Applied Evidence

Obesity: When to consider surgery

J Fam Pract. 2018 October;67(10):614-616,618-620

Author(s):

Sarah R. Barenbaum, MD

Katherine H. Saunders, MD, DABOM

Leon I. Igel, MD, FACP, DABOM

Alpana P. Shukla, MD, MRCP

Louis J. Aronne, MD, FACP, FTOS, DABOM

Bariatric surgery is underutilized despite an obesity epidemic. Here, 3 patients pursue a surgical option when they can't reach their target weight and optimal health by nonsurgical means.

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PRACTICE RECOMMENDATIONS

Among adult patients with body mass index* ≥40, or ≥35 with obesity-related comorbid conditions:

› Consider bariatric surgery in those who are motivated to lose weight but who have not responded to lifestyle modification with or without pharmacotherapy in order to achieve sufficient and sustained weight loss. A

› Consider bariatric surgery to help patients achieve target health goals and reduce/improve obesity-related comorbidities. A

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

*Calculated as weight in kilograms divided by height in meters squared.

References

1. Must A, Spadano J, Coakley EH, et al. The disease burden associated with overweight and obesity. JAMA. 1999;282:1523-1529.

2. Wing RR, Lang W, Wadden TA, et al. Benefits of modest weight loss in improving cardiovascular risk factors in overweight and obese individuals with type 2 diabetes. Diabetes Care. 2011;34:1481-1486.

3. Magkos F, Fraterrigo G, Yoshino J, et al. Effects of moderate and subsequent progressive weight loss on metabolic function and adipose tissue biology in humans with obesity. Cell Metab. 2016;23:591-601.

4. American Academy of Family Physicians. Clinical preventive service recommendation: Obesity. www.aafp.org/patient-care/clinical-recommendations/all/obesity.html. Accessed August 22, 2018.

5. American Academy of Family Physicians: USPSTF draft recommendation: Intensive behavioral interventions recommended for obesity. www.aafp.org/news/health-of-the-public/20180221uspstfobesity.html. Published February 21, 2018. Accessed August 22, 2018.

6. Saunders KH, Shukla AP, Igel LI, Aronne LJ. Obesity: When to consider medication. J Fam Pract. 2017;66:608-616.

7. Roux CW, Heneghan HM. Bariatric surgery for obesity. Med Clin North Am. 2018;102:165-182.

8. Sjöström L, Peltonen M, Jacobson P, et al. Bariatric surgery and long-term cardiovascular events. JAMA. 2012;307:56-65.

9. Sjöström L. Review of the key results from the Swedish Obese Subjects (SOS) trial - a prospective controlled intervention study of bariatric surgery. J Intern Med. 2013;273:219-234.

10. Reges O, Greenland P, Dicker D, et al. Association of bariatric surgery using laparoscopic banding, Roux-en-Y, gastric bypass, or laparoscopic sleeve gastrectomy vs usual care obesity management with all-cause mortality. JAMA. 2018;319:279-290.

11. Lee JH, Nguyen QN, Le QA. Comparative effectiveness of 3 bariatric surgery procedures: Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and sleeve gastrectomy. Surg Obes Relat Dis. 2016;12:997-1002.

12. American Society for Metabolic and Bariatric Surgery. Estimate of bariatric surgery numbers, 2011-2017. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Published June 2018. Accessed August 22, 2018.

13. Courcoulas AP, King WC, Belle SH, et al. Seven-year weight trajectories and health outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study. JAMA Surg. 2018;153:427-434.

14. Heymsfield SB, Wadden TA. Mechanisms, pathophysiology, and management of obesity. N Engl J Med. 2017;376:254-266.

15. Colquitt JL, Pickett K, Loveman E, Frampton GK. Surgery for weight loss in adults. Cochrane Database Syst Rev. 2014;(8):CD003641.

16. Jensen MD, Ryan DH, Apovian CM, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines; Obesity Society. 2013 AHA/ACC/TOS guideline for the management of overweight and obesity in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society. Circulation. 2014;129:S102-S138.

17. Garvey WT, Mechanick JI, Brett EM, et al; Reviewers of the AACE/ACE Obesity Clinical Practice Guidelines. American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for comprehensive medical care of patients with obesity. Endocr Pract. 2016;22 Suppl 3:1-203.

18. Carlin Am, Zeni Tm, English WJ, et al; Michigan Bariatric Surgery Collaborative. The comparative effectiveness of sleeve gastrectomy, gastric bypass, and adjustable gastric banding procedures for the treatment of morbid obesity. Ann Surg. 2013;257:791-797.

