My conflict with IFSO Position Statement on Bariatric Surgery for Class I Obesity

My conflict with IFSO Position Statement on Bariatric Surgery for Class I Obesity

At first glance, I would definitely support the statement recently made by prominent authors from the society I proudly belong to, IFSO:

“Therefore, the denial of bariatric surgery to a patient with class I obesity suffering from a significant obesity-related health burden and not achieving weight control with nonsurgical therapy simply on the basis of the BMI level does not appear to be clinically justified.” Bariatric surgery in class I obesity. Obes Surg (2014) 24: 487-519.

Well, why do I feel a tad uncomfortable about it?

Perfectly written as the rest of the paper, perfectly balanced, this statement had every word duly considered: e.g. "refusing to deny surgery" is not the same as "promoting surgery", and one can but commend such an understatement.

Besides, the paper also addresses the resources issue, surgery being an expensive tool albeit cost-effective in the end. The problem comes from the equation between public health priorities, including the staggering "epidemic" of obesity, and the allocation of spending to a given group or subset of patients.

We actually fail to convince the vast majority of those who could be legitimate candidates for obesity surgery, namely class III obese patients, then why should we enrol more patients who by current standards are not the best candidates?

Even if bariatric surgery, cleverly re-baptized "metabolic surgery", may address for instance class I obesity patients with unstable type 2 diabetes, we are far from recommending it for such a huge population.

Moreover, it has been demonstrated (see for instance the Lancet Commission on Global Surgery) that most of the basic needs in surgery around the world are not covered enough. In other words we should train more surgeons who can safely perform appendectomies rather than sleeve gastrectomies...

If I may criticize my fellow surgeons, what is at stake here is seeing the world through a different pair of glass, rather than the surgical ones. Surgery, whatever our endeavour, is aggressive. Even if rightly proven relatively innocuous when primarily performed, it bears serious consequences in the long run, for example the necessity of sometimes multiple reoperations over the time.

On the other hand, I am equally upset when reading that a UK Health Select Committee criticized the English NHS (National Health Service) for spending more money on weight loss surgery than on measures to prevent obesity. The report argued that more emphasis should be placed on spreading awareness of the benefits of exercise, which no one denies. Yet obesity surgery has been proven a valuable method to cut down the costs of morbid obesity over a long-term period. In other words, nobody blames cancer surgery whereas some cancers are connected to lifestyle habits (e.g. smoking) that could get more funding to be prevented...

My final word: place ourselves as public health decision makers, public audience and average citizens, and recommend what is feasible and reasonable for the time being given the resources we have. Obesity is not viewed anymore (or should not be) as a self-inflicted disease, and bariatric surgery deserves credit. The case has been duly made, but extending its boundaries may not be the right move for now.