Surgeons say the eligibility threshold should be lowered, but others worry the bypass operation could be used as a crutch.
Imagine how frustrating it would be if you had a life-altering tool in your surgical toolbox that you know could change the progress of someone’s disease and yet you don’t get to use it very often.
That’s the position bariatric surgeons find themselves in when it comes to using weight loss surgery to treat people with diabetes.
The current three-decade-old criteria for the surgery is that a person have a body mass index (BMI) of 40 or more.
Or, the person can have a BMI of 35 and higher if they also have another life-threatening condition such as diabetes, high blood pressure, or heart disease.
But bariatric surgeons say there is growing evidence that lowering that threshold to 30, which is considered in the mild obesity range, could be life-altering for people with diabetes.
“The surgery really changes their trajectory. It puts the majority of those patients into [diabetes] remission, meaning they’re off all their medication and they have a normal glucose level. Even if they don’t achieve remission, they’ll see improvement. They may be able to get off insulin, and just take a pill, or they have fewer medications to take. Most importantly, their day-to-day glucose will be under control,” said Dr. Stacy Brethauer, a professor of surgery at The Ohio State University College of Medicine and a senior past president of the American Society for Metabolic and Bariatric Surgery.
Brethauer helped draft a new set of ASMBS guidelines that pushes for the lower threshold BMI criteria as an early intervention for diabetes.
In 2016, the 2nd Diabetes Surgery Summit published its own guidelines that suggested metabolic surgery be considered for people with diabetes who fall into the lower BMI threshold, if their blood sugars are uncontrolled by medications.
The policy was formally endorsed by 45 worldwide medical and scientific societies, including the American Diabetes Association.
In a study published in April, Danish researchers reported that 74 percent of people with diabetes who had gastric bypass were in remission at the one-year mark.
They also had a reduced risk of developing vascular complications.
However, by the five-year mark, 27 percent had relapsed.
So far, the research has focused on lowering the BMI threshold for bariatric surgery for people with diabetes because weight is so closely tied to the disease.
However, some medical professionals worry that a lower threshold might open the door to using weight loss surgery as a way to attack the country’s obesity epidemic.
They say people who are obese might seek the surgery as a crutch, instead of making lifestyle changes such as diet and exercise. Then, some simply regain weight at some point after the surgery.
“There are patients who regain weight, but it is not a failure of the operation,” Brethauer told Healthline.
He says even for people with diabetes, bariatric surgeons begin conservatively at first, prescribing medication and recommending lifestyle changes before escalating to the weight loss surgery.
These patients work with a multidisciplinary team that often includes a nutritionist, psychologist, fitness expert, and medical weight loss specialist along with the surgeon.
“Anyone who goes into bariatric surgery as a patient thinking it’s a magic bullet pill and they never have to worry about managing their food intake [is] going in with unrealistic expectations,” Dr. Scott Kahan, the director of the National Center for Weight and Wellness, told Healthline.
“No matter whether you get bariatric surgery or you don’t, behavioral change, living a healthy life, managing what you eat, managing physical activity and managing your stress, that’s inevitable if you’re going to manage your weight,” Kahan said.
“But just addressing the public health environment isn’t necessarily going to help people who already have severe obesity,” he added.
Obesity medicine specialists say there are new advances that can help.
“It’s a new area. The new generation anti-obesity medications have only been around four to six years. So people are getting used to this idea that it’s not just nutrition and physical activity or surgery. I have an option in the middle. And maybe I should try that less invasive option first, if my disease state is at a point that can allow that,” said Dr. Deborah Horn.
Horn is chair of the board of trustees of the Obesity Medicine Association, medical director of the Center for Obesity Medicine and Metabolic Performance, and a clinical assistant professor at the University of Texas Medical School.
“The average weight loss on the medications is between 5 and 10 percent,” Horn told Healthline. “That’s enough for many people to get their diabetes in remission. There’s a new generation of medications coming out in the next two years or so. Those meds reach into the 14 to 15 percent weight loss range. That starts to approach some of our surgical capabilities.”
However, many of those anti-obesity drugs aren’t covered by insurance. It’s also one of the biggest hurdles bariatric surgeons face in performing the lower BMI threshold surgeries on patients with diabetes.
“If I have a patient with a BMI of 34 who has diabetes, I will submit them to the insurance company for approval, expecting a denial. That opens the door to a conversation. I share the data with them. It’s a step-by-step process to change the thinking,” Brethauer said.
“One of the arguments we make is that the surgery is cost effective. It’s the only operation I can think of that pays for itself in one to two years. The patient requires fewer medications, uses fewer resources,” he said.
“We’ve got lots of strong evidence-based arguments. It is just a matter now of continuing to push forward with both the payers and referring physicians,” he added.