19. Gill RS, Birch DW, Shi X, et al. Sleeve gastrectomy and type 2 diabetes mellitus: a systematic review. Surg Obes Relat Dis. 2010;6:707-713.

20. Karamanakos SN, Vagenas K, Kalfarentzos F, et al. Weight loss, appetite suppression, and changes in fasting and postprandial ghrelin and peptide-YY levels after Roux-en-Y gastric bypass and sleeve gastrectomy. Ann Surg. 2008;247:401-407.

21. Abdeen G, le Roux CW. Mechanism underlying the weight loss and complications of Roux-en-Y gastric bypass. Obes Surg. 2016;26:410-421.

22. Schauer PR, Bhatt DL, Kirwan JP et al; STAMPEDE Investigators. Bariatric surgery versus intensive medical therapy for diabetes - 5-year outcomes. N Engl J Med. 2017;376:641-651.

23. Aminian A, Brethauer SA, Andalib A, et al. Individualized metabolic surgery score: procedure selection based on diabetes severity. Ann Surg. 2017;266:4:650-657.

24. Smetana GW, Jones DB, Wee CC. Beyond the guidelines: Should this patient have weight loss surgery? Grand rounds discussion from Beth Israel Deaconess Medical Center. Ann Intern Med. 2017;166:808-817.

25. Wolfe BM, Morton JM. Weighing in on bariatric surgery: procedure use, readmission rates, and mortality [editorial]. JAMA. 2005;294:1960-1963.

Patients with overweight and obesity are at increased risk of multiple morbidities, including cardiovascular disease, stroke, type 2 diabetes (T2D), osteoarthritis, obstructive sleep apnea (OSA), and all-cause mortality.¹Even modest weight loss—5% to 10%—can lead to a clinically relevant reduction in this risk of disease.^2,3The American Academy of Family Physicians recognizes obesity as a disease, and recommends screening of all adults for obesity and referral for those with body mass index (BMI)* ≥30 to intensive, multicomponent behavioral interventions.^4,5

For some patients, diet, exercise, and behavioral modifications are sufficient; for the great majority, however, weight loss achieved by lifestyle modification is counteracted by metabolic adaptations that promote weight regain.⁶For patients with obesity who are unable to achieve or maintain sufficient weight loss to improve health outcomes with lifestyle modification alone, options include pharmacotherapy, devices, endoscopic bariatric therapies, and bariatric surgery.

Bariatric surgery is the most effective of these treatments, due to its association with significant and sustained weight loss, reduction in obesity-related comorbidities, and improved quality of life.^1,7 Furthermore, compared with usual care, bariatric surgery is associated with a reduced number of cardiovascular deaths, a lower incidence of cardiovascular events in adults with obesity, and a long-term reduction in overall mortality.^8-10

What are the options? Who is a candidate?

The 3 most common bariatric procedures in the United States are sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), and laparoscopic adjustable gastric band (LAGB).¹¹ SG and RYGB are performed more often than the LAGB, consequent to greater efficacy and fewer complications.¹² Weight loss is maximal at 1 to 2 years, and is estimated to be 15% of total body weight for LAGB; 25% for SG; and 35% for RYGB.^13,14

Weight loss is estimated to be 15% of total body weight for the laparoscopic adjustable gastric band, 25% for sleeve gastrectomy, and 35% for Roux-en-Y gastric bypass.

Not all patients are candidates for bariatric surgery. Contraindications include chronic obstructive pulmonary disease or respiratory dysfunction, poor cardiac reserve, nonadherence to medical treatment, and severe psychological disorders.¹⁵ Because some patients have difficulty maintaining weight loss following bariatric surgery and, on average, patients regain at least some weight, patients must understand that long-term lifestyle changes and follow-up are critical to the success of bariatric surgery.¹⁶

When should bariatric surgery be considered?

American Heart Association/American College of Cardiology/The Obesity Society guidelines¹⁶ conceptualize 2 indications for bariatric surgery:

adults with BMI ≥40
adults with BMI ≥35 who have obesity-related comorbid conditions and are motivated to lose weight but have not responded to behavioral treatment, with or without pharmacotherapy, to achieve sufficient weight loss for target health goals.

American Association of Clinical Endocrinologists guidelines¹⁷ conceptualize 3 indications for bariatric surgery:

adults with BMI ≥40
adults with BMI ≥35 with 1 or more severe obesity-related complications
adults with BMI 30-34.9 with diabetes or metabolic syndrome (evidence for this recommendation is limited).

Continue to: The 3 illustrative vignettes presented...