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In part 1 of this series we looked at the basic issues of a healthcare system that is allowed to demand weight loss before patients are able to access healthcare. In this section, we’ll look at BMI-based denials of care. These occur when a patient is denied care unless or until they reach a certain BMI. It is often justified by the idea that higher-weight patients have more complications/worse outcomes and that weight loss will improve this. But it’s far from being that simple.
Before we get into it, I would argue that there isn’t nearly enough research showing that weight loss actually improves surgical outcomes. At the end of this post you’ll find a research list around this.
I believe that ethical healthcare fits the people who exist, and that people shouldn’t be asked to change themselves to fit into healthcare. Still, even if someone believes it’s appropriate to demand weight loss before healthcare is rendered, there are two important questions to ask.
Will the weight loss method recommended actually produce enough weight loss for the patient to “make weight” for their procedure and/or accommodation?
What is the impact of the delay in care that occurs when a higher-weight patient is made to wait for healthcare while they try to “make weight.”
Today we’ll focus on the first question.
Evidence for the ability of the weight loss intervention to reach the required BMI
Notice that I use “the ability of the weight loss intervention” and not “the ability of the patient.” That is very intentional. For far too long the weight loss industry, and the healthcare industry (largely through weight loss industry influence,) have blamed patients for failed weight loss interventions. That has lessened recently only as the weight loss industry has found it to be a good marketing technique to sell weight loss drugs.
Again, when it comes to behavior-based weight loss interventions we are talking about a very small amount of weight loss in the first year, most of which is gained back in years 2-5. For example, in their study “Probability of an Ob*se Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records,” Fildes et al found that “The annual probability of achieving a 5% weight reduction was 1 in 8 for men and 1 in 7 for women with m*rbid ob*sity” So even if someone only needed to lose 5% of their body weight to “qualify” for a procedure or be accommodated in healthcare, they are looking at about a 12-14% chance of that happening over a year.
A study from May, 2025 looked at both high-dose semaglutide (Wegovy) and high-dose tirzepatide (Zepbound) for weight loss over 72 weeks. It found 15.4% and 21.6% weight loss respectively. The numbers are lower in studies that included patients with type 2 diabetes. It seems to go downhill longer term (the 4 year semaglutide study, for example, averaged 10% weight loss and lost 89.5% of the sample over four years) but I’m using the short-term study since the goal is to take these drugs to “make weight” for surgery or accommodation.
So if a patient needs to lose 21.6% of their body weight or less to be considered “worthy” of healthcare by the person or company making the decision, these are a good option right? Not so fast.
Those are the average percentages of weight loss. Consistently in short-term studies of these drugs, about half the people do NOT manage to reach these averages, and some lose very little. There’s also the issue of delaying care while the patient tries to lose weight, but we’ll cover that in part 3.
Let’s look at some math.
A patient who is 5’3, 300 pounds has a BMI of 53.1 (BMI is, of course, a deeply problematic measure, but it is what is used for these care denials, so I’m using it here.) The surgeon has decided she doesn’t want to operate on people with a BM over 35.
For that BMI the patient would have to weigh a maximum of 197.5
Which means they would have to lose 102.5.
Which is 34.1% of their body weight.
That’s more than twice the average weight loss of high-dose semaglutide (Wegovy)and 12.5% more than the average for high-dose tirzepatide (Zepbound) and remember that about half the people in the short-term studies of these drugs did not lose even the average and if the patient has type 2 diabetes, or is a cis-male, the numbers are even lower.
There is no official data that I can find on this, but what I’m hearing from multiple patient, and providers who are advocating for patients, is that providers/facilities/insurance companies aren’t doing the math - they’re just telling patients that they are over the weight limit to receive the healthcare they need and then prescribing these drugs to “make weight” for care, thus delaying care and exposing the patient to significant adverse events without providing the patient with any understanding of the chance of actually reaching a BMI/weight that the provider/facility/insurance has deemed worthy of receiving healthcare.
Of course, if they can’t lose enough with the drugs the next recommendation is that, even if they’ve been told that the surgery they want/need is too dangerous at their size, they should have weight loss surgery which is typically even more dangerous with significant side effects (including putting a healthy digestive system into a typically irreversible disease state) and many patients still won’t lose enough weight to get the healthcare they want/need.
There are multiple types of weight loss surgeries (I discuss them more in-depth here) The most extreme can create about 50% weight loss in the first year (though longer-term studies show that weight is steadily regained over time,) but of course these surgeries have significant risks and long-term side effects, and the research is mixed, at best, on whether rapid weight loss due to extreme food restriction actually improves surgical outcomes. It is especially problematic to refer a patient who has been told that surgery is too dangerous at their size to…surgery. I talked more about that here.
While my goal here is to address the situation that currently exists, there are deeper questions to be asking here.
