Metabolic and Bariatric Surgery
By Hope Warshaw, MMSc, RD, CDCES, BC-ADM, FADCES
Today’s Dietitian
Vol. 26 No. 1 P. 24
Key Trends Impacting RDs Working in Weight Management
According to the CDC’s 2022 US obesity prevalence statistics, the rate of adult obesity continues to increase in 22 states, with a concentration in the Southeast, having a prevalence at or above 35% compared with 19 states in 2021.1 Severe obesity, classified as Class III, particularly when calculated with bias-corrected estimates rather than self-reported data, also is increasing, especially in women.2 (See sidebar “Evolving Classification Systems for Obesity.”)
The use of metabolic and bariatric surgery (MBS) for the treatment of severe obesity has been shown time and again to be the most effective evidence-based long-lasting treatment across all BMI classes and significantly reduces several weight related diseases.3,4 (See sidebar “Prevent, Reduce Comorbidities With MBS.”)
In 2019, 256,000 procedures were performed in the United States, according to data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP).5,6 This number dipped to just under 200,000 in 2020 due to the COVID-19 pandemic but returned to prepandemic levels in 2021.4,6,7 Notably, only about 1% of people annually who are eligible for MBS have the procedure, making it among the least used medical treatments.4,6
In this article, Today’s Dietitian (TD) provides an update on the evolution of MBS, describes the most common surgeries performed today, gives details on key long-term MBS research studies with expert takeaways, and reviews the latest guidelines and resources for MBS nutrition therapy and how the new antiobesity medications are impacting the decision to have MBS as well as their use pre- and postsurgery.
MBS Evolution to Today
As in many areas of science, surgical methods and techniques often change. In the case of obesity, changes have occurred in the types of MBS performed. The origins of MBS date back to the 1960s when researchers observed substantial weight loss in people who underwent subtotal gastrectomy for cancer treatment.8
The most commonly performed procedures today are vertical sleeve gastrectomy (VSG) and Roux-en Y gastric bypass (RYGB), with surgeons performing VSG slightly more frequently in the United States and globally.6,8 Together, these two MBS procedures account for roughly 90% of all surgeries performed worldwide.9 According to trend data, the adjustable gastric band procedure is performed less often, and the biliopancreatic diversion with duodenal switch procedures are performed somewhat more frequently. (For more information, visit the American Society of Metabolic and Bariatric Surgery [ASMBS] at https://asmbs.org/conditions-procedures).6
“Over the past 60 years, MBS has become safer by decreasing both complications and mortality,” says Marina Kurian, MD, FACS, FASMBS, DABOM, 2023–2024 president of ASMBS and a surgeon in New York City specializing in minimally invasive surgeries. “Today, MBS is as safe as—if not safer than—having a laparoscopic cholecystectomy. We utilize minimally invasive and robotic techniques that have resulted in decreased pain and allow for earlier mobilization that, in turn, improves recovery,” Kurian says. The Two Common Surgeries
• VSG. Often referred to as the “sleeve,” this surgery divides the stomach vertically to create a sleeve and removes about 75% of the stomach volume. The piece that remains is the size and shape of a banana. The VSG technically is simpler than RYGB; however, the downside is that it’s nonreversible.8,9
• RYGB. Often referred to as the “gastric bypass,” its translation of the French term means “in the form of a Y.” The stomach is divided, and a small gastric pouch (~30 mL) is created with the top portion of the stomach. Food continues to pass through this pouch. The surgery bypasses the larger part of the stomach, and food no longer reaches it. The small intestine also is divided. A portion is anastomosed (connected) to the new small stomach pouch, and another portion is anastomosed to the proximal jejunum three to four feet lower, where continuity of the intestine is restored with another connection in the shape of a Y. The result is that food bypasses most of the stomach, the entire duodenum, and the proximal jejunum, where it’s then rejoined and mixed with digestive juices lower in the GI tract.8,9
Both surgeries remove the portion of the stomach that produces the hunger hormone ghrelin. Due to the rearrangement of the bowel, both surgeries also increase the rise of other hormones, including the incretins glucagon-like peptide-1 (GLP-1) and glucose-dependent Insulinotropic polypeptide, along with peptide YY8,9—all of which are produced in the small intestine. These three hormones decrease hunger and increase fullness. The incretins also lead to rapid improvements in insulin release and sensitivity independent of weight loss, which also improves insulin release and sensitivity. What’s more, the surgeries cause limited or no macronutrient malabsorption.8,9
