Bariatric Surgery Offers Cardiovascular Benefits to People Over 65

By Daniel K. Brantley
Monday, September 26, 2022

New research finds bariatric surgery after age 65 offers substantial cardiovascular health protection and reduces all-cause mortality.

Bariatric surgery has been a safe and effective means of achieving and maintaining a healthy weight among obese individuals for decades. Now, new research indicates it may also provide additional benefits for obese people over age 65.

The research, published in the Journal of the American College of Cardiology, sheds light on several specific benefits for these patients.

“Bariatric surgery was associated with lower risk of death, myocardial infarction, new-onset heart failure and ischemic stroke in both patients younger than 65 years and patients 65 to 75 years old,” says Amgad Mentias, MD, cardiologist with the Heart, Vascular and Thoracic Institute at the Cleveland Clinic Foundation, who led the study. “Bariatric surgery, in the right patient and the right setting, could offer a very helpful intervention to not only lose weight, but also to improve … overall metabolic health.”

“Physicians should not preclude the possibility of bariatric surgery in their patients just based on their age, [just because they are] elderly.”
Amgad Mentias, MD, cardiologist with the Heart, Vascular and Thoracic Institute at the Cleveland Clinic Foundation

Seeing and Responding to Results

These results came from an observational study of 189,770 patients (30% male and 70% female). Half underwent bariatric surgery from 2013 to 2019, while half did not. The two groups shared similar BMI (44.7 ± 7.3 kg/m2) and age (mean of 62.33 ± 10.62 years).

Dr. Mentias and his team reviewed each patient’s outcome an average of four years after observation began. Using instrumental variable analysis, the researchers found those who underwent bariatric surgery experienced a reduction of risk factors:

  • All-cause mortality (improvement of 5.5 per 1,000 person-years or 37% reduction)
  • New-onset heart failure (surgical patients experienced a 64% drop in risk or 0.46 HR)
  • Myocardial infarction (HR of 0.63, which was 37% lower than their control group peers)
  • Ischemic stroke (reduced risk of 29% or 0.71 HR)

Of those who underwent surgery, 62,101 (65.5%) had sleeve gastrectomy, 31,546 (33.3%) received gastric bypass and 1,238 (1.3%) had gastric banding. Though the study did not break down results by surgical technique, Dr. Mentias suspects the study’s findings “could be applicable in the two most prevalent types in our study: sleeve gastrectomy and gastric bypass.”

Faced with the results of the study, clinicians must now determine how to move forward to ensure optimal care for obese and morbidly obese patients 65 and older. Dr. Mentias suggests beginning with an open dialogue about the options.

“If [a clinician’s] patients are interested in the possibility of bariatric surgery, they should be referred to experienced centers that offer this surgery for evaluation and consideration,” he says.

Factors Impacting Surgery’s Success

To reap the greatest benefits bariatric surgery offers those 65 and older, there are some particular factors to consider when operating on this population. Older patients may be more likely to experience circumstances which can limit their ability to access or benefit from metabolic surgery.

An editorial published simultaneously in the Journal of the American College of Cardiology discussed the effects of age combined with poverty and other environmental factors.

“Obesity is a complex disease related not only to social determinants of health but also biologic susceptibility and even exposures in your mother’s womb,” says Tiffany M. Powell-Wiley, MD, MPH, FAHA, FABMR, Stadtman Investigator; Chief of the Social Determinants of Obesity and Cardiovascular Risk Laboratory in the Cardiovascular Branch of the Division of Intramural Research at the NIH’s National Heart, Lung, and Blood Institute. “Among social determinants, many of them work by having feedback on factors contributing to obesity to create systems that have effects on obesity risk.”

Such determinants may include housing, education, income, dietary intake, physical activity and even the kind of insurance coverage a patient has, says Dr. Powell-Wiley, who is an adjunct investigator of the Intramural Research Program at the National Institute on Minority Health and Health Disparities. “Patients who have Medicare and Medicaid coverage are less likely to undergo bariatric surgery as compared to patients with private insurance,” she says.

Unique Needs

Why are Medicare and Medicaid holders less likely to undergo bariatric surgery? The reasons are unclear, but those who don’t undergo bariatric surgery also miss out on its potential life-saving benefits, and since many older patients rely on Medicare, the point is particularly relevant.

For older adults who do choose to have bariatric surgery, Dr. Powell-Riley sees a particular need for clinicians to take a multidisciplinary approach to their care. This includes evaluation and monitoring by a nutritionist, psychologist and cardiologist, along with access to support groups, all of which help mitigate surgical risk and increase the likelihood of success.

Greater success for more patient populations will come, Dr. Powell-Wiley says, when medical organizations train clinicians on evidence-based bariatric practices, government agencies and healthcare systems identify and resolve barriers to obesity treatment for all socioeconomic levels, and medical school curricula train future clinicians to view obesity as a disease that may require surgical intervention.

Dr. Mentias agrees that social determinants would likely impact an individual’s access to bariatric surgery and likelihood of success. His team still provides critical information on the additional value bariatric surgery affords older patients.

“[T]he benefit was evident early on,” he says, “and assuming that the measured association was causal, the number needed to treat to prevent one major adverse cardiovascular event was only 15.”

With such substantial reduction in MI and other cardiovascular events, Dr. Mentias encourages referring physicians to recommend bariatric surgery to qualifying senior citizens, which would potentially position patients to take control of their health and prolong and improve their lives.