Goodbye Bariatric, Hello Metabolic Surgery

Are we ready for a re-think of obesity and metabolic health? Ready to change the conversation about obesity medicines and bariatric surgery? Sergio Santoro, Scott Shikora, and Ricardo Cohen certainly think so. Writing in Obesity Surgery, they say it’s time to say goodbye to bariatric surgery and move on to the framework of metabolic surgery. They’re right.

But the need to move on comes from more than just surgery. It is really about the way we frame obesity and its treatment. The old way of thinking is weight centric and people are rejecting it on many fronts. The new frame is all about health – gaining health rather than merely losing weight.

Lasting Gains in Health

That old frame focused on weight is the reason we have term bariatric attached to these surgeries. The original thinking was that the value of a gastric bypass was simply to cause a person to lose weight. Metabolic health benefits were almost an afterthought. The etymology of bariatric tells us that it was coined to mean weight treatment.

But now clinical scientists know quite clearly that gastric bypass and gastric sleeve operations don’t simply make people lose weight by restricting what they can eat. They correct dysfunctional signaling between the brain and the gut for better regulation of metabolic health. Weight loss is part, but not all of that picture.

Reminding us of the lasting gains in health is a new study in JAMA Surgery published yesterday. Joonas Kauppila and colleagues found that after metabolic surgery, people had less need for cholesterol and diabetes medicines – even 15 years later. For heart medicines, the need went down after surgery, but it crept back up over the long term, almost matching what the non-surgical control group was using after 15 years.

This data adds to the clear evidence that metabolic surgery delivers lasting benefits for health – less heart and liver disease, less diabetes, less cancer, and less premature death.

A Future of Comprehensive Care

So the future of surgery in obesity care will be strong as a part of multi-modal comprehensive care. Just as we treat cancer with both medicine and surgery, metabolic surgery will likely continue to play an important role for treating obesity. But the emphasis will continue to shift toward this as metabolic more than bariatric surgery.

No Longer Blinded by Weight Loss

No doubt, people will still talk about the weight outcomes from metabolic surgery for some time to come. Just as they (misleadingly, we think) label new, advanced obesity medicines as weight loss drugs. It’s natural because weight loss is the most immediate and visible effect of the improved metabolic health that good obesity care delivers.

But for the long term, it fades in importance. Weight loss has its limits. Gains in health and life quality become far more important over time. People who live and cope successfully with obesity come to understand this. Everyone else is missing the point.

Click here for the perspective from Santoro et al, here for the study by Kauppila et al. For further perspective on the enduring importance of metabolic surgery, click here.

Carrots of Many Colors, photograph by Stephen Ausmus for the U.S. Agricultural Research Service

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May 25, 2023