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New Guidelines Promote Expansion of Bariatric Surgery to Treat Obesity

Analysis  |  By Christopher Cheney  
   August 06, 2019

New guidelines for bariatric surgery update recommendations that were set more than two decades ago.

A co-author of new guidelines for bariatric surgery says more patients, clinicians, and payers should embrace surgical interventions to treat obesity.

From 2015 to 2016, 39.8% of Americans over age 20 were obese, according to the Centers for Disease Control and Prevention (CDC). For the same time period, 20.6% of adolescents were obese, the CDC says. In 2008, the estimated annual medical cost of obesity was $147 billion.

Stacy Brethauer, MD, a surgeon at Ohio State University Wexner Medical Center in Columbus, Ohio, who helped draft the new guidelines for bariatric surgery, says millions of obese patients could benefit from surgical approaches to their condition if payers would cover the procedures.

"People make lifestyle choices that predispose them—or lead to—specific cancers and cardiovascular disease, and yet nobody hesitates to provide effective treatment for those problems," he says.

New bariatric surgery guidelines

The American Society for Metabolic and Bariatric Surgery (ASMBS) recently adopted a new set of guidelines that recommend surgical interventions for Class I obesity patients, who have a Body Mass Index (BMI) from 30.0 to 34.9 kg/m2. Obese patients with a BMI of 35 or higher have met the criteria for surgical interventions for more than two decades.

The new guidelines feature eight points and recommendations:

1. Class I obesity is linked to several other diseases, decreases longevity, and diminishes quality of life. Class I obesity patients need durable treatment.

2. Nonsurgical treatments for Class I obesity are often ineffective.

3. The longstanding BMI inclusion threshold of at least 35 kg/m2 is arbitrary and was established in the era of high-risk open surgery. Current surgical techniques for bariatric and metabolic surgery are much safer than in the past.

4. For patients with Class I obesity, bariatric surgery should be offered for suitable patients such as those who do not achieve substantial weight loss with nonsurgical methods.

5. Patients with Class I obesity and Type 2 diabetes are strong candidates for bariatric surgery.

6. The primary laparoscopic surgical interventions for obesity—adjustable gastric banding, Roux-en-Y gastric bypass, and sleeve gastrectomy—are safe and effective in the treatment of Class I obesity. The results of these procedures in Class I obesity patients are similar to results achieved in severely obese patients.

7. Patients who undergo surgical interventions for obesity should receive perioperative and long-term nutritional, metabolic, and nonsurgical support such as measures in the ASMBS Clinical Practice Guidelines.

8. For Class I obesity patients, the best evidence for bariatric and metabolic surgery supports the procedures for patients aged 18 to 65.

Surgical options

Gastric bypass and sleeve gastrectomy are the best surgical options for Class I obesity patients, Brethauer says. "Both of those procedures are considered good metabolic operations in terms of diabetes and metabolic improvement."

For Class I obesity patients, the ideal patient for gastric bypass or sleeve gastrectomy has diabetes that is not well controlled with medical therapy and continues to have to escalate their medical therapy, he says.

"In general, gastric bypass is a more powerful operation for diabetes in terms of getting patients off all their medications and achieving remission of their diabetes. In the long term, both operations achieve good control of glucose levels in patients, but patients with gastric bypass are more likely to achieve remission off medication," Brethauer says.

Obesity is not simply a matter of will power alone, he says.

"Obesity is a disease that consists of genetic factors that lead to predisposition; environmental factors, which have a lot to do with calorie-dense food that is easily available and cheap; and behavioral factors linked to an increasingly sedentary lifestyle. Those three factors all go into our obesity epidemic."

Although long-term societal efforts should be launched to address the environmental and behavioral components of the obesity epidemic, many obese Americans could benefit from surgical interventions now, Brethauer says.

"There are already millions of people who are suffering with obesity, and they need to be offered treatment for it. Typically, diet, behavioral therapy, and even medications do not offer good long-term results once someone has already become severely obese."

Christopher Cheney is the CMO editor at HealthLeaders.


Obesity is at epidemic proportions in the United States, with the condition afflicting about 40% of Americans over age 20.

New guidelines lower the BMI threshold for obesity patients who are considered suitable for bariatric and metabolic surgery.

A surgeon who helped draft the new guidelines says millions of obese patients could safely benefit from surgical interventions.

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