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Wednesday, Feb. 22, 2023



Science is learning more about medical issues

In December 2022, the American Society for Metabolic and Bariatric Surgery (ASMBS) and the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) published their consensus statement to replace the National Institute of Health (NIH) 1991 consensus statement. This was prompted by 30 years of research and advancements in both the results and safety of metabolic bariatric surgery.

Previous guidelines stated that metabolic bariatric surgery was appropriate for patients with a Body Mass Index (BMI) of at least 40 or a BMI of 35 or more with an obesity-related condition such as heart disease, type 2 diabetes, osteoarthritis and obstructive sleep apnea.

The new guidelines recommend the surgery for individuals with a BMI of 35 or more “regardless of the presence, absence or severity of obesity-related conditions.” The full guidelines give additional details for even lower BMI considerations for other patient populations.

Currently, the 1991 standards are the minimum required by those insurance companies that cover this type of surgery. Unfortunately, many policies still list metabolic bariatric surgery as an exclusion, meaning that regardless of the medical necessity for the patient, the plan will not cover the surgery. For patients today, we are probably many years away from insurance companies updating to accept these new professional guidelines.

What have we learned about the disease of morbid obesity and the treatment with metabolic bariatric surgery over these 30 years? Obesity is now recognized as a chronic disease by the American Medical Association, the National Institute of Health, and the World Health Organization. Both professionals and, hopefully, the public who follow the research are now understanding that there are several factors well beyond personal choices that influence obesity. As the new consensus paper summarizes, “Obesity is associated with a chronic, lowgrade, inflammatory state and immune dysfunction.” This prolonged inflammation leads to metabolic disorders associated with obesity.

I think of this chronic issue as a “software problem.” In my review of the research and 30 years of my own patient experiences, I have learned that our genetics is not “hardware,” something static and unchanging.

Through the incredible advances in the field of epigenetics, we have learned that not only can our environment impact our genes and contribute to becoming obese, but once we become obese, that physical state can then act to alter our genetics in the development of new diseases.

As noted by researcher Vidhu V. Thaker, M.D., of Columbia University, in his paper published in fall 2017 titled “Genetic and Epigenetic Causes of Obesity,” “Obesity is a complex, heritable trait influenced by the interplay of genetics, epigenetics, metagenomics and the environment. With the increasing access to high precision diagnostic tools for genetic investigations, numerous genes influencing the phenotype have been identified, especially in early onset severe obesity.”

In everyday terms, this is what I refer to as genetic predisposition meets environmental influence. I like to think of epigenetics as the software programming aspect of our DNA, which can essentially switch off or on the expression of obesity in our genes. Environmentally, as an example, pregnant mothers who are either undernourished or morbidly obese can predispose the infant to both metabolic deficiencies and obesity. Researchers are now finding that even after the environmental influences have improved or changed, these changes may still be passed on genetically in future generations.

The use of metabolic bariatric surgery has been a transformative tool in treating this

chronic disease. Although, as I explain to all my patients, surgery is not a cure, it is a powerful tool that requires constant monitoring and support for long-term success. It may even require revisional surgery years down the road to change or enhance the tool.

As stated in the consensus paper, studies of patients five, 10 and 20 years after metabolic bariatric surgery have consistently shown maintenance on average of 60% of excess weight loss and results superior to diet, exercise and lifestyle change alone in improving obesity-related health conditions. Obesity can negatively affect almost every organ in the body. These studies have shown improvements and even complete remission in disease and “significant and durable clinical improvement of metabolic syndrome following surgery.”

Now as perhaps never before, we are at a transformational time in the study of obesity with an amazing future ahead in new developments in both the causes and treatments of this chronic problem, but don’t wait to address this issue. The most common statement I hear from my patients is “I wish I had gotten the surgery sooner.”

George R. Merriman II, MD, FACS, FASMBS. For more information, visit ASBMS.org, ncbi.nlm.nih.gov or FreedomFromObesity.com


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