UK NICE Expedites Access to Bariatric Surgery in Diabetes

November 28, 2014

Access to bariatric surgery for some obese individuals in the United Kingdom should improve dramatically following new guidance issued by the National Institute for Health and Care Excellence (NICE).

The new recommendations stress that individuals with a body mass index (BMI) of 35 kg/m2 or more who have recent-onset type 2 diabetes should be offered an expedited assessment for bariatric surgery.

They also advise, for the first time, the consideration of bariatric surgery as a treatment option for those with a lower BMI of 30 to 35 kg/m2 and recent-onset diabetes.

"This is a really positive step and acknowledges that this patient group will also benefit," Dr Rachel Batterham (University College London Hospitals Centre for Weight Loss, Metabolic & Endocrine Surgery, United Kingdom) told Medscape Medical News. "These patients will be able to access [bariatric] surgery paid for by the National Health Service (NHS) for the first time."

Dr Batterham was one of the 12 members of the NICE obesity guideline development group.

In all, the new guidelines—the first on the topic since 2006—are expected to result in a doubling or tripling of the number of people referred for bariatric surgery in the United Kingdom each year. Draft guidance was issued in the summer and final recommendations are now published.

Only 18 000 people had bariatric surgery, 4000 of whom also had diabetes, between 2010 and 2013 in the UK—just a sixth of the number who underwent the procedure in other European countries such as France, Belgium, Germany, Sweden, and the Netherlands, says Dr Batterham.

She explained that there are currently serious delays in many parts of the United Kingdom because patients need assessment and counseling over several months before surgery, and many hospitals do not have services in place.

The new guidance should make the process easier, and it is thought that the number of NHS operations could rise from about 6000 per year to about 15,000 a year as a result.

Dr Batterham stresses that savings will be made because the majority of individuals will have remission of diabetes following weight-loss surgery, allowing them to stop taking all diabetes medications and reducing the risk for diabetes-related complications.

In addition, bariatric procedures can prevent obese patients who have not yet developed type 2 diabetes from doing so. In a recent UK study published in the Lancet Diabetes & Endocrinology, bariatric surgery reduced the risk of developing type 2 diabetes by 80% among obese patients, with up to 7 years of follow-up.

There are no NICE recommendations on which bariatric-surgery option is preferred, Dr Batterham said. Currently, around half of all such operations done each year around the globe are gastric bypass, she noted (55% in the United Kingdom), 30% to 40% are sleeve gastrectomies, and the remainder are lap-band surgeries. These percentages differ in different countries, she noted.

Surgery and Prevention Both Needed

Not everyone is convinced that bariatric surgery holds all the answers, however.

Barbara Young, chief executive of the charity Diabetes UK, said: "There is good evidence that weight-loss surgery can benefit both people who have type 2 diabetes and those at high risk of developing it. It should be considered one route for people recently diagnosed with type 2 diabetes who are obese.

"But it is important to stress that all surgery carries risks, and so as the NICE guidance makes clear, people should only be offered surgery if attempts to lose weight through healthy eating and physical activity have been tried and have not worked," she said in a statement.

“We also need to remember that although weight-loss surgery for type 2 diabetes is an important treatment option, it should not be seen as the definitive remedy that can fix the type 2 [diabetes] epidemic on its own."

In particular, "it makes no sense that the NHS is currently spending more on bariatric surgery than it is on preventative measures to stop people from getting type 2 diabetes in the first place," she added.

But Dr Batterham stressed that the NICE review group has assessed the economic implications of bariatric surgery and concluded that it is cost-effective: "It saves money in addition to saving lives and improving health.

"We need prevention and treatment, and this is a key message—but prevention is not going to help the people who already have type 2 diabetes and obesity," she concluded.

Dr Batterham reports no relevant financial relationships.

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