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Year : 2023  |  Volume : 2  |  Issue : 2  |  Page : 51-52

Time to discontinue body mass index (BMI) as a qualifying criterion for metabolic (diabetes) surgery

Center of Bariatric Surgery, Wockhardt Hospitals, Mumbai, Maharashtra, India

Date of Submission14-Jul-2023
Date of Acceptance14-Jul-2023
Date of Web Publication04-Aug-2023

Correspondence Address:
Dr. Ramen Goel
Center of Bariatric Surgery, C10, Wockhardt Hospitals, Agripada, Mumbai - 400 011, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbs.jbs_11_23

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How to cite this article:
Goel R. Time to discontinue body mass index (BMI) as a qualifying criterion for metabolic (diabetes) surgery. J Bariatr Surg 2023;2:51-2

How to cite this URL:
Goel R. Time to discontinue body mass index (BMI) as a qualifying criterion for metabolic (diabetes) surgery. J Bariatr Surg [serial online] 2023 [cited 2023 Sep 29];2:51-2. Available from: http://www.jbsonline.org/text.asp?2023/2/2/51/382974

Recent changes in the Metabolic and Bariatric Surgery (MBS) guidelines by the International Federations for the Surgery of the Obesity and Metabolic Disorders (IFSO) and American Society of Metabolic and Bariatric Surgery (ASMBS),[1] almost 30 years after the precedent-setting 1995 NIH statement,[2] were long overdue. The surgical community is yet to grasp the implications of the altered body mass index (BMI) cutoffs for practice. Unfortunately, millions fail to qualify and thus benefit from surgery, even with the revised guidelines.

A recent interaction with a 72-year-old, 26.5 BMI Indian man with glycated hemoglobin of 11 can explain my clinical predicament. Refusing to accept my denial to offer metabolic surgery (BMI<27.5), the patient broke down and accusingly asked, “How can you, as a doctor, deny an effective treatment for a disease from which I am suffering for so many years, and which can help me live longer?”

Fully aware that, just 6 months back, we denied surgical treatment to anyone below 35 BMI; I was left wondering for which other disease, we refuse a treatment based on an unrelated physical attribute. The 2022 guidelines have continued to use BMI as the selection parameter, based on the ease of use and baggage of bariatric past associated with these gastro-intestinal surgeries. Debate over the use of BMI criterion for obesity has been raging in the bariatric community. However, for diabetes treatment, glycemic control remains the sole criterion used by physicians for times immemorial.

As a hapless physician, cornered into a situation, I realized that the limiting factors for the acceptance of surgery for diabetes are not related to its efficacy, but the use of guidelines based on obesity management and not diabetes understanding. Though recent guidelines expressly state that access to surgery should not be denied solely based on BMI risk zones, they fail to define a different criterion for diabetes patients. How can one deny treatment for blood sugar control based on the height (a major contributor in BMI calculation) and weight of the patient? It is likely that over decades, millions of eligible patients with uncontrolled diabetes have been denied access to a treatment (based on the NIH 1991 guidelines), which could have improved disease, reduced morbidity,[3] improved quality of life, and added extra years to their life.[4]

Studies[5],[6],[7],[8],[9] have shown that diabetes and other metabolic effects of metabolic surgery are similar in lower BMI patients compared to >35 BMI patients. Even apprehension of excessive weight loss is not valid, as the weight loss in low BMI surgery patients is significantly less[8] than in morbidly obese patients. Furthermore, the postsurgical diet can be individualized to avoid weight loss in low BMI diabetes patients. The benefit of glycemic control in such patients far outweighs the potential side effect of a few kilograms of weight loss.

It is time, instead of waiting for 30 more years, to call out the continued use of BMI as the qualifying criterion for metabolic (diabetes) surgery.

  References Top

Eisenberg D, Shikora SA, Aarts E, Aminian A, Angrisani L, Cohen RV, et al. 2022 American society for metabolic and bariatric surgery (ASMBS) and international federation for the surgery of obesity and metabolic disorders (IFSO): Indications for metabolic and bariatric surgery. Surg Obes Relat Dis 2022;18:1345-56.  Back to cited text no. 1
Gastrointestinal surgery for severe obesity. Consens Statement 1991;9:1-20.  Back to cited text no. 2
Johnson BL, Blackhurst DW, Latham BB, Cull DL, Bour ES, Oliver TL, et al. Bariatric surgery is associated with a reduction in major macrovascular and microvascular complications in moderately to severely obese patients with type 2 diabetes mellitus. J Am Coll Surg 2013;216:545-56.  Back to cited text no. 3
Syn NL, Cummings DE, Wang LZ, Lin DJ, Zhao JJ, Loh M, et al. Association of metabolic-bariatric surgery with long-term survival in adults with and without diabetes: A one-stage meta-analysis of matched cohort and prospective controlled studies with 174 772 participants. Lancet 2021;397:1830-41.  Back to cited text no. 4
Schauer PR, Kashyap SR, Wolski K, Brethauer SA, Kirwan JP, Pothier CE, et al. Bariatric surgery versus intensive medical therapy in obese patients with diabetes. N Engl J Med 2012;366:1567-76.  Back to cited text no. 5
Shah SS, Todkar JS, Shah PS, Cummings DE. Diabetes remission and reduced cardiovascular risk after gastric bypass in Asian Indians with body mass index <35 kg/m(2). Surg Obes Relat Dis 2010;6:332-8.  Back to cited text no. 6
Panunzi S, De Gaetano A, Carnicelli A, Mingrone G. Predictors of remission of diabetes mellitus in severely obese individuals undergoing bariatric surgery: Do BMI or procedure choice matter? A meta-analysis. Ann Surg 2015;261:459-67.  Back to cited text no. 7
Cummings DE, Cohen RV. Bariatric/metabolic surgery to treat type 2 diabetes in patients with a BMI <35 kg/m2. Diabetes Care 2016;39:924-33.  Back to cited text no. 8
Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient – 2013 update: Cosponsored by American association of clinical endocrinologists, the obesity society, and American society for metabolic & bariatric surgery. Obesity (Silver Spring) 2013;21 Suppl 1:S1-27.  Back to cited text no. 9


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