“They won’t operate on me until I lose another 35 pounds.”
She was having a tough day. Severe osteoarthritis in her hips had rendered her nearly homebound, forcing her to rely on muscle relaxants and opioids just to maintain a semblance of quality of life. At 315 pounds, she was determined to reach her goal weight of 285 before qualifying for surgery. In just three months, she lost 25 pounds, a victory that felt fleeting when the holiday season arrived, bringing with it her weakness for sweets.
Her nutritionist suggested a keto diet, and she embraced it, shedding another 13 pounds. Overjoyed, she received congratulations from her surgeon, who urged her to lose just 10 more. I started her on a GLP-1, and she lost 30 pounds. But once again, the goal moved; now she needed to lose another 20 and she felt overwhelmed.
Her surgeon suggested that she exercise more. But how could she, with her hips in such pain?
“I’m just going to give up,” she sighed, despair heavy in her voice.
I looked at her, feeling helpless. What more could I offer than empathy, validation, and encouragement? With a BMI of 39, she was trapped in a cycle of frustration, feeling defeated, and questioning whether the surgery was even worth it anymore.
“Maybe I should get a second opinion,” she said, a flicker of hope breaking through her despair.
I gave her a referral.
With the rising prevalence of obesity, reducing risk factors in the preoperative setting is crucial. Surgical interventions for obese patients are inherently more complex and carry heightened risks due to comorbid conditions commonly associated with obesity. These patients often experience more severe perioperative and postoperative complications, including surgical failure, longer hospital stays, and greater utilization of health care resources. Consequently, approximately 85% of surgeries are postponed or denied until the patient reaches a “safer” weight, creating a care gap for those with higher BMIs. Many institutions have implemented specific policies outlining weight loss goals that patients must meet before undergoing surgery. While these policies aim to improve outcomes, they are often implemented without adequate resources or support for those affected, leaving patients without the guidance they need to achieve these goals.
What happens to patients who are denied surgery? Many individuals who fail to meet weight loss goals often abandon their efforts and do not seek second opinions at other institutions. My patient never sought that second opinion. She lost trust in the medical system and left the orthopaedics clinic after being denied surgery. In the past five months, she has made approximately 26 visits to the ER, all for pain control. Her experience reflects a broader trend of patients feeling discriminated against, often facing judgment about failing to take personal responsibility for their weight without understanding their broader circumstances. In her case, significant weight gain was largely a result of taking prednisone for debilitating rheumatoid arthritis.
Then there are life-or-death situations. I remember a young woman who presented with acute on chronic abdominal pain, quickly linked to her chronic pancreatitis. Over the next few days, her condition worsened; she developed leukocytosis and was diagnosed with severe acute cholecystitis. Three surgical teams evaluated her for a cholecystectomy, but all deemed her a poor surgical candidate due to her BMI of 41. Tragically, she passed away two days later from septic shock. Her parents felt she was discriminated against because of her weight. Were they right? While she was considered a “high-risk” surgical candidate, did the potential for increased perioperative complications outweigh the certainty of death without the procedure?
Back in 2017, the National Health Commission (NHC) in the United Kingdom introduced a health policy that delayed elective or nonurgent surgeries for obese patients in an effort to optimize their health. Under this policy, local clinical commissioning groups (CCGs) established strict criteria that patients needed to meet before they were considered eligible for surgery. For example, those with a BMI over 40 were required to lose 15% of their body weight within nine months, while those with a BMI over 30 faced a target of 10%.
This policy was controversial. If patients failed to meet the weight loss targets, their surgical wait times could be extended indefinitely. It has also spurred significant contention, as it often ignores the severe pain and diminished quality of life that these patients experience while waiting for surgery, potentially leading to further health deterioration. The ethical implications of this policy have also raised concerns about financial motivations to delay surgery and the rationing of care in addition to accusations of discrimination and inequality against vulnerable populations.
As an internal medicine physician, I regularly encounter patients whose surgeries are delayed due to obesity. While some are able to achieve the required weight loss, many struggle with significant barriers. Most of my patients choose to work with dedicated nutritionists and secure gym memberships — valuable options, though often costly. Fortunately, some insurance providers offer complimentary health coaching, which can assist with nutrition and exercise plans. In cases where lifestyle changes are ineffective — something not too surprising but commonly the case — medications like GLP-1s present a viable alternative for weight loss. However, accessing these medications can be challenging due to insurance coverage issues and national shortages.
These are merely some resources that can support patients in their weight loss journey while also ultimately leading to cost savings by reducing the expenses associated with delaying surgery and minimizing potential complications. Although it is reasonable to defer surgery until modifiable risk factors are addressed, it is imperative that we ensure patients have access to the essential resources and support they need to reach their health goals.
How do you support your patients with obesity? Share in the comments.
Dr. Siya Bhagat is a second-year internal medicine resident and aspiring cardiology fellow. She enjoys playing pickleball, exploring new restaurants, and spending time with friends and family. She is a 2024–2025 Doximity Op-Med Fellow.
Image by Alphavector / Shutterstock
