Weight Loss Surgery: New Guidelines Are Released, Expanding Eligibility

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The new guidelines for weight loss surgery expand the number of people who are eligible. Olga Rolenko/Getty Images
  • Two organizations have released the first new guidelines for weight loss surgery in more than 30 years.
  • The guidelines expand the eligibility for these surgeries by lowering the body-mass index threshold and adding in other conditions.
  • The guidelines do not recommend the surgery for children and adolescents.

The first new guidelines for weight loss surgery in more than three decades were announced today by the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO).

The new evidence-based clinical guidelines from two of the field’s leading authorities recommend expanding patient eligibility and endorsing metabolic surgery for people with type 2 diabetes, starting at a body mass index (BMI) of 30.

The organizations published theASMBS/IFSO Guidelines on Indications for Metabolic and Bariatric Surgery – 2022 in the journals Surgery for Obesity and Related Diseases(SOARD) and Obesity Surgery.

The National Institutes of Health (NIH) released a consensus statement more than 30 years ago, setting standards upon which most insurers and doctors still rely to decide whether to recommend weight-loss surgery, what kind people should get, and when they should get it.

“The 1991 NIH consensus statement on bariatric surgery served a valuable purpose for a time, but after more than three decades and hundreds of high-quality studies, including randomized clinical trials, it no longer reflects best practices and lacks relevance to today’s modern-day procedures and population of patients,” said Dr. Teresa LaMasters, the president of ASMBS, in a statement.

“It’s time for a change in thinking and in practice for the sake of patients. It is long overdue,” she added.

Why weight loss surgery guidelines needed change

The 1991 consensus statement said bariatric surgery should be confined to people with a BMI of at least 40 or a BMI of 35 or more and at least one obesity-related condition such as hypertension or heart disease.

“The word on this really needs to get out there,” Dr. Steven Patching, the medical director of bariatric surgery at Sutter Medical Center in Sacramento, California., told Healthline. “New guidelines were needed. Bariatric surgery and bariatric science have come a long way over the past 30 years.”

Patching, who hadn’t seen the new guidelines yet, said the BMI criteria for selected diabetic patients need to come down, which he said has been discussed for years.

“Our center, along with others, have seen diabetes resolution rates up to 85 percent on patients with type 2 diabetes That is an amazing cure rate and therefore should be available to patients under the current minimal BMI of 35,” he said.

Patching remembered a patient who years ago was on five medications for diabetes that was still poorly controlled.

“This woman was at extremely high risk with her health,” Patching said. “Her BMI was less than 35 and yet her insurance still authorized her operation. Within a few months she was able to come off all of her diabetes medications and her blood sugars were under excellent control.”

“The treatment saved her life. Instead of simply lowering her sugars with medications, which are frequently very expensive, her diabetes was essentially cured,” he said.

The improvements in surgery technology

Experts say surgical complications and death rates have decreased over the past 30 years, thanks to advancements such as minimally invasive and robotic surgery, which has also decreased pain and recovery times.

“The morbidity and mortality have greatly improved from 30 years ago,” Dr. Mir Ali, a bariatric surgeon and medical director of MemorialCare Surgical Weight Loss Center at Orange Coast Medical Center in California, told Healthline.

“Not only has the technology improved tremendously with the implementation of the laparoscopic approach, but our understanding of the pathophysiology of the disease has significantly improved,” Ali said. “The safety of weight loss surgery is equivalent, if not better, than that of cholecystectomy, which is a more commonly performed procedure.”

Dr. Kuldeep Singh, the director of the Bariatric Center at Mercy Medical Center in Baltimore, told Healthline it’s a completely different surgical landscape than 30 years ago.

“Nearly all surgeries are now laparoscopic or robotic,” Singh said. “Less than 6 percent; rarely there is an open operation. Mortality has fallen from 3 percent to less than 0.1 percent. That is one per thousand, making bariatric surgery one of the safest in surgery. Surgery benefits outweigh the risks in certain groups who were once considered not safe for surgery, such as elderly, children, and patients needing transplants.”

The benefits of weight loss surgery

Dr. John Morton is the medical director of bariatric surgery for the Yale New Haven Health System in Connecticut.

He told Healthline the new guidelines are good news for people of smaller physical stature or those of certain ethnic backgrounds.

“The guidelines recognize that certain patients with different ethnicities can benefit from intervention at lower BMI, i.e. South Asian Americans,” Morton said. “Patients with BMI 30-35 and diabetes and/or South Asian background can benefit sooner rather than waiting until reaching a BMI of 35.”

Morton said bariatric surgery is now safer than knee replacement or gallbladder removal.

“Additionally, more evidence of the benefit of bariatric surgery is now demonstrated with a 50 percent reduction in mortality and diabetes long-term,” he noted.

Who should or shouldn’t have weight loss surgery

According to a statement from ASMBS and IFSO, the new guidelines don’t reference metabolic surgery for diabetes or the emerging laparoscopic techniques and procedures.

The statement also recommended against weight loss surgery for children and adolescents, even with BMIs over 40, because it hasn’t been sufficiently studied.

The new ASMBS/IFSO guidelinesrecommend metabolic and bariatric surgery for individuals with a BMI of 35 or more “regardless of presence, absence, or severity of obesity-related conditions” and that it be considered for people with a BMI of 30 to 34.9 and metabolic disease and in “appropriately selected children and adolescents.”

Even without metabolic disease, the guidelines say weight-loss surgery should be considered starting at BMI 30 for people who don’t achieve substantial or durable weight loss or obesity disease-related improvement using nonsurgical methods.

They also recommend obesity definitions using standard BMI thresholds be adjusted by population and that Asian individuals consider weight-loss surgery beginning at a BMI of 27.5.

The guidelines say “metabolic and bariatric surgery is currently the most effective evidence-based treatment for obesity across all BMI classes” and that “studies with long-term follow-up, published in the decades following the 1991 NIH consensus statement, have consistently demonstrated that metabolic and bariatric surgery produces superior weight loss outcomes compared with non-operative treatments.”

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