New Guidelines for Weight Loss Surgery?
In October, “Guidelines on Indications for Metabolic and Bariatric Surgery” were put out. While I don’t think that these surgeries meet the requirement for ethical, evidence-based medicine, in looking at these guidelines specifically, here are some things that I think it’s important to know.
The guidelines were put out by The American Society for Metabolic and Bariatric Surgery (ASMBS) which is “the largest group of bariatric surgeons and integrated health professionals in the United States” and the International Federation for the Surgery of Ob*sity and Metabolic Disorders (IFSO) which “represents 72 national associations and societies throughout the world.” These are both organizations that primarily represent those who profit from these surgeries.
They were published in two journals. Surgery for Ob*sity and Related Diseases (SOARD) a medical journal “medical journal covering the use of surgery to treat obesity and related medical conditions” and Ob*sity Surgery which is a journal dedicated to bariatric surgery which is “the official journal of the International Federation for the Surgery of Obesity and Metabolic Disorders.” Note that it is the official journal of the organization that created the guidelines, that represents people who profit from the surgeries. I also think that this is an example of the ways in which (what passes for) science around “ob*sity *medicine” can end up putting profits first.
In this case, two organizations that represent those who profit from weight loss surgery have published in two journals dedicated to supporting these surgeries, in order to create new guidelines which would vastly increase their market share because those who belong to these organizations can use the guidelines to justify performing these surgeries on many more patients.
Fox, meet henhouse.
The guidelines gain ground on two of the industry’s constant focuses – lowering the BMI threshold for these procedures, and lowering the age of the patients they are allowed to perform these procedures on.
To do this, they rely on several tried-and-true questionable ideas:
Pathologizing higher-weight bodies
This is the result of a long game that they (and the entire weight loss industry) have been playing to pathologize bodies based on size (and regardless of actual metabolic health.) Making up the concept of “ob*sity” (based on a height/weight ratio) and then transitioning that to a standalone “disease” allows them to make every fat person their market.
In this case, the old guidelines were a adults with “BMI of at least 40 or a BMI of 35 or more and at least one obesity-related condition” the new guidelines are adults and “appropriately selected children and adolescents” with a BMI of 35 or more “regardless of presence, absence, or severity of obesity-related conditions,” a “BMI of 30-34.9 and metabolic disease” and in “Asian individuals beginning at BMI 27.5.”
If you’re playing the home game, these new guidelines increase the market for these surgeries by creating a 5-point BMI drop for the weight at which, no matter what the patient’s metabolic health, they want to give them a surgery that risks their life and quality of life, a 5 point BMI decrease for patients for whom they are recommending these dangerous surgeries based on the fact that they are fat and have a health issue that thin people also get, and a special category for Asian people
There is a lot to unpack here. First of all, the idea that people at a higher BMI should have the surgery regardless of metabolic health, but that those with a lower BMI must have a “metabolic condition” (more on this in a moment) means that they are predicating the significant risks of this surgery purely on body size. They are medically defining higher-weight people’s lives as more riskable, which is pure weight stigma. Beyond that, the concept of metabolic conditions being “ob*sity related” is questionable at best, and is based on extremely dubious research (much of which was funded and/or conducted by the weight loss industry) that uncritically links being higher weight to health issues using (well, abusing, really) correlation and ignoring confounding variables in ways that wouldn’t get past a freshman research professor but that keep getting past peer review.
In one of the ways that we see racism and weight stigma intersect (and please read Sabrina Strings: Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison: Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness to learn more about this,) the industry is very interested in the idea that the standard BMI chart doesn’t necessarily apply to Asian populations, because it allows them to lower BMI threshhold and therefor perform more surgeris. On the other hand, it has shown no interest in the fact that a standard based on cis-white European men since likely creating over-representation of many people of color and cis-women as “ob*se.” In truth, the use of BMI is, in and of itself, the problem. It has racist origins and has created (and continues to create) harm, with the most harm being done to those at the highest weights and those with marginalized identities.
Setting the bar low (really, really low)
They are promoting these surgeries based on the idea that they produce more weight loss than non-surgical means, which isn’t saying much since about 95% of the time non-surgical means end up not producing any weight loss (and up to 66% of the time they actually end in weight gain.) They are ignoring the fact that many people regain their weight after these surgeries (but will never regain their healthy, correctly functioning digestive system.) They are also ignoring the fact that behavior-based weight loss methods and even weight loss drugs, don’t have anywhere near the potential dangers and side effects of these surgeries because they aren’t purposefully creating a typically irreversible disease state in a previously healthy digestive system.
Using a short definition of long-term
The guidelines refer to “studies with long-term follow up, published in the decades following…1991”. If you read to mean that there are decades-long studies published since 1991 I wouldn’t blame you, but you would be still be wrong. The research in this area (much of which is funded and/or conducted by those with a profit interest in these surgeries) is generally ten years at best and very often shorter than that. In truth there is very little outcome data past ten years, and often “success” is simply defined as the patient losing some weight and not dying.
Using questionable comparisons
At some point I’ll do a deeper dive into this, but for now I’ll point out that when they claim that fat people who have the surgery have better outcomes than fat people who don’t, this is often based on comparisons of people who were selected to have the surgery with those who weren’t selected to have the surgery. Of course, they fail to mention that the reasons that the second group weren’t selected for surgery could also be the reasons for their different outcomes and, again, these outcomes are seldom tracked past ten years.
Change the Procedure, Forget the Old Evidence
The industry also has a history of making small changes to the procedure, then claiming that the new procedures are safer than the old procedures based on very short-term data. This also conveniently allows them to claim that unfavorable research is outdated.
The bottom line
These procedures take a healthy digestive system and surgically move it into a disease state, risking the patient’s life and quality of life in ways that are fairly unpredictable and with almost no long-term outcome data past ten years. The evidence for children/adolescents is even more sketchy and there are many other issues that often go completely unmentioned let alone studied in this population. I’ll write more about this later, but it starts with the fact that we have very little data about what happens when you purposefully create a lifelong state of forced food restriction and malabsorption in a child.
These guidelines appear to me to be a brazen attempt to manipulate medicine for profit. Unfortunately, it’s not surprising that these groups would behave this way, and there may be well-intentioned practitioners who are following these guidelines, but that doesn’t make it ok, and it doesn’t help the patients who are harmed or killed in this process.
For more information on this, I have a series about weight loss surgeries, including the basics, the use of these surgeries as a treatment for type 2 diabetes, long-term outcomes and informed consent, and the risks of different procedures.
Did you find this newsletter helpful? You can subscribe for free to get future newsletters delivered direct to your inbox, or choose a paid subscription to support the newsletter and get special benefits! Click the Subscribe button for details:
Like this piece? Share this piece:
For a full bank of research, check out https://haeshealthsheets.com/resources/
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings: Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison: Belly of the Beast: The Politics of Anti-Fatness as Anti-Blackness for more on this.