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Different from white people, they first fat their ass and thighs, and Chinese they grow their
belly first.
Abdominal obesity accounts for 31.
5%
of obese people in China.
BMI is used to define overweight and obesity and is not applicable to all populations
.
BMI alone cannot be used to determine the population for bariatric surgery
.
Written by | Yan Xiaoliu
Recently, the American Society for Metabolic Bariatric Surgery (ASMBS) and the International Federation of Obesity and Metabolic Disease Surgery (IFSO) jointly issued a statement to comprehensively lower the threshold for
bariatric surgery.
According to its contents, simple obese patients with a body mass index (BMI, kg/m2) of ≥35, regardless of whether they have metabolic diseases, can be considered for surgical treatment
.
Patients with a BMI of 30-34.
9 and metabolic disorders may consider surgery
.
This standard is significantly lower
than the 1991 National Institutes of Health (NIH) guideline of at least 40, or ≥35, and the presence of metabolic disease.
It should be noted that the latest statement is also of guiding significance
to China.
It separately proposes indications for Asian populations, saying that a BMI of ≥25 indicates clinical obesity and metabolic surgery
≥27.
5 can be considered.
"This is wider
than the current surgical indications in our country.
" Bi Hui, head of the Department of Internal Medicine of the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences, said
.
ASMBS is the largest community of
bariatric surgeons and integrative care professionals in the United States.
With 72 national associations around the world, IFSO is the most influential institution
in the world.
The latest statement, jointly issued by the two institutions, is authoritative and widely accepted, and may change the implementation of
bariatric surgery worldwide.
Chief Physician Zhu Jiangfan, professor and chief expert of the Bariatric and Metabolic Center of the Tenth People's Hospital of Tongji University, pointed out that today, the 1991 version of the NIH guidelines have obvious limitations, and there is insufficient
understanding of the significant advantages of bariatric surgery, technological advances, and surgical relief of metabolic diseases.
Academics have
long called for innovation.
In 2014, The Lancet issued a proposal and revised
it.
for Asian populations in the "Keywords" section.
/SOARD
Asians are "different"
Zhu Jiangfan told the "medical community": "Bariatric surgery is to reduce food intake or absorption by removing part of the stomach or short-circuiting the small intestine, regulating metabolism, achieving weight loss, improving and treating obesity-related metabolic diseases
.
" The latest statement pointed out that Asian people with a BMI of 27.
5 can undergo bariatric metabolic surgery
.
This means that BMI is at this level and surgery
may be considered in the absence of metabolic disease.
The statement, under the entry "Surgical Criteria," explains the peculiarities of BMI in
Asian populations.
It notes that the World Health Organization (WHO) defines overweight and obesity
in terms of BMIs ≥ 25 and 30, respectively.
There are two major drawbacks
to this.
First, the associated BMI is based on epidemiological surveys of Caucasian people, without taking into account racial differences
.
Second, it does not take into account individual circumstances
such as gender, age, fat distribution, etc.
Taking the Asian population as an example, it has become a clinical consensus
that Asians are fat and "different".
Anatomically, Asians usually have higher body fat content than Caucasians, especially the upper body fat is significantly more
.
Therefore, at the same height and weight, the shoulders and backs of Caucasian people are muscular lines like knife carvings, while Asians are thick and rounded without edges
.
In addition, unlike Caucasians, they first fat their ass and thighs, and Chinese they grow their
belly first.
According to the 2020 Report on the Status of Nutrition and Chronic Diseases of Chinese Residents, abdominal obesity accounts for 31.
5%
of the number of obese people in China.
This type of obesity is important for
a variety of metabolic disorders.
Studies have shown that those with a BMI of 30 who have visceral fat accumulation have a significantly higher risk of metabolic disorders and cardiovascular disease than those
with a BMI of =40, but the main fat accumulation is in the lower limbs.
In layman's terms, it is that the belly poop is bigger than the thick legs and butt, which is more fatal
.
Bi Hui often participates in consultations with the Obesity and Metabolic Disease Center of the hospital and has seen a large number of overweight people
.
She said obesity is an independent risk factor for
metabolic diseases.
