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Key takeaways:
Among metabolic bariatric surgery candidates, 73.8% met criteria for clinical obesity.
These candidates faced higher risk for complications and had greater comorbidity burden and cardiovascular risk.
New Lancet Diabetes and Endocrinology Commission criteria, which distinguish clinical obesity from preclinical obesity, may better inform patient selection and risk assessment for bariatric surgery than BMI, analysis showed.
Nearly 75% of surgical candidates met criteria for clinical obesity — defined as excess adiposity with obesity-related organ dysfunction — which was associated with greater preoperative disease burden and higher perioperative risk.
“Because this risk doesn’t track with BMI, I think having [a clinical obesity] assessment may inform and improve anesthetic management and surgical planning in general,” Francesco Rubino, MD, chair of metabolic and bariatric surgery at King’s College London, told Healio.
Metabolic bariatric surgery demonstrates the most effective long-term results of any obesity treatment, according to study background. Many health systems base patient prioritization for the surgery on BMI thresholds.
However, individuals with similar BMI can present with varied levels of organ dysfunction, Rubino and colleagues noted.
They applied Lancet Diabetes and Endocrinology Commission’s clinical and preclinical obesity framework to a retrospective, multicenter cohort of bariatric surgery candidates.
The commission defines preclinical obesity as excess adiposity with no associated organ dysfunction.
Prevalence of clinical obesity served as the primary outcome. Secondary outcomes included the types and prevalence of organ dysfunction, BMI levels, baseline American Society of Anesthesiologists classification and Charlson Comorbidity Index, 10-year cardiovascular risk and incidence of 30-day major postoperative complications.
All participants underwent bariatric surgery between 2014 and 2025 at one of four tertiary centers in the United Kingdom, Spain, France or Brazil.
Of 2,316 surgical candidates included in analysis, 73.8% had clinical obesity (mean age range, 45.6-48.9 years; 67.2% women), whereas 26.2% had preclinical obesity (mean age range, 34.7-40 years, 80.1% women).
Patients with clinical obesity exhibited higher American Society of Anesthesiologists and Charlson Comorbidity Index scores, all-cause mortality risk and greater long-term cardiovascular risk. Clinical obesity was associated with increased 30-day major postoperative complications compared with preclinical obesity in the French cohort.
Researchers observed no statistically significant difference in BMI levels between candidates with clinical obesity vs. preclinical obesity.
Study limitations included potential variability in reporting between the four institutional registries and lack of data on clinical outcomes beyond weight loss.
“There is no point in saying how much weight loss we have achieved in a person with clinical obesity if that weight loss has not resulted in an improvement or remission of the clinical manifestations,” Rubino said.
Rubino and colleagues recommend future research refine clinical and preclinical obesity prevalence estimates and assess long-term surgical outcomes with prospective studies utilizing standardized clinical assessments.
The study findings may lend themselves to develop improved frameworks for surgical candidate prioritization, individualized treatment and risk stratification.
“Preclinical obesity is a health risk, but it’s a very heterogeneous one,” Rubino told Healio. “There will be people with very low risk and people with very high risk.
“Developing systems that allow us to score that risk more appropriately at the individual level, beyond just using BMI, will allow us to understand which preclinical cases can be managed with lifestyle interventions, which ones are higher risk and warrant use of pharmacotherapy, and those that have highest risk, where surgical interventions may make sense.”