While both of these surgeries lead to successful weight loss outcomes, why does one person choose the VSG and another the RYGB? “Surgery selection often includes the person’s preference, but ultimately the decision is based on which surgery is most medically appropriate for them,” says Melissa Page, MS, RDN, CSOWM, senior bariatric dietitian at Maine Health Weight & Wellness Program and current chair of the Academy of Nutrition and Dietetics’ (the Academy) Weight Management Dietetic Practice Group (WM DPG). Page offers two concrete examples: If a person has a history of gastroesophageal reflux disease, a surgeon may not recommend the VSG due to the slightly higher risk of reflux. If a person has type 2 diabetes, a surgeon may recommend RYGB over VSG due to the higher rates of resolution of type 2 diabetes with that procedure. (See sidebar “Criteria for Metabolic and Bariatric Surgery.”)8,9
Due to the intense focus and research on understanding the pathophysiology of obesity over the last couple of decades, significant knowledge has amassed on how large increases of weight impact physiology and, conversely, how dramatic weight loss does the same. Today, other mechanisms appear to be at play that go beyond the understanding that MBS promotes a decrease in energy (calorie) absorption. These mechanisms include appetite control, increased release of gut peptides (such as GLP-1 and other incretins), the roles of peptide YY and ghrelin, adipose tissue function, changes in the microbiota, and other factors. Research will continue to further elucidate these mechanisms.9
Evidence for Long-Term Weight Loss and Maintenance
Many post-MBS studies that track weight loss and other clinical outcomes have been conducted over the years. For instance, the Swedish Obesity Study (SOS) is the largest cohort researchers have followed for more than 20 years.11,12 “The other key outcomes study that continues to be regularly cited in terms of five-year outcomes for people with diabetes is the Surgical Treatment and Medication Potentially Eradicate Diabetes Efficiently (STAMPEDE) trial,” says Laura Andromalos, MS, RD, RN, CSOWM, CDCES (www.lauraandromalos.com), a dual-discipline clinician who specializes in weight management, diabetes, and women’s health, who’s currently an inpatient nurse at Hennepin County Medical Center in Minneapolis, and immediate past chair of the Academy’s WM DPG.13,14
• The SOS. Initiated in 1987, the SOS recruited subjects through 2001. A total of 2,010 subjects underwent MBS: vertical banded gastroplasty (68%), banding (19%), or gastric bypass (13%), and 2,037 matched control subjects received conventional obesity treatment. Subjects were between the ages of 37 and 60 and had a BMI of at least 34 for men and 38 for women. All subjects were eligible for MBS to allow for randomization. SOS was conducted at 25 public surgical departments and 480 primary health care centers in Sweden. The mean changes in body weight after two, 10, 15, and 20 years were -23%, -17%, -16%, and -18% in the surgery group, respectively, and 0%, 1%, -1%, and -1% in the control group, respectively.12 Many papers have been published by the SOS researchers on various aspects of the study. A recent publication on the SOS showed that subjects who underwent MBS experienced a longer life expectancy than those who received usual obesity care. However, mortality remained higher in all subjects compared with the general population.11
• STAMPEDE. Initiated in 2007, the STAMPEDE trial recruited subjects through 2011. Eligible participants (n=150) were randomized to undergo intensive medical therapy (IMT) alone or IMT plus RYGB or VSG. Subjects had a diagnosis of type 2 diabetes and were between the ages of 20 and 60, with a BMI of 27 to 43. The study’s primary endpoint was the proportion of people with an A1c of 6% or less (with or without glucose-lowering medications) 12 months after randomization.13 At baseline in 2012, the mean A1c was 9.2 + 1.5%, and the mean BMI was 37 + 3.5. At 12 months, 93% of subjects completed follow up. Just 12% (5 of 41) in the IMT-alone group vs 42% (21 of 50) in the RYGB group and 37% (18 of 49) in the VSG group met the primary endpoint. Weight loss was greater in the RYGB group (-29.4 + 9.0 kg) and VSG group (-25.1 + 8.5 kg). Use of related medications was significantly lower in both surgical groups and increased in the IMT-alone group. After five years of follow up, 90% of subjects completed the study, with only 5% of the IMT-alone group achieving the primary endpoint, whereas 29% who had RYGB and 23% who underwent VSG achieved this goal.14
From Research to Teaching Takeaways
While RYGB and VSG lead to weight loss success, many patients may regain some weight postsurgery. “Prior to surgery, I share with prospective surgery patients the research that generally shows people will reach their lowest weight within a year postsurgery and may experience some weight regain in future years,” Page says. “I do this not to scare them, but to prepare them mentally. Many people feel they have failed if they regain any weight after surgery. That’s just not true. We monitor weight to assure expected weight loss and offer other tactics, if needed, such as behavioral interventions or an adjuvant therapy such as an antiobesity medication. (See subhead “New Antiobesity Medications’ Impact on MBS” below.)
