To the Editor: Given the increasing evidence that bariatric surgery may result in major improvement in diabetes control, a survival advantage, and a potential for cost-effectiveness, Drs Purnell and Flum1 asked in their Commentary why surgery has not yet become the standard of care for obese diabetic patients. Their lucid analysis of opportunities and challenges in diabetes surgery highlighted the importance of a constructive dialogue between clinicians and policy makers on this subject. Particularly timely is their call for practical solutions that reconcile an individual's right to a potentially life-saving treatment with the fact that the up-front costs of increasing the number of procedures may be unaffordable at a time of limited resources.
However, their proposal to prioritize consideration for surgery to patients with a body mass index (BMI) of 50 or more (calculated as weight in kilograms divided by height in meters squared) has several shortcomings. The arbitrary BMI cutoff does not accurately predict diabetes-specific risks; therefore, this strategy would delay a potentially life-saving option for patients with lower BMI but at similar risk from diabetes. Furthermore, prioritizing access to surgery to patients with BMI of 50 or more might be perceived as discriminatory since the BMI-related risk is influenced by sex and ethnic differences.2 The approach might also fail to address the concerns about the up-front costs of surgery since BMI of 50 or more is associated with longer operative time and length of hospital stay.3
An alternative strategy could be based on the use of diabetes-specific indicators of risks and benefits rather than BMI cutoffs, which are not supported by scientific evidence.1 Priority access to diabetes surgery might be initially offered to obese patients who, after a reasonable period of intensive lifestyle intervention and medical management, had inadequate glycemic control, were at high risk of developing diabetes-related complications, or both. This risk would be better quantified by metabolic parameters and other predicting factors of cardiovascular disease than by BMI alone.
The potential increase in up-front costs from expanding surgical indication to mildly obese patients (BMI ≥30) would be controlled by the use of intensive lifestyle and medical intervention as a means to screen immediate candidates for surgery. This strategy can improve diabetes control,4 thereby decreasing the actual number of patients for whom priority access to surgery would be warranted. In addition, this strategy would select surgery patients who are prone to costly diabetes complications despite expensive yet ineffective lifelong medical treatment.
Financial Disclosures: Dr Rubino reported receiving consulting fees from GI Dynamics, Ethicon, Covidien, and NGM Biotech and being on the speakers' bureau for Covidien, Ethicon, and Gore.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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