Bariatric and metabolic surgery during and after the COVID-19 pandemic

The COVID-19 pandemic has caused serious disruptions to the health-care system and has revealed substantial racial, ethnic, socioeconomic, and other health-care disparities. The role of obesity has also been highlighted, as obesity severity appears to be related to higher rates of hospitalisation and poorer clinical outcomes of COVID-19.¹ Obesity treatment has been hugely affected by the pandemic, leaving millions of children, adolescents, and adults at high risk for worsening comorbidities, with less access to treatment and increased risk for poor outcomes from COVID-19.

We applaud Francesco Rubino and colleagues’ recommendations for bariatric and metabolic surgery during and after the COVID-19 pandemic, published in The Lancet Diabetes & Endocrinology.² The attention to detail of resumption of services for individuals with obesity and diabetes are comprehensive and serve as a call to action for this important patient population. However, we were disappointed at the omission of psychosocial factors in their framework, which research suggests impact assessment and decision making for bariatric and metabolic surgery. Surgery teams are interdisciplinary, requiring the expertise of multiple providers, and the necessary role of a mental health provider on a surgical team is well documented.³

Notably, clinics and insurance companies require extensive pre-operative investment by patients to have access to surgery. The individuals who are now experiencing delays in their care have probably been eagerly anticipating needed treatment for their illness for many months. Even under normal circumstances, research indicates that waiting for surgery is anxiety provoking for individuals.⁴ Now there is the additional stress of potential concerns about disruption to insurance coverage because of job loss, worries about risk of exposure to COVID-19, isolation, and lack of social support. Moreover, COVID-19 increases risk for compromised mental health overall,⁵ resulting in another disproportionate burden on those with severe obesity who might already have high rates of psychological concerns. Obesity increases risk for poor physical and mental health outcomes related to COVID-19, and delaying surgery will exacerbate both of these risks, necessitating monitoring by and involvement of both medical and mental health providers.

To complement the proposed framework, we urge that mental health concerns be assessed for those at risk for surgery delays and that such assessments be included in determining who is prioritised as urgent for surgery. Mental health providers play an important role on surgery teams in assessment, support for psychological concerns, promotion of healthful behaviour change, and adherence to treatment and behaviour change.