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Scaled-up Surgery

Hospitals and doctors are promoting weight-loss surgery for cosmetic reasons, leading to fears the operation is not targeting those who need it most

By NewsChina Updated Jul.1

In August 2020, Yang Tianzhen, CEO of Easy Entertainment, a well-known company that reps some of China’s hottest young stars, announced she would undergo bariatric surgery to treat type 2 diabetes. Although Yang said her choice was prompted by health concerns, many in China are undergoing weight loss surgery for cosmetic reasons.  

Searches for “weight loss” on social media platforms such as Weibo or Douyin – the Chinese version of TikTok – reveal dozens of posts about hospitals and weight loss centers offering bariatric surgery.  

Weight loss surgery is an emerging industry in China. Addressing this during a telephone interview, Francesco Rubino, professor of bariatric surgery at King’s College London, told NewsChina that bariatric surgery, which is intended to treat diseases of obesity by restricting food intake and triggering weight loss, has been “misconceived as a cosmetic operation.” As an “efficacious therapy” used for diabetes, in reality, according to Rubino, “only a minority of people with obesity who have threats come to do a bariatric surgery.”  

Appetite for a Smaller Stomach 
There are three main types of bariatric surgery: gastric band, gastric sleeve and gastric bypass. Developed in the 1950s, laparoscopic sleeve gastrectomy (sleeve gastrectomy) involves removing part of the stomach so it becomes much smaller, and recipients feel fuller on less food. Arriving in China more than 20 years ago, it has become popular in the past decade. Gastric bypass surgery is a proven therapeutic option for the treatment of severe obesity and severe type 2 diabetes. It creates a small pouch in the stomach which is connected directly to the small intestine, so people absorb fewer calories from the food they eat. A gastric band is a reversible surgery where a band is placed around the stomach to make it smaller and produce a feeling of satiety.  

“The logic was, if you make your stomach smaller, or if you bypass the intestine, you reduce the amount of food that somebody can eat, or the amount of food that somebody can absorb. You reduce the energy intake, therefore, people will lose weight,” Rubino said. Compared to a sleeve gastrectomy, a gastric bypass can induce more weight loss and better glycemic control, but it may lead to higher risk of post-operative complications and long-term malabsorption of nutrients.  

Both sleeve gastrectomy and gastric bypass are well-accepted and safe surgical procedures. Normally, the surgery is done when diet and exercise have not worked or when the patient has serious health problems due to obesity.  

According to statistics released by the “Annual Report 2019 of China Obesity Metabolic Surgery Database,” in 2008 there were only 117 cases of bariatric surgery nationwide, but by 2019 it had soared to 11,700, indicating a 100-fold increase over a decade.  

In 2013, out of a total of 4,106 bariatric surgeries nationwide, only 777 were sleeve gastrectomies, while over 80 percent were gastric bypasses. By 2014, 2,200 sleeve gastrectomies were performed, and 2,920 gastric bypasses. Sleeve gastrectomy, a much more radical procedure, became more popular and by 2019 accounted for 86 percent of all bariatric surgeries performed in the Chinese mainland.  

As chief physician of general surgery at the China-Japan Friendship Hospital in Beijing and head of its health management center for weight-loss diabetes surgery, Meng Hua is regarded as China’s top surgeon for bariatric surgery. His Douyin account has millions of followers.  

Since 2012, Meng has performed over 4,000 bariatric surgeries. According to the “Annual Obesity Report 2019,” less than 55,000 bariatric surgeries were performed from 2012 to 2019. 

In 2020, affected by the Covid-19 pandemic, Meng and his team resumed routine procedures in July, and by the end of 2020, they had performed around 500 bariatric surgeries. Meng told NewsChina that his hospital would likely perform more than 1,000 bariatric procedures in 2021. 

“At present, no [other] hospital in the country can perform 1,000 bariatric surgeries a year. Most hospitals can perform at most dozens,” Meng said. On the first day of 2021, Meng performed seven procedures. NewsChina learned from the hospital that the surgery is so popular there is a five-month waitlist.  