“As with any chronic disease, obesity requires lifelong management, which evolves over time based on the person’s health goals and priorities,” Andromalos says. “MBS is effective at improving metabolic dysfunction related to visceral fat. However, people still need to commit to healthful lifestyles, micronutrient supplementation, and consistent check-ins with their MBS health care team to maximize the benefits of surgery, since surgery is a tool, not a cure.”
For patients’ optimal success with surgical outcomes, “Accreditation should be considered when comparing programs,” Andromalos says. “MBS programs that are accredited through the MBSAQIP meet national standards and undergo independent reviews for health and safety outcomes. Regardless of the type of surgery, or the surgeon who performs it, MBS requires an interdisciplinary team, including an RD and a behavioral health provider. We remind people it’s stomach surgery, not brain surgery.”
One important benefit of MBS is that people with type 2 diabetes can go into remission. “People with type 2 diabetes are more likely to go into diabetes remission if they have MBS within eight years of their diabetes diagnosis and if they’re not using insulin,” Andromalos says. “It’s all about beta-cell preservation. If we intervene after a person’s beta cells have been exhausted, MBS has a less robust effect because a good bit of their endogenous insulin production already has been lost. While both RYGB and VSG can improve glycemic management, gastric bypass has a greater effect on gut hormones that improve glycemia.”
Role of RDs and Nutrition Therapy
As part of the multidisciplinary team, the RD’s role in providing nutrition therapy to MBS patients has been well integrated into go-to practice guidelines at obesity medicine and obesity treatment centers located within and outside of academic medical centers.3,15,16 “From my dual perspective, I believe RDs possess a unique blend of scientific knowledge and practical application to engage in interdisciplinary collaboration, which is vital in the MBS space,” says Diane Enos, MPH, RDN, CAE, who worked in various roles at the Academy for more than 20 years and in mid-2023 became executive director at ASMBS.
Practice guidelines detail the RD’s involvement in the care of the patient undergoing MBS from the initial decision-making process through long-term follow up.15,16 These guidelines include a preoperative nutrition assessment along with a comprehensive review of weight history, correcting micronutrient deficiencies before surgery, preoperative nutrition education to prepare the patient for the postsurgical phase, reintroduction of nutrition postsurgery, managing postsurgical food intolerances, feeding and malabsorption issues, weight loss and weight regain postsurgery, and long-term follow up. Page synthesizes the primary weight management goal as maintaining a calorie deficit while also promoting satiety and adequate nutrition to prevent malnourishment.
Enos encourages RDs to engage in continuous learning to stay current with the latest research, guidelines, and best practices to elevate their professional prowess and impact patient outcomes. Andromalos recommends RDs consider the guidelines published by Mechanick and colleagues and the Academy’s Pocket Guide to Bariatric Surgery as the most current go-to resources.14,16 She also draws attention to the bariatric surgery subunit in the Academy’s WM DPG.17 Page suggests RDs refer to the Quick Guides when working with complex patients, the quarterly newsletter with articles on MBS, the subunit virtual meetups for networking, and the Academy’s bariatric RD mentor program. Enos highlights the professional network agreement between ASMBS and WM DPG and encourages RDs to join ASMBS to take advantage of the many membership opportunities.18
New Antiobesity Medications’ Impact on MBS
RDs also must keep abreast of the ever-widening cadre of antiobesity medications (AOMs) (see Today’s Dietitian’s November/December 2023 feature article, “The New Weight Management Meds”). It’s important to learn how these medications may impact the MBS arena. Will they decrease the number of people seeking MBS because they’re opting to use AOMs? Will they be integrated into the care paradigm of MBS providers?
