When Does Obesity Become a Surgical Problem?

This case study briefly reviews the diagnosis and pre-operative work-up for the surgical management of morbid obesity.

One of your long-term patients schedules a clinic visit with you to discuss her weight. Naomi is a 25-year-old woman who has been struggling with her weight since childhood. Despite repeated attempts at weight loss, including Weight Watchers, the Atkins diet, and most recently a supervised medical fast, she has been unable to lose more than 20 lbs at a time. When she does lose weight, she always regains it within the next six months.

Naomi tells you that her grandmother recently died from complications from obesity-associated diabetes. She is worried that if she does not lose a large amount of her excess weight, she will develop obesity-related complications, as well. In particular, she is worried about diabetes and heart disease. Naomi has a question for you:

“Am I good candidate for gastric bypass surgery?”

You have also been wondering if surgical management is the next step for her and decide to look into the matter further. First you calculate her body mass index (BMI). Naomi is 5 feet 8 inches tall and weighs 270 lbs. In order to calculate her BMI, you can either use an online calculator or convert her height to meters and weight to kilograms. The formula to calculate BMI is

BMI = weight(in kg)/(height (in m))2.

Using this equation, you find that Naomi’s BMI is 41.1, placing her in the obese range for BMI. You explain to Naomi that she meets the BMI requirement for undergoing surgery. If she had a BMI between 35 and 40, she would still be eligible if she had any weight-associated co-morbid conditions. However, she is quite healthy and has no other medical problems.

In addition to meeting BMI requirements, Naomi needs to be screened for psychiatric and physical problems that may interfere with her surgical success. So you ask her, does she have any problems with drugs or alcohol? Does she have any unmanaged psychiatric disorders? Has she had any difficulties getting through surgery in the past? She tells you “no” to all of these questions. Then you turn to the most commonly used guidelines for bariatric surgery developed by the National Institutes of Health (NIH) in 1992.[1]

According to these guidelines, Naomi should have tried medical management of her weight before considering surgical intervention. She tells you that she has attempted programs integrating diet, exercise, and behavior modification without success. She is willing to learn more about bariatric surgery and is motivated to follow through.

What do you do next?

You can recommend that Naomi follow up with a local bariatric surgeon. You should ensure that you refer her to bariatric center that uses an interdisciplinary team approach, one that includes medical, nutritional, psychiatric and surgical expertise. The surgeon should have a good track record and his or her office should be prepared to follow up with Naomi for the rest of her life if she has complications or requires surgical revision in the future.

Watch for next month’s blog on the Medical Management of Obesity. 

[1] Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(2 Suppl):615S-619S.


Dr. V. Silverstein
Durham, NC

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