NICE Guidelines need specific BMI cut–off limits for Asians
The recent guidelines by NICE regarding management of overweight and obesity mention a lower BMI for South Asians than the other populations for treatment of obesity, particularly with regards to opting for bariatric surgery. The BMI cut-off limits are not mentioned in the guidelines. The need for a separate cut-off limits for Asians has been highlighted by the World Health Organization (WHO) and in their expert consultation concluded in 2004, it has been re-iterated that Asians have a higher percentage of body fat than Caucasian people of the same age, sex and BMI. Even the occurrence of type 2 diabetes is more in lower BMI than the WHO cut-off limit of 25 kg/m2. Thus, WHO recommended that for many Asians the limits for public health action should be 23 kg/m2. The categories suggested for Asians are: less than 18.5 kg/m2 (underweight); 18.5–23 kg/m2 (normal); 23–27.5 kg/m2 (overweight) and 27.5 kg/m2 or higher (obesity). (1)
Recognizing the need for separate guidelines for Asians regarding bariatric surgery, the IFSO-Asian Pacific Chapter (APC) consensus statement was put forward in 2011. It is based on the consultation of bariatric experts from the Asia Pacific region during the IFSO APC Congress on 24th February 2011 in Rusutsu, Hokkaido, Japan. All voting delegates represented their respective the conclusion of the consensus summit is summarized below. (2)
•Bariatric surgery should be considered for the treatment of obesity for acceptable Asian candidates with BMI greater than 35 kg/m2 regardless of the existence of comorbidities.
•Bariatric/GI metabolic surgery should be considered for the treatment of T2DM or metabolic syndrome, for patients who are inadequately controlled by lifestyle alternations or medical treatment for acceptable Asian candidates with BMI greater than 30 kg/m2.
•The surgical approach may be considered as a non primary alternative to treat inadequately controlled T2DM or metabolic syndrome for suitable Asian candidates with BMI greater than 27.5 kg/m2.
•Any surgery for T2DM or metabolic syndrome for Asian patients with a BMI less than 27.5 kg/m2 should be strictly performed only under clinical study protocols with the informed consent of the patient and prior approval from an ethics committee.
• IFSO-APC generally recommends the following procedures for Bariatric and GI metabolic surgery for Asians: Gastric bypass, sleeve gastrectomy, gastric banding, biliopancreatic diversion with duodenal switch (BPD-DS).
•Clinical study should be organized by highly experienced bariatric surgeons, with experience in over 100 cases of bariatric surgery.
The variations in the guidelines are also seen in the International Diabetes Federation (IDF) position statement in March 2011. According to IDF, for Asians, surgery should be considered as an alternative treatment option with a BMI between 27.5 and 32.5 kg⁄m2 when diabetes cannot be adequately controlled by an optimal medical regimen, especially in the presence of other major cardiovascular disease risk factors. Thus, the NICE guidelines should also consider some of these guidelines while setting BMI cut-offs for Asians.
1. NIH conference. Gastrointestinal surgery for severe obesity. Consensus development conference panel. Ann Intern Med. 1991; 115:956-61.
2. Raj PP, Palanivelu C. Guidelines for Bariatric (Metabolic) Surgery for Indian Population.http://www.apiindia.org/medicine_update_2013/chap172.pdf (accessed on 5th December 2014).
Competing interests: No competing interests