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Why the NHS should do more bariatric surgery; how much should we do?

BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i1472 (Published 11 May 2016) Cite this as: BMJ 2016;353:i1472
  1. Richard Welbourn, consultant surgeon1,
  2. Carel W le Roux, professor of metabolic medicine2,
  3. Amanda Owen-Smith, lecturer in social medicine3,
  4. Sarah Wordsworth, associate professor of health economics4,
  5. Jane M Blazeby, professor of surgery5
  1. 1Department of Upper Gastrointestinal and Bariatric Surgery, Musgrove Park Hospital, Taunton TA1 5DA, UK
  2. 2Diabetes Complications Research Centre, Conway Institute, University College Dublin, Ireland
  3. 3School of Social and Community Medicine, University of Bristol, Bristol, UK
  4. 4Nuffield Department of Population Health, University of Oxford, Oxford, UK
  5. 5Centre for Surgical Research, School of Social and Community Medicine, University of Bristol, UK
  1. Correspondence to: R Welbourn Richard.Welbourn{at}tst.nhs.uk

The number of people getting bariatric surgery is falling despite rising rates of obesity and diabetes. Richard Welbourn and colleagues examine why and argue that better access has potential to reduce long term costs of care

As the epidemic of severe and complex obesity worsens, availability of the most successful treatment, bariatric surgery, is limited. Less than 1% of those who could benefit get treatment. By contrast, people with other lifestyle health problems such as alcohol related liver disease are treated. We explore the clinical and cost effectiveness of bariatric surgery and examine the barriers to access.

Effectiveness of surgery

A Cochrane review of 22 randomised controlled trials of bariatric surgery found that it is more effective and cost effective for the treatment of severe obesity than non-surgical measures after two years.1 Longer term trial data also favour surgery.2 Non-randomised data from the Swedish Obese Subjects study (SOS), a long running cohort study of 2000 patients who received surgery and 2000 matched controls, shows weight loss being maintained for 20 years,3 with glycaemic control improved for at least 10 years after surgery. Patients having surgery were also more likely to go into glycaemic remission of diabetes than those having non-surgical approaches, and fewer patients progressed from prediabetes to diabetes.3

In the UK a national registry of over 3000 patients with diabetes operated on between 2011 and 2013 shows that 65% had acceptable glycaemic control without medication after surgery.4 Swedish registry data also show a 58% reduction in the relative risk of dying during an average of 3.5 years’ follow-up of 6000 patients with diabetes compared with matched patients without surgery.5 In all the surgical series the average weight loss is 25-35% of body weight (usually at least 15 kg) after one year for patients who are severely …

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