Even so, in Meng’s opinion, demand for bariatric surgery will grow. “Among the 330 million people in the US, 300,000 to 350,000 bariatric surgeries are conducted annually, accounting for 1 percent of the population. Thus in China, the number of bariatric surgeries can reach at least one million per year, 100 times more than we do now,” he said.  

Li Guangwei, former director of Endocrinology at the China-Japan Friendship Hospital, said that the increasing trend of weight-loss metabolic surgery in China is “astonishing.”  

Dr Meng Hua and his team perform sleeve gastrectomy surgery, China-Japan Friendship Hospital, Beijing, December 31, 2020

Cosmetic vs Health 
Yang Tianzhen’s surgery is aimed at reducing her blood sugar levels. She has had to take insulin daily since she was diagnosed with type 2 diabetes six years ago. Type 2 diabetes is associated with diet and obesity, but it can be reversed with diet, exercise and other healthy lifestyle behaviors. Yang said medication is not effective enough to control her blood sugar level, so she decided on the surgical route.  

The Diabetes Surgery Summit in Rome in 2007 was the first of its kind. Professor Francesco Rubino was one of the initiators and organizers. He told NewsChina that after the summit, international experts realized that bariatric surgery could be used to treat diabetes, and this should be the main purpose of the surgery. “We could offer this to more people with diabetes because it could save lives,” Rubino said.  

China, which tops the global league tables in many areas, now also leads in obesity with some 90 million people and diabetes at 129.8 million. However, the majority of people undergo the procedure in China not for medical reasons, but to lose weight or other cosmetic motivations.  

There are criteria to be considered for a sleeve gastrectomy. According to the “Guidelines for Surgical Treatment of Obesity and Type 2 Diabetes in China (2019),” there are two main indications for sleeve gastrectomy: a person’s body mass index (BMI) is 32.5 or higher to indicate extreme obesity, or a person’s BMI is 27.5 to 32.5, and that person has serious weight-related health problems to such a degree that they are beyond the help of medications or lifestyle interventions.  

NewsChina found that in clinical practice, many private and public hospitals do not strictly implement these medical indications. The reporter consulted leading hospitals that perform sleeve gastrectomy surgery, including Shanghai Ninth Hospital, Chengdu No.3 People’s Hospital and Zhengzhou No.2 People’s Hospital, and was informed that even when a person’s BMI is below 30 and the person does not have other health complications, they could still have bariatric surgery.  

Wu Canghui, director of integrated surgery at Xingtai No.9 Hospital in Hebei Province, told our reporter that one can have the surgery even if their BMI is below 30 and there are no other complications. Meng Hua is a visiting surgeon at Xingtai No.9 Hospital who performs procedures on weekends. Wu told the reporter that if a person chooses Meng as their surgeon, they must pay 10,000 yuan (US$1,546) to skip the normal waiting list on top of the usual fee.  

The cost of a sleeve gastrectomy varies according to hospital, ranging from 40,000 to 90,000 yuan (US$6,184-13,914). Wang Cunchuan, Chairman of the Committee of Surgeons on Obesity and Diabetes and vice president of the No.1 Affiliated Hospital of Jinan University, told NewsChina that about 400 hospitals in China can carry out minimally invasive bariatric surgery, and 30 to 40 of those perform more than 100 procedures a year.  

At present, most doctors who carry out bariatric surgery in China do it in addition to their usual practice in fields such as gastrointestinal surgery or stomach cancer. There are less than 10 full-time surgeons in this field in China.  

To market bariatric surgery in China, doctors began to promote themselves on social media platforms and set up WeChat groups to expand the potential patient pool.  

BMI level seems to have become the only standard indicator. Some patients who underwent the surgery told NewsChina that they contacted doctors through Weibo or Douyin, and instead of being asked health-related questions, they were only asked about their BMI before being told they were eligible. 

Some patients said they had got the impression that the process is like an assembly line.  

In order to meet the BMI criterion, some people who would not normally qualify are encouraged to gain weight quickly before the surgery, which is widespread in both the US and Europe too, according to Rubino. The situation is the same in China. Some of Meng Hua’s patients told NewsChina what they did to gain weight quickly to qualify. One patient joked that it was an endeavor of “gaining weight to lose weight.”  

