After 30 Years—New Guidelines for Weight Loss Surgery: Medical Groups Replace Outdated Consensus Statement that Overly Restricts Access to Modern-Day Weight Loss Surgery

| December 1, 2022

NEWBERRY, FL – Oct. 21, 2022 – Two of the world’s leading authorities on bariatric and metabolic surgery have issued new evidence-based clinical guidelines that among a slew of recommendations expand patient eligibility for weight loss surgery and endorse metabolic surgery for patients with Type 2 diabetes beginning at a body mass index (BMI) of 30kg/m2, a measure of body fat based on a person’s height and weight and one of several important screening criteria for surgery.

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

The ASMBS1 is the largest group of bariatric surgeons and integrated health professionals in the United States (US), and IFSO2 represents 72 national associations and societies throughout 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 lacks relevance to today’s modern-day procedures and population of patients,” said Teresa LaMasters, MD, President, ASMBS. “It’s time for a change in thinking and in practice for the sake of patients. It is long overdue.” 

In the 1991 consensus statement,3 bariatric surgery was confined to patients with a BMI of at least 40kg/m2 or a BMI of 35kg/m2 or more and at least one obesity-related condition, such as hypertension or heart disease. There were no references to metabolic surgery for diabetes or references to the emerging laparoscopic techniques and procedures that would become mainstay and make weight loss surgery as safe or safer than common operations,4 including gallbladder surgery, appendectomy, and knee replacement. The statement also recommended against surgery in children and adolescents even with BMIs over 40kg/m2 because it had not been sufficiently studied. 

New Patient Selection Standards—Times Have Changed

The ASMBS/IFSO Guidelines now recommend metabolic and bariatric surgery for individuals with a BMI of 35kg/m2 or more “regardless of presence, absence, or severity of obesity-related conditions” and that it be considered for people with a BMI 30 to 34.9kg/m2 and metabolic disease and in “appropriately selected children and adolescents.” 

But even without metabolic disease, the guidelines say weight loss surgery should be considered starting at BMI 30kg/m2 for people who do not achieve substantial or durable weight loss or obesity disease-related improvement using nonsurgical methods. It was also recommended that obesity definitions using standard BMI thresholds be adjusted by population and that Asian individuals consider weight-loss surgery beginning at BMI 27.5kg/m2. 

Higher Levels of Safety and Effectiveness for Modern-Day Weight-Loss Surgery

The new guidelines further state “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.” 

It is also noted that multiple studies have shown significant improvement of metabolic disease and a decrease in overall mortality after surgery and that “older surgical operations have been replaced with safer and more effective operations.” Two laparoscopic procedures, sleeve gastrectomy and Roux-en-Y gastric bypass (RYGB), now account for about 90 percent of all operations performed worldwide. 

Roughly 1 to 2 percent of the world’s eligible patient population get weight loss surgery in any given year. Experts say the overly restrictive consensus statement from 1991 has contributed to the limited use of such a proven safe and effective treatment. Globally, more than 650 million adults had obesity in 2016, which is about 13 percent of the world’s adult population. The Centers for Disease Control and Prevention (CDC) reports5 over 42 percent of Americans have obesity, the highest rate ever in the US.

“The ASMBS/IFSO Guidelines provide an important reset when it comes to the treatment of obesity,” said Scott Shikora, MD, President, IFSO. “Insurers, policy makers, healthcare providers, and patients should pay close attention and work to remove the barriers and outdated thinking that prevent access to one of the safest, effective, and most studied operations 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 statement6 that metabolic surgery should be considered for patients with Type 2 diabetes and a BMI 30 to 34.9kg/m2 if 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—2022.7 

The full article can be viewed here: https://link.springer.com/article/10.1007/s11695-022-06332-1.

References

  1. American Society for Metabolic and Bariatric Surgery. https://asmbs.org/. Accessed 8 Nov 2022.
  2. International Federation for the Surgery of Obesity and Metabolic Disorders. https://www.ifso.com/. Accessed 8 Nov 2022.
  3. National Institutes of Health. Consensus statement. 1991;9(1):1–22. https://consensus.nih.gov/1991/1991gisurgeryobesity084PDF.pdf. Accessed 8 Nov 2022. 
  4. Aminian A, Brethauer SA, Kirwan JP, et al. How safe is metabolic/diabetes surgery? Diabetes Obes Metab. 2015;17(2):198–201.    
  5. Hales CM, Carroll MD, Fryar CD, Ogden CL. Prevalence of obesity and severe obesity among adults: United States, 2017–2018. NCHS Data Brief, no 360. National Center for Health Statistics. 2020.
  6. Rubino F, Nathan DM, Eckel RH, et al. Metabolic surgery in the treatment algorithm for Type 2 diabetes: a joint statement by international diabetes organizations. Diabetes Care. 2016;39(6):861–877.
  7. American Diabetes Association Professional Practice Committee. 8. Obesity and weight management for the prevention and treatment of Type 2 diabetes: Standards of Medical Care in Diabetes—2022. Diabetes Care. 2022;45(Supplement 1):S113–S124.   

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