Bariatric Surgery
Bariatric surgery is the most appropriate treatment option for this man that would not be indicated for his wife.
Rationale Based on BMI and Comorbidities
The 53-year-old man meets clear criteria for bariatric surgery while his wife does not:
The man qualifies for bariatric surgery with BMI 43 kg/m² (≥40 kg/m²) regardless of comorbidities, and he additionally has multiple severe obesity-related comorbidities including treatment-resistant hypertension, sleep apnea, and type 2 diabetes 1, 2.
The wife does not qualify with BMI 32 kg/m² and only musculoskeletal problems, as she lacks both the BMI threshold (≥35 kg/m² with comorbidities or ≥40 kg/m² without) and the severe comorbidities required for surgical intervention 1, 2.
Why Other Options Don't Differentiate These Patients
All other treatment modalities would be appropriate for both patients:
Behavior therapy is recommended for all patients with BMI ≥25 kg/m², making it appropriate for both the man (BMI 43) and woman (BMI 32) 1.
Exercise and dietary restriction are first-line interventions recommended for all overweight and obese patients regardless of BMI or comorbidity status 1.
Orlistat is indicated for patients with BMI ≥30 kg/m² or BMI ≥27 kg/m² with comorbidities, making both patients eligible since the woman has BMI 32 kg/m² 1.
Sympathomimetic drugs (such as phentermine) are indicated for BMI ≥30 kg/m² or BMI ≥27 kg/m² with comorbidities, again making both patients potential candidates 1.
Specific Bariatric Surgery Criteria
The National Heart Lung Blood Institute guidelines clearly delineate when bariatric surgery is appropriate:
- BMI ≥40 kg/m² regardless of comorbidities 1.
- BMI 35-39.9 kg/m² with severe comorbidities including established coronary heart disease, other atherosclerotic diseases, type 2 diabetes, or sleep apnea 1.
- BMI 30-34.9 kg/m² may be considered for type 2 diabetes that could potentially go into remission, though this remains more controversial 1, 2.
Expected Outcomes for the Man
Bariatric surgery would provide substantial benefits for this patient's multiple comorbidities:
Mortality reduction: Large observational studies demonstrate decreased all-cause mortality, deaths from diabetes, and deaths from coronary artery disease following bariatric surgery 1.
Diabetes improvement: Most patients experience complete remission or significant improvement of type 2 diabetes, often within days of surgery 1, 3.
Hypertension and sleep apnea: These comorbidities typically improve significantly or resolve after bariatric surgery 4, 5, 6.
Critical Caveat
The man should have attempted conventional weight loss methods (diet, exercise, behavioral therapy) before surgery, though given his treatment-resistant hypertension and multiple severe comorbidities, surgical intervention should not be unduly delayed 1, 2.