Surgical Weight Loss For Lower BMI Patients
For people in the Body Mass Index range of 28 to 35, up until recently there have been few options available for weight loss surgery. However, as weight loss surgery has become less and less invasive and associated with fewer and fewer risks, the notion of weight loss surgery for people in a lower BMI category has increasingly appeared to make good sense. After all, like with any surgery or other health treatments intervention, one should always think about and then balance the risks and benefits. On the risk side, laparoscopic or minimally invasive weight loss surgery has become increasingly safe with fewer and fewer risks. This is evidenced by the shift towards the outpatient arena. Laparoscopic adjustable gastric banding surgery (LAGB, Lap-Band and REALIZE band) has proven to be an even less invasive procedure. The complications or problems with surgery have become increasingly rare and are also less severe or acute, meaning that they are typically the kinds of problems that can be solved over time with office visits with the doctor and/or strategic re-operations, if necessary. It is becoming exceedingly rare to require any sort of emergency intervention. So the risk side has fallen to such degree that broadening this option for more people would make great sense if the evidence was also there to show its effectiveness or benefit to people in this lower BMI category. So what does the evidence show?
I have reviewed a number of studies that demonstrate a great, high level of effectiveness for people in this Body Mass Index category undergoing weight loss surgery and specifically Lap-Band surgery. These studies show that people undergoing Lap-Band surgery lose weight with a similar high rate of success, and they also improve their health by resolving health conditions including:
- Breathing difficulties
- Obstructive sleep apnea
- High blood pressure
- High cholesterol
- Bone and joint degenerative pain and diseases and many others
Furthermore, it appears that these people also prevent these same conditions from developing if they have not already done so. For example, less people are likely to progress from prediabetes (or impaired glucose tolerance) on to full diabetes if they undergo Lap-Band surgery.
So the evidence to date would indicate that the benefits exist. A program with Lap-Band surgery will have a high likelihood of resulting in lower weight, better health, resolution of health conditions, longer life and better quality of life. The lower invasiveness of the procedure reduces the risks down to very small ones which pale in comparison to the health risks associated with ongoing overweight and obesity. So why has this not become more widely available?
The reasons that Lap-Band surgery has not become more widely available for people in this low BMI group have to do with several factors and several interests that slow down the process. For starters, the medical devices have been approved for use in people with a Body Mass Index over 35 who have obesity related health conditions, or for people with a BMI over 40 regardless of those specific identified health conditions. This means that the FDA has not approved the device for placement in people with a Body Mass Index under 35 yet. It is always important to bear in mind that many medical devices are approved for one fairly narrow indication, but are then used and placed by physicians for patients in many other more broad circumstances. Certainly, the Lap-Band is one example of this as there are now many studies showing its effectiveness in lower Body Mass Index patients. This was referred to as “off label” use of a medical device. The same thing is true for medications. Oftentimes, the pharmaceutical companies, just like medical device companies, obtain FDA approval for an indication but then over time physicians will prescribe the medication for a broader set of clinical circumstances when it is proven effective. Part of this is because there is enormous expense and time involved in obtaining an officially sanctioned, more broadened indication from the FDA and part of it is because there may be a long lag time of years before the FDA catches up with the medical science about a particular topic, medical device or drug.
So it appears to most experts in the field that we are currently living in this window of time where the medical science demonstrates the benefit of placement of laparoscopic adjustable gastric band in people with lower Body Mass Index, bu the indication from the FDA has not yet caught up with the science. This situation is likely to change because the science is so overwhelming and the medical device manufacturers will soon enough get this data a fair hearing at the FDA and it will undoubtedly be approved at some point in the future.
One of the other reasons that this highly effective procedure is not more available for people with lower Body Mass Index is the cost associated with it for the insurance plans. While the insurance plans can look at data showing overall reduction of health expenditures and cost effectiveness over a one and a half to three year time frame for weight loss surgery, they tend to focus on the short-term costs and the perceived increase in cash outlay if a much greater number of people take advantage of Lap-Band surgery for their weight loss goals. This is too bad because it represents a short-term, short sighted thinking. But nonetheless, it is very unlikely that commercial health insurance plans are going to approve laparoscopic adjustable gastric banding surgery for lower BMI individuals any time in the near future. That will likely take years and will only occur after it is approved by Medicare and other government sponsored plans, in my opinion.
It’s possible though that the same data from numerous studies that will be put before the FDA can also be put before insurance plans who do have a better longer term, more forward thinking outlook. Because they do stand to save money with reduced expenditures covering diseases like obstructive sleep apnea, high blood pressure, heart disease and diabetes after people undergo weight loss surgery. Also, employers who increasingly decide the specific coverage’s that they will approve in their health care plans, may also wish to examine this data because they tend to have a more forward thinking approach than the insurance plans. They realize that they will enjoy less medical absenteeism and less health expenditures, Worker’s Compensation claims and future health insurance premium increases if their workforce can become healthier, fitter and suffer less from obesity.
But in today’s environment, it is unlikely that the insurance carriers are covering it and it forces many people to obtain financing to cover the cost of the procedure or find resources to cover the cost of the procedure.
Examining costs and the potential risks of complications and further costs:
Comparing apples to apples
LAGB is a low risk, low invasiveness intervention. I have performed many LAGB procedures in people with this lower BMI category under our research protocol, whereas our protocol has not included laparoscopic sleeve gastrectomy or Roux-en-Y gastric bypass surgery. In the future, this may change, but right now the risk/benefit analysis in my view favors making available the less invasive weight loss surgical option for this low BMI group of 28 to 35.
It is important that any price that you ultimately decide to pay includes some protection against hidden costs or the costs of further procedures due to complications. Our study has taken this into account and provides a coverage for complications that might arise. While no coverage is absolutely perfect, this coverage was designed to cover 95% of the potential events which may occur as complications to the band including unexpected hospitalization and reoperation for the most commonly identified problems such as band slippage and port dislodgement or dysfunction.
The low BMI research study
Approved by the institutional review board in our region, the study for laparoscopic adjustable gastric banding in moderately obese subjects continues to accrue study participants.
Each study subject receives a thorough evaluation and must be approved as a candidate by the principal investigator, Dr. Sasse.
Subjects are all given educational materials and offered the opportunity to attend support groups and receive ongoing band adjustments in an effort to optimize weight loss success. These groups can be a valuable weight loss tool as they can help motivate you to reach a better level of fitness and lose weight in the process.