Among people with a BMI of more than 28, 99% will have metabolic abnormalities
such as blood lipids, blood sugar, and fatty liver.
The mass effect of excess adipose tissue, or its direct metabolic effects, has also been linked to a variety of chronic diseases, including diabetes, stroke, coronary artery disease, hypertension, respiratory disease, obstructive sleep apnea, polycystic ovary syndrome, etc
.
Multiple surveys have shown that there are more than 200 comorbidities
associated with obesity.
The longer you gain weight, the more late complications there are and the higher the
risk of disability and death.
Chinese fatness is also manifested as more serious
consequences.
In 2021, the Lancet published an article saying that after adjusting for age and gender, the incidence of type 2 diabetes in white people when BMI = 30 was consistent
with that of Chinese at 26.
9.
"This shows that the BMI value of Chinese type 2 diabetes is lower than the obesity cut-off value set by the academic community for this population (BMI = 27.
5)
.
"
Among Asian populations, people with low BMI have higher rates of diabetes and cardiovascular disease than non-Asian populations
.
The latest statement states: "The use of BMI to define overweight and obesity is not suitable for all people
.
BMI alone cannot be used to determine the population for bariatric surgery
.
Bi Hui, head of the Department of Internal Medicine of the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences (with a case holder) and colleagues during
the consultation.
/ Respondents can
not only look at BMI
in the assessment, in fact, China's relevant guidelines and consensus have made personalized definitions
based on the characteristics of "Chinese-style obesity".
The Expert Consensus on the Prevention and Control of Obesity among Chinese Residents (2022) points out that it is recommended to use BMI=24.
0-27 and BMI ≥28 to define overweight and obesity
.
The waist circumference of men and women ≥ 90 and 85 cm respectively, which is "central obesity"
.
For example, for adults, both men and women, being 1.
70 meters tall and weighing more than 73 kilograms is overweight; Exceeding 81 kilograms, it is fat.
Based on this, the threshold for bariatric surgery in China is lower than the NIH standard
in 1991.
Taking obesity alone as an example, the Chinese Guidelines for the Surgical Treatment of Obesity and Type 2 Diabetes (2019 Edition) (hereinafter referred to as the "China Guidelines 2019") say that the BMI ≥ 32.
5, that is, surgery
is recommended 。 A BMI between 27.
5 and 32.
5, meeting at least 2 metabolic syndrome components, or having comorbidities that are difficult to control with lifestyle changes and medical treatment, may be considered for surgery
.
For patients with type 2 diabetes, the BMI ≥ 27.
5, which means surgery
is recommended.
If the BMI is between 25 and 27.
5, if there is central (abdominal) obesity, the recommended level
of surgery can be increased as appropriate.
The so-called metabolic syndrome components and comorbidities include metabolic abnormalities such as blood pressure, blood lipids, and blood sugar, as well as organic diseases such as obstructive sleep apnea-hypopnea syndrome (OSAHS), diabetes, male sexual dysfunction, polycystic ovary syndrome, and renal dysfunction.
Wu Jia, a registered dietitian and well-known popular science writer, told the "medical community" that she saw in the weight loss clinic that most people can successfully lose weight
through nutrition, exercise, drugs, lifestyle interventions and other means.
"Everyone has different compliance, and there are indeed people who cannot adhere to
it for a long time.
"
There are many reasons for
this.
Some people's obesity is a metabolic problem, eating very little and still growing meat
.
Some people secrete a large amount of insulin, but the body cannot use it normally, and the brain always produces the illusion of hunger, causing their appetite to be strong
.
Others are obese, inactive, and difficult to tolerate high-intensity exercise
.
Bi Hui believes that the larger the weight base, the less obvious the effect of non-surgical weight loss and the more
difficult it is to improve metabolism.
"I have encountered people with repeated weight fluctuations and developed uremia due to the abuse of diet pills
.
I can understand their desire to lose weight, and I regret that they have taken a detour
.
In this case, bariatric surgery is safer
than other methods.
"
Compared with China's bariatric surgery guidelines, the latest statements by ASMBS and IFSO may expand the number of
people who can be used for surgery.