First of all, are any worse outcomes experienced by higher weight people actually due to their weight? Or are they due to weight stigma within the healthcare system. In the case of surgical procedures that can include things like surgical tools, procedures, and best practices created using research that excluded higher-weight people, provider bias (implicit and/or explicit,) and lack of tools needed for post-operative care. Just one example, a lack of appropriate staffing ratios and/or hoyer/overbed lifts leads to higher-weight patients who would otherwise be able to ambulate not being able to ambulate post-surgery, leading to increased postoperative complications, which will be blamed on their weight and not the lack of accommodation.
Second, we need to ask if weight neutral options could provide similar or more benefits with far less risk.
Still, even if the provider (and even the patient) think weight loss is an appropriate requirement in order to receive healthcare/be accommodated, there is still the issue of whether the amount of weight loss required is realistic or possible. And even if it is, we have to ask about the impact of waiting around for weight loss to get care (that a thinner patient would have received immediately). We’ll talk about that in part 3.
Research List: Evidence around weight loss and surgical outcomes
With behavior-based interventions, we know that they produce very little weight loss and that weight that is lost is almost always regained. Even if research shows improved outcomes there is essentially never a mechanism to determine whether it was weight loss or the behavior changes that preceded it that actually improved outcomes. And some research shows a lack of improvement and even worse outcomes.
Inacio et al.’s 2014 study “The risk of surgical site infection and re-admission in ob*se patients undergoing total joint replacement who lose weight before surgery and keep it off post-operatively” found worse outcomes in patients who lost weight prior to surgery and maintained the weight loss than those whose weight remained stable, concluding “These findings raise questions about the safety of weight management before total replacement of the hip and knee joints.”
Smith et al.’s 2016 study “Does bariatric surgery prior to total hip or knee arthroplasty reduce post-operative complications and improve clinical outcomes for obese patients? Systematic review and meta-analysis” found:
“For most peri-operative outcomes, bariatric surgery prior to THA or TKA does not significantly reduce the complication rates or improve the clinical outcome. This study questions the previous belief that bariatric surgery prior to arthroplasty may improve the clinical outcomes for patients who are ob*se or m*rbidly ob*se.
Other research finds that higher weight people can actually have better outcomes.
Giesinger et al.’s 2021 “Higher body mass index is associated with larger postoperative improvement in patient-reported outcomes following total knee arthroplasty” concluded:
“Post-operative improvement in joint-specific outcomes was larger in obese patients compared to normal weight patients. These findings suggest that obese patients may have the greatest benefits from TKA with regard to function and pain relief one year post-op.”
I have research lists specific to joint surgeries, lumbar spinal procedures, and gender affirming care if you want to take a deeper dive.
When it comes to GLP-1 weight loss drugs, the research is even more sparse and the results are less than overwhelming.
A 2025 study called “GLP-1 Agonists for Weight Loss: Do They Increase Complications in Non-diabetic Patients Undergoing Primary Total Hip Arthroplasty?” was only able to conclude “Use of a GLP-1 agonist does not appear to increase the odds of postoperative medical and surgical complications after THA in nondiabetic patients taking GLP-1 medications for weight loss alone” after finding no difference in risk of deep venous thrombosis, pulmonary embolism, mortality, stroke, myocardial infarction, acute kidney injury, sepsis, or aspiration pneumonia.
A 2025 study called “Association of Perioperative Glucagon-like Peptide-1 Receptor Agonist Use and Postoperative Outcomes” found “significant reductions in risk-adjusted readmission, wound dehiscence, and hematoma, and no difference in infection and bleeding rates” but, unlike the study above, which excluded those with Type 2 Diabetes, this study included only people with T2D. Given that these drugs are actually T2D drugs with a side-effect of weight loss, it’s not clear whether weight had anything to do with the improved outcomes, or if it was improved blood sugar management. The study concluded “Further study is warranted to elucidate any causal association.”
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More research
The Research Post
More resources
The Resource Post
*Note on language: I use “fat” as a neutral descriptor as used by the fat activist community, I use “ob*se” and “overw*ight” to acknowledge that these are terms that were created to medicalize and pathologize fat bodies, with roots in racism and specifically anti-Blackness. Please read Sabrina Strings’ Fearing the Black Body – the Racial Origins of Fat Phobia and Da’Shaun Harrison’
It’s so upsetting that we aren’t getting all the information from our providers to make informed decisions about our bodies.
In the situation with the spinal surgeon in my previous comment, where the doctor said I’d need to lose weight before a thoracic surgeon would assist him with my spine, I mentioned that there were no studies that showed how someone could lose weight long term, and that most people regained more than they lost, so it seemed like a bad idea to tell someone to attempt something that’s just not going to work and may even backfire and result in gaining more than was lost, the doctor was clearly dumbfounded. I don’t think anyone’s ever said that to him before. He sputtered and stammered and eventually says “there are balloon devices you can swallow so you don’t eat as much.” I said that’s a bold assumption that my size is due to overeating when he didn’t even ask about my eating habits.
Obviously the appointment went off the rails by that point and I thanked him for his time and asked for copies of my imaging and records… I hate how that visit ended. I hope i at least planted some seeds, but who knows.