You’ve probably had friends and family corner you to look at a rash or talk about medications. With social media exploding about Ozempic, these questions and even curbsides from physicians have boomed. We all want to know more about weight.

As a bariatric surgeon, here are five things every physician should know about weight:

1. How to start a conversation with a patient about weight
2. When to refer a patient to a bariatric specialist
3. Anti-obesity medications may not be wonder drugs but matter on weight
4. Bariatric surgery is the best treatment for some
5. Mental health, physical activity, and nutrition help fight barriers to weight management

How to start a conversation with a patient about weight

Weight is a tough topic to discuss. The majority of my 45-minute initial bariatric visits with patients are spent building trust. The anchoring principle of any conversation about weight is respect.

Consider a few approaches to start a conversation with your patient:

1. Determine a go-to bariatric specialist for referrals
2. Ask your patient about quality of life and goals
3. Invite patients to discuss weight on their terms
4. Consider dedicating visit time to this topic
5. Discuss health goals such as decreasing medications

When to refer a patient to a bariatric specialist

Fewer than 1% of eligible patients ever visit a bariatric specialist. Most bariatric specialists offer non-surgical services regardless of patient BMI and comorbidities. If in doubt, refer.

The most common criteria used by health insurers for bariatric surgery are:

• BMI over 40 OR,
• BMI over 35 with any of the following conditions:
  • Diabetes
  • Hypertension
  • Obstructive sleep apnea, asthma
  • Osteoarthritis
  • Polycystic ovarian syndrome (PCOS)
  • GERD, hiatal hernias​​
  • NASH
  • Hyperlipidemia
  • Cardiovascular disease
  • Anxiety/ depression

2022 ASMBS/ IFSO guidelines expand criteria to BMI over 35 and over 30 with comorbidities.

So now that you want to refer, how do you find a bariatric specialist?

• ASMBS find a provider
• SAGES find a surgeon
• OMA find a clinician
• Refer within your network or ask peers for referral advice

Anti-obesity medications may not be wonder drugs, but matter in weight

There are currently 9 FDA-approved anti-obesity medications in several classes:

1. Phentermine (Adipex-P) and analogues
2. Bupropion/ naltrexone (Contrave) and analogues
3. Orlistat (Alli)
4. GLP-1 agonists (Wegovy/ Ozempic and Saxenda)

Outside of FDA approval, some medications, such as topiramate, are used off-label. Ttirzepatide (Mounjaro) is pending FDA approval.

While not the wonder drugs as sometimes touted by media, anti-obesity medications have important benefits, including:

1. Non-invasive: Self-administered oral and subcutaneous formulations
2. Accessible: Can be taken by patients with BMI under 35
3. Multimodal: Some treat multiple comorbidities
4. Synergy: Can be used with bariatric surgery

However, anti-obesity medications have limitations, including::

1. Efficacy: Maximum loss of 20% excess body weight on average
2. Durability: Work only while taken
3. Side effects: Range from mild to severe, can cause contraindication
4. Cost: Few insurers cover AOMs; Out of pocket costs top $1500 monthly for GLP-1s
5. Reach: Few providers manage anti-obesity medications

Since medications have limits, let’s talk about how bariatric surgery fits into the equation.

Bariatric surgery is the best treatment for some.

Bariatric surgery is the most effective and durable weight management method for patients with excess weight. Bariatric surgery also treats many comorbidities. Over 70% of patients achieve diabetes remission after bariatric surgery. Health care cost reductions outweigh the cost of bariatric surgery within an average of 18 to 36 months.

After surgery, patients often experience improvements in movement, sleep, breathing, sexual function, and mental health. My own patients have accomplished many goals, including:

• Running a 5K after years of knee pain
• Normalized HbA1c and having a “second chance at life” after diabetes resolution
• Becoming pregnant, resolved PCOS
• Stopping CPAP machine use with OSA resolution
• Dancing at a daughter’s wedding
• Becoming a cheerleading coach
• Reflux resolution
• Taking skydiving lessons

Patients go through months of evaluation, workup, nutrition, medical, and mental health counseling to prepare for safe and successful bariatric surgery.

You may be asking, how does bariatric surgery work?

Bariatric surgery causes both restrictive and metabolic changes. Restriction occurs through size reduction along the GI tract. GI tract modifications alter food absorption, cellular function, and endocrine signaling. Medical, mental, and nutrition education for patients undergoing surgery enables maintenance and prevents regain.

While bariatric surgery continues to evolve, the primary types of bariatric surgery include:

• Sleeve gastrectomy, SG
• Roux-en-Y gastric bypass, RNYGB
• Duodenal bypass, BP-DS and SADI
• Gastric band

Most bariatric surgeons perform sleeves and bypasses, all of which cause restrictive and metabolic changes and treat metabolic comorbidities. Sleeves allow patients to lose 40 to 65% of excess weight on average; bypasses allow 60 to 90%.

While bariatric surgery can cause physical and mental complications, complication rates are low, even compared to other elective surgeries. Bariatric specialists, organizations, and patient advocates continue to implement safety factors, including:

• Accreditation and monitoring
• Multidisciplinary support: surgical, medical, nutrition, and mental health
• Structured patient evaluation, optimization, and education
• Perioperative care protocols
• Regular patient follow-up

Mental health, physical activity, and nutrition help fight barriers to weight management.

Weight management does not happen in a bubble. We all live in a society that promotes excess rather than sustainability. Our patients face barriers to weight management, including:

• Work-based culture
• Lack of reliable public transportation, walkable environments
• Absence of affordable access to childcare
• Lack of affordable access to healthy food
• Cultural emphasis on overeating and eating on the go
• Gender and cultural identity tied to food
• Stigma towards mental health treatment
• Limited health care access

We can help patients counteract some of these barriers through support and interventions in nutrition, mental health, and physical activity. These interventions allow patients to identify barriers and learn how to implement sustainable changes over time. Many bariatric programs offer these services essential for long-term weight management.

My goal in sharing the top five things every physician should know about weight is to make the path easier for at least one patient. Together, we can help more than 1% of bariatric patients reach bariatric care.

Maria Iliakova is a bariatric and general surgeon.