UK May Lower BMI Threshold From 35 to 30 for Bariatric Surgery

July 11, 2014

Access to bariatric surgery in the United Kingdom may soon become easier if draft guidance issued today is ultimately put in place. This suggests lowering the body mass index (BMI) threshold at which obese patients with recent onset type 2 diabetes can be considered for such weight-loss procedures, from 35 to 30 kg/m2.

In addition, patients of certain ethnicities, such as Asians, may qualify at even lower BMIs, says the updated draft of the guidance on obesity from the UK National Institute for Health and Care Excellence (NICE).

This would mean that half a million more people could soon meet the criteria for bariatric surgery, taking the total eligible population to almost a million people in the United Kingdom, all paid for by the National Health Service (NHS). Such surgeries cost from £6000 to £15,000 per person, meaning the bill to the nation could range from £6 billion to £15 billion.

Simon Heller, MD, from the academic unit of diabetes, endocrinology, and metabolism at the University of Sheffield, United Kingdom, told Medscape Medical News, "This raises really important issues, such as the morality [and cost] of giving a surgical procedure for what is essentially a behavioral disease. This is something that we as a society have really got to think about, and that's true for every country in the world," he noted, adding that NICE guidance "has influence way beyond the UK."

"This is an extremely difficult situation with all kinds of vested interests," he said. "The pharmaceutical industry, for example, presumably doesn't want to see surgery adopted too widely, because these extremely expensive [obesity and diabetes] drugs they have developed are undoubtedly more expensive than bariatric surgery."

Adequate Support Essential if Surgery Is to Be Expanded

Currently, said Dr. Heller, patients in the United Kingdom need to have a BMI of 35 or greater to be assessed for bariatric surgery.

And although people are required to participate in a weight-loss program first before being considered for such surgery, in an attempt to limit numbers being referred, this has often inadvertently led to the opposite, somewhat-crazy situation "where we have been encouraging very obese patients to gain weight to meet the criteria for surgery," he said.

The new guidance, if adopted, "will require us to refer a considerably larger number of people for surgery," Dr. Heller noted. And while this will undoubtedly be expensive, it may ultimately be more cost-effective than waiting for diabetes-related complications to occur, he commented.

"We are going to pay in the end: we are not going to refuse to treat the people who go blind from diabetes, or when they have a myocardial infarction, or when their kidneys pack up," he commented.

In other countries, recommendations vary regarding the point at which people can be considered for bariatric surgery. In the United States, most clinical guidelines and insurance coverage for bariatric surgery limit access to patients with a BMI of 35 kg/m2 or greater.

The recent 3-year STAMPEDE results were some of the first to address use of bariatric surgery in a randomized fashion in obese diabetic patients with a BMI less than 35; those patients appeared to enjoy the same benefits as those with a BMI greater than 35.

Indeed, said Dr. Heller, performing surgery earlier in the course of obesity-related type 2 diabetes may make sense, "because there would be less morbidity from anesthesia, for example, among the less obese," and they are less likely to have started to develop complications, he says.

But he stressed that adequate support is essential if the bariatric-surgery provision is to be successfully expanded.

"Doing the operation in isolation is not a good thing. But if you provide proper support, the procedure can be very successful." This includes counseling so that patients appreciate the implications of surgery and to ensure good long-term follow-up, he noted.

The draft NICE guidance does include recommendations for this, including the provision of support groups and "at least annual monitoring of nutritional status and appropriate supplementation according to need following bariatric surgery."

But Other Options Exist: Culture Change Needed

The new draft UK NICE guidance also proposes that very low-calorie diets should be used more selectively in the obese, noting that they "are…likely to be nutritionally incomplete."

The charity Diabetes UK is currently funding the largest study in the UK into this approach, the Diabetes Remission Clinical Trial (DIRECT) to compare the long-term health effects of current type 2 diabetes treatments with those of a very low-calorie diet, followed by a long-term approach to weight management.

However, the full results will not be available until 2018.

"We are pleased to see that these new NICE guidelines are cautious about the use of low-calorie diets....Until we have the evidence that this approach is more effective than the current best-available treatment, we do not recommend that people with type 2 diabetes attempt to lose weight this way," says Simon O'Neill, RN, director of health intelligence and professional liaison at Diabetes UK, in a statement.

Dr. Heller doesn't hold out much hope that very-low calorie diets will prove successful. "Are you really going to make people eat the most bizarre diet in the world long term?" he noted.

He is also concerned that the whole focus on expensive operations and drugs "is sending society in the wrong direction. For example, we have lots of data showing that self-management programs for both type 1 and type 2 diabetes are very successful, more so than for any other condition I can think of," he said.

"But such programs are not properly funded and not always available throughout the UK," he stressed. "So here we are throwing surgery or drugs at people when we don't even provide self-management training, and we haven't formed a joined-up system."

And, he said, the problem is compounded because the vast majority of these patients are now dealt with at the primary-care level, and knowledge of the issues among GPs "is widely disparate."

"We surely should be asking ourselves what we are feeding our kids and how we change our culture. There are many issues that haven't been dealt with," he concluded.

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