In the Swedish Obese Subjects (SOS) study, the largest and longest-duration study comparing bariatric surgical procedures with conventional medical care for patients with obesity, the study group undergoing bariatric procedures including gastric banding, vertical banded gastroplasty, and gastric bypass achieved greater and more sustained weight loss than did the control group.1 In addition, recovery from diabetes, hypertriglyceridemia, low levels of high-density lipoprotein cholesterol, hypertension, and hyperuricemia was more favorable in the surgery group than in the control group. A recent meta-analysis2 showed that remission of type 2 diabetes (defined as maintenance of glycemia with glycated hemoglobin levels below 7% with the patient receiving no diabetes-related medications) occurs in approximately 77% of patients and resolves or improves in 85%. Dyslipidemias also improve or resolve in 70% to 95% of surgically treated patients and hypertension in 87% to 95%.2 Together, these short-term effects would predict favorable effects on mortality. Concordantly, longer-duration follow-up in the SOS study reveals that, in patients without diabetes at baseline, bariatric surgery reduces incident diabetes by 83%; moreover, considering the entire cohort of obese patients, surgery also lowered cardiovascular event rates by 43%, cancer rates by 33%, and overall mortality by 30%.1,3 Similarly, in a retrospective cohort study, Roux-en-Y gastric bypass surgery resulted in a 40% lower relative risk of death compared with controls, and diabetes-related deaths were reduced by 90%.4 Yet in a recent JAMA Surgery article,5 health care cost assessment based on claims paid by BlueCross BlueShield for a period up to 6 years postoperatively for almost 30 000 patients who had undergone bariatric surgery failed to demonstrate a cost benefit for weight loss surgery compared with a contemporary matched comparison group who did not undergo surgery but who had similar obesity-related diagnoses. Likewise, cost-effectiveness analysis of data from the US Department of Veterans Affairs did not show a cost benefit for Roux-en-Y gastric bypass.6 Together, these studies have prompted substantial debate on the merit of bariatric procedures at a time of intense scrutiny of optimal use of health care dollars. So where are the anticipated health care cost savings with bariatric surgery used for obesity management?
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