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Primary care providers may be involved in initiating conversations with people regarding metabolic surgery (also referred to as bariatric surgery) to determine whether they are appropriate candidates for referral. Third-party payers typically have specific criteria that they require to approve surgery for a patient. These may include a BMI of ≥40 or a BMI of >35 with comorbid conditions; thresholds may be lower for Asian patients and those with type 2 diabetes (Pennings et al., 2025).
Metabolic surgery can produce much greater weight loss than usually occurs with lifestyle modifications and pharmacotherapy. Weight loss may be in excess of 35% of initial body weight and comorbid conditions such as type 2 diabetes may go into remission shortly after surgery. Surgery also reduces risk for certain cancers (e.g., breast, endometrial, and prostate) and major adverse cardiovascular events (all-cause mortality, myocardial infarction, cerebrovascular events, and heart failure) (Pennings et al., 2025).
However, the risks of these procedures must be carefully weighed against potential benefits. For older adults, the risk-to-benefit consideration is further complicated by short-term risks of surgery, the ability to recover from surgery and adhere to needed lifelong changes in diet and other aspects of daily life, and the number of years of expected life remaining for the person to enjoy the benefits of surgery. Long-term success hinges on thorough preoperative nutritional and psychological assessments, strong patient commitment, and seamless, interdisciplinary, patient-centered care. Continued support from an RD or RDN can also help improve weight loss outcomes (Andromalos et al., 2019).
More information about metabolic surgery, including a review of surgical procedures and details about the risk and benefits in older adults, is provided in Summarizing Consensus Guidelines on Obesity Management from the International Federation for the Surgery of Obesity & Metabolic Disorders (IFSO) and World Gastroenterology Organisation (WGO) (Sharaiha et al., 2023).
Bariatric surgery, though used in less than 5% of older adults, is safe and effective with outcomes comparable to younger populations. Newer GLP-1 and dual agonist medications offer promising treatment options but data in adults over 75 is limited. We must be cautious about risks such as weight loss–induced sarcopenia and osteoporosis and individualize treatment with close medical monitoring and adjuncts like protein supplementation and exercise.
Importantly, surgery is not a cure-all for obesity. Although most people experience rapid weight loss following surgery, dietary modifications are needed to help maintain weight loss and minimize regain. Further, nutritional supplementation is generally required to ensure that people avoid nutritional inadequacies (Sharaiha et al., 2023).
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