Ask The Experts

Which Patients are Appropriate Candidates for Bariatric Surgery?

Clinicians should discuss obesity as objectively as they would any other health condition when offering bariatric surgery as a treatment option

With Caroline Apovian MD, Scott Cunneen MD, and J. Michael Gonzalez-Campoy MD, PhD 

Obesity is not typically thought of as a disease in this country, said Caroline Apovian MD, Professor of Medicine and Pediatrics in the section of Endocrinology, Diabetes, and Nutrition at Boston University, and President of the Obesity Society. And, calorie restriction often fails because the body resists weight loss by going into starvation mode to protect energy stores; hence, patients’ bodies do not respond favorably to diet alone, especially among those with obesity.

Approximately one out of three of your patients may present with obesity, for which there are a range of medical interventions, and yet, patients are too rarely advised of their options for medical nutrition therapy, pharmacotherapy, and bariatric surgery despite a general acknowledgment of their efficacy.

Treating obesity as a complex metabolic disease

A complex metabolic disease, obesity for many patients is best managed with bariatric surgery. Several compelling studies offer evidence that patients feel more motivated to achieve weight loss if advised by their physician but at 60% of doctor visits, no advise was offered.

For patients struggling with obesity, the long-term health benefits of having bariatric surgery are overwhelmingly beneficial: patients not only lose an average of 20-32% of their body weight (of which about 18% is sustained over 20 years) but they experience a reversal or even prevention of the commonly related chronic diseases. Yet, out of the 20 million people in the US who are suitable for this surgery, fewer than one percent opt to have it.

“Many patients still consider obesity a moral failure, thinking they just can’t seem to eat right or exercise,” and their doctors don’t say anything to help them think differently, Apovian said, “but obesity is a disease, affecting 33% of the population.”

Remove guilt from the conversation and discuss obesity as you would any other health condition

Insightful research by Ornellas et al, offers evidence that obesity is inherited from fathers as much as mothers, confirming the genetic influences for this disease. That is as important for clinicians to recognize, as it is to share with your patients. Removing the guilt and discussing obesity with the same objectivity as any other medical condition will make exploring the medical options a less formidable task for both clinician and patient.

Bariatric surgery is a viable choice for the vast majority of our patients, Dr. Apovian said. The procedure goes far beyond restricting food intake and calories, as bariatric surgery has been shown to reset the body weight setpoint and readjust the metabolic rate, making both weight loss and maintenance more achievable.

However, many primary care physicians who are not trained to treat obesity simply don’t refer their patients for bariatric surgery. “Rather, clinicians are treating the comorbidities that arise from obesity, such as diabetes and hypertension, with medications, even as some of these medications actually promote weight gain,” Dr. Apovian told Endocrine Web.

Some doctors tend to hold off on recommending the surgery, according to Scott A. Cunneen MD, Chief of Bariatric Surgery at Cedars Sinai Medical Center in Los Angeles. “They are hesitant to recommend something they think might hurt their patients,” he said, “perhaps because they may not realize how safe and effective bariatric surgery can be. Today, it is as safe as having a gallbladder removed.”

Currently, about 250,000 bariatric surgery procedures are performed each year in the US, Dr. Apovian said. Bariatric surgery has been shown to reverse type 2 diabetes as well as improve hypertension, hyperlipidemia, sleep apnea, and osteoarthritis, reducing or even eliminating the need for medications, and may even improve fertility in women, and increase testosterone levels in men.

Partner with your patients for the best results when treating obesity

Do you typically discuss this option with your patients, particularly for patients with poorly controlled diabetes, hypertension, or at high risk for cardiovascular disease (CVD)? If not—going forward—it's an important option for them to be aware.

The majority of patients with diabetes who have had bariatric surgery experienced a remission of their diabetes, according to findings published in the New England Journal of Medicine, and this procedure also had a favorable effect on patients with cardiovascular disease, according to another study. Additionally, research shows that the risk of death over time is some 35% lower among very obese patients who had bariatric surgery versus those who did not have the surgery.

