake.
Psychosocial influences on food consumption.
Hormonal adaptation to weight loss.
Alterations in glucose and lipid metabolism in
obesity.
Concepts of metabolically normal and
metabolically abnormal obesity.
Alterations in cell metabolism in obesity.
Recognize differences in rates of obesity based
on sex, race/ethnicity, and socioeconomic status.
Knowledge of various genetic and epigenetic
influences on obesity.
Screen for and assess diseases that may affect
weight loss (eating disorders, depression,
obstructive sleep apnea).
Comprehensive clinical and laboratory assessment
of the patient with obesity.
Prescribe an appropriate caloric
recommendation.
Advise patients on diets with different
macronutrient components.
Recommend an exercise program of appropriate
intensity (including when to perform cardiac
clearance before initiating an exercise program).
Perform behavior coaching.
Use lifestyle intervention for treatment of obesity-
related GI diseases (nonalcoholic fatty liver
disease, GERD, Barrett’s esophagus, GI cancers).
Direct a multidisciplinary obesity program with
other practitioners (registered dietitian,
psychologist, nurse, etc).
Comprehensive knowledge of and ability to
prescribe pharmacotherapy options for
treatment of obesity.
Recommend changes to patient’s medication
regimen to minimize medications that are
contributing to weight gain or preventing
weight loss.
Knowledge of the increasing use of medications in
combination with EBTs and in patients with
weight regain after bariatric surgery.

Guidelines for endoscopic experience TRAINING PROCESS AND CONTENT AREAS

No guidelines or established quality metrics have been
published regarding training or credentialing in regular
endoscopic procedures in patients with obesity, for endo-
scopic management of post–bariatric surgery adverse
events, or for EBTs. Programs offering training in EBTs
should ensure that trainees have access to a broad spec-
trum of cases. As noted previously, faculty should evaluate
trainee performance in this regard and provide regular
feedback.
Overview
Fellowship training in gastroenterology should provide
gastroenterology trainees with adequate knowledge of
the basic pathophysiology of obesity, clinical evaluation
of patients with obesity, and the available treatment
options, including endoscopic bariatric and metabolic
therapies. These skills can be acquired through a combi-
nation of didactic lectures and clinical patient care. All

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 Obesity core curriculum

TABLE 3. Recommended training for currently available EBTs, management of bariatric surgical adverse events, and weight regain after Roux-en-
Y gastric bypass

Skills All gastroenterology fellows Additional training

EBTs Knowledge of approved EBTs. Comprehensive knowledge of various EBTs

Recognize the basic indications, contraindications, and weight
loss outcomes with approved EBTs.
Knowledge of and the ability to identify common adverse
events associated with EBTs and situations that require
consultation of an EBT specialist or surgeon.
Bariatric surgical adverse Knowledge of common bariatric surgeries and associated
events adverse events.
Endoscopic recognition and accurate reporting of common
postbariatric adverse events (marginal ulcers, fistulae,
anastomotic site assessment, and gastric sleeve stenosis).
Ability to manage common bariatric surgical adverse
events (marginal ulcers, gastrojejunostomy stricture,
bleeding) or identify need for referral to advanced
endoscopist or surgeon.
Endoscopic treatment of
weight regain after
Roux-en-Y gastric
bypass
EBT, Endoscopic bariatric therapy.
including indications, contraindications, weight
loss outcomes, and patient selection.
Adequate endoscopic training for all aspects of the
EBT that is offered including placement and
removal.
Ability to provide comprehensive postprocedure
care for patients specific to the EBT that is
offered.
Recognize and treat adverse events associated
with EBTs.
Manage a broad array of bariatric surgical
adverse events (micronutrient deficiencies,
anastomotic strictures, gastric sleeve stenosis).
Manage complex bariatric surgical adverse events
(refractory marginal ulcers, gastrojejunostomy
strictures, leaks, fistulae).
