COMMENTARY

Bariatric Surgery: Not Just for BMI Anymore

Jeffrey I. Mechanick, MD; Mark Harmel, MPH

Disclosures

April 15, 2016

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Bariatric surgery has evolved quite a bit over the past decade, and especially in the last few years, for two reasons. The first and fairly obvious reason is the many technological advancements that have occurred, not only in surgical but also in nonsurgical techniques.

However, I think the more important reason is the context within which bariatric surgery fits very snugly: This is not a body mass index (BMI)–centric model but rather an obesity complications–centric model.

Let's think that through. Rather than suddenly deciding that a patient needs bariatric surgery because they happen to have gained enough weight to cross some arbitrary numerical threshold of BMI, now we are able to do a more robust, more comprehensive clinical assessment based on the biological ramifications of that excess weight.

Due to that, we now have a lot more complex decision-making that can be personalized for the patient with obesity.

For instance, you could have a patient with mild obesity who has rather severe obesity-related complications who would be a better candidate for a more aggressive bariatric procedure. In contrast, you could have a patient who might actually have more adiposity but either without any evidence of obesity-related complications or with just mild complications, whom you are going to manage with either a lesser bariatric procedure or with intensification of medicines.

Here's the context: We have a lot more medicines and more evidence for how to mix and match them. And, of course, for every aspect of comprehensive management for the patient with obesity, we have structured lifestyle modifications. We now have a lot more evidence, not only about the theory of how to apply lifestyle medicine but also about how to better implement it.

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