Bariatric Surgery in the Time of COVID-19

Approximately three-quarters of American adults suffer with overweight or obesity. Societal mythos stigmatizes obesity as a lifestyle choice or cosmetic issue, but research tells a different story: 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 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."

Weight loss 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: Early on, when we were collecting initial information, there was this kind of warning bell or 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.

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

That's actually one of the questions we're trying to figure out, though ultimately, I think it's an evolving discussion.

There are physical reasons that people with obesity might get sicker, such as obesity hypoventilation syndrome, 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. 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.

Q: Is weight loss surgery an option during the pandemic?

Yes, all treatment options are still available at the Weight Center. We have a multidisciplinary approach to weight loss that offers both surgical and 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: What steps is Mass General taking to ensure surgery is safe?

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 daycare, 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.

The entire process is streamlined, and it's very safe.

People who prefer to meet in person are welcome to do so as well. Patients visiting the Weight Center are finding that it's much easier during COVID-19 because there is more parking and commutes are easier. 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 significant weight loss safe during the pandemic?

Yes—weight loss is safe. If a patient with obesity receives surgery, they will likely experience about a 73% weight loss. This tends to happen more quickly at first, and then flatten out. After around a year, many people get nervous because they gain a bit back. But their weight tends to stay at this 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 and/or sleep apnea most often goes into remission, and they are at a lesser risk of severe COVID-19.

Q: Do you have any additional advice for people with obesity in this challenging time?

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. Often, people believe that weight loss surgery might be too big of a deal. But the truth is, many people benefit from 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. That is certainly a challenge.

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 crave comfort food. And while some people notice that they're eating out less and making healthier meals, many others will not.

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. But for patients with obesity, weight loss surgery can be a powerful preventative step.