Bariatric and metabolic surgery for obesity and associated disorders 28th March #obsmuk chat

Bariatric and metabolic surgery for obesity and associated disorders


Severe and complex obesity is associated with many complications such as type 2 diabetes, hypertension, ischaemic heart disease, liver disease, sleep apnoea, subfertility, osteoarthritis, depression and increased risk of cancer. Contrary to the popular concept among the public, media and healthcare professionals, obesity is not a simple case of energy intake versus energy expenditure. The causes of obesity are multifactorial and include genes, psychology, microbiome, hormones, environment, diet, lifestyle.

There are several treatment options for obesity. Any treatment for obesity should meet some and preferably all of the following criteria.
1) The treatment should result in a substantial and sustainable weight loss.
2)   The treatment should result in resolution, remission or improvement in obesity  complications.
3)   The treatment should result in prolongation of life and reduction in mortality
4)   The treatment should improve the quality of life.
5) The treatment should be cost-effective.
6)   The treatment should have a good safety profile.

People affected by obesity often report many attempts at losing weight using dietary and lifestyle changes.

While dietary and lifestyle changes are important in the treatment of obesity (as stand-alone treatment or as complementary to other treatment options), only a minority of patients will achieve health affecting weight loss and a significant portion regain weight.

Adding medications to dietary and lifestyle changes may result in meaningful weight loss attainment and maintenance. However, the currently available medications still have a small impact on obesity and some are not licensed  or available in many countries. There is currently only one antiobesity medication available in the national health service in the UK and its effectiveness is limited.

Bariatric and metabolic surgery, especially when combined with dietary and lifestyle changes, achieve much better outcomes than dietary and lifestyle changes alone and medications in regards to all the above mentioned criteria.

  • The Swedish Obese subject study has shown that obesity achieves substantial and sustainable weight loss for more than 15 years after surgery.It has also shown that that bariatric surgery achieves better outcomes than non-surgical treatment with  regards to improvement, remission or cure of obesity related health conditions (for example. There is three times better remission of diabetes in the surgical group compared to the non-surgical group. Remission of HTN is achieved in 50% more patients who undergo bariatric surgery compared to non-surgical treatment. It reduces fatal myocardial infarctions and strokes by 50%. In addition, it reduces the risk of cancer in women by 50%.)All of the above has resulted in 25% reduction in mortality in the surgical group. Bariatric surgery is also associated with a better quality of life.

Several randomised studies, systematic reviews and meta-analyses have shown the effectiveness of bariatric and metabolic surgery in achieving a significant improvement in diabetes control and frequently remission of type 2 diabetes. Even when intensive medical therapy is used, bariatric and metabolic surgery achieve better outcomes.

The recently published  randomised GATEWAY study concluded that bariatric surgery represented an effective strategy for blood pressure control in a broad population of patients with obesity and hypertension.

Bariatric surgery has been shown to be associated with a lower mortality than gallbladder surgery. The long term risks of surgery are also low as long as the patient understands the need for long term follow-up.

Bariatric surgery is a cost effective method to treat obesity. The cost of bariatric surgery is offset by the benefits. Economic analysis for NICE confirms that the financial outlay for surgery is justified for the NHS. In patients with diabetes, for example, the cost of surgery will be recouped within three years through reduced prescriptions. Surgery also has indirect cost benefits. For example, state disability allowances are reduced if improved activity levels allow patients to return to paid employment. The UK registry data found that only 28% of patients could climb three flights of stairs before surgery and this improved to over 72% 12 months later. (https://www.bmj.com/content/353/bmj.i1472 ). A study from McGill University has shown that the the healthcare costs of people affected by obesity and who have not undergone bariatric surgery is 45% higher than the total healthcare costs of people affected by obesity and who are treated by bariatric surgery during the first five years after surgery is performed (analysis include the cost of surgery)..

Because of the benefits of bariatric and metabolic surgery, across the world, it is a recommended treatment option for obesity in people who have body mass index above 40 or body mass index above 35 who have obesity related health conditions. Patients who have diabetes of a recent onset and whose BMI is above 30 should also be considered for metabolic surgery.

In the UK, NICE Clinical Guideline 189 recommends bariatric surgery as an appropriate treatment option https://www.nice.org.uk/guidance/cg189
Recommendation 1.10 Surgical interventions:
1.10.1 Bariatric surgery is a treatment option for people with obesity if all of the following criteria are fulfilled:
-They have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight.
-All appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss.
-The person has been receiving or will receive intensive management in a tier 3 service.
-The person is generally fit for anaesthesia and surgery.
-The person commits to the need for long-term follow-up.

Bariatric surgery is also known as metabolic surgery partly also because of its impact on recent onset type 2 diabetes. Therefore NICE made additional recommendations:
Recommendation 1.11 Bariatric surgery for people with recent-onset type 2 diabetes:
1.11.1 Offer an expedited assessment for bariatric surgery to people with a BMI of 35 or over who have recent-onset type 2 diabetes as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent).
1.11.2 Consider an assessment for bariatric surgery for people with a BMI of 30–34.9 who have recent-onset type 2 diabetes as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent).
1.11.3 Consider an assessment for bariatric surgery for people of Asian family origin who have recent-onset type 2 diabetes  at a lower BMI than other populations (see recommendation 1.2.8) as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent).

The International Diabetes Organizations also concluded “there is sufficient clinical and mechanistic evidence to support inclusion of metabolic surgery among antidiabetes interventions for people with T2D and obesity”.  http://care.diabetesjournals.org/content/39/6/861

Despite these recommendations, the numbers of bariatric surgery procedures has decreased over recent years.

We would like to invite you to join our discussion on this topic.

  1. How does bariatric surgery’s effectiveness compare with non-surgical treatment with regards to weight loss?
  2. How does bariatric surgery’s effectiveness compare with non-surgical treatment for conditions associated with or caused by obesity?
  3. How safe is bariatric surgery?
  4. What are the barriers that prevent people from pursuing bariatric surgery?
  5. What are the reasons for the decrease in number of bariatric procedures performed? How can this be reversed?

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