New evidence-based clinical guidelines expand patient eligibility for metabolic and bariatric surgery

New evidence-based clinical guidelines expand patient eligibility for metabolic and bariatric surgery

Two of the world's leading experts in bariatric and metabolic surgery have released new evidence-based clinical guidelines that, among a number of recommendations, expand patient eligibility for weight loss surgery and advocate metabolic surgery for patients with type 2 diabetes and above a body mass index (BMI) of 30, a measure of body fat that is based on a person's height and weight and is one of several key screening criteria for surgery.

The ASMBS/IFSO Guidelines on Indications for Metabolic and Bariatric Surgery – 2022, published online today in Surgery for Obesity and Related Diseases (SOARD) and bariatric surgery,are intended to replace a consensus statement developed more than 30 years ago by the National Institutes of Health (NIH) that sets standards that most insurers and doctors still rely on to make decisions about who should have weight-loss surgery, what type they should have and when they should get it.

The American Society for Metabolic and Bariatric Surgery (ASMBS) is the largest group of bariatric surgeons and integrated health professionals in the United States and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) represents 72 national associations and societies around the world.

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 is no longer relevant to today's modern procedures and patient population. It is time for a rethink and practice for the benefit of patients. It's long overdue.

Teresa LaMasters, MD, President, ASMBS

The 1991 consensus statement limited bariatric surgery to patients with a BMI of at least 40 or a BMI of 35 or more and at least one obesity-related condition such as high blood pressure or heart disease. There was no evidence of metabolic surgery for diabetes or evidence of the emerging laparoscopic techniques and procedures that would become the mainstay and make weight loss surgery as safe or safer than traditional surgeries such as gallbladder operations, appendectomies and knee replacements. The statement also advised against surgery for children and adolescents with a BMI over 40, as this had not been sufficiently examined.

New standards for patient selection – times have changed

The ASMBS/IFSO guidelines now recommend metabolic and bariatric surgery for individuals with a BMI of 35 or greater, “regardless of the presence, absence, or severity of obesity-related diseases,” and that it should be considered and “appropriate” for individuals with a BMI of 30–34.9 and a metabolic disease in selected children and adolescents.

But even without a metabolic disease, according to guidelines, weight loss surgery should be considered for people with a BMI of 30 or more who cannot achieve significant or lasting weight loss or improvement caused by the obesity disease using non-surgical methods. It also recommended that obesity definitions be adjusted to the population using standard BMI thresholds and that Asian individuals with a BMI of 27.5 or above should consider weight loss surgery.

Greater safety and effectiveness for modern weight loss surgery

The new guidelines continue: "Metabolic and bariatric surgery is currently the most effective evidence-based treatment for obesity across all BMI classes" and that "long-term follow-up studies published in the decades following the 1991 NIH Consensus Statement have consistently confirmed this." have shown that metabolic and bariatric surgery results in better weight loss outcomes compared to non-surgical treatments.”

It also notes that several studies have shown significant improvement in metabolic diseases and a decrease in all-cause mortality after surgery and that “older surgical procedures have been replaced by safer and more effective procedures.” Two laparoscopic procedures, sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), now account for approximately 90% of all operations performed worldwide.

Approximately 1 to 2% of the global eligible patient population undergoes weight loss surgery each year. Experts say the overly restrictive 1991 consensus statement has contributed to limited use of such a demonstrably safe and effective treatment. Globally, more than 650 million adults suffered from obesity in 2016, representing approximately 13% of the global adult population. CDC reports that over 42% of Americans suffer from obesity, the highest rate ever recorded in the United States

“The ASMBS/IFSO guidelines represent an important new beginning when it comes to the treatment of obesity,” said Dr. Scott Shikora, President of IFSO. “Insurers, policymakers, healthcare providers and patients should pay close attention and work to eliminate the barriers and outdated thinking that prevent access to one of the safest, most effective and most studied surgeries in medicine.”

The ASMBS/IFSO guidelines are just the latest in a series of new recommendations from medical groups calling for expanded use of metabolic surgery. In 2016, 45 professional societies, including the American Diabetes Association (ADA), issued a joint statement that metabolic surgery should be considered in patients with type 2 diabetes and a BMI of 30.0–34.9 when hyperglycemia is inadequately controlled despite optimal treatment with either oral or injectable medications. This recommendation is also included in the ADA’s “Standards of Medical Care in Diabetes – 2022.”

Source:

American Society for Metabolic and Bariatric Surgery

Reference:

Eisenberg, D., et al. (2022) 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for metabolic and bariatric surgery. Surgery for Obesity and Related Diseases. doi.org/10.1016/j.soard.2022.08.013.

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