Spirals in a Sage Trunk

Bariatric Surgery: Information, Misinformation, and Inertia

A striking pair of papers in JAMA Surgery offers powerful food for thought about bariatric surgery. The first is a systematic review of how safe and effective it is for Medicare patients. The second is a commentary from well-respected health policy researchers. After reading these papers, we see a huge huge gap. On one hand, we have expert health researchers who say the benefits are clear. Even in older patients. Yet, in the real world, misinformation about bariatric surgery bombards us.

Equivocation by healthcare professionals serves to keep this misinformation alive.

Efficacy and Safety for Medicare Patients

The AHRQ study is quite a rigorous study of comparative effectiveness. Orestis Panagiotou and colleagues relied on data from 16 studies in Medicare populations. Of course, randomized studies of bariatric surgery are quite rare. In fact none of these studies had a randomized design.

Nonetheless, the authors found plenty of evidence that bariatric surgery is effective for Medicare patients. They rate the evidence as low to moderately strong. The researchers looked at a wide range of outcomes. Naturally, they looked at sustained weight loss. But they also looked at complications and mortality. In addition, they examined metabolic, heart, lung, joint, and kidney health. They examined evidence that people could take fewer meds after having surgery.

The biggest fault they find with existing data is its heterogeneity. These data come from very diverse studies. So a meta-analysis wasn’t possible. They could not combine all of the data into one big and powerful analysis. So naturally, the researchers call for more research.

Enough Already!

Margaret Smith and Amir Ghaferi offer a slightly different view in their commentary. Of course they agree with the need for more research. But they’re a bit more focused on long-term outcomes and looking at the big picture. They argue against more studies that focus narrowly on Medicare patients.

More importantly, Smith and Ghaferi call for an end for equivocating. “It remains abundantly clear that bariatric surgery is the most effective treatment of obesity in older adults,” they say. Their biggest concern is that so many people who might benefit from bariatric surgery never get the option.

It’s not hard to see why. To begin with, surgery is intimidating. There’s no such thing as minor surgery when you’re the patient. But on top of that, many healthcare professionals are ignorant about obesity and its treatment. Many of them believe that  behavior change is all it takes to resolve this disease. Unfortunately, study after study shows that diet and exercise does not cure obesity or even put it into remission for most patients.

On top of that, exaggerated perceptions of the risks of bariatric surgery are common. Nearly 70 percent of people with severe obesity say that they would never consider bariatric surgery – mostly because they think it’s too risky.

We must agree with Smith and Ghaferi. The benefits of bariatric surgery are clear. Decisions about obesity care are important. Patients need good information with less equivocation.

Click here for the systematic review and here for the commentary.

Spirals in a Sage Trunk, photograph © Peter Prehn / flickr

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July 10, 2018