Outdated guidelines preventing patients with class I obesity from accessing bariatric surgery

Outdated guidelines issued by the National Institutes of Health (NIH) more than 30 years ago may be stopping a large portion of patients with a lower body mass index (BMI), who could otherwise benefit, from having the bariatric surgery or even considering it an option, according to researchers from Kaiser Permanente, South Sacramento, CA.

In the retrospective study, researchers found little more than 8,100 weight-loss procedures, either laparoscopic sleeve gastrectomy or laparoscopic Roux-en-Y gastric bypass, were performed on patients with BMIs of less than 35kg/m2 (class I obesity) between 2015 and 2019. This is about 1% of the more than 760,000 weight-loss surgeries that were performed during that period. Data was obtained from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for the analysis.


Researchers theorise that so few low BMI patients had weight-loss surgery because most US insurers still rely on NIH Guidelines from 1991, which recommend that surgery only be offered to those with a BMI>35kg/m2, rather than newer and recent guidelines, including from the NIH itself, ASMBS, and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) that lower the BMI cut-off to 30 for patients with an obesity-related disease such as type 2 diabetes.


"The NIH Guidelines from 1991 are outdated and its recommendations do not reflect decades of data regarding the safety and effectiveness of metabolic and bariatric surgery. Nor does it take into consideration the development of laparoscopic procedures that make the surgery less invasive and safer," said study co-author, Dr Theresa Jackson, , a general surgeon and bariatric surgery fellow at Kaiser Permanente.

In 2016, 45 professional societies, including the American Diabetes Association, issued a joint statement that metabolic surgery should be considered for patients with type 2 diabetes and a BMI 30.0–34.9 if hyperglycaemia is inadequately controlled despite optimal treatment with either oral or injectable medications.


"While non-surgical methods may result in weight loss for patients with class I obesity, metabolic or bariatric surgery is the most effective and durable treatment for their diabetes mellitus and other comorbidities," said lead study author and bariatric surgeon, Dr Zhamak Khorgami, Assistant Professor, Dept of Surgery, School of Community Medicine, University of Oklahoma, Tulsa. "These patients should not be excluded from such an effective treatment."


In the study, patients with lower BMIs undergoing weight-loss surgery tended to be older and female, and have higher rates of type 2 diabetes, hyperlipidaemia, and gastroesophageal reflux disease (GERD). There were few differences in the health and safety outcomes between lower- and higher-BMI patients and between weight-loss procedures.


A comparison of 30-day sleeve gastrectomy outcomes found low-BMI patients had significantly shorter initial hospital stays and operative times, and were less likely to have a complication or be readmitted to the hospital within 30 days than higher-BMI patients, who had a higher rate of admission to the intensive care unit (ICU).


Gastric bypass patients with lower BMIs had an increased rate of 30-day hospital readmissions and blood transfusions compared to patients with more severe obesity.


"Most insurers are ignoring the data and still basing coverage decisions for lower BMI patients on something created more than 30 years ago. It's time for them to catch up so patients can be treated for obesity and related diseases, including type 2 diabetes, earlier in the disease process," said Dr Shanu Kothari, President, ASMBS, who was not involved in the study. "Insurance companies generally look to guidelines developed by professional societies to help them determine patient eligibility for surgery. We are simply asking them to more strongly consider data after 1991 and bring their coverage decisions up to date."


In an updated position statement released in 2018, the ASMBS recommended that individuals with a BMI between 30 and 35 be offered bariatric surgery as an option after failure of nonsurgical treatments. It notes that current nonsurgical treatments "are often ineffective at achieving major, long-term weight reduction and resolution of co-morbidities."