Weight-Loss Surgery: What to Know Before You Decide

The short version

• Current guidelines support considering surgery at a BMI of 35 or more, or 30 to 34.9 with metabolic disease.
• People commonly lose about 25 to 30% of their body weight, and many see major improvements in type 2 diabetes.
• It's generally safe in experienced centers, but complications are possible.
• You'll need to change how you eat, and take vitamins and have follow-up care for life.

Who it's for

The 2022 guidelines from the leading surgical societies support considering surgery for:

• A BMI of 35 or more, whatever other conditions you have
• A BMI of 30 to 34.9 with metabolic disease, such as type 2 diabetes
• Lower thresholds in some people of Asian descent

Actual eligibility depends on your insurance and your surgical program. Some still use the older rule: a BMI of 40 or more, or 35 or more with a serious weight-related health problem. You'll typically go through a medical, nutritional and psychological evaluation.

The main types

There are also less invasive procedures, such as endoscopic sleeve gastroplasty, which generally lead to less weight loss.

What the benefits look like

• Significant, long-lasting weight loss for most people
• Improvement or remission of type 2 diabetes for many, sometimes within days, before much weight has been lost
• Improvements in sleep apnea, blood pressure, cholesterol and joint pain
• Lower long-term risk of death in large observational studies

Some people regain part of the weight over the years, and diabetes can return. Follow-up matters.

The risks

• Around surgery: Bleeding, infection, leaks, blood clots and, rarely, death. In experienced centers, risk of death is low, roughly similar to that of gallbladder or joint replacement surgery.
• Later on: Vitamin and mineral deficiencies, reflux, gallstones, hernias, dumping syndrome after bypass (nausea, sweating and diarrhea after sugary foods), and low blood sugar.
• Alcohol: It hits harder after surgery, and rates of alcohol use problems go up.
• Mental health: Adjustment can be difficult. Some studies report higher risk of depression and self-harm, so ongoing mental health support is important.
• Excess skin: May bother you, and may need surgery of its own.

Life afterward

• Food stages: You go from liquids to puréed foods, then soft foods, over several weeks.
• Small portions, protein first. Eat slowly and chew thoroughly.
• Vitamins for life. Typically a multivitamin, calcium, vitamin D and B12, and others as directed. Skipping them can cause serious, sometimes permanent harm.
• Regular blood work, for life.
• Pregnancy. Usually postponed for 12 to 18 months after surgery. Talk with your care team.
• Exercise and support groups. Both are linked to better results.

Surgery vs. medication

These aren't always either/or. Surgery still produces the largest and most durable loss for most people, while newer medications avoid an operation but generally need to be taken long term. Some people use medication after surgery to deal with regain. Talk through the trade-offs with a specialist. Choosing surgery isn't taking "the easy way out."

Questions to ask a program

• How many of these operations do you do each year, and what are your complication rates?
• Is your center accredited? (In the US, look for MBSAQIP accreditation.)
• What's your follow-up and nutrition support, and for how long?
• What will my insurance cover, including vitamins and follow-up?
• Which procedure do you recommend for me, and why?

Sources

1. Eisenberg et al., Surg Obes Relat Dis (2022): ASMBS and IFSO indications for metabolic and bariatric surgery
2. NIDDK: Bariatric Surgery
3. American Society for Metabolic and Bariatric Surgery

This guide is general information, not medical advice. Please check with a clinician before making big changes, especially if you have a health condition, take medication, or are pregnant. Read the full disclaimer.