Even patients with diabetic nephropathy experienced either long-term improvement or a resolution of their albuminuria, as reported by Heneghan et al. Some 80% of the patients (n=101) who underwent bariatric surgery at the Cleveland Clinic between 2005 and 2014 and were followed for 4 to 10 years had an overall improvement in their condition, with resolution of albuminuria resolving in half of these patients by the last follow-up.

The efficacy of bariatric surgery is further demonstrated by the strength of reimbursement provided by Medicaid across 46 states.

Which patients are appropriate candidates for bariatric surgery?

Traditionally, we tell patients to lose weight through changes in their diet and or exercise. But for a person with obesity, weight loss by lifestyle alone, which typically results in a five to 10% weight loss that will then be regained within six months, is often not clinically sufficient, Dr. Apovian said.

There is no hard and fast rule about when to recommend bariatric surgery. However, “bariatric surgery should only be recommended for patients with a high burden of disease who have engaged with a clinical team and been on a medical regimen for weight loss without sufficient success in meeting treatment goals,” said J. Michael Gonzalez-Campoy MD, PhD, Medical Director and Chief Executive Officer at the Minnesota Center for Obesity, Metabolism, and Endocrinology in Eagan, Minnesota.

Finding the right method of weight management requires an acute understanding of the specific needs of each patient. Individualized care is paramount since there is no one approach or procedure that will be a good fit for every one of your patients.

If you haven’t already:

  • Have a conversation about your patients’ dieting and weight loss history in order to ascertain their readiness to try a medical nutrition plan or commercial weight loss program, pharmacotherapy, or surgery.
  • Consider referring patients to a dietitian for a more comprehensive assessment, especially if they have prediabetes, diabetes, or cardiovascular disease. They can assess the best intervention for each patient and make a recommendation to you.
  • It’s okay to admit that you don’t have the interest or time, both very valid, and to refer your patients to an obesity specialist or a bariatric surgeon, just as you would with any other health condition. 

Which Surgical Procedure is Preferable?

Patients who decide to proceed with bariatric surgery have several options.

  • Laparoscopic sleeve gastrectomy
  • Laparoscopic adjustable gastric band
  • Gastric bypass: Roux-en-Y

The most common procedure, gastric bypass, involves creating a small pouch at the top of the stomach and attaching it to a section of the small intestine. This eliminates the functional use of most of the stomach and a sizable section of the small intestine. Food intake is restricted, which induces a feeling of fullness more quickly.

With gastric banding, an adjustable band is placed around the top part of the stomach to create a small pouch above the band. The tightness of the band opening controls the passage of food between the two parts of the stomach, and patients feel full more quickly. However, weight loss tends to be gradual, and the band may break necessitating repeated surgeries for replacement.

In a sleeve gastrectomy, more than half the stomach is removed to create the shape of a tube, or “sleeve,” that restricts how much food is consumed in a sitting.

Having a bariatric procedure matters more than which type of surgery is selected as all three methods of surgical weight loss are associated with improved outcomes in comparison to nonsurgical medical management. The issue is one of personal preference and helping your patient understand the long-term side effects as well as the dietary adjustments needed to manage their weight post-surgery.

After bariatric surgery, patients tend to be in the hospital for a day or two, then they are able to return to work in a few weeks, according to Dr. Cunneen. “There is definitely some fatigue, and patients are restricted from lifting for a month or so,” as well as similar restrictions to most other surgical procedures.

For more on post-operative care, Neff et al offer a useful overview.

After bariatric surgery, a patient usually becomes satisfied with smaller amounts of food and weight loss results, Dr. Apovian said, but most importantly, bariatric surgery appears to reset the natural body weight set-point as well as produce substantive metabolic changes with positive effects on and interaction with the brain, gut, adipose tissue, muscle and multiple organs.

None of the physicians offering commentary have any financial conflicts of interest.

Continue Reading:
Adults with Obesity: Clinical Practice Guideline for Office Visits
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