“The approval of AOMs has been welcomed by both obesity medicine specialists and bariatric surgeons,” Kurian says, adding that their availability has shown that obesity is a disease that can be treated with medication and/or surgery. “The reality is antiobesity medications won’t replace MBS. They result in up to 15% to 20% of total body weight loss. A person seeking MBS with 80 to 100 lbs to lose won’t get to a healthy weight with medication alone. We find that antiobesity medications are helping people reduce weight preoperatively and postoperatively to maximize weight loss and reduce weight regain,” Kurian says.
Page agrees: “At our practice, we use AOMs in both our preop and postop patients. Some people begin our program undecided about whether they’d like to pursue bariatric surgery. They’re typically more apt to try an AOM first and see if it produces their desired results. Some people have done very well with an AOM and lifestyle changes, and they decide not to pursue surgery, which is wonderful. Conversely, we have many patients who see some weight loss with an AOM but not enough weight loss to improve their quality of life or metabolic factors. An added plus of using an AOM preoperatively is that patients who do have MBS benefit from being at a lower weight heading into surgery, which can reduce their risk of complications.”
RD’s Role in Obesity Therapy Decision Making
With the rising incidence of severe obesity, RDs will increasingly be in dialog with people who need information about treatments and guidance for making informed decisions about their course of treatment.1,2 “We need to present factual, evidence-based, and person-centric information regarding their options to choose lifestyle changes, the use of an AOM in addition, and/or consider MBS,” says Melissa Hermann Dierks, RDN, LDN, CDCES, owner of Eat Smart Nutrition Company (eatsmartnutritionco.com), based in Huntersville, North Carolina. “Our advice should reflect our assessment and understanding of each person’s obesity-related comorbidities, their willingness and ability to inject a medication, appropriateness for surgery, and insurance coverage,” she says. “If a client brings up the question about MBS, I refer them to one of the local bariatric centers to learn more about their surgery options and become familiar with the whole process.”
As people consider their options, they can use the process of shared-decision making, a communication process that involves patients and clinicians working together to make optimal health care decisions that prioritize patients’ goals and preferences.19 “Be honest and open and underscore that no available therapy is a magic bullet or a cure,” Page says. “Making and maintaining healthful behaviors is key to long-term success with any of these therapies.”
Future of MBS
As MBS has evolved, surgeons have reduced the risk of complications, decreased mortality, and the side effects of surgery, Kurian says. “However, we’re always looking for ways to further decrease complications and side effects and making our techniques even more minimally invasive.” This is good news for patients, as studies are and will continue to explore novel, minimally invasive, and nonsurgical endoscopic bariatric procedures.
— Hope Warshaw, MMSc, RD, CDCES, BC-ADM, FADCES, is owner of Hope Warshaw Associates, LLC, a diabetes- and nutrition-focused consultancy based in Asheville, North Carolina. She’s a book author and freelance writer specializing in diabetes care and education. Warshaw served as the 2016 president of ADCES and was chair of the Academy of Nutrition and Dietetics Foundation, 2022–2023. She currently serves as past chair of the foundation through May 2024.
References
1. Adult obesity prevalence maps. Centers for Disease Control and Prevention website. https://www.cdc.gov/obesity/data/prevalence-maps.html. Updated September 21, 2023. Accessed October 16, 2023.
2. Zhao L, Park S, Ward ZJ, Cradock AL, Gortmaker SL, Blanck HM. State-specific prevalence of severe obesity among adults in the US using bias correction of self-reported body mass index. Prev Chronic Dis. 2023;20:E61.
3. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis. 2022;18(3):314-325.
4. Kissin R, Khoury L. Wallenborn G, Kothari SN. When the COVID-19 pandemic collides with the obesity epidemic in the United States: a national survey. Surg Obes Relat Dis. 2023;19:434-439.
5. Metabolic and bariatric surgery accreditation and quality improvement program. American College of Surgeons website. https://www.facs.org/quality-programs/accreditation-and-verification/metabolic-and-bariatric-surgery-accreditation-and-quality-improvement-program/. Accessed October 19, 2023.
