Bariatric Surgery in the Time of COVID-19

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Approximately three-quarters of American adults suffer with overweight or obesity. Research shows that obesity is a serious chronic disease requiring long-term, multidisciplinary treatment—and it puts patients at an increased risk for many serious comorbidities.

Earlier this year, clinicians and researchers identified the disease of obesity as a recognized risk factor for serious cases of COVID-19. More recently, studies indicate that even patients with overweight are high risk. As Matthew M. Hutter, MD, MPH, director of the Massachusetts General Hospital Weight Center and president of the American Society of Metabolic and Bariatric Surgery, says: "Many people don't think of obesity as a disease. In fact, it's a pandemic. And when you introduce a new pandemic—COVID-19—on top of that, the result is very dangerous."

Bariatric surgery is a highly effective approach to treating the disease of obesity. But amidst news about rising case numbers of COVID-19, pursuing the option can feel daunting. Dr. Hutter explains the value of pursuing this potent weight loss solution during this time and discusses safety protocols that ensure each visit and procedure is safe.

Q: In what ways is obesity a risk factor for COVID-19?

Hutter: When we were collecting initial information, there was this kind of warning bell/observation that obesity was a link to severe COVID-19, especially in younger patients. In the intensive care unit (ICU), you'd see elderly patients and patients who had been brought in from nursing homes—and then you'd see young people.

We were asking ourselves, "Why are these young people here?" And we discovered that many of them were patients with obesity or overweight. It was clinically striking. Now, the data has come back to support that observation. Some data and articles indicate that individuals with obesity are more than 46% more likely to be COVID-19 positive. Their risk of ICU admission is increased almost twofold. They face a 50% higher risk for death.

It's important to remember that our research has also shown us that obesity is not a lifestyle choice. It's not a cosmetic thing. Obesity is really a disease, and it puts people at risk for more severe COVID-19.

Q: Why are people with obesity at a greater risk?

Hutter: One element we consider is the angiotensin converting enxyme 2 (ACE2) receptor. The ACE2 receptor, which sits on the surface of some different types of cells, is an enzyme that cuts angiotensin (a protein) into smaller proteins that regulate various cell functions.

SARS-CoV-2 is able to latch onto ACE2 receptors, infiltrate and replicate itself inside the cells. ACE2 is found in lung cells (among others), and it is also in the adipose (fat) cells. People with obesity tend to have more adipose cells than those without.

In addition, there are physical reasons that people with obesity might get sicker, such as sleep apnea, which occurs when abdominal obesity makes it harder to take deep breaths. In other words, the mechanics of the lungs make it harder for people with obesity to breathe, which can thereby induce a systemic low-grade inflammatory state leading to an upregulation (increased inflammation). So they don't really have the same response to SARS-CoV-2 early on. And then, when they do, it goes a bit haywire and the inflammatory response becomes even more severe. From there, it impacts their immune regulatory system. So to some extent, it's an immunocompromised state.

Patients with obesity are also at a greater risk of type 2 diabetes, hypertension and hypercholesterolemia, among other issues. So while we're still trying to put all this together, obesity is a clear link to those other diseases, all of which put a person at high risk for severe COVID-19 symptoms.

Unfortunately, there is concern that when a vaccine is available, people with obesity may have a lower response to it. This has been shown in previous outbreaks as well. For instance, when the H1N1 outbreak occurred, they found similar, increased prevalence among people with obesity in the Middle East.

Q: Is bariatric surgery an option during the pandemic?

Hutter: Yes, all treatment options are still available at the Mass General Weight Center. We have a multidisciplinary approach to weight loss that offers both surgical or nonsurgical treatments. Our patients meet with a team of clinicians who discuss nonsurgical treatments such as medicine or working with our dietitians, psychologists and other behaviorists, to figure out the right treatment choice for you. If one approach doesn't work, we find other options; from there, we offer surgical options.

All our surgical options are currently available: Bariatric surgery, gastric bypass and sleeve gastrectomy. We have some new interventional gastroenterologists who are developing new endoscopy procedures we can use going forward. And all treatments are just as safe during the pandemic as they were before.

Q: How is Mass General ensuring surgery remains safe?

Hutter: First off, we're offering a completely virtual option for patients—and we're almost 100% telehealth lately. This enables people to avoid any exposure from traveling to the hospital. And patients are liking the way we can interact. We have more focused discussions, and we're able to have more frequent meetings as people don't have to worry about things like day care, parking or driving into Boston.

