Features July 2013 Issue

Should the Criteria for Bariatric Surgery be Changed?

Recent studies suggest that the weight-loss surgery may be effective for people with pre-diabetes and who don’t meet the BMI requirements.

Bariatric surgery is considered a last-ditch effort to help morbidly obese individuals lose weight and reverse the progression of diabetes. Studies in recent years have shown that the weight-loss surgery is an effective approach, though the criteria for patients to undergo the treatment may be excluding others who could benefit from the operation.


Recent research suggests that in addition to weight loss, bariatric surgery also positively impacts hormonal activity in the body that helps reduce diabetes symptoms and improves blood glucose control. There are a few different types of bariatric surgery, but among the most common is a procedure in which a small portion of the stomach is closed off to the rest of the stomach and is attached directly to the small intestines, thus making a person feel full after less food and cutting down on the time calories can be absorbed by the body.

Philip Schauer, MD, director of the Bariatric and Metabolic Institute at Cleveland Clinic, explains that at the outset, the weight loss that followed bariatric surgery was considered a health benefit in its own right. “We’re dealing with a different goal,” he adds. “Particularly with diabetics with a lower BMI (body mass index), weight loss is a secondary issue. The primary issue is better glycemic control, controlled blood pressure, and control of lipids. The problem is that the bariatric eligibility criteria are based on BMI.”

In general, bariatric surgery is only for individuals with a body-mass index (BMI, a score determined by a person’s height and weight) of at least 40, or a BMI of 35 to 39 along with the presence of weight-related health problems, such as type 2 diabetes, hypertension or serious obstructive sleep apnea. In some cases, a person with a lower BMI might qualify, but only if he or she has other serious health problems.
“It turns out that the majority of diabetics in the U.S. have a BMI of between 25 and 35, so they are not eligible for surgery based on existing criteria,” Dr. Schauer says.

The issue of whether the criteria should be changed was discussed in detail at the recent Prediabetes and Metabolic Syndrome 2013 Congress. Dr. Schauer acknowledged that the idea of allowing someone with prediabetes and a BMI less than 40 remains a controversial suggestion. Other experts also offered their opinions, admitting that it makes sense to intervene with someone who has prediabetes before the condition worsens to diabetes.

“Surgery’s been shown… to be extremely effective at preventing prediabetes from progressing to type 2 diabetes, which otherwise happens in almost 100 percent of patients, eventually, even when on medical therapy,” Dr. Schauer says.

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