He noted that long-term data consistently demonstrate that bariatric metabolic surgery is safe, effective and durable in the treatment of clinically severe obesity and its comorbidities, and reduces mortality
compared with non-surgical treatments.
However, there may still be some "ambiguous areas"
in clinical practice.
"We saw a patient with very high blood sugar and no other treatment worked
.
In strict accordance with domestic and foreign standards, its BMI is 0.
5 worse, which is not within the scope of recommended surgery, what should I do? Zhu Jiangfan introduced that the case has undergone bariatric surgery
after comprehensive evaluation.
The day after surgery, fasting blood glucose dropped to 8mmol/L, which is fully expected to fall to the normal range <B23>。
In 2014, the New England Journal of Medicine published a randomized controlled study that found that 24% of obese people (BMI = 36.
0±3.
5) after bariatric surgery for 3 years met the primary endpoint, that is, glycated hemoglobin levels could be reduced to 6.
0% or less
regardless of medication.
In the non-surgical group, only 5%
met the target.
In addition, the surgical group had a more pronounced weight loss, significantly better quality of life than the drug treatment group, and no major late surgical complications
.
"Chinese Expert Consensus on Precision Obesity Metabolic Surgery (2022 Edition)" said that the individualization of obesity varies greatly, and there may be different causes, fat distribution, concurrent diseases and other aspects, relying solely on BMI classification can not accurately reflect the complexity and heterogeneity of obesity, it is necessary to use including waist circumference, hip circumference, waist-hip ratio, body fat rate, Many indicators such as visceral fat area content and obesity comorbidities are carried out for more refined classification and more accurate diagnosis and treatment
.
Chief physician Zhu Jiangfan, professor and chief expert of the Bariatric Metabolism Center of the Tenth People's Hospital Affiliated to Tongji University, and his team during
the operation.
Respondents don't
misunderstand the NIH's 1991 guidelines for bariatric surgery, and another big change in the latest statements by ASMBS and IFSO is that there is no upper age limit for bariatric metabolic surgery
.
It shows that over the past few decades, more and more people over the age of 70 have benefited from surgery, and the postoperative complication rate is slightly higher than that of younger people
.
Therefore, the elderly can fully undergo bariatric surgery, and weakness, cognitive ability, smoking history and organ function are the real contraindications to
surgery.
"Surgical techniques have
changed.
Traditional surgical procedures have been replaced
by safer, more effective minimally invasive procedures.
At present, bariatric metabolic surgery has become one of the most common procedures performed in general surgery, and the perioperative mortality rate is very low, between 0.
03% and 0.
2%.
According to the statement, there are two mainstream bariatric surgeries, laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB), accounting for 90%
of the total number of bariatric surgeries in the world.
Both procedures are performed
laparoscopically.
LRYGB is designed to divert the stomach into two parts, the upper small and the lower large, and a fork in the "small stomach" to connect
to the small intestine.
LSG is a volume reduction by cutting off 70% of the stomach and suturing it to make the nearly semi-round stomach into an elongated banana shape
.
The picture on the right shows laparoscopic sleeve gastrectomy; The photo on the left shows laparoscopic Roux-en-Y gastric bypass
.
Bariatric surgeon India
China Guide 2019 lists three recommended procedures, including sleeve gastric, gastric bypass, and biliopancreatic diversion duodenal transposition (BPD/DS), and proposes clear surgical indications
.
Zhu Jiangfan was one of
the compilers of this guide.
He introduced that China's bariatric surgery is also mainly LSG and LRYGB, and BPD/DS is rarely
used.
"It used to be thought that laparoscopic surgery had limited field of view, severe postoperative adhesions, and gallbladder removal could not be done
.
Today, laparoscopes have become standard in
surgery.
Zhu Jiangfan said that with the continuous development and maturity of technology and instruments, the complication rate and mortality of minimally invasive bariatric surgery are similar to appendix and gallbladder removal
.
Reliable, safe, and seemingly once and for all, these "selling points" of bariatric surgery also attract a group of beauty lovers
who are not overweight, but want to lose weight.
"I have met many people, who are plump at best, and run to the hospital, determined to operate
.
" Bi Hui said that such people are likely to "fail"
when they have bariatric surgery.
