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  • Review Article
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Bariatric and metabolic surgery: a shift in eligibility and success criteria

Nature Reviews Endocrinology volume 11, pages 465–477 (2015)Cite this article

Subjects

Key Points

  • Bariatric surgery has a proven role in achieving sustained weight loss, improving obesity-related comorbidities and reducing mortality

  • Bariatric surgery is considered to address mainly weight loss, whereas metabolic surgery focuses mainly on improving type 2 diabetes mellitus

  • Bariatric and metabolic surgery cannot be viewed as dichotomic procedures, as most of the clinical benefits of both approaches have a multifactorial origin derived from a combination of effects

  • Detailed patient phenotyping shows that the BMI cut-off points for determining eligibility for surgery are blurred when considering total adiposity and fat distribution, as BMI often does not tally with these factors

  • Changes in eligibility and follow-up criteria that move away from a merely BMI-centric view for indicating bariatric or metabolic surgery should be pursued

  • A more functional, individualized and holistic approach with extensive evaluation of comorbidities will yield improved patient selection that does not have a 'weight-centric' focus

Abstract

The obesity epidemic, combined with the lack of available and effective treatments for morbid obesity, is a scientific and public health priority. Worldwide, bariatric and metabolic surgeries are increasingly being performed to effectively aid weight loss in patients with severe obesity, as well as because of the favourable metabolic effects of the procedures. The positive effects of bariatric surgery, especially with respect to improvements in type 2 diabetes mellitus, have expanded the eligibility criteria for metabolic surgery to patients with diabetes mellitus and a BMI of 30–35 kg/m2. However, the limitations of BMI, both in the diagnosis and follow-up of patients, need to be considered, particularly for determining the actual adiposity and fat distribution of the patients following weight loss. Understanding the characteristics shared by bariatric and metabolic surgeries, as well as their differential aspects and outcomes, is required to enhance patient benefits and operative achievements. For a holistic approach that focuses on the multifactorial effects of bariatric and metabolic surgery to be possible, a paradigm shift that goes beyond the pure semantics is needed. Such a shift could lead to profound clinical implications for eligibility criteria and the definition of success of the surgical approach.

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Figure 1: Summary of the effects (expressed as mean data for efficacy and 95% confidence intervals) of the main bariatric surgery procedures on weight loss (reported as excess and mean weight loss) and principal comorbidities (hypertension, hyperlipidaemia and T2DM) at 3–5 years.10,19,21,23,27,31,32,61,62
Figure 2: Short, medium and long-term trajectories of EWL, BMI and total adiposity following bariatric surgery.
Figure 3: The separation of bariatric and metabolic surgery.
Figure 4: Radial plot comparing the main clinical characteristics of patients undergoing bariatric and metabolic surgery.

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Acknowledgements

The author would like to acknowledge the support of Fondo de Investigación Sanitaria-FEDER (FIS PI12/00515) from the Spanish Instituto de Salud Carlos III. CIBER de Fisiopatología de la Obesidad y Nutrición (CIBERobn) is an initiative of the Instituto de Salud Carlos III, Spain.

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  1. Department of Endocrinology & Nutrition, CIBEROBN, Clínica Universidad de Navarra, University of Navarra, IdiSNA, Avda. Pío XII 36, Pamplona, 31008, Spain

    Gema Frühbeck

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Correspondence to Gema Frühbeck.

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Frühbeck, G. Bariatric and metabolic surgery: a shift in eligibility and success criteria. Nat Rev Endocrinol 11, 465–477 (2015). https://doi.org/10.1038/nrendo.2015.84

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