Transoral gastrojejunal outlet reduction.
Endoscopic closure of gastrogastric fistula.

gastroenterology trainees will need to recognize that
obesity is a complex disease with genetic, physiologic,
environmental, and psychosocial pathways contributing
to the disease process. Gastroenterology fellows who
are specifically interested in incorporating obesity treat-
ment into their practice should have a comprehensive
knowledge of multidisciplinary collaborations that are
required for obesity treatment and the various therapeu-
tic options.
Pathophysiology of obesity
Obesity is complex disease affected by multiple fac-
tors, with the gut being the primary organ for nutrient
sensing. All general gastroenterology trainees should
have a detailed understanding of the GI tract and
non-GI tract contributors to obesity. Trainees should
also understand the roles of the pancreas, liver, gut mi-
crobiome, and non-GI organs (eg, adipose tissue) on
appetite and energy regulation. Trainees should under-
stand how the central nervous system integrates signals
regarding nutrient sensing, metabolism, and stored en-
ergy from the body to regulate energy intake through
changes in food intake and energy expenditure.
Trainees should develop an understanding of the fac-
tors that influence regulatory mechanisms in obesity,
which include but are not limited to genetics, epige-
netics, the environment, medical conditions, and psy-
chosocial factors.
Treatment of patients with obesity
Trainees should be familiar with the comprehensive
obesity treatment guidelines for the management of patient
who are overweight or obese published by the American
Heart Association, the American College of Cardiology, and
The Obesity Society.5 It is important to note that this
document was published before any of the EBTs were
approved for use in the United States; therefore, these
guidelines were not included in the obesity treatment
algorithm. Trainees should be aware of the ASGE position
statement on incorporating EBTs as adjunctive therapies
to comprehensive lifestyle intervention.6 The American
Gastroenterological Association white paper, which was
published in concert with several other societies, is also a
comprehensive guideline for trainees on the multidisciplinary
treatment of obesity.7
Identifying patients. Gastroenterologists who incor-
porate obesity management in their practices will see pa-
tients who are specifically referred for obesity treatment.
However, even in the general gastroenterology outpatient
practice, many patients will have obesity and related co-
morbidities. General gastroenterology trainees should be
able to diagnose obesity and related comorbidities and
determine patients who meet criteria for treatment.
Evaluation of patients with obesity. General gastro-
enterology trainees should understand the importance of
weight loss for the treatment of obesity-related comorbid
GI diseases. Obesity is also associated with multiple

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Obesity core curriculum
metabolic and nonmetabolic abnormalities. Trainees
should be able to identify these obesity-related comorbid-
ities and recognize when multidisciplinary care with refer-
rals to other experienced practitioners (primary care
physicians, endocrinologists, cardiologists, etc) are needed
for optimal patient management. Trainees should be able
to assess a patient’s current level of readiness to change
(such as on a scale of 1-10). Because lifestyle change re-
quires substantial effort on the part of the patient, the
assessment of readiness to change is important in deter-
mining the timing of referral for obesity treatment.
Gastroenterology fellows who plan to treat obesity
should be able to document a patient’s weight history
across his or her lifespan and include relevant information
on life events that coincide with changes in weight, dietary
habits, physical activity, barriers to exercise, and medical
conditions or medications that cause weight gain before
formulating a treatment plan. They should also obtain in-
formation about previous weight loss attempts, methods,
and outcomes as part of an obesity treatment plan.
Comprehensive lifestyle intervention
Comprehensive lifestyle intervention is the foundation
for any obesity treatment plan. It is important for all trainees
to recognize that other therapies are considered adjunctive
to comprehensive lifestyle intervention. In clinical practice,
the delivery of the comprehensive lifestyle intervention
will likely be performed by other trained providers (eg,
registered dietitian, psychologist, etc). All trainees should
have a thorough understanding of the components of a
comprehensive lifestyle intervention program including die-
tary interventions, exercise, and behavior modification. As
above, this knowledge could be readily imparted via rota-
tions with faculty caring for patients with obesity if available
or via didactic means such as grand rounds, journal clubs,
and review of online educational resources.
