Unfortunately in the field of weight loss surgery we use the phrase “NIH criteria” frequently. What does this mean? If refers to a 1991 National Institute of Health consensus statement on which patients should qualify for weight loss surgery. That’s right folks, in many cases we are basing our decisions today on a loose set of mandates from 30+ years ago, when all procedures were open surgeries with 12 inch incisions, were mostly all gastric bypasses, and had a mortality rate of 1-2%.
Nowadays the gastric sleeve is the most commonly performed procedure, and nearly all procedures are done with a laparoscopic, minimally invasive technique. Therefore both the short-term and long-term risk of bariatric surgery is a least an order of magnitude lower than in 1991. Yet most insurance companies still follow these outdated guidelines.
The truth is that lower BMI patients suffering from class I or II obesity have an increased risk of weight-related medical issues and mortality.
Weight loss and metabolic surgery in lower BMI patients who continue to struggle with class 1 or II obesity, in the setting of failed attempts at lifestyle modification & weight loss programs is proven effective at leading to significant weight loss and an overall reduction in comordities and cardiovascular risk.
Also, it has been shown that diet, exercise, and weight loss drugs are largely ineffective for achieving durable weight loss, even in lower BMI patients. In this setting, weight loss surgery is reasonable and is supported by the recent American Society of Metabolic and Bariatric Surgery’s position statement in 2018 (Surgery for Obesity and Related Diseases 14 (2018) 1071-1087).
Obesity is probably the only disease where we make patients wait until they are sicker and a higher operative risk to offer them the most successful treatment option, which is weight loss surgery. We need a change in thinking here as lower BMI patients often times have a higher success rate and are almost always a lower operative risk. Waiting until a patient is heavier and sicker is not the best strategy!