Metabolic surgery: Transformational or quick-fix?

19 Nov 2018 --- More than one-third of US adults are obese and some of the lead causes of non-communicable disease’ deaths – such as stroke, diabetes and cancers – are obesity-related. Although a healthy diet and lifestyle are key to healthy weight management, more drastic measures, such as bariatric surgery, are becoming more commonplace as obesity levels rise. NutritionInsight takes a look into the discussion around bariatric surgery, following research presented during last week’s Obesity Week event based in Tennessee, US.

According to 2017 data from the US Centers for Disease Control and Prevention (CDC), 24 million US citizens would qualify for metabolic or bariatric surgery – due to a Body Mass Index (BMI) of at least 40, or 35 if they have other risk factors such as diabetes. 

BMI is a measure of body size and is generally accepted by physicians as an adequate indicator of health. However, while the BMI is commonly accepted, there are medical experts in the field of obesity who consider it to be inaccurate because it cannot distinguish among bone mass, muscle mass and excess fat. BMI also does not account for the influence of gender – women generally have more body fat than men.

Even those with a healthy BMI may still be at danger if they have a “fat belly,” findings from the Mayo Clinic revealed earlier this year. “Fat belly,” or central obesity, is a store of excess fat around the middle of the body, and this marker of abnormal fat distribution can induce heart problems.

Significantly, the findings showed that people with normal weight and central obesity were more at risk from heart problems than all people without central obesity – whether they were of a healthy weight or obese. This could be due to the level of muscle in the body, explains the lead author, Medina-Inojosa.

By combining both American Society for Metabolic & Bariatric Surgery (ASMBS) and The Obesity Society (TOS) annual meetings, Obesity Week brings together world-renowned experts in obesity to share innovation and breakthroughs in science.

One crucial area of focus in the fight against obesity is the use of bariatric and metabolic surgery for obesity control and reduction.

Weight loss surgery
According to the ASMBS, bariatric surgery is currently the most effective and long-lasting treatment for severe obesity resulting in significant weight loss and leading to the improvement, prevention or resolution of many related diseases including Type 2 diabetes and heart disease.

Surgery has been recommended as a viable option for patients with a BMI of 40 or higher or a BMI of 35 or higher, who have two other cardiovascular risk factors such as diabetes or high blood pressure by a range of key expert groups, such as the American Heart Association (AHA) and American College of Cardiology. 

However, undergoing surgery is always a risk and, thereby, caution should be recommended to those who choose to go down this route.

Despite the risks, the levels of obesity in the US have led to an increase in instances of the surgery, although the rates are relatively low compared to the level of US citizens who would qualify for the surgery. ASMBS data show that the number of people in the US that had a bariatric procedure in 2016 represents only 1 percent of the estimated 24 million adults who would qualify for the surgery.

One study presented at Obesity Week noted, in a first-time finding, that bariatric surgery has a significant protective and survival benefit on patients who suffer heart failure later in life. 

In the study, heart failure patients with a history of bariatric surgery were 50 percent less likely to die than patients with heart failure without a history of bariatric surgery, a finding that was “fascinating” to study author Ali Aminian, MD, Associate Professor of Surgery at Cleveland Clinic, Ohio, US. “There are studies indicating bariatric surgery decreases risk of development of heart failure, but despite that, unfortunately, some patients develop heart failure,” Dr. Aminian tells NutritionInsight. “This study could show that in those patients, prior history of bariatric surgery would be associated with better survival.”

A further study conducted by obesity researchers at the Cleveland Clinic, Florida, US, showed that one-year after bariatric surgery, the chances of getting coronary heart disease within the next ten years dropped by 40 percent. The patients saw significant improvements in blood pressure and diabetes – more than 40 percent of patients had complete resolution of diabetes and 44 percent no longer had arterial hypertension. Patients also lost more than 25 percent of their total weight and had a nearly 70 percent drop in BMI.

Obesity is, of course, a risk factor for heart problems, as well as diabetes. Heart troubles are especially severe in the US, with the Centers of Disease Control and Prevention (CDC) stating that 5.7 million adults in the US have heart failure and about half of those diagnosed with the condition die within five years. These statistics may demonstrate the potential of the Cleveland Clinic's findings.

“No other treatment, in such a relatively short period, can result in such significant weight loss, improvements in high blood pressure and resolution of Type 2 diabetes. The key, however, is for patients to continue to have a healthy diet and exercise well after surgery to maintain their heart benefits,” says Emanuele Lo Menzo, MD, Ph.D., study co-author, Associate Professor of Surgery and Chair of Research, Cleveland Clinic.

A further study presented by German researchers highlighted the beneficial impacts of the surgery on diabetes in obese patients. Their findings demonstrated that patients with diabetes and severe obesity who had metabolic surgery were much less likely to die from diabetes or any other cause than those who received drug therapy alone.

Based on an analysis of 19 studies – six randomized controlled trials and 14 clinical trials published between 1997 and 2017 – 66 percent fewer metabolic surgery patients died than patients who received standard medical therapy for their diabetes. Patients were also 62 percent less likely to suffer a heart attack or stroke.

“This study adds to the enormous amount of data demonstrating the profound and definitive effect of metabolic surgery on obesity, diabetes and its complications that no other therapy can achieve, yet surgery remains vastly underutilized as a treatment,” says Samer Mattar, MD, President, ASMBS and Medical Director at Swedish Weight Loss Services in Seattle, Washington, who was not involved in the study. 

“While metabolic surgery is certainly not for everyone – there are many factors to consider – many are missing out on a transformational procedure.”

However, the option shouldn’t be seen as a quick fix, some industry experts warn.

Roberto Jongejan of DEKAs at the 40th European Society for Clinical Nutrition and Metabolism (ESPEN) Congress, held in Madrid in September, told NutritionInsight that bariatric surgery is a “booming” area, and further expressed concern with regards to the high medical costs and nutritional problems, such as vitamin malabsorption, that may result from such procedures.

“I am seeing pediatricians considering giving children bariatric surgery, but we must know that it can do damage to people. It changes the piping in someone when, in essence, nothing is wrong with it. It’s difficult from a medical and ethical position,” Jongejan says.“We are up for a tsunami of patients with bariatric survey and this is a problem. Payers do not recognize what many years of obesity will bring them in terms of costs and payload.”

One costly factor that recipients of the surgery may not take into account is vitamin use. Patients will often suffer from malabsorption, he explains, meaning nutritional deficiencies ar

e common and possible. Therefore, adequate supplementation is necessary but often not followed through.

“If we are going to operate on more people, we need to be prepared. All these people have to pay their own vitamins, but they do no not as they often have financial problems, so they don’t take them and this comes at a dangerous price,” he adds.

Instances of bariatric surgery will likely continue to rise, transforming the lives of many recipients. However, surgery is always a serious route to take, and the repercussions must be wisely considered.

By Laxmi Haigh, with additional reporting by Lucy Gunn