ASMBS statements/guidelines
ASMBS updated position statement on bariatric surgery in class I obesity (BMI 30–35 kg/m2)

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Preamble

The American Society for Metabolic and Bariatric Surgery (ASMBS) issued a position statement on the role of bariatric surgery in class I obesity in 2012 [1]. That statement was developed in response to inquiries made to the ASMBS by society members, physicians, patients, hospitals, health insurance payers, policymakers, and the media regarding the safety and efficacy of bariatric surgery for patients with body mass index (BMI) 30 to 35 kg/m2. In the evolving field of bariatric and metabolic

Impact of class I obesity on health

Class I obesity is associated with increased risk of medical and psychological co-morbidities. The risk of developing diabetes, hypertension, and dyslipidemia increases with weight gain. Furthermore, weight loss can significantly reduce the incidence of these cardiometabolic risk factors. Several studies have shown associations between class I obesity and nonalcoholic fatty liver disease, obstructive sleep apnea (OSA), polycystic ovary syndrome, and bone and joint diseases, among others [9],

Nonsurgical treatment of class I obesity

Safety and efficacy are 2 important factors when considering a treatment method in clinical practice. In the treatment algorithm for class I obesity, the best-tolerated treatment that is effective should be the preferred option. All individuals seeking weight loss should begin with nonsurgical therapy and consider bariatric surgery only if they are unable to achieve sufficient long-term weight loss and co-morbidity improvement with nonsurgical therapies [1].

Lifestyle modification programs

National Institutes of Health Consensus Conference, USA

The morbidity and mortality caused by the disease of obesity is well established and has long been recognized by all major advisory bodies, including a National Institutes of Health consensus development conference on obesity in 1985 and a subsequent separate consensus conference on gastrointestinal surgery for obesity held in March 1991, which considered the role of bariatric surgery for these patients [6]. A synthesis of the views of the opinion leaders present at that time recommended that

Bariatric surgery for class I obesity

There is a robust body of literature to support the safety profile and efficacy of bariatric surgery in patients with class I obesity. The first ASMBS position statement in 2012 summarized data from 4 RCTs [50], [51], [52], [53], 16 observational studies, and 1 meta-analysis [54] on outcomes of bariatric surgery in patients with BMI 30 to 35 kg/m2 [1]. In the last 5 years, there is mounting evidence to support surgical treatment of obesity in patients with class I obesity.

Since the publication

Safety of bariatric surgery

According to the literature, as shown before (Table 1, Table 2, Table 3), bariatric surgery is associated with modest morbidity and very low mortality in patients with class I obesity.

Furthermore, among 1300 patients with diabetes and a BMI <35 kg/m2 in the American College of Surgeons data set, the incidence of all individual major complications was ≤.5% after bariatric surgery except for postoperative bleeding (1.7%). Thirty-day postoperative composite morbidity, serious morbidity, and

Cost-effectiveness

Recognition of efficacy and safety of surgery may not suffice for advocacy of bariatric surgery for class I obesity. Economic evaluation to determine the cost-effectiveness of bariatric surgery for mild obesity has also been performed.

The majority of studies support cost-effectiveness of surgery over medical therapy in patients with severe obesity, especially in patients with type 2 diabetes. Recently, several clinical and economic reviews examined the value of bariatric surgery in class I

Preferred procedure in class I obesity

The decision regarding the choice of bariatric procedures must take into account the risk/benefit analysis for a particular patient, presence of obesity-related co-morbidities (e.g., type 2 diabetes, gastroesophageal reflux disease) as well as patient preferences [98]. In the BMI 30- to 35-kg/m2 group and for bariatric surgery in general, there is currently no predictive method to match a particular patient with a particular operation to achieve the optimal outcome. Caregivers must have

Summary and recommendations

  • 1.

    Class I obesity (BMI 30–35 kg/m2) causes or exacerbates multiple other diseases, decreases longevity, and impairs quality of life. Patients with class I obesity require durable treatment for their disease.

  • 2.

    Current nonsurgical treatments for class I obesity are often ineffective at achieving major, long-term weight reduction and resolution of co-morbidities.

  • 3.

    The existing BMI inclusion criterion of ≥35 kg/m2 as a prerequisite for bariatric and metabolic surgery—excluding individuals with class I

Acknowledgments

This statement has been supported by the American Diabetes Association (ADA) and has been endorsed by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Disclosures

The authors have no commercial associations that might be a conflict of interest in relation to this article.

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