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Bariatric surgery is effective alternative for some obese patients

Quality Improvement Monitor, October 15, 2004

Surgery may be a more effective way for extremely obese patients to lose weight, but only if those patients have tried and failed to lose weight by exercising and dieting, according to a report issued October 8 by HHS' Agency for Healthcare Research and Quality (AHRQ).

Surgery can also improve control of some obesity-related health problems, such as high blood pressure, heart disease, diabetes and sleep apnea. AHRQ defines an obese person as someone whose Body Mass Index (BMI) is 40 or greater.

Researchers led by Paul Shekelle, MD, PhD, of the Southern California-RAND Evidence-based Practice Center in Santa Monica, reviewed scientific evidence as the basis for the AHRQ report.

They uncovered data suggesting that weight-loss surgery, also known as bariatric surgery, may be more effective than drugs for people with BMIs of 35 to 40; however, the evidence is not strong enough to draw firm conclusions for this group.

The AHRQ review did not find enough evidence to draw conclusions about differences in the safety of different types of weight-loss surgery, which include adjustable gastric banding, vertical-banded gastroplasty, and biliopancreatic diversion procedures. Less than than 1% of patients operated on by experienced bariatric surgeons die as a result of the surgery or from complications. However, the rate may be higher for patients who are operated on by less experienced surgeons.

The evidence review also found that some prescription medicines--particularly orlistat and sibutramine, the most widely studied drugs--promote moderate weight loss when prescribed along with recommendations for dieting. The amount of weight loss directly attributable to these drugs averages less than 11 pounds, but research shows that even such a modest weight loss may decrease the occurrence of diabetes.

No weight-loss drug appears to be superior to others, and, like all medications, each has side effects. The drugs have not been studied sufficiently to evaluate the risk of rare side effects, nor has there been enough research to determine the optimal time to treat obesity with drugs or how this may vary by patients' age, gender, or race.

Roughly 60 million adults in the United States are obese, and 9 million are extremely obese. A BMI of 40 or greater is not the sole criterion for selecting patients who might benefit from weight-loss surgery. Of the 9 million extremely obese adults, only a small fraction, about 1.5% or 140,000, undergo weight-loss surgery each year in the United States.

"For adults whose health is severely compromised, using surgery to achieve weight loss is an option, but is not a total solution or magic bullet for obesity," says AHRQ Director Carolyn M. Clancy, MD. "Healthy behaviors have an important role in the management of obesity, even for those who have surgery."

CMS's Medicare Coverage Advisory Committee will consider the report, along with other information, when it meets on November 4, 2004, to discuss the risks and benefits of bariatric surgery in the Medicare population.

In July, CMS removed language in its Medicare Coverage Issues that had stated that obesity is not an illness. This prior language prevented beneficiaries from receiving Medicare coverage for treatments for obesity-related diseases. CMS' removal of the language allows beneficiaries to ask CMS to review medical evidence to determine whether it will pay for certain treatments related to obesity.

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