Trainees who offer obesity treatment should also under-
stand how the intensity and mode of delivery of lifestyle
intervention affect overall weight loss, as described in the
obesity guidelines and other published literature. Trainees
should be able to develop a comprehensive lifestyle inter-
vention program in conjunction with other trained pro-
viders (registered dietitian, psychologist, etc) and direct
an obesity treatment program.
Pharmacotherapy
The general trainee should know the medications avail-
able for obesity treatment, their contraindications and
adverse effects, weight loss average, and responder rates.
Further, trainees should be able to identify medications
the patient may be on for other medical conditions that
may contribute to weight gain.
Trainees who offer obesity treatment should be able to
prescribe weight loss medications and understand how to
use medications in combination. These trainees should
also be able to evaluate a patient’s concurrent medications
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that could be contributing to weight gain and, in coordina-
tion with the patient’s other physicians, identify suitable
alternative medications. Limited data are available on the
use of pharmacotherapy in combination with EBT, but 2 tri-
als have demonstrated superior weight loss in patients
treated with both intragastric balloons and pharmaco-
therapy compared with monotherapy.8,9 Trainees who offer
obesity treatment should also have knowledge of the poten-
tial use of these medications in combination with EBTs and
for treatment of weight regain after bariatric surgery.
Endoscopic bariatric therapies
EBTs are adjunctive obesity therapies that require flex-
ible endoscopy for some portion of placement or removal
of a device or involve endoscopic luminal alteration. All
trainees should have basic knowledge of approved EBT
procedures, indications, and patient selection (Table 3).
All trainees should also be able to identify common
adverse events associated with EBTs and recognize
situations that require consultation of an EBT specialist
or surgeon for further management. This level of
exposure and understanding should be feasible for
general trainees to receive from external sources even at
programs where local expertise and experience in
performing EBTs are not available.
Trainees who are interested in the treatment of obesity,
including offering EBTs, should be able to screen for and
address related medical issues such as depression, eating
disorders, and other psychological conditions before pro-
ceeding with EBTs. Trainees who are interested in per-
forming EBTs should recognize the need for additional
training in both the procedural aspects and the postproce-
dural care of the patient. Further, these trainees should be
able to diagnose and treat adverse events associated with
EBTs. This level of understanding will require in-person
experience with faculty who perform EBT and may require
obtaining outside electives for interested trainees at pro-
grams where this is not available.
As with trainees who are interested in offering medical
obesity treatment, those offering EBTs should also have a
comprehensive knowledge of the medical aspects of obesity
management including pharmacotherapy. Although most
physicians will offer EBTs in the framework of multidisci-
plinary bariatric programs or a referral network where the
medical management is primarily undertaken by colleagues
with specific expertise in this area, physicians who offer
EBTs may need or desire to be more involved in the medical
management of patients before and after their procedures.
As such, it is suggested that trainees interested in perform-
ing EBTs develop those core competencies outlined in
Table 2 under the category of additional training with
regard to medical treatment and lifestyle intervention.
Bariatric surgery
All gastroenterology trainees need to have knowledge of
indications, preoperative evaluation, common bariatric
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surgical procedures, and associated adverse events.
Trainees should be able to accurately describe the anatomy
and report endoscopic findings in patients with post–
bariatric surgical anatomy who are undergoing endoscopy.
They should understand the endoscopic management of
certain common bariatric surgical adverse events (eg,
bleeding) and recognize the adverse events that may
require more complex therapeutic endoscopic procedures
or surgical reintervention. It is recommended that fellows
who train at programs where exposure to postsurgical pa-
tients is limited acquire the above skills through other re-
sources (such as lectures or online resources), because
they may need to care for patients presenting with an
adverse event of bariatric surgery performed elsewhere.
