Is Bariatric Surgery the Standard of Care for Sleeve Obesity?
By Alan C. Wittgrove, MD, FACS, FASMBS, and Christopher Still, DO, FACS, FTOS
Dr. Wittgrove is the medical director of the Wittgrove Bariatric Center in Del Mar, California, and performed the world’s first laparoscopic gastric bypass procedure more than 25 years ago.
Dr. Still is the director of the Geisinger Obesity Institute, the medical director of the Center for Nutrition and Weight Management, and. A professor of medicine in Danville, Pennsylvania.
Bariatric surgery meets the medical definition of the standard of care for severe obesity in every way but one: It is not a common treatment for the disease. Despite its high safety and superior effectiveness to other treatments, only a fraction of those individuals who could potentially benefit receive the surgery each year. By default, today’s standard of care for the 24 million who suffer from severe obesity is actually actually diet and exercise, the least effective treatment for the disease.
Research shows more than 80% to 90% of people with obesity who lose weight with diet and exercise eventually regain it. The odds are even worse for those with severe obesity. A team of researchers at King’s College London found that men with severe obesity have a 1 in 1,290 chance of reaching a healthy body weight without bariatric surgery, and women have a 1 in 677 chance. This leaves an enormous gap between current and best practices. About 1% of eligible patients receive bariatric surgery each year. While 66.7% of Americans with obesity are trying to lose weight with mostly diet and exercise alone. This is no way to treat a life-threatening disease.
Part of the problem may be that the public and even health care professionals are still divided over whether obesity is a disease or a lifestyle choice, despite calls to the contrary by leading medical groups. In a 2013 resolution, the American Medical Association, the nation’s largest physician group, declared obesity a “multi-metabolic and hormonal disease state” that is directly related to type 2 diabetes, cardiovascular disease, and some cancers. “The suggestion that obesity is not a disease but rather a consequence of a chosen lifestyle exemplified by overeating and/or inactivity is equivalent to suggesting that lung cancer is not a disease because it was brought about by individual choice to smoke cigarettes,” The resolution stated.
The National Institutes of Health has recognized obesity as a chronic disease since 1998 and the American Society for Metabolic and Bariatric Surgery (ASMBS) did the same when it endorsed a 2008 position statement from The Obesity Society (TOS) in 2012, The American Association of Clinical Endocrinologists joined the club. TOS reaffirmed a position in 2018 and called for a shit in “public perceptions of obesity away from the misinformed view that obesity is a lifestyle choice or aberrant behavior toward a chronic disease model for understanding and addressing obesity at individual and population levels.”
If obesity were truly treated like the disease it is, the most effective treatments would be readily available and accessible, and more doctors would referring their patients to obesity specialists and bariatric surgeons. Other diseases do not have such disparities between treatment and non-treatment.
In 2014, it was reported the among adults diagnosed with diabetes in the United States, 88.2% use oral medications, insulin, or a combination of both to treat and control diabetes. Treatment rates for hypertension increased from 65%(2003-2004) to 75% (2011-2012). Compare this to the 1% of those with severe obesity who receive bariatric surgery and roughly 2% of the 93.3 million who have obesity and receive pharmacologic agents.
Who Would Have Thought?
From the Last Resort to Gold Standard
Bariatric surgery remains the most effective long-term treatment for severe obesity since the first gastric bypass operations performed by the “father of bariatric surgery,” Dr Edward Mason in 1966. With 50 years of progress in surgical techniques and technologies, the rise of the multidisciplinary approach to care, continuous quality improvement, and accreditation, bariatric surgery now enjoys a safety profile comparable to some of the most common operations performed in America. In addition, the benefits of bariatric and metabolic surgery extend far beyond weight loss.
“Who would have thought it? An operation proves to be the most effective therapy for adult-onset-diabetes Mellitus,” as Dr Walter Pories put it, based on his observational study of 608 patients published in Annals of Surgery in 1995. Nearly 25 years and several randomized clinical trial later, guidelines endorsed by 45 worldwide medical and scientific societies including the American Diabetes Association—recommend metabolic surgery to treat diabetes in patients with a body mass index (BMI) of greater than 40 and a BMI 35.0-39.9 when hyperglycemia is inadequately controlled by lifestyle and optimal medical therapy, and it should be a consideration for patients with BMI 30.0-34.9. Who would have thought, Dr Pories?
Beyond diabetes, studies have shown bariatric surgery leads to the improvement, prevention, or resolution of many other diseases including heart disease, hypertension, sleep apnea, fatty liver disease, and certain cancers. The days of considering bariatric surgery treatment of last resort should be over. Bariatric surgery can be a safe and effective treatment to be used when appropriate, not only when other options have been exhausted. Too many patients first present to a bariatric surgeon with advanced diabetes, renal disease, or hypertension, which may lower the chances for remission.
Operating in a Vacuum
Currently, care is too often delivered in silos for the complications of obesity: Cardiologists take care of heart problems; orthopedic surgeon address joint disease, endocrinologist treat diabetes; bariatric surgeons treat severe obesity, warranting a more coordinated multidisciplinary approach.
Obesity should be evaluated and treated much like cancer, a concept raised by Dr Pories and Konstantinos Spaniolas, MD, in 2016, They called for the organization of “metabolic boards,” which would function similarly to tumor boards in cancer centers. As Drs Pories and Spaniolas described it, complex cases of metabolic disease would be seen simultaneously by the endocrinologist, primary care physicians, surgeons, nutritionists, social workers, and other essential providers.” Depending on the patient, the interdisciplinary team may also include cardiologists, nephrologists, OB/GYNs, and orthopedists, among others. This metabolic board could then recommend the best possible treatment and care plan based on shared knowledge, current literature, best practices, and the individual patient’s health status. Bariatric surgeons would no longer be operating in a vacuum. This way, bariatric surgery could be recommended when needed and most beneficial, and not reserved for only the more advanced and complicated states of disease.
Several specialty organizations—American Heart Association, American College of Cardiology, ASMBS, TOS, American Diabetes Association, International Diabetes Federation, American Association of Clinical Endocrinologists, and many others—have developed evidence-based guidelines each containing recommendations for bariatric surgery. Unfortunately, these recommendations are not carrying over to everyday practice.
This must change, and the bariatric community can help by making the words on the page in the bariatric surgery section of each of the guidelines come to life through communication and collaboration with the specialists and primary care providers in their practice areas. The bariatric community can share data, dispel outdated notions, and help turn guideline recommendations into healthier patients.