6. Clapp B, Ponce J, DeMaria E, et al. American Society for Metabolic and Bariatric Surgery 2020 estimate of metabolic and bariatric procedures performed in the United States. Surg Obes Relat Dis. 2022;18(9):1134-1140.
7. Estimate of bariatric surgery numbers, 2011-2021. American Society of Metabolic and Bariatric Surgery website. https://asmbs.org/resources/estimate-of-bariatric-surgery-numbers. Published June 2022. Accessed October 20, 2023.
8. Akalestou E., Miras AD, Rutter GA, le Roux CW. Mechanisms of weight loss after obesity surgery. Endocr Rev. 2022;43(1):19-34.
9. Bariatric surgery procedures. American Society of Metabolic and Bariatric Surgery website. https://asmbs.org/patients/bariatric-surgery-procedures. Updated May 2021. Accessed October 17, 2023.
10. Casimiro I, Sam S, Brady MJ. Endocrine implications of bariatric surgery: a review on the intersection between incretins, bone and sex hormones. Annu Rev Physiol. 2019;7(10):1-13.
11. Carlsson LMS, Sjoholm K, Jacobson P, et al. Life expectancy after bariatric surgery in the Swedish Obese Subjects Study. N Engl J Med. 2020:16:1535-1543.
12. Sjostrom 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(3):219-234.
13. Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery vs. intensive medical therapy in obese patients with diabetes. N Engl J Med. 2012;366:1567-1576.
14. Schauer PR, Bhatt DL. Kirwan JP, et al. Bariatric surgery vs. intensive medical therapy for diabetes — 5 year outcomes. N Engl J Med. 2017;376:641-651.
15. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures — 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologist. Endocr Pract. 2019;25:(Supp 2):1-75.
16. Academy of Nutrition and Dietetics. Pocket Guide to Bariatric Surgery, 3rd Ed (ebook). https://www.eatrightstore.org/product-type/ebooks/pocket-guide-to-bariatric-surgery-3rd-ed-ebook. Accessed October 17, 2023.
17. Weight Management Dietetic Practice Group of the Academy of Nutrition and Dietetics website. https://www.wmdpg.org/. Accessed October 17, 2023.
18. Become a member. American Society of Metabolic and Bariatric Surgery website. https://asmbs.org/integrated-health/membership. Accessed October 19, 2023.
19. What is shared decision making? Massachusetts General Hospital Health Decision Sciences Center website. https://mghdecisionsciences.org/about-us-home/shared-decision-making/. Accessed October 17, 2023.
20. Recognition of obesity as a disease H-440.842. American Medical Association website. https://policysearch.ama-assn.org/policyfinder/detail/obesity?uri=%2FAMADoc%2FHOD.xml-0-3858.xml. Accessed October 19, 2023.
21. Nadolsky K, Addison B, Agarwal M, et al. American Association of Clinical Endocrinology consensus statement: addressing stigma and bias in the diagnosis and management of patient with obesity/adiposity-based chronic disease and assessing bias and stigmatization as determinants of disease severity. Endocr Pract. 2023;29(6):417-427.
22. Defining adult overweight & obesity. Centers for Disease Control and Prevention website. https://www.cdc.gov/obesity/basics/adult-defining.html. Updated June 3, 2022. Accessed October 16, 2023.
23. Finella ME, Laxarus JV, Ratziu V, et al. A multisociety Delphi consensus statement on new fatty liver disease nomenclature. J Hepatol. 2023:S0168-8278(23)00418-X.
24. American Diabetes Association. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in Diabetes — 2023. Diabetes Care. 2023;46(Supp 1):S128-S139.
Evolving Classification Systems for Obesity
In 2013, the American Medical Association officially recognized obesity as a disease.1 Since that time, many other medical organizations in the United States and globally individually or jointly have issued guidelines and recommendations.2 Several aimed to identify obesity staging systems by adding ethnicity and adiposity-related complications that define the stages beyond the classification of obesity by BMI. One example below was developed by American Association of Clinical Endocrinologists and continues to be promoted by this organization.3
CLASSES OF OBESITY4
• Class I: BMI of 30 to < 35;
• Class II: BMI of 35 to < 40; and
• Class III: BMI of 40 or higher (sometimes categorized as “severe” obesity).