Fellows seeking additional training in the endoscopic
management of complex bariatric surgical adverse events
such as fistulae and leaks should recognize the need to
obtain additional procedural training in the endoscopic
management of these issues. This will require either spe-
cific training during the general 3-year fellowship or
subsequently.
MODES OF TRAINING
To provide a comprehensive and well-rounded training
experience, all trainees should have a balanced exposure to
patient care, didactics, technical aspects of interventions
for obesity, and relevant research in the field. Although
some fellowship programs may not have expertise in
EBTs and management of other aspects of obesity, inter-
ested trainees have multiple other avenues to acquire
this training and skills such as away-electives, courses,
and workshops offered by gastroenterology and other spe-
cialty societies. Where available, multidisciplinary clinical
case-conferences that integrate input from various spe-
cialties other than gastroenterology, such as endocri-
nology, nutrition, and bariatric surgery services, can be
valuable in educating trainees regarding the interdisci-
plinary care of patients with obesity.
Certain advanced EBTs and endoscopic management of
certain bariatric surgical adverse events may only be per-
formed in select specialty centers. These techniques
require additional training, and as such, the trainee should
understand that the availability of such training will be
dictated by local expertise and resources. When local
expertise is not available, interested trainees can seek
training and practice in these skills through participation
in hands-on workshops and various courses. Some tech-
niques such as intragastric balloon placement and removal
may be technically learned in a brief hands-on setting.
Other procedures, such as those that require endoscopic
suturing, require considerably more training; whereas
mini-courses may enhance the learning process for
trainees for these complex techniques, trainees will likely
need actual patient experience mentored by an experi-
enced endoscopist.
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Obesity core curriculum
The general trainee should understand the incremental
risks associated with EBTs and the performance of endos-
copy in patients with obesity. Depending on local exper-
tise, trainees may acquire this knowledge through
inpatient or outpatient rotations with obesity medicine
specialists, bariatric surgery service, nutrition service, pro-
viders performing EBT, and the therapeutic endoscopy ser-
vice for more complex procedures. In addition, as part of
their continuity clinic and other outpatient rotations,
trainees should recognize obesity-related comorbidities in
their patients and, if indicated, appropriately refer patients
for the management of these comorbidities.
Trainees are expected to read current textbooks and
relevant scientific literature. Didactic training should incor-
porate core curriculum lectures on basic concepts of
obesity. Further didactics for interested trainees can be
provided by local or visiting faculty with expertise in
obesity or obtained through online resources or symposia
conducted by various societies throughout the year.
Several courses and workshops are offered by national so-
cieties such as The Obesity Society, American Society for
Metabolic and Bariatric Surgery, ASGE, Association for Bar-
iatric Endoscopy, and others as a part of annual confer-
ences, which cover a wide array of topics including
didactics, clinical best practices, and the latest therapies
in obesity management. Some of these courses are de-
signed to provide state-of-the-art information, education,
and practice support to endoscopists with special interest
in EBTs. Many gastroenterology, surgery, and obesity soci-
eties also offer webinars on various aspects of obesity man-
agement throughout the year. Several institutions conduct
comprehensive courses, which offer didactic lectures and
workshops focused on practical strategies in the manage-
ment of obese patients.
SIMULATORS AND ADDITIONAL TRAINING
RESOURCES
Currently, no dedicated electronic simulators are avail-
able for training in EBTs. However, an ex vivo model, typi-
cally a porcine stomach, is often used for hands-on EBT
training. Custom preparation of ex vivo models, which
simulate the altered anatomy of patients with prior
bariatric surgery, can be obtained from vendors. The
ASGE Institute for Training and Technology supports
various hands-on and didactic courses related to EBTs
throughout the year. These courses are taught by expert
faculty and offer the trainee opportunities to learn various
techniques and obtain practical advice on performing
these procedures. Trainees are encouraged to optimize
procedural skills by taking advantage of these hands-on
training sessions and programs and to explore the availabil-
ity of these resources locally. Although simulator work is
engaging and may offer those fellows interested in more
advanced bariatric training valuable exposure to expert
Volume 91, No. 6 : 2020 GASTROINTESTINAL ENDOSCOPY 1227
Obesity core curriculum
faculty and risk-free repetitive practice, the basic require-
ments of this core curriculum for general gastroenterology
fellows do not require any particular simulator experience.
