Introduction

Dietary and lifestyle modifications alone seldom allow long‐term maintenance of weight loss. Patients will often, therefore, give a history of ‘Yo‐Yo’ weight following numerous attempts at weight loss utilising commercial diets. Medical therapy for weight loss results in an average total body weight loss of 10–15% and requires costly and ongoing treatment with pharmacological agents. Most patients will have tried numerous commercial diets and/or medications prior to seeking bariatric and metabolic surgery (BMS).

BMS is well established as the only means to enable patients with severe obesity to achieve sustained long‐term weight loss (typically 20–35% total body weight loss at 12 months after surgery). This not only results in longevity but also improvement in quality of life, mobility and self‐confidence/esteem. Sustained long‐term weight loss also results in significant health gains with improvement/remission of numerous obesity‐related medical co‐morbidities such as type 2 diabetes, treatment‐resistant hypertension, obstructive sleep apnoea, non‐alcoholic fatty liver disease and improved fertility. Similarly, patients benefit from reduced risk of heart attack, stroke, developing cancers and complications of SARS‐Co‐V2. However, BMS should not be sought as a shortcut to losing weight, and patients should be carefully selected and counselled regarding the lifelong dietary and lifestyle changes that will be necessary to achieve and maintain to enable good clinical outcomes.

BMS pathways should function within the remits of a specialist multi‐disciplinary team (MDT) that should assess all patients seeking surgery. Members of the MDT include bariatric surgeons, obesity physicians, specialist bariatric anaesthetists, gastrointestinal radiologists, specialist dieticians, clinical psychologists, bariatric clinical nurse specialists and physiotherapists.

Patient assessment focuses on the following criteria:

• Establishing the weight history and previous non‐surgical attempts at weight loss.
  
• Presence and severity of obesity‐related medical and surgical co‐morbidities.
  
• Medication use and effects of the latter on co‐morbidities.
  
• Smoking status, alcohol intake and/or substance misuse or dependency.
  
• Presence of psychological co‐morbidities and effects on lifestyle and dietary habits.
  
• History of deliberate self‐harm or previous suicide attempts.
  
• Social factors, such as home ownership, access to kitchen facilities and ability to buy and cook fresh meals.
  
• Support structure from family members or partners.

Defined criteria and indications are in use by most centres who perform bariatric surgery. Whilst local and regional variations may exist, access to BMS is often curtailed due to availability of health resources, funding and specialist expertise. Most patients will be able to access services either free of charge through national healthcare systems, insurance schemes or by paying privately for surgery.

Indications

The criteria for surgical intervention in obesity, still in use today, were established by the National Institutes of Health (NIH

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