AACE’S ADIPOSITY-BASED CHRONIC DISEASE STAGING SYSTEM3
• Stage 0: Overweight or obesity by BMI classification with no complications;
• Stage 1: Overweight or obesity by BMI classification with mild-to-moderate complications; and
• Stage 2: Overweight or obesity by BMI classification with severe complications.
References
1. Recognition of obesity as a disease H-440.842. American Medical Association website. https://policysearch.ama-assn.org/policyfinder/detail/obesity?uri=%2FAMADoc%2FHOD.xml-0-3858.xml. Accessed October 19, 2023.
2. Mechanick JI, Apovian C, Brethauer S, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures — 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologist. Endocr Pract. 2019;25:(Supp 2):1-75.
3. Nadolsky K, Addison B, Agarwal M, et al. American Association of Clinical Endocrinology consensus statement: addressing stigma and bias in the diagnosis and management of patient with obesity/adiposity-based chronic disease and assessing bias and stigmatization as determinants of disease severity. Endocr Pract. 2023;29(6):417-427.
4. Defining adult overweight & obesity. Centers for Disease Control and Prevention website. https://www.cdc.gov/obesity/basics/adult-defining.html. Updated June 3, 2022. Accessed October 16, 2023.
Prevent, Reduce Comorbidities With MBS
Research repeatedly shows that the following diseases can be prevented, put into remission, and/or clinically improved after metabolic and bariatric surgery with significant and durable weight loss1:
• asthma;
• obesity-associated cancer, such as esophagus, breast, colorectal, stomach, liver, and others;
• chronic kidney disease;
• coronary artery disease, heart failure, and stroke;
• dyslipidemia;
• gastroesophageal reflux disease;
• hypertension;
• infertility;
• insulin resistance, prediabetes, and type 2 diabetes;
• mental health;
• metabolic dysfunction-associated steatotic liver disease (new term for nonalcoholic fatty liver disease);
• obstructive sleep apnea;
• osteoarthritis; and
• polycystic ovary syndrome.
— HW
Reference
1. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis. 2022;18(3):314-325.
Criteria for Metabolic & Bariatric Surgery
Current recommendations for metabolic and bariatric surgery (MBS) from the American Society for Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders include the following1:
• Recommended BMI >35 kg/m2, regardless of presence, absence, or severity of existing comorbidities. (Note: Clinical obesity in the Asian population is recognized in people with a BMI >25 kg/m2.) Access to MBS shouldn’t be denied solely based on BMI risk.
• Recommended in people with type 2 diabetes and a BMI >30 kg/m2.
• Consider MBS in people with BMI between 30 and 34.9 kg/m2 who don’t achieve substantial or durable weight loss or improvement of comorbidities with nonsurgical weight loss methods.
• Consider MBS in older individuals who can benefit from MBS after adequate assessment.
• Consider MBS in children and adolescents with a BMI >120% of the 95th percentile and who have a major comorbidity, or a BMI >140% of the 95th percentile after adequate evaluation.
Current recommendations for MBS from the American Diabetes Association include the following2:
• Recommend MBS as an option to treat type 2 diabetes in screened individuals who have the following issues:
- BMI >40 kg/m2 (BMI >37.5 kg/m2 in Asian Americans);
- BMI 35 to 39.9 kg/m2 (32.5 to 37.5 kg/m2 in Asian Americans) who don’t achieve durable weight loss and improvement in comorbidities with nonsurgical methods; and
- BMI 30 to 34.9 kg/m2 (27.5 to 32.4 kg/m2 in Asian Americans) who don’t achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods.
• MBS should be performed in high-volume centers with multidisciplinary teams knowledgeable about and experienced in managing obesity, diabetes, and gastrointestinal surgery.
References
1. Eisenberg D, Shikora SA, Aarts E, et al. 2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): indications for metabolic and bariatric surgery. Surg Obes Relat Dis. 2022;18(3):314-325.
2. American Diabetes Association. 8. Obesity and weight management for the prevention and treatment of type 2 diabetes: standards of care in Diabetes –— 2023. Diabetes Care. 2023;46(Supp 1):S128-S139.