ASSESSMENT OF TRAINING
Currently, no criteria are proposed for the assessment
of trainees in the evaluation and management of patients
with obesity. Further, competency thresholds for EBTs
have not been established. As such, trainees should seek
feedback from faculty during their clinical rotations and
during the performance of endoscopic procedures in pa-
tients with obesity and when involved in performing
EBTs. Trainees who are interested in acquiring board cer-
tification in obesity medicine can explore the requirements
of the American Board of Obesity Medicine.
QUALITY MEASUREMENT
Quality metrics or benchmarks for the performance of
EBTs and weight loss outcomes in patients who undergo
these procedures have not been proposed. Trainees are
encouraged to have knowledge of the reported weight
loss outcomes with specific EBTs and evaluate their
personal outcomes relative to reported averages.
DISCLOSURES
The following are the conflicts of interest disclosed
at the time of submission. All authors consulted
openpayments.gov.
Dr Pannala is a consultant for HCL Technologies, the
recipient of research support and general payments
from Apollo Endosurgery, and the recipient of general
payments from Boston Scientific, Abbvie, and Olympus.
Dr Sharaiha is a consultant for and the recipient of
research support from Aspire Bariatrics, the recipient of
research support from Lumendi LLC, and the recipient
of general payments from Apollo Endosurgery, Boston Sci-
entific, Conmed, Cook Medical, US Endoscopy, Shire
North America, Microtech Endoscopy, Endogastric solu-
tions, Covidien LP, Ninepoint Medical, Takeda Pharma-
ceuticals, Allergan Inc, Siemens Medical Solutions,
Medigus Ltd, Valeant Pharmaceuticals, Mauna Kea Tech-
nologies, and Ironwood Pharmaceuticals. Dr Sullivan is
a consultant for Aspire Bariatrics, USGI Medical, Obalon
Therapeutics, GI Dynamics, Elira, Spatz FGIA, Endo Tools
Therapeutics, Phenomix Sciences, and Nitinotes; the
recipient of research support from Aspire Bariatrics, Allu-
rion, BARONova, Elira, Finch Therapeutics, Obalon Ther-
apeutics, and ReBiotix; and the holder of stock warrants
from Elira. Dr Wagh is a consultant for Medtronic; the
recipient of general payments from Boston Scientific, Lu-
mendi LLC, Conmed Corporation, Endogastric Solutions,
Pinnacle Biologis, US Endoscopy, Olympus America,
1228 GASTROINTESTINAL ENDOSCOPY Volume 91, No. 6 : 2020
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ERBE USA, Ninepoint Medical, Cook Medical, Pentax of
America, Torax Medical, Apollo Endosurgery; and the
recipient of general payments and research support
from Merit Medical. Dr Cohen is a consultant and
speaker for Olympus, Otsuka, and Ferring; an advisor
for Virtual Health Partners and Stratis (pending); the
recipient of royalties from Wiley and Up-to-Date; and
the recipient of general payments from AMAG Pharma-
ceuticals, QOL Medical LLC, Janssen Biotech Inc, Synergy
Pharma, US Endoscopy, Olympus Latin America, Boston
Scientific, Covidien LP, Valeant Pharmaceuticals, Shire
NA, Takeda Pharmaceuticals, Merck, Sharp and Dohme
Corporation. Dr Thompson is the recipient of research
support from Aspire Bariatrics, Boston Scientific, and
the recipient of general payments from Olympus Corpora-
tion, Boston Scientific, Spiration Inc, Covidien LP, Apollo
Endosurgery, Aspire Bariatrics, Fujifilm New Develop-
ment, ERBE USA, Microtech Endoscopy, Endogastric
Solutions, and Olympus Latin America.
