Guidelines for Metabolic Surgical Candidates

By Alan L. Rubin

Metabolic surgery isn’t for everyone who wants to treat type 2 diabetes. When you have surgery for obesity, you must be committed to lifelong medical follow-up. You must be willing to give up large meals and be determined to lose weight. These sections examine the specific guidelines for you to review before talking about surgery with your doctor.

Eyeing medical determinants

In 1991 the National Institutes of Health published the indications for the appropriateness of metabolic surgery. Unfortunately these indications had very little basis in scientific evidence. Nevertheless, insurance companies have based their willingness to pay for the surgery on these criteria. The result is that many patients who should have surgery have been denied because they didn’t fit these criteria:

  • Any patient with a body mass index (BMI) greater than 40.

  • Patients with a BMI of 35 or greater who have another medical condition such as type 2 diabetes, high blood pressure, heart disease, severe joint disease, or obesity-related severe psychological problems when less invasive methods of weight loss have failed.

  • Metabolic surgery can result in substantial weight loss and is an available option for well-informed and motivated patients so the surgery is limited to patients who are acceptable operative risks.

  • Patients opting for surgery should be followed by a multidisciplinary team so patients should find such a team.

  • Lifelong medical surveillance after surgery is a necessity so patients who don’t recognize the need for this should be excluded.

Noting psychological determinants

Most surgical programs also insist on a number of psychological determinants in addition to the physical determinants. They include the following:

  • The individual needs to demonstrate adherence to recommendations by attending appointments, practicing self-monitoring with recordkeeping, making time for healthy eating and activity, taking medication, and completing blood work.

  • The individual must have an understanding of the benefits and limitations of a surgical procedure to assist with management of his obesity.

  • The risks of surgical intervention must not be excessive and must be lower than the risks of not providing the treatment.

  • If psychological disorders such as depression are present, they won’t necessarily prevent surgery, but they need to be treated.

Knowing who shouldn’t have surgery

Not every person who needs the surgery can have it. These are some of the current criteria that exclude the operation:

  • BMI less than 35

  • Age less than 18 or greater than 65

  • A medical condition that makes surgery too risky

  • Clinically significant or unstable mental health concerns

  • Unrealistic expectations for surgery

  • A history of poor compliance with lifestyle, medical, or mental health interventions

  • Pregnant, breast-feeding, or planning a pregnancy within two years of surgery

  • Smokers (must quit at least eight weeks before surgery) — all smokers must participate in smoking-cessation programs after surgery.