One of the great things about our virtual visits is that it's much easier to communicate in some ways: For example, I can clearly draw diagrams and pictures for patients. Consent forms are reviewed digitally as well. And all patient visits can take place this way, including their meeting with their anesthesiologist and preadmission testing.

When patients come to the hospital, they are tested within 72 hours before surgery to ensure they are COVID-19 free, and they go home the next day after surgery. And it makes it much easier for us to schedule follow-ups and check ins with patients. After all, obesity is a chronic condition and we want to be able to support people long term. With virtual visits, we can check-in with patients more easily and provide the care they need.

People who prefer to meet in person are welcome to do so as well. At Mass General, patients have multiple check-in steps to ensure they are wearing fresh masks and have easy access to hand sanitizer stations. We also provide visual reminders encouraging proper hand hygiene.

Q: Is it safe to help my patient lose weight during the pandemic?

Hutter: Yes—weight loss is safe. If a patient with obesity receives bypass surgery, they will likely experience about a 73% loss of their extra weight. This tends to happen more quickly at first, then flatten out. After around a year, many people get nervous because they gain a bit back. But their weight tends to stay roughly at that level from there out. So if someone is 100 pounds overweight, they lose an average of 73 pounds (though some do lose more or less). Their quality of life is improved, their diabetes or sleep apnea has gone and they are at a lesser risk of severe COVID-19.

Across the country, we've also started research to determine patient safety at the time of surgery. I helped develop the national data collection program for bariatric surgery. Now, we've even added a variable of people to find out, at the national level, if people are getting COVID-19 around the time of surgery, or even shortly thereafter. This research is designed to ensure that bariatric surgery is safe as well.

Q: What protocols should providers follow to help patients with obesity protect themselves against COVID-19?

Hutter: Many people are asking themselves what they can do to stay protected against COVID-19. Patients with obesity are concerned about their increased risk of either contracting the virus or the increased likelihood of experiencing it more severely via ICU admission, intubation and mortality rates.

The major thing is this: Everybody needs to be safe. That means wearing a mask, physical distancing and hand washing. If you are going in for surgery, you want to be even more cautious around the time of your procedure, and avoid opportunities where you may be exposed to COVID-19.

Q: When should a provider refer a patient to a place like the Mass General Weight Center?

Hutter: It's a very difficult conversation—and as providers, it's one we really need to have. In many cases, patients can walk into a provider's office with a BMI of 45, and clearly showing outward signs of obesity, but not have a conversation about their weight issue. As clinicians, we need to speak out about this just as we would if we saw a patient with any other disease.

When introducing or treating a new diagnosis, providers have an opportunity to talk about weight loss. Sometimes patients come in who once were heavy and healthy, but now have diabetes, sleep apnea and/or hypertension and want to take the next step toward weight loss. Or maybe they're just not able to do the physical activities they once loved. Sometimes these patients are frustrated because they don't know if there are good treatments available. Some perceive bariatric surgery as too extreme, or unsafe. They don't know that people go home the next day; that their lives are changed for the better. I think all that needs to be addressed.

If you have tried to have a discussion with a patient and are not able to, or they're simply not ready to have that discussion, that's the time to refer them. They can speak with someone on our team about their weight and treatment options. If you have discussed the disease of obesity with your patient and previous attempts to treat it have been unsuccessful, that's another great opportunity to refer them.

Q: What advice can providers offer patients with obesity in this challenging time?

Hutter: Many people believe that bariatric surgery might be too big of a deal. They might think, "I don't need all that," or "I just need a little help." But the truth is, many people benefit from bariatric surgery—and the impacts last for the rest of their lives.

It's also important to remember that this is an incredibly stressful time and a very challenging time to lose weight. Suddenly, many people can't engage in the physical activities they once enjoyed. They can't go to the gym or simply don't feel safe doing so. Many of us are commuting less and being sedentary more. And as the weather gets worse, it's going to get even harder.

People's reactions to stress can also impact their weight. It's not only eating habits, it's what their body does: create stress hormones that make them hungrier, or simply seek comfort food. And while some people notice that they're eating out less and making healthier meals, many others will not.

Bariatric surgery is a very safe procedure that can benefit the lives of many. If you're struggling with overweight or obesity, talk to your provider, or contact the Weight Center to learn more.

Q: Is there anything else you think providers should know about bariatric surgery at this time?

Hutter: As a provider, it's important to recognize that obesity is a disease that many people are biased against. It's important that we don't perpetuate these biases and that we don't blame and shame patients with obesity. Instead, generate awareness of available treatment options, and help your patients understand that bariatric surgery is a very effective treatment they can safely pursue.

Visit the Mass General Weight Center

Refer a patient to the Mass General Weight Center