Intended for healthcare professionals

Clinical Review State of the Art Review

Bariatric surgery for obesity and metabolic conditions in adults

BMJ 2014; 349 doi: (Published 27 August 2014) Cite this as: BMJ 2014;349:g3961

Time to end medical nihilism in non-surgical weight management

Bariatric surgery is without doubt highly effective at inducing significant and durable weight loss and remission of type 2 diabetes as well as improving long term survival, reducing the risk of incident cardiovascular disease, and inducing improvements in obesity related comorbidities.1 Nevertheless, non-surgical options including lifestyle and dietary interventions and pharmacotherapy have a role in medical management for the vast majority of people with obesity.2 In our experience at a tertiary weight management centre that includes provision of bariatric surgery, we have treated scores of patients who have achieved significant weight loss on medical measures alone. This has included patients who wished to pursue weight reduction via non-surgical measures alone, as well as patients who were unsuitable for bariatric surgery.

Lifestyle and dietary management have been shown to induce reversal of type 2 diabetes in the short term.3 Furthermore, data from the US National Weight Control Registry, a longitudinal study that is tracking over 10,000 individuals who have achieved and maintained a minimum 13.6 kg weight loss for one year or longer, has demonstrated that weight-loss maintenance comparable with that after bariatric surgery can be accomplished through intensive lifestyle and behavioural management.4 Successful weight maintenance behaviours included eating a diet low in fat and calories, exercising regularly, monitoring weight regularly, eating breakfast, maintaining a consistent eating pattern including during the weekends and holidays, and catching ‘slips’ early before turning into larger regains.5 A medical trigger to the weight loss process, for instance a new diagnosis of type 2 diabetes, was also associated with increased chance of successful weight loss.

Emerging pharmacotherapy for obesity and recent advances in weight-friendly therapies for diabetes such as glucagon-like peptide–1 receptor agonists and sodium glucose co-transporter–2 inhibitors bring further optimism to a field that has been plagued by medical nihilism. Whereas bariatric surgery offers the biggest early gains, we wish to reiterate that even a 5–10% weight reduction, which is easily achieved by non-surgical means at virtually no risk, offers marked health benefits.6

1. Arterburn DE, Courcoulas AP. Bariatric surgery for obesity and metabolic conditions in adults. BMJ 2014;349:g3961.
2. Rueda-Clausen CF, Padwal RS. Pharmacotherapy for weight loss. BMJ 2014;348:g3526.
3. Lim EL, Hollingsworth KG, Aribisala BS, Chen MJ, Mathers JC, Taylor R. Reversal of type 2 diabetes: normalisation of beta cell function in association with decreased pancreas and liver triacylglycerol. Diabetologia 2011;54(10):2506-14.
4. Bond DS, Phelan S, Leahey TM, Hill JO, Wing RR. Weight-loss maintenance in successful weight losers: surgical vs non-surgical methods. Int J Obes (Lond) 2009;33(1):173-80.
5. Wing RR, Phelan S. Long-term weight loss maintenance. Am J Clin Nutr 2005;82(1 Suppl):222S-25S.
6. Logue J, Thompson L, Romanes F, Wilson DC, Thompson J, Sattar N. Management of obesity: summary of SIGN guideline. BMJ 2010;340:c154.

Competing interests: No competing interests

30 September 2014
Angelos Kyriacou
Consultant Endocrinology & Diabetes
Alexis Kyriacou, Clinical Dietitian, KMED Nutrition & Dietetics Centre, Limassol, Cyprus; Akheel A Syed, Consultant Endocrinology & Diabetes, Salford Royal NHS Foundation Trust & University Teaching Hospital
Salford Royal NHS Foundation Trust & University Teaching Hospital
Salford M6 8HD