Metabolic & Bariatric Surgery

EDITORIAL

By Philip Schauer, MD, FACS, FASMBS

The obesity epidemic is well recognized. Yet hidden within it is another epidemic that has received remarkably little attention: extreme obesity.

Over the past two decades, extreme obesity has increased at a staggering rate in the United States. Recent studies by Hartmann, Schauer, and colleagues demonstrate that the prevalence of the most extreme forms of obesity has risen more than 200% in adults and more than 250% in children and adolescents—far outpacing the approximately 30%–40% increase in less severe obesity. BMI levels of 60, 70, 80 kg/m² and beyond, once considered extraordinarily rare, are increasingly encountered in clinical practice.

Yet where are the headlines? Where are the public-health alarms, research initiatives, clinical guidelines, and treatment strategies?

In our recent study, Albaugh et al. examined 1,262,454 patients undergoing metabolic and bariatric surgery and found that more than 66,000 had BMI ≥60 kg/m². Increasing BMI was associated with progressively greater disease burden, functional dependence, postoperative complications, and mortality. Extreme obesity is not simply “more obesity.” It is a particularly devastating form of the disease.

For many affected individuals, mobility and basic activities of daily living become major challenges, and quality of life can be profoundly impaired. Yet there are no clearly established treatment standards for this rapidly growing population.

The remarkable advances in GLP-1–based pharmacotherapy offer tremendous promise, but the pivotal trials establishing their efficacy have largely involved patients with mean BMIs in the 30s. We have remarkably little evidence regarding their safety, efficacy, or durability in patients with BMI ≥60, 70, or 80 kg/m². Ironically, those with the greatest disease burden remain among the least studied.

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Metabolic and bariatric surgery currently has the strongest evidence for substantial and durable weight reduction in extreme obesity, although evidence specifically at these extraordinary BMI levels remains modest. Many surgeons remain reluctant to operate because of perceived risk. Our findings confirm that operative risk increases with BMI, but importantly show that absolute risk remains surprisingly low—particularly when weighed against the enormous risks of untreated disease.

Pharmacotherapy and surgery should not be viewed as competitors. GLP-1–based therapy may prove particularly valuable as a bridge to surgery, reducing weight and potentially making an operation safer and more feasible. This strategy urgently requires prospective study.

It is time for the obesity community, pharmaceutical industry, funding agencies, and public-health establishment to recognize extreme obesity as an urgent research and treatment priority.

Shouldn’t those who need treatment the most also be among those we study—and treat—the most?

Disclosures. Dr. Schauer is a co-author and senior author of the Albaugh et al. study discussed in this editorial. His financial and professional relationships are listed in the MBS Digest Disclosure Registry. Entries are self-reported and shown as submitted. The views expressed in this editorial are the author’s own and do not necessarily represent the position of the MBS Digest Editorial Board.

Production Editor: John D. Scott, MD, FACS | [email protected]

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