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BMI 30-35 Kg/M2 Surgery for Obesity and Related Diseases 14 (2018) 1071–1087 ASMBS statements/guidelines ASMBS updated position statement on bariatric surgery in class I 2 obesity (BMI 30–35 kg/m ) a, ∗ a a b Ali Aminian , Julietta Chang , Stacy A Brethauer , Julie J. Kim , for the American Society for Metabolic and Bariatric Surgery Clinical Issues Committee a Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, Ohio b Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts Received 31 May 2018; accepted 31 May 2018 Preamble creased from 3% to 10% in men and from 6% to 15% in women [2] . In 2015, the prevalence of obesity in the The American Society for Metabolic and Bariatric United States among adult women and men was 35% Surgery (ASMBS) issued a position statement on the role and 31%, respectively. In 2015, obesity contributed to 4 of bariatric surgery in class I obesity in 2012 [1] . That million deaths worldwide. Cardiovascular disease and di- statement was developed in response to inquiries made to abetes were the leading causes of death and disability- the ASMBS by society members, physicians, patients, hos- adjusted life-years related to high BMI [3] . Particularly pitals, health insurance payers, policymakers, and the me- in the United States, between 1999–2002 and 2011–2014, dia regarding the safety and efficacy of bariatric surgery the percentage of adults with class I obesity increased from for patients with body mass index (BMI) 30 to 35 kg/m 2. 17.9% to 20.6%. In the United States, more than half of In the evolving field of bariatric and metabolic surgery, those who are obese fall into the class 1 obesity range [4] . the Clinical Issues Committee of ASMBS recognized the The American Medical Association now recognizes obe- necessity to update the position statement since additional sity, defined as a BMI ≥30, as a chronic multisystem dis- high-quality data has emerged in the past 5 years to sup- ease, which is associated with multiple anatomic, physi- port bariatric surgery in class I obesity. In this updated ologic, and psychological consequences [5] . Management statement, the ASMBS recommendations are presented that of obesity along with its co-morbidities requires a chronic are derived from available knowledge, peer-reviewed scien- disease model of care that includes various therapies, such tific literature, and expert opinion. The statement may be as lifestyle, pharmacologic, and surgical intervention to im- revised in the future should additional evidence become prove long-term outcomes [1] . available. The statement is not intended as, and should not The principal purpose of this review was to assess be construed as, stating or establishing a local, regional, the evidence regarding the benefits and risks of bariatric or national standard of care. surgery in patients with class I obesity (BMI of 30.0–34.9 kg/m 2), which constitutes > 20% of the U.S. population Introduction [4] . The current high-quality data support lowering the ar- bitrary BMI inclusion criteria of 35 kg/m 2 for bariatric The global pandemic of obesity and its associated co- surgery, which was established > 25 years ago [6–8] . morbidities have become a major burden to individual patients and society at large. Over the last 4 decades, Impact of class I obesity on health worldwide prevalence of obesity (BMI ≥30 kg/m ²) in- Class I obesity is associated with increased risk of ∗Correspondence: Ali Aminian, Bariatric and Metabolic Institute, medical and psychological co-morbidities. The risk of Cleveland Clinic, 9500 Euclid Avenue, M61, Cleveland, OH 44195. developing diabetes, hypertension, and dyslipidemia in- E-mail address: [email protected] (A. Aminian). creases with weight gain. Furthermore, weight loss can https://doi.org/10.1016/j.soard.2018.05.025 1550-7289/© 2018 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved. 1072 Ali Aminian et al. / Surgery for Obesity and Related Diseases 14 (2018) 1071–1087 significantly reduce the incidence of these cardiometabolic treatment algorithm for class I obesity, the best-tolerated risk factors. Several studies have shown associations be- treatment that is effective should be the preferred op- tween class I obesity and nonalcoholic fatty liver disease, tion. All individuals seeking weight loss should begin with obstructive sleep apnea (OSA), polycystic ovary syndrome, nonsurgical therapy and consider bariatric surgery only if and bone and joint diseases, among others [9–18] . they are unable to achieve sufficient long-term weight loss Excess weight is increasingly recognized as an im- and co-morbidity improvement with nonsurgical therapies portant risk factor for some cancers [19–24] . A large [1] . standardized meta-analysis showed that in men, a 5-kg/m 2 Lifestyle modification programs designed to improve increase in BMI was strongly associated with esophageal, eating habits and physical activity are the first option for thyroid, colon, and renal cancers. In women, strong weight control in class I obesity, given