Indications for Metabolic and Bariatric Surgery

Publication Date: October 20, 2022

Key Takeaways

Major updates to 1991 National Institutes of Health guidelines for bariatric surgery

  • Metabolic and bariatric surgery (MBS) is recommended for individuals with a body mass index (BMI) ≥35 kg/m2, regardless of presence, absence, or severity of co-morbidities.
  • MBS should be considered for individuals with metabolic disease and BMI of 30-34.9 kg/m2.
  • BMI thresholds should be adjusted in the Asian population such that a BMI ≥25 kg/m2 suggests clinical obesity, and individuals with BMI ≥27.5 kg/m2 should be offered MBS.
  • Long-term results of MBS consistently demonstrate safety and efficacy.
  • Appropriately selected children and adolescents should be considered for MBS.


  • Since the NIH published its statement on gastrointestinal surgery for severe obesity in 1991, the understanding of obesity and MBS has significantly grown based on a large body of clinical experience and research.
  • Long-term data consistently demonstrate the safety, efficacy, and durability of MBS in the treatment of clinically severe obesity and its co-morbidities, with a resultant decreased mortality compared with nonoperative treatment methods.
  • MBS is recommended for individuals with BMI ≥35 kg/m2, regardless of presence, absence, or severity of co-morbidities.
  • MBS is recommended in patients with T2D and BMI ≥30 kg/m2.
  • MBS should be considered in individuals with BMI of 30–34.9 kg/m2 who do not achieve substantial or durable weight loss or co-morbidity improvement using nonsurgical methods.
  • Obesity definitions using BMI thresholds do not apply similarly to all populations. Clinical obesity in the Asian population is recognized in individuals with BMI >25 kg/m2. Access to MBS should not be denied solely based on traditional BMI risk zones.
  • There is no upper patient-age limit to MBS. Older individuals who could benefit from MBS should be considered for surgery after careful assessment of co-morbidities and frailty.
  • Carefully selected individuals considered higher risk for general surgery may benefit from MBS.
  • Children and adolescents with BMI >120% of the 95th percentile and a major co-morbidity, or a BMI >140% of the 95th percentile, should be considered for MBS after evaluation by a multidisciplinary team in a specialty center.
  • MBS is an effective treatment of clinically severe obesity in patients who need other specialty surgery, such as joint arthroplasty, abdominal wall hernia repair, or organ transplantation.
  • Consultation with a multidisciplinary team can help manage the patient’s modifiable risk factors with a goal of reducing risk of perioperative complications and improving outcomes. The ultimate decision for surgical readiness should be determined by the surgeon.
  • Severe obesity is a chronic disease requiring long-term management after primary MBS. This may include revisional surgery or other adjuvant therapy to achieve desired treatment effect.

Recommendation Grading




Indications for Metabolic and Bariatric Surgery

Authoring Organizations

Publication Month/Year

October 20, 2022

Supplemental Implementation Tools

Document Type


Country of Publication


Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Ambulatory, Operating and recovery room

Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D050110 - Bariatric Surgery


bariatric surgery, weight loss surgery, metabolic surgery

Source Citation

2022 American Society for Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO): Indications for Metabolic and Bariatric Surgery; Eisenberg, Dan et al. doi: 10.1016/j.soard.2022.08.013