The weight-loss (bariatric) surgeons are on the prowl, looking for new candidates for surgery. Now it seems they have some more evidence to back up their claims. New studies report that “mildly obese” people (BMI 30–34.9) gain as much benefit from surgery — in terms of weight, blood glucose, blood pressure, and cholesterol control — as heavier people do.
I apologize if this is starting to sound more like a weight blog than a diabetes blog. But these are important questions and this is interesting science. Last week I reported on studies showing that overweight people (BMI 25–29.9) lived longer than normal weight people. What does this new report mean for us?
Speaking at the American Society of Metabolic and Bariatric Surgery meeting in Dallas at the end of June, Jenny Choi, MD, of Columbia University in New York, said that the current guidelines for bariatric surgery “should be reevaluated.”
Choi reported on five studies showing great benefit for people with BMIs under 35 who received surgery. (Note: For a 5′ 10″ person, a BMI of 30 is a weight of roughly 210 pounds, a BMI of 35 is about 245 pounds, and a BMI of 40 is approximately 280 pounds. I used this BMI calculator to determine these numbers.) The largest of the studies involved 210 people with BMIs under 35 who were treated with gastric banding and followed for five years. Loss of excess weight averaged 71% for these people. More importantly, 89% of the people saw an improvement or complete resolution of conditions such as Type 2 diabetes, hypertension, sleep apnea, as well as other conditions including arthritis, asthma, and depression. Six percent of people had “significant” complications of the surgery, including two cases of the gastric band slipping and one of the band eroding, but none of the complications were fatal.
What does it Mean?
Currently, the National Institutes of Health (NIH) guidelines approve bariatric surgery for people with BMI over 40 or a BMI over 35 and significant “comorbidities.” “Comorbidities” basically means “other conditions.” The ones usually mentioned with obesity are diabetes, high cholesterol, and high blood pressure.
Choi and colleagues suggest the guidelines be lowered to a BMI of less than 35 without comorbidities or a BMI of less than 30 with comorbidities. In Italy and India, they’re doing surgery for people with even lower BMIs. In an Indian study, Shashank Shah, MD, reported on 15 people who had a BMI of 22 to 35. All had poorly controlled Type 2 diabetes. Most also had hypertension and cholesterol problems. Most of them had improved BMIs, blood pressure, and cholesterol at nine months follow-up. The article I read did not mention surgical complications in this group.
The surgeons want the guidelines changed so they can get paid for doing more surgeries, which means we should be skeptical of their claims. However, this evidence does look pretty strong.
Surgery might be appropriate for people who are having metabolic symptoms. If you have elevated A1C, cholesterol, or blood pressure, or if weight is contributing to arthritis, sleep apnea, or gastric reflux (GERD), banding might be an option, even if your BMI is below 40.
On the other hand, if your metabolic numbers and general health are good, you might want to leave the weight alone. You’re probably all right with it, as long as you stay in shape and your numbers are OK. Unfortunately, that situation doesn’t apply to many people with diabetes.
But Does it Last?
It’s important to note that both the weight loss and metabolic improvements from surgery may not last. Long-term follow up of people who have had gastric bypass show significant regain of weight, and often of cholesterol, as well as fasting glucose level over five or more years. There are also dangerous side effects of some surgeries, although for gastric banding, the incidence is low. Banding and some gastric bypasses can now be done by laparoscope (a method of minimally invasive surgery in which only small incisions are made), so it’s much easier to heal from.
Other studies show additional advantages of surgery. A recent report from Utah found a lower cancer risk and a roughly 40% reduction in cancer deaths in people who’d had bariatric surgery, compared to obese people in a control group.
As you can probably tell, I’m conflicted about this. I hate the notion that we have to mutilate our bodies to be “healthy.” It kind of twists the idea of what health even means. But it seems to me that the environment is sick, with too much bad food and stress, and so many obstacles to physical activity. The bodies we are born with may not be good matches for our environment any more.
What do you think? Let me know, and I’ll stop discussing weight for a while.