Bariatric surgery and metabolic syndrome: are the 91 NIH guidelines still adequate?

US have the highest mean BMI among high income countries. One in three adults has BMI >30. Between 1980 and 2008, global mean BMI increased at an annualized rate of 0.4 kg/m2/decade for men and 0.5 for women. Diabetes parallels the obesity trend. Total estimated cost of obesity in US is $147 billion to nearly $210 billion per year. Dietary restrictions have demonstrated only 6% success. Physician supervised, medically approached weight loss strategies have about 12% success rate. Bariatric surgery has proved to be the most effective strategy in treating obesity. Currently, indications for bariatric surgery are based on the guidelines established by National Institute of Health (NIH) in 1991 (BMI>35+ associated medical co-morbidities or BMI >40). A significant and growing number of patients who have one or more components of metabolic syndrome and a BMI <35 are left out from bariatric surgery intervention as payers base their coverage for bariatric surgery on the 1991 NIH guidelines. We do review the currently available literature on the topic and present our bariatric surgery center experience and initiatives aiming to overcome the limitations of NIH guidelines for bariatric surgery and to start a constructive and collegial conversation on their possible revision.