For the first time in over 30 years, weight loss surgery guidelines have been updated to expand eligibility to more people, Karen Weintraub writes for USA Today. However, experts say there are still several barriers to care for patients with obesity, including a lack of coverage for treatments.

New guidelines vastly expand eligibility for weight loss surgery

According to Weintraub, guidelines for weight loss surgery were last set in 1991 and had not been updated since. Under these guidelines, patients had to have a body mass index (BMI) of at least 40 or a BMI of at least 35 and at least one obesity-related condition, such as hypertension or heart disease, to qualify for weight loss surgery.

However, Shanu Kothari, immediate past president of the American Society for Metabolic and Bariatric Surgery (ASMBS), said these requirements were "trapped in the past" and did not account for new scientific developments.

In recent years, weight loss surgery has become significantly safer, and research has shown it can improve or even reverse dozens of weight-related health conditions. For example, death rates from weight loss surgery have declined 20- to 30-fold, dropping from two to three deaths per 100 patients to around one in 1,000.

To account for these new developments, as well as the growing prevalence of obesity in many countries, ASMBS and the International Federation for the Surgery of Obesity and Metabolic Disorders, which represents 72 countries, convened to update the guidelines.

Under the new guidelines, anyone with a BMI over 35, regardless of whether they have any health problems, is eligible for weight loss surgery. People with a BMI over 30, which is the official definition of obesity, are also eligible if they have not been able to achieve substantial or long-term weight loss.

Among individuals of Asian descent, the BMI requirement was dropped to 27.5 since they often have weight-related health issues at a lower body mass.

In addition, children and adolescents are now eligible for surgery under the new requirements since there is now data to support the potential benefits.

According to Ali Aminian, director of the Bariatric and Metabolic Institute at the Cleveland Clinic who helped draft the new guidelines, weight-related diseases are easier to combat if they are treated in adolescence.

"We have a lot of data to support that the outcomes of kids who underwent surgery were much better than the outcomes of patients who had surgery for their obesity in their 40s and 50s," he said. "If we wait a long time, some of those consequences of obesity are not reversible."

However, some health experts expressed disappointment that the updated guidelines still rely on BMI as a determining factor for surgery.

"I hate BMI," said Fatima Cody Stanford, a weight loss specialist at Massachusetts General Hospital. "It's an arbitrary thing. It doesn't define one's health." Instead of BMI, Stanford said she would prefer a decision for surgery based on other measures of health, such as high blood sugar levels, high cholesterol, or fatty liver disease.

Even with the new guidelines, barriers remain

According to Stanford, even with the expanded guidelines, many patients still face significant barriers to weight loss, including inadequate medical training and a lack of insurance coverage.

Although more than 100 million Americans struggle with their weight, there are relatively few doctors who are trained to help patients lose weight, making it difficult for people to get care. Currently, Massachusetts General's weight loss center has 4,000 people on its wait list.

In addition, health coverage for weight loss treatment is inconsistent across the country. In general, Medicare and private insurers do not cover weight loss surgery or other obesity-related treatments unless a patient also has severe weight-related health problems.

However, Kothari said he hopes the updated guidelines will encourage insurance companies to update their coverage. When other medical organizations, such as the American Heart Association or the American Diabetes Association, update their treatment guidelines, insurers usually do the same with their coverage.

"We have plenty of data to show obesity is a disease and needs to be treated as such," Kothari said. The goal of the updated guidelines "is to improve access to patients who deserve it based on contemporary evidence and ... to impact and change coverage policies." (Weintraub, USA Today, 10/21)