Low BMI surgery: Metabolic or Cosmetic?

Total Bariatric Care by Eric J. Demaria, MD

This month’s topic: Low BMI surgery: Metabolic or Cosmetic?

Dr. DeMaria is from New Hope Wellness Center, Raleigh, North Carolina.

Bariatric Times. 2011;8(7):22

This column is dedicated to providing updates and commentary on a wide range of topics within the specialty of bariatric surgery.

In the future, bariatric surgery may no longer be reserved for the patient with so-called morbid obesity. Low body mass index (BMI) surgery has made its entrance into the treatment armamentarium. Recently, the United States Food and Drug Administration (FDA) approved Allergan’s request to expand the indications for their adjustable gastric band product for the treatment of patients with BMIs between 30 and 35kg/m2. This expansion of the scope of interventional treatment may dramatically change the application of bariatric surgery and allow for dramatic growth in interventional treatment, with surgical treatment becoming an option for an additional 37 million Americans.

News of the favorable FDA decision sparked great controversy in the media. Many criticized the panel decision, expressing that obesity is a “choice” rather than a disease, and that patients who choose surgery in the low BMI range are unwilling to make a serious commitment to the behavioral changes needed for long-term, successful weight loss. As a specialty, we have faced such criticisms before and have slowly turned the tide of public opinion and convinced others of the life-saving benefits of bariatric surgery for individuals with morbid obesity. We also understand that bariatric surgery should not be considered a “quick fix” and that patients must adhere to comprehensive lifestyle changes in order to be successful in the long term after surgery. By contributing their data to the Bariatric Outcomes Longitudinal Database (BOLD), participants in the American Society for Metabolic and Bariatric Surgery (ASMBS) Bariatric Surgery Centers of Excellence (BSCOE) program have contributed significantly to our current knowledge in this area. These pioneering surgeons have demonstrated that low BMI surgery is predominantly done in the presence of comorbidities in the United States. A study[1] presented at the 2nd World Congress on Interventional Therapies for Type 2 Diabetes, March 28–30, 2011, New York, New York, demonstrated that 87 percent of surgically treated patients in the low BMI range demonstrated accepted cardiovascular risk factors. In another investigation of BOLD data,[2] both gastric bypass and adjustable gastric banding were found to dramatically improve diabetes in 235 patients with  a baseline BMI between 30 and 35kg/m2. There was a high level of safety, with the vast majority of complications being minor in nature, such as self-limited nausea/vomiting, and no deaths. Overall, 39 percent of patients were able to discontinue all medications to treat diabetes within 6 to 12 months of surgery.

One central focus of the low BMI debate is that patients undergoing surgery may be more motivated by cosmetic concerns rather than the need to treat serious comorbidities, such as metabolic diseases. In the language of media soundbites, “Is it metabolic surgery or cosmetic surgery?”

According to the World Health Organization (WHO), obesity is the greatest healthcare concern facing mankind. The primary reason for this concern is the prevalence of familiar diseases, particularly those of the metabolic variety, such as diabetes, hypertension, cardiovascular atherosclerosis, and nonalcoholic fatty liver, which are either aggravated or caused by obesity. As an example, nonalcoholic steatohepatitis (NASH), liver inflammation caused by a buildup of fat in the liver, is predicted to become the most common cause of liver cirrhosis in the coming decades. The concept of treating metabolic diseases with bariatric surgery is not new, but the term “metabolic surgery” is driving the re-invention of weight loss surgery as it becomes a strategy for the treatment of all degrees of obesity. Application of metabolic surgery to individuals with lower body weight who suffer from the early stages of this chronic, unrelenting, and debilitating disease, offers the promise that they may avoid the long-term health consequences of obesity, including organ damage to the heart, lungs, kidneys, liver, blood vessels, eyes, joints, and spine, to name but a few organ systems impacted by progressive obesity.

Metabolic surgery for individuals with low BMI is about to emerge as a major change in available treatment for the obesity crisis. With this emergence will come increased attention to surgical treatment in general, as well as awareness that surgery offers the only successful, durable treatment yet identified to control obesity. Metabolic surgery implies treatment will not just be reserved for the most severe and disabling cases. Our societal obsession with weight control, combined with an aging population fighting comorbidities related to obesity, will work synergistically to elevate metabolic surgery to new heights of acceptance in our culture. The availability of low BMI surgery will contribute significantly to bariatric procedures being considered as an earlier treatment option, rather than the current status of bariatric surgery as a last-ditch attempt to rescue patients with end-stage disease.

But the question remains: Is low BMI surgery going to be applied predominantly as “metabolic surgery” or as cosmetic surgery? My perspective is that this controversy is not what we, as bariatric surgeons, should focus on. For one thing, patients with an initial low BMI often become patients with higher BMI over time, and the number and severity of obesity-related comorbidities generally increase as people age and as their BMI increases. In addition, studies of surgical risk demonstrate enhanced safety when procedures are performed in individuals with lower body weight who are younger and have less serious health problems. People who are motivated by concerns about their appearance still experience health-related concerns over time due to progressive obesity. And, we know that weight loss does translate into cosmetic value for many people, even when health concerns are also present. The cosmetic surgery industry exists because our culture believes that it is acceptable for patients to modify their appearance, even with very invasive interventions, as long as it is accomplished at the patient’s own expense. I anticipate that weight loss interventions will be increasingly available to patients motivated by solely cosmetic concerns. We can do very little to stop this progression. We should shift focus from this issue to our primary responsibility as a specialty, which should be to make certain that these procedural offerings are of the lowest possible risk and are undertaken by appropriately trained specialists in qualified surgery centers.

And do not forget that surgery is not standing still—it is evolving. Less invasive procedures are being developed and tested, including incisionless endoscopic interventions that may work well in patients with lower BMI who have less weight to lose to obtain success. The expanding list of available treatment interventions will carry a broad profile of invasiveness, risk, disability, and effectiveness. Although not ideal, common sense supports the concept that one accepts less effectiveness in exchange for reducing the risk of an intervention; thus, our standards and how we define success for a bariatric intervention are constantly being challenged and revised as new procedures are developed.

A key change in our cultural attitudes could be one of the most important off-shoots of the evolution of low BMI surgery. Current data support the superiority of obesity treatment by an intervention in combination with programs that support lifestyle change, rather than individual attempts at lifestyle change alone. Acceptance of this concept offers the opportunity to improve the adoption of, and access to, interventional treatments, including surgery, to control the obesity epidemic. Tremendous results can be expected as surgeons bring the proven strategy of bariatric surgery into the armamentarium as we work to reduce risk and prevent morbid obesity, rather than try to rescue patients from its serious health consequences.

References
1.    Winegar DA, DeMaria EJ, Sherif B, Apovian CA. Indications for bariatric surgery in the BMI<35kg/m2 population treated at ASMBS Bariatric Centers of Excellence (BSCOE) as reported in the bariatric Outcomes Longitudinal Database (BOLD). Presented at: The 2nd World Congress for Interventional Therapies for Diabetes; March 28–30, 2011;New York, New York.
2.    DeMaria EJ, Winegar DA, Pate VW, et al. Early postoperative outcomes of metabolic surgery to treat diabetes from sites participating in the ASMBS bariatric surgery program as reported in the Bariatric Outcomes Longitudinal Database. Ann Surg. 2010;252(3):559–566; discussion 566–567.

Category: Past Articles, Total Bariatric Care