Bariatric Surgery Remains Missed Opportunity for Medical Care

Given the surging rates of diabetes, hypertension, cardiovascular disease, and obesity-related cancers, the time has arrived for clinicians to address bariatric surgery as an appropriate option for many patients.

With Caroline Apovian, MD, Scott A. 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, FACP, FACN, professor of medicine and pediatrics in the section of endocrinology, diabetes, and nutrition at Boston University, and the 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.

At least one out of three of your patients will present with obesity,1 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.2

Bariatric surgery should be recommended to many more patients with diabetes by their doctors.

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 fewer than 60% of doctor visits, no advise was offered.2-3

For individuals 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.4,5 Yet, out of the 20 million people in the US who are suitable for this surgery, fewer than one percent opt to have it.1

Obesity is Often Best Managed with Bariatric Surgery

“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, she said, “but obesity is a disease, affecting more than 33% of the population.”1

Insightful research by Ornellas et al,6 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 will make exploring the medical options less formidable task for both clinician and patient.

Bariatric surgery is an excellent choice for the vast majority of our patients, Dr. Apovian said. The procedure goes far beyond restricting food intake and calories, 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,” she told EndocrineWeb.

Some doctors tend to hold off on recommending the surgery, according to Scott A. Cunneen, MD, FACS, FASMBS, 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,1 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.5

Partner with Your Patients: Time to Address Obesity Directly

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—you should.

The majority of patients with diabetes who have had bariatric surgery experienced a remission of their diabetes,6 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 individuals who had bariatric surgery versus those who did not have the surgery.4

Even patients with diabetic nephropathy experienced either long-term improvement or a resolution of their albuminuria,7 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.7

The efficacy of bariatric surgery is demonstrated by the strength of reimbursement provided by Medicaid across 46 states.8

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 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, FACE, 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.1,2 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 ok to admit that you don’t have the interest or time, both very valid, so refer your patients to an obesity specialist or a bariatric surgeon.

Assess Patients for Prerequisite Factors. In ascertaining whether to the patient may be a candidate for bariatric surgery, begin with the patient’s weight and whether s/he would be a good candidate for the surgery. The basic starting point is body mass index (BMI). A healthy weight is considered a BMI of 18 to 25 kg/m3, so patients with a BMI > 30 or a waist circumference greater than 35 inches (women) or 40 inches (men) have the clinical parameters.9 However, they need to have the psychological readiness and desire to consider having a surgical procedure.

Which Surgical Procedure is Preferable?

Patients who decide to proceed with bariatric surgery have several options.3

  • 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 and 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.

Of note, 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.4,5  The issue is one of personal preference and having the patient know 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;” similar restrictions to most other surgical procedures.

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.

Bariatric surgery side effects include infection, bleeding, and diarrhea, immediately following surgery but resolve, as well as leaking from the surgical sites, nutritional deficiencies, gallstones, and strictures and hernia.In the case of gastric bypass, some people may have difficulty absorbing and metabolizing alcohol.7

For more on post-operative care, Neff et al offer a useful overview.10

Considerations in Select Populations with Specific Weight Control Needs

More prevalent in women than men, obesity introduces health concerns that are sex-specific. In particular, there is a need for clinicians to consciously avoid prescribing weight-promoting medications.

Particularly to women with type 2 diabetes and/or prolonged overweight and tendency toward weight gain,11 according to Tauqueer et al. Even modest weight loss has been shown to improve issues of fertility, pregnancy outcomes, and pelvic floor disorders.11

As for the role of bariatric surgery, recent research strengthens our understanding of the significant adverse effects of perinatal obesity on fetal and long-term health as contributed by both the father and mother. And, babies born to mothers who have achieved weight loss with the assistance of bariatric surgery prior to their pregnancy had improved metabolic outcomes;11 this is a very compelling argument for clinicians to raise the option of bariatric surgery with women who have obesity and whose long-term goal is pregnancy.

Pediatric Considerations. Recent research supports the benefits of bariatric surgery in adolescents with obesity, and that these procedures are effective and well-tolerated, particularly when diabetes is present.12,13  Despite sufficient clinical support, pediatric clinicians, as a whole, remain hesitant to recommend surgery viewing it as a drastic procedure rather than one that is life-affirming.14

“Obesity is a life-long disease,” said Dr. Gonzalez-Campoy.  “Patients who view bariatric surgery as a means to improve their health in the short term, but then continue to work with their doctor to treat the obesity, do well. Conversely, patients who think bariatric surgery will be a ‘cure’ tend not to continue managing their obesity, and they are at high risk of weight regain,” he told EndocrineWeb.

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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