More people may now qualify for bariatric surgery. Here's why 2 CT doctors pushed for the new guidelines. – Hartford Courant

People who are overweight and seeking bariatric surgery can qualify more easily under the first revision of guidelines since 1991.
Dr. Pavlos Papasavas, co-director of research for the department of surgery at Hartford Hospital, was on the committee that recommended lower weights to be eligible for the surgery.
Now, according to the American Society for Metabolic and Bariatric Surgery, anyone with a body mass index of 35 or more is eligible whether or not they have underlying conditions, such as diabetes. Those with comorbidities are eligible with a BMI of 30 or more. Each is five points lower than before.
Dr. Pavlos Papasavas (Hartford HealthCare/Hartford HealthCare)
For people of Asian descent, the numbers are even lower.
“They develop diabetes with a lower BMI. So the new guidelines say that if you are of Asian descent and you have a BMI over 27.5 and diabetes, you may qualify for surgery,” Papasavas said.
“We still screen patients for bariatric surgery based on guidelines that were established in 1991, and a lot of things have changed since then,” Papasavas said.
Thirty years ago, he said, there were no standards for the weight-loss surgery and no surgeons dedicated to the procedure. Laparoscopic surgery also had not come into general use in 1991.
“Once this was applied to bariatric surgery, it became a much safer type of surgery,” Papasavas said. “A lot of good research has taken place.”
He said studies in the last three decades “established bariatric surgery as a safe surgery and very effective to treat not only obesity but also diabetes, high blood pressure, high cholesterol, sleep apnea, fatty liver disease, and this is why we changed the name of the surgery. We call it metabolic surgery.”
The surgery has been endorsed by the American Diabetes Association, he said.
Obesity has become a severe problem in the United States. According to the Centers for Disease Control and Prevention, obesity increased from 30.5% in 1999-2000 to 41.9% in 2017-March 2002. Severe obesity increased from 4.7% to 9.2%.
The CDC also reported that adults with obesity spent $1,861 more in medical costs than those with a healthy weight.
“Other studies that have come out showed that people live longer after bariatric surgery,” Papasavas said. “There are also good studies that show that there is a decrease in the risk of cancer, several types of cancer including breast cancer and endometrial cancer and several gastrointestinal cancers. So it helps in many fronts. And, of course, the quality of life.”
However, where many people go wrong is thinking it will cure them of their obesity, Papasavas said.
“Like any other chronic disease, it does not have a cure,” he said. “It can come back like cancer can … so you can have weight recurrence. And some people may not respond to surgery. So we tell them, this is an opportunity and you need to view this as a unique opportunity to address obesity and prepare yourself to have the healthy diet lifestyle.”
He recommends people stop smoking and exercise more in addition to eating a more healthful diet.
While a sleeve will remove 80% of the stomach and a bypass makes a small pouch of the stomach, “this changes with time, so about a year after surgery, people can eat up to 60% of what they used to eat before surgery,” Papasavas said.
After two years, people can eat more “because the gastric tissue is stretchy and the pouch will become larger and the sleeve will become wider. So people can eat more,” he said.
“There’s about 25 to 30% of patients who may not respond to surgery in the long run,” Papasavas said. “But still, even for these patients, if we give them five, 10 years of good quality of life, and we stopped the progression of weight gain, this is still a benefit. So it’s simply a battle against a very complicated and complex disease that we’re still learning a lot about.”
There are also other effects because food goes from the stomach to the intestine more quickly, which then sends signals to the brain, pancreas and liver.
“We’re still learning about how the surgeries work,” Papasavas said, but one effect is on diabetes, with the disease going into remission within days of the surgery.
“So first of all, we start feeling less hungry when this happens,” he said. “So it makes the body more efficient to absorb blood sugar, glucose. So the insulin resistance goes down. So the insulin becomes more efficient.”
“They did a lot of research to find out why type 2 diabetes gets better before the person loses weight and because of this research they developed new medications for diabetes, and we use these medications now for medical weight loss,” he said. The medications are glucagon-like peptides, or GLP-1, such as Wegovy, which is suffering a shortage.
Using medications before and after surgery is known as a multimodal approach, which is more successful than bariatric surgery alone, Papasavas said.
Dr. John Morton of the Yale School of Medicine (Yale University/Yale University)
Dr. John Morton, vice chairman of surgery at the Yale School of Medicine and past president of the American Society of Metabolic and Bariatric Surgery, said the society launched the initiative to change the guidelines eight years ago, when he led the group.
“I think one thing that we’ve learned over the course of the last 20 years is bariatric surgery is both safe and effective. And what we wanted to do is provide that benefit to as many people that are in need,” he said.
Doctors have come to realize that obesity is a chronic disease, like cancer, Morton said. “Like any other chronic disease, you can’t necessarily eradicate it, but you can manage it,” he said. “And you can take people from high risk and make them low risk. … The data do support that people keep about a third of their body weight off long term.”
Also, those who regain weight are those with the highest BMI, he said. “So if we take a page from our cancer colleagues, we know that the patients who recur cancer are the ones who have most advanced. … A similar concept exists for us and obesity,” he said.
Morton said the society has an accrediting body that he’s led for 10 years, which has accredited 900 hospitals to perform the surgery “with an emphasis on quality improvement and patient safety, resulting now in a mortality rate for bariatric surgery of about 0.1% or one out of 1000. It is indeed safer than hip or knee replacement or removal of a gallbladder. That’s how safe bariatric surgery’s become.”
One issue may be insurance coverage, which will not come automatically. One reason for changing the guidelines, Papasavas said, is because insurance companies interpreted the old ones overly strictly.
“The problem with the first guidelines is sometimes they were interpreted by insurance companies and policies in an abusive way,” he said. “To give you an example, you have a BMI of 37 and hypertension. Based on the guidelines, you qualify for surgery. Some insurance companies will say, well, the hypertension is not severe enough. The person takes only one medication.”
While progress has been made, Papasavas said, “based on these guidelines, probably you’re going to get some denials. But this is a process that will take time and effort and education. Hopefully governmental insurance and also the private insurance policies will start adopting these guidelines.”
While other New England states are not willing to cover bariatric surgery, Papasavas said, “Overall in Connecticut, we have good insurance coverage for bariatric surgery,” including Medicaid, Medicare and most private insurance.
“The problem is with people who work in small companies,” he said. “So let’s face it, these companies have a hard time purchasing plans that cover bariatric surgery. And we feel that it’s unacceptable for insurance companies to sell cheaper plans that do not cover bariatric surgeries.”
Ed Stannard can be reached at estannard@courant.com.
Copyright © 2022, Hartford Courant
Copyright © 2022, Hartford Courant

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