Zhu Jiangfan believes that the human body will self-regulate and will not lose weight all the time after undergoing surgery
.
The most common is that the appetite is slowly recovered after surgery, the pocket stomach is expanded little by little, and the nutrient absorption is getting better and better
.
Especially for those who weigh small before surgery, weight reversal may be faster, and it is impossible to "lose weight into lightning"
.
On the one hand, bariatric surgery can lose about
80% of excess weight.
The smaller the weight base, the more limited the weight that can be lost through surgery, and the easier it is to
regain weight.
On the other hand, to maintain weight loss results, it is necessary to practice a healthy lifestyle, keep your mouth shut and take a step
forward.
The China Guidelines 2019 proposes for postoperative management, daily exercise during the postoperative recovery period, encouraging at least 150 minutes of aerobic exercise per week, and strength training 2-3 times a week to minimize carbohydrate and fat intake
.
People who want to take shortcuts often have poor self-control, and the weight lost by surgery can quickly "eat back"
.
According to the "China Guidelines 2019", surgery is not recommended for those with a BMI of less than 25, who cannot cooperate with changes in diet and lifestyle habits after surgery, and who have poor compliance
.
Although minimally invasive surgery is safer and more effective, undergoing bariatric surgery comes at a physical cost.
Bi Hui pointed out that for a period of time after surgery, patients can only eat liquid food and full nutritional meal
replacements.
Excessive or indigestible food may be quickly repelled, forming reflux vomiting
.
A survey by China News Weekly found that many patients after gastric incision still have symptoms such as heartburn and acid reflux 3 months or even a year after surgery, ranging from mild to severe
.
After cutting the stomach for more than two years, some people have been strongly refluxing, resulting in esophageal erosion
.
Francisco Rubino, chair of the Department of Metabolic and Bariatric Surgery at King's College London, once pointed out that compared with the role of bariatric surgery to relieve diabetes, people always pay more attention to its weight loss function, simply treating it as a bariatric surgery, which is a common misunderstanding and misconception
.
The result: on the one hand, bariatric surgery is being abused, and too many people do it unnecessarily
.
On the other hand, people who really need it do not undergo surgery
for various reasons.
Zhu Jiangfan said that at this stage, BMI reaching the obesity index is the bottom line of bariatric surgery and should not be exceeded
.
But there are for-profit medical institutions that take a radical approach to
bariatric surgery.
For those with insufficient BMI, let them eat fat first and then lose weight
.
This is against medical ethics, but in reality it exists
due to the lack of effective regulation.
References:
[1]2022 American Society for Metabolic and Bariatric Surgery(ASMBS)and International Federation for the Surgery of Obesity and Metabolic Disorders(IFSO):Indications for Metabolic and Bariatric Surgery.
Surgery for obesity and related diseases.
doi.
org/10.
1016/j.
soard.
2022.
08.
013[2]Guidelines for the Surgical Treatment of Obesity and Type 2 Diabetes in China (2019 Edition).
Chinese Journal of Practical Surgery.
Vol.
39, No.
4, April 2019.
DOI:10.
19538/j.
cjps.
issn1005-2208.
2019.
04.
01[3]Guidelines for nutritional treatment of overweight/obesity medicine in China (2021).
Chinese Journal of Medical Frontiers.
Vol.
13, No.
11, 2021.
DOI:10.
12037/YXQY.
2021.
11-01 [4] Ethnicity-specific BMI cutoffs for obesity based on type 2 diabetes risk in England:a population-based cohort study.
The Lancet Diabetes & Endocrinology.
doi.
org/10.
1016/S2213-8587(21)00088-7[5]Chinese Expert Consensus on Precision Obesity Metabolic Surgery (2022 Edition).
Chinese Journal of Gastrointestinal Surgery.
October 2022, Vol.
25, No.
10[6]Cut the stomach for weight loss, Do They Regret It?.
China Newsweekly.
2021.
4.
26 Issue 993[7]Bariatric Surgery versus Intensive Medical Therapy for Diabetes—3-Year Outcomes.
N Engl J Med.
2014; 370:2002-2013.
DOI:10.
1056/NEJMoa1401329
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