their low cost and associations between a 5 kg/m 2 increase in BMI and the minimal risk of adverse events. However, the modest endometrial, gallbladder, esophageal, and renal cancers weight loss is only partly maintained over time and weight were found. Furthermore, weaker positive associations regain is common after discontinuation of lifestyle inter- (relative risk < 1.2) between increased BMI and many vention program [30–34] . other cancers were observed [19] . Pharmacotherapy is also indicated to augment the A meta-analysis of 89 studies showed significant as- weight loss effects of lifestyle interventions in individuals sociations between all classes of overweight/obesity and with class I obesity. Currently, there are 4 approved type 2 diabetes, hypertension, coronary artery disease, con- monotherapies (orlistat, phentermine, lorcaserin, and li- gestive heart failure, stroke, asthma, pulmonary embolism, raglutide) and 2 combination weight loss medications gallbladder disease, 9 common cancers, osteoarthritis, and (phentermine–topiramate and naltrexone–bupropion) with chronic back pain. Although patients with class I obesity different mechanisms of action. However, patients are were not separately analyzed from overweight or patients often disappointed by modest weight loss, high cost, and with more severe forms of obesity, the findings were con- adverse events [35–41] . sistent in overweight and all 3 classes of obesity, showing Endoscopic intraluminal procedures including temporary the effect of class I obesity in the pathogenesis of these intragastric balloons, gastric partitioning procedures, and conditions [15] . gastrointestinal liners have been developed to mimic the From a mortality standpoint, an adjusted collaborative effects of bariatric surgery [42–45] . However, the outcomes analysis of data from almost 900,000 adults in 57 prospec- of endoscopic treatments have not been consistent to date. tive studies showed that overall mortality was lowest at ap- Specifically, the high-quality data on safety, tolerability, proximately 22.5 to 25 kg/m 2 in both sexes and at all ages. efficacy, and durability of these procedures in patients with Above this range, each 5 kg/m 2 higher BMI was associated class I obesity is limited. with approximately 30% higher all-cause mortality (40% For most people with class I obesity, therefore, it is for vascular; 60%–120% for diabetic, renal, and hepatic; clear that the nonsurgical group of therapies will not pro- 10% for neoplastic; and 20% for respiratory and for all vide a durable solution to their disease of obesity. The other mortality). At 30 to 35 kg/m 2, median survival was majority of individuals with class I obesity will not lose reduced by 2 to 4 years [25] . a substantial amount of weight with these measures, and It is important to mention that BMI alone is a poor for those who do lose weight, the majority will regain the indicator of adiposity, metabolic disease, and cardiovascu- weight within 1 to 2 years. Systematic reviews of the nu- lar risk. Individuals with the same BMI can have signif- merous randomized controlled trials (RCTs) of programs icantly different health conditions given the presence of incorporating diets, exercise, pharmacotherapy, and behav- different visceral fat versus muscle mass [9,26–29] . For ioral therapy have reported a mean weight loss in the range example, the health risk in a patient with BMI 33 kg/m 2 of 2 to 6 kg at ≤1 year and poor maintenance of that with visceral and ectopic fat accumulation and subsequent weight loss beyond that time [1,9,34–37] . metabolic disease would be significantly higher than that Nonetheless, within the total group of participants stud- of a metabolically healthy obese individual with BMI 37 ied in these trials and within the general practice of kg/m 2. bariatric medicine, approximately 25% to 50% of individ- Altogether, we can conclude that class I obesity is uals can achieve substantial weight loss ( > 10% weight) at a chronic disease that leads to additional serious co- 1 year and some have been able to maintain meaningful morbidities and can possibly shorten life expectancy [1] . weight loss for several years. Therefore, before consider- Therefore, class I obesity deserves effective and durable ing surgical treatment for obesity for any individual, an treatment. adequate trial of nonsurgical therapy should always be re- quired. If, however, the attempts at treating their obesity Nonsurgical treatment of class I obesity and obesity-related co-morbidities have not been effective, Safety and efficacy are 2 important factors when con- we must recognize that the individual has a disease that sidering a treatment method in clinical practice. In the threatens their health and decreases their life expectancy Ali Aminian et al. / Surgery for Obesity and Related Diseases 14 (2018) 1071–1087 1073 and as such, we must seek an effective, durable therapy, obesity-related co-morbidity simply on the basis of the such as bariatric surgery [1,9,35] .
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