Entertainment company CEO Yang Tianzhen announced in August 2020 she was having bariatric surgery due to type 2 diabetes

Sustainable Losses 
At some public hospitals, such as the China-Japan Friendship Hospital, weight-loss surgeons told patients that gastric surgery could reduce their excess weight by 70 to 80 percent. But some patients told the reporter that there was a gap between the effect of bariatric surgery and what doctors claimed. Patients are unaware that the touted figure of 70 to 80 percent loss of excess weight refers to the ideal result in the first year after surgery.  

Dr Scott Kahan, director of the National Center for Weight and Wellness in Washington, DC, told NewsChina that long-term sustainability for post-operative effect is the real challenge. Healthcare institutions in the US are more cautious in conducting such surgeries and tell patients that gastric surgery will see them lose about 50 percent of their excess weight. They tell patients at the same time that the best weight-loss effect comes four to six months after surgery, but long-term, adopting a healthier lifestyle is necessary.  

Dr Yu Jianchun, chief surgeon at Peking Union Hospital, conducted follow-up research on 75 obese patients who underwent sleeve gastrectomy surgery in the hospital from 2012 to 2017. Yu found they lost an average of 81.6 percent of their excess weight in the first year after the operation, and the figure remained at 79.7 percent in the third year after surgery.  

In an article titled “Effectiveness of Laparoscopic Sleeve Gastrectomy in Treating Obesity and its Co-morbidities” published in 2018 on the Peking Union data, the authors reached a conclusion that “sleeve gastrectomy is effective and safe in treating obesity and its comorbidities in China.” 

In addition, due to differences in dietary structure between Eastern and Western people, the effect of sleeve gastrectomy surgery on weight loss for obesity in Chinese is likely to be better than that shown among Westerners. However, the paper added that “nearly half of the cases were followed up for less than three years, which may lead to deviation in the final results. In international practice, an assessment of the long-term effects of a surgical procedure should be tracked for at least five years, and preferably over 10 years.”  

Abuse vs. Under-utilization 
In China, the lower threshold for the weight-loss gastric surgery in many hospitals has enabled more people, most of whom are women, to pursue an easy route to weight loss.  

This is happening everywhere around the world. In recent decades, there are continued “misconceptions and stigma around obesity,” Rubino said. “Obesity is considered the fault of an individual which is a mistake... Obesity is the end result of complex environmental factors and genetic factors.” Globally, the majority of patients for gastric surgery are overwhelmingly female. According to Rubino, it is mostly due to societal pressure.  

According to the fourth annual report of the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) published in 2018, the federation reviewed 394,431 cases of bariatric surgery from 51 countries and found that 73.7 percent of the patients were female in the four years from 2014 to 2018.  

According to the 2019 report “Northern China Clinical Database on Bariatric and Metabolic Surgery,” among the 2,259 cases included (while amounts to about 20 percent of those performed in China that year) from 19 provinces, autonomous regions and municipalities, women accounted for over 70 percent of patients and the median age was 31.  

Rubino said that aesthetic discrimination and social prejudice surrounding obesity are the main causes of the gender disparity. Compared with the effect of bariatric surgery to alleviate diabetes, people focus on its weight-loss effects, a common misconception. Men, more than women, fear that having surgery will make them look weak, which possibly contributes to fewer men seeking gastric surgery in any country. The main problem is, according to Rubino, that bariatric surgery is abused considering that too many people who do not need it have had it, whereas in reality it is under-utilized for those who really need it. In fact, the problem of the abuse contributes to this trend in other parts of the world. “Because inevitably, the abuse of the surgery could lead to regulators or insurance or others to say we should not do it at all, [so] we should restrict it,” Rubino said.  

To avoid misuse of the surgery, Rubino said the profession has the responsibility to self-regulate and recommends creating quality standards. He told NewsChina that in many countries, organizations check the validity of clinical services, and they have created a system of networks to provide properly trained professionals to do the surgery.  

Rubino cautioned that as China is in the early days of bariatric surgery, there is an opportunity to course correct and not make the same mistakes as countries like the UK and the US. “This surgery should be offered to people who need it. If you offer it to people who need it, there should be no reason to be afraid of an expansion issue. The expansion is actually necessary,” he added. 
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