LISTING OF GENERAL REFERENCES
Clinical guidelines
Acosta A, Streett S, Kroh MD, et al. White paper
AGA: POWERdPractice Guide on Obesity and Weight
Management, Education, and Resources. Clin Gastroen-
terol Hepatol 2017;15:631-49.
ASGE Bariatric Endoscopy Task Force, ASGE Technology
Committee, Abu Dayyeh BK, 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;82:425-38.
Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/
TOS guideline for the management of overweight and obesity
in adults: a report of the American College of Cardiology/
American Heart Association Task Force on Practice Guide-
lines and The Obesity Society. Circulation 2014;129:S102-38.
Berthoud HR, Klein S. Advances in obesity: causes, con-
sequences, and therapy. Gastroenterology 2017;152:1635-7.
Videos
ASGE video tips on bariatrics. Available at:
https://www.asge.org/search-results?TypeFacetZVideoTips&
CategoriesZ357e2164-1d27-6839-97eb-ff000074820c. Ac-
cessed June 6, 2019.
Books
Akabas SR, Lederman SA, Moore BJ, editors. Textbook
of obesity: biological, psychological and cultural influences,
Hoboken, NJ: Wiley-Blackwell; 2012.
Steelman GM, Westman EC. In: Youdim A, ed. Obesity:
evaluation and treatment essentials, 2nd ed. Boca Raton,
FL: CRC Press; 2016.
Youdim A, et al. The clinicians guide to the treatment of
obesity. New York, NY: Springer; 2015.
www.giejournal.org

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1. Flegal KM, Kruszon-Moran D, Carroll MD, et al. Trends in obesity
among adults in the United States, 2005 to 2014. JAMA 2016;315:
2284-91.
2. Heymsfield SB, Wadden TA. Mechanisms, pathophysiology, and
management of obesity. N Engl J Med 2017;376:254-66.
3. American Association for the Study of Liver Diseases, American College
of Gastroenterology, AGA Institute, American Society of Gastrointestinal
Endoscopy. A journey toward excellence: training future gastroenterol-
ogists–the gastroenterology core curriculum, third edition. Am J Gastro-
enterol 2007;102:921-7.
4. ABE Task Force, ASGE Technology Committee; Abu Dayyeh BK,
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:
425-38.
www.giejournal.org
Downloaded for Adina Braha (braha.adina@umft.ro) at University of Medicine and Pharmacy Victor Babes Timisoara from ClinicalKey.com by
Elsevier on June 16, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
Obesity core curriculum
5. Jensen MD, Ryan DH, Apovian CM, et al. 2013 AHA/ACC/TOS guideline
for the management of overweight and obesity in adults: a report of the
American College of Cardiology/American Heart Association Task Force
on Practice Guidelines and The Obesity Society. Circulation 2014;129:
S102-38.
6. Sullivan S, Kumar N, Edmundowicz SA, et al. ASGE position statement on
endoscopic bariatric therapies in clinical practice. Gastrointest Endosc
2015;82:767-72.
7. Acosta A, Streett S, Kroh MD, et al. White paper AGA: POWERdPractice
Guide on Obesity and Weight Management, Education, and Resources.
Clin Gastroenterol Hepatol 2017;15:631-49.
8. Farina MG, Baratta R, Nigro A, et al. Intragastric balloon in association
with lifestyle and/or pharmacotherapy in the long-term management
of obesity. Obes Surg 2012;22:565-71.
9. Coskun H, Bostanci O. Assessment of the application of the intragastric
balloon together with sibutramine: a prospective clinical study. Obes
Surg 2010;20:1117-20.
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