This month, ASMBS and its members were featured in several new stories about updated clinical practice guidelines, the Affordable Care Act and bariatric surgery, treatment of diabetes in people with mild to moderate obesity and VTE prophylaxis for bariatric surgery patients.
New Guidelines Broaden Eligibility for Bariatric Surgery
General Surgery News reports on a “major shift in policy,” three major medical societies (ASMBS, TOS and AACE) have changed their formal guidelines for bariatric surgery and expanded eligibility to include patients with mild to moderate obesity and diabetes or metabolic syndrome. Additionally, the guidelines upgraded sleeve gastrectomy from investigational status to a “proven surgical option.” The changes will bring the U.S. guidelines in line with practices increasingly used around the country and reflect evidence that has emerged in the four years since the previous guideline was developed. “We’ve gleaned important new insights, cautions and best practices based on the thousands of studies that were published in medical journals in just the last four years alone, and these are reflected in the new guidelines,” said Dr. Daniel Jones, professor of surgery, Harvard Medical School, Boston, and one of a 12-member panel that developed the guidelines.
For Many, Affordable Care Act Won't Cover Bariatric Surgery
Drs. John Morton and Erin Cummins are featured on NPR's Morning Edition discussing the impact the Affordable Care Act (ACA) will have on patient access to obesity treatments. The story notes uninsured Americans who are hoping the new health insurance law will give them access to weight loss treatments including bariatric surgery are likely to be disappointed, especially in the Deep South where obesity rates are highest.
When discussing the issue of patients with obesity, diabetes, hypertension, heart disease and severe joint pain, the report references bariatric surgery as “the most effective treatment to induce significant weight loss.” ASMBS' Dr. Morton who “has led national and state lobbying efforts to get insurance coverage for the surgery” comments, "Our hope was that there would be a single benefit for the entire country, and as part of that benefit there would be coverage for obesity treatment.” The story continues that Dr. Morton applauds the growing awareness around obesity prevention in the U.S., but, he says, some 15 million Americans who are already severely obese still need medical treatment. “If they don't have insurance, they're not going to get the therapy. We see cancer therapy covered routinely. We see heart disease covered routinely. Why is it that we don't see obesity coverage routinely?”
Gastric Bypass Surgery May Lower Diabetes Risks, but Also
Two news JAMA studies made news this month. One study showed gastric bypass was better than medication and lifestyle changes in reducing or reversing diabetes in patients with mild to moderate obesity, but that possible serious complications need to be considered when deciding to have surgery. Articles reference a statement from ASMBS that says “obesity surgery is safe and that the death rate is less than 1 percent, lower than for gallbladder and hip replacement surgery.”
The second study by UCLA suggested that there was not enough scientific support to widely recommend bariatric surgeries for patients with moderate obesity and diabetes. In an accompanying editorial, Dr. Bruce M. Wolfe called for more research on the topic. He added that the risk of the surgery plus the cost were two huge factors working against gastric bypass procedures. “Recent large scale trials of intensive medical management for obesity and diabetes have been disappointing,” he wrote. “Substantial resources are required to cause modest weight loss and diabetes control. Bariatric surgery does result in substantial weight loss with excellent diabetes control but is offset by initial high cost and risks for surgical complications. The optimal approach for treatment of obesity and diabetes remains unknown. The answer will only come from more well designed, randomized trials such as that performed by (the first study mentioned) that provide definitive answers.”
Cleveland Clinic Employee is First to Benefit from its Groundbreaking Research on Bariatric Surgery and Diabetes
A gastric bypass patient who had uncontrolled diabetes and is a Cleveland Clinic employee, was reportedly the first person with a BMI less than 35 for whom insurance covered the surgery -- the first at the Clinic, and perhaps nationally. ASMBS member Dr. Phil Schauer who performed the operation said, “Under every other insurance company's requirements today, he would not qualify for coverage of bariatric surgery, because his BMI is less than 35.” In January, the Clinic's insurance plan began to cover bariatric surgery for patients whose Type II diabetes was not being well controlled through oral medication and injections and a BMI as low as 30. The patient was taking insulin eight times a day before surgery. A day after surgery -- his blood sugar had plummeted to 130. The next day the patient went home. He has not needed any insulin injections since the surgery but is still taking oral medication for his diabetes -- “for the time being.”
Positive Outcomes for Bariatric Surgery Stretch Nine Years in Study
Dr. Stacy Brethauer from Cleveland Clinic presented findings from a long-term follow-up study showing patients continue to experience significant improvements in their diabetic and cardiovascular status up to nine years after bariatric surgery. While 20 percent of patients in the study had a recurrence of their Type 2 diabetes after an initial remission, more than 85 percent met goals set by the American Diabetes Association. Dr. Walter Pories commented that this research adds to the evidence that medical specialists from outside the bariatric surgery field have been calling for supporting the claim that surgery has lasting metabolic effects.
Bariatric Surgery Patients Don't Need Extra VTE Prophylaxis: Study
According to a meta-analysis published in JAMA Surgery, standard, not high doses, of anticoagulants should be used and mechanical filters should be avoided to prevent venous thromboembolism (VTE) in bariatric surgery patients. The AHRQ-funded study conducted by Johns Hopkins University showed mechanical filters “increase the risk of pulmonary embolism.” Dr. Jaime Ponce commented, “The findings in this comprehensive review support our [ASMBS] thoughts and really correlate with our position statement that bariatric patients need some kind of DVT prophylaxis; that there is evidence that low-molecular-weight heparin is probably better than regular heparin; that there is insufficient data to support that bariatric patients need a higher dose; and that the IVC filters are questionable.” He added, “I think we all know that filters can protect some of the higher risk patients but they also cause a lot of problems and so many centers have moved away from using IVC filters and that's been supported by this study.” Dr. Ponce also noted while surgery patients “need some kind of protection,” laparoscopic bariatric procedures allow patients to get up and begin moving sooner after having surgery, so the risk for VTE is decreased.
Surgery - And Then the Hard Part
In a follow-up to the news Governor Chris Christie had gastric band surgery, the Philadelphia Inquirer reports “the hard part” for most patients is after surgery. ASMBS IH member Dr. David Sarwer said about 20 percent lose less than expected or regain weight. Most of the time, it's more behavioral in nature. People return to the “eating behaviors that got them in trouble in the first place.” Dr. Jaime Ponce added that, to help his patients achieve the best results possible, he suggests the rule of 20s: “Chew each bite 20 times. Put the fork down for 20 seconds. Stop eating in 20 minutes.”
Losing Weight in the Public Eye
Dr. Sanjay Gupta reports on high-profile figures that have made the decision to have bariatric surgery, and the second decision they face: whether or not to tell the public. The article noted that while Al Roker and Billy Nungesser, a New Orleans parish president who became a national figure during the 2010 Gulf oil spill, opted to go public with the news, others, such as N.J. Governor Chris Christie, did not discuss the surgery publicly right away. Nungesser’s surgeon, Dr. Thomas Lavin said Nungesser and Roker are the exception, adding, “The majority of patients who get these procedures who are in the public eye never tell anyone,” but those who open up about the surgery are doing “a public service.”