Two groups of bariatric surgeons have overhauled weight loss surgery guidelines for the first time in more than 30 years, saying the previous standards are out of date and inadequate to cope with America’s growing levels of obesity.
The new standards, released early Friday, will vastly increase the number of people eligible for the operations.
Weight loss surgery has become dramatically safer in recent decades and shown to reverse or improve dozens of weight-related diseases, but guidelines last set in 1991 haven’t been updated to reflect the improvements. That’s why the American Society for Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders, which represents 72 countries, decided to make the new recommendations.
The old guidelines were “trapped in the past,” said Dr. Shanu Kothari, immediate past president of the American Society for Metabolic and Bariatric Surgery. “We’ve made tremendous strides in the fields of metabolic and bariatric surgery in three decades. So, we feel it’s time to update these.”
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The new guidelines reduce the weight limit to qualify for the surgery and drop the requirement that all but the heaviest people must have a medical problem resulting from their obesity. Children and adolescents are also now eligible for surgery.
Kothari said he hopes insurance companies will update their coverage to comply with the new standards. Other medical organizations like the American Heart Association and the American Diabetes Association update their treatment guidelines every year or two, and insurance coverage usually reflects those changes.
Confusion over who qualifies for surgery
Today, many patients and their doctors are confused about who qualifies for surgery and who doesn’t.
“It’s a mess,” said Dr. Ali Aminian, who was involved in drafting the new guidelines.
At last count, before the pandemic, 42% of Americans met the definition for having obesity and about 10% have diabetes, which increases the risk for a wide range of medical problems, from heart disease to amputations. More than 200 diseases have been tied to excess weight.
Weight loss operations that used to require five to seven days of hospitalization and several months of recovery are now done with keyhole incisions, often with robotic assistance, Aminian said.
Patients routinely go home the next day and can resume their normal lives, without post-surgical pain, in two or three days, he said. Death rates from surgery have fallen 20- to 30-fold, from 2 or 3 per 100 patients to about 1 in 1,000.
Changing the guidelines won’t remove the lack of public awareness, stigma or fear around bariatric surgery or guarantee insurance coverage, but it will remove one barrier to care, said Aminian, who directs the Bariatric and Metabolic Institute at the Cleveland Clinic.
“Even if you have simply failed conventional means, regardless of your comorbidity status, we think surgery should be considered,” said Kothari, also chair of surgery at Prisma Health in Greenville, South Carolina
New guidelines still based on BMI
The new guidelines, like the old ones, are based on body mass index, a measure of weight versus height.
Previously, to qualify for surgery patients had to have a BMI of at least 40 or a BMI of 35 or more and at least one obesity-related medical condition such as hypertension or heart disease. Diabetes was not included, though the surgery has since been shown to make a dramatic different in metabolism, often rapidly reversing diabetes.
Under the new guidelines, anyone with a BMI over 35 should be considered for surgery, whether or not they have health problems, according to the new guidelines, along with people whose BMI tops 30, the official definition of obesity, if they have not being able to achieve significant or long-lasting weight loss.
For people of Asian descent, the surgeons dropped the BMI requirement for surgery to 27.5 because they often have weight-related health problems starting at a lower body mass.
Children and adolescents with severe obesity are also eligible for surgery under the new criteria. They were generally excluded from the earlier ones because of a lack of data.
Weight-related diseases are easier to reverse if treated in adolescence, Aminian said.
“We have a lot of data to support that the outcomes of kids who underwent surgery were much better than the outcomes of patients who had surgery for their obesity in their 40s and 50s,” he said. “If we wait a long time, some of those consequences of obesity are not reversible.”
Dr. Fatima Cody Stanford, a weight loss specialist at Massachusetts General Hospital, said she wishes the surgeons had moved away from using BMI as a determining factor for surgery.
“I hate BMI,” she said, noting that it was initially developed as a standard for 19th century Belgian soldiers and is irrelevant in the face of America’s current, diverse population. “It’s an arbitrary thing. It doesn’t define one’s health.”
Instead, she said, she would rather see a decision for surgery based on true measures of health, such as high blood sugar levels, evidence of inflammation, high cholesterol and fatty liver disease. She’s seen people with a BMI of 22 fare poorly by those standards, she said, and those with a BMI well over 30 who are healthy.
Her experience with surgery has been mixed, Stanford said.
She had one patient whose diabetes was uncontrollable for years, even though he followed doctors’ instructions to the letter. Surgery reversed his diabetes completely.
But many others have surgery and years later, their weight creeps back up, along with hormonal problems, as the body fights back against weight loss. They benefit from medication, she said, and maybe could have done fine on medication alone.
Regaining weight after surgery can affect someone’s self-worth, she said.
Inadequate medical training and lack of insurance coverage remains a huge barrier to weight loss, whether from surgery, medication or both, Stanford said.
Doctors are not routinely taught how to help patients lose weight, though more than 100 million Americans struggle with their weight. Her practice is so busy that she doesn’t accept new patients and Massachusetts General’s weight loss center has 4,000 people on its wait list.
Health coverage for obesity is uneven across the country, but Medicare and insurers rarely cover obesity-related treatments or surgery, unless the person also has severe weight-related health issues. In Massachusetts, for instance, Medicare covers surgery but not medications, while top-tier health plans cover both, Stanford said.
It’s ironic, Kothari said, that data from the Veterans Administration helped establish the effectiveness of surgery, but the VA doesn’t cover the cost of obesity surgery.
Historically, he said, coverage was denied because the inability to lose weight was seen as an issue of willpower, but decades of research shows instead that it is driven by biology.
“We have plenty of data to show obesity is a disease and needs to be treated as such,” Kothari said. The aim of the new surgical guidelines “is to improve access to patients who deserve it based on contemporary evidence and … to impact and change coverage policies.”
Contact Karen Weintraub at firstname.lastname@example.org.
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