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Cardiovascular Disease and Adiposity · Journal article
JAMA Network Open · August 11, 2026
Encouraging direction, but not yet definitive.
This multicenter retrospective audit of 2316 MBS candidates demonstrates that 73.8% met criteria for clinical obesity (organ dysfunction) versus 26.2% preclinical obesity (preserved function), despite similar BMI distributions. Patients with clinical obesity were older, had higher perioperative risk scores (ASA, Charlson, Framingham), higher estimated cardiovascular risk, and greater 30-day major complication rates in the French cohort (4.0% vs 1.1%), suggesting the clinical obesity framework may better stratify surgical risk than BMI alone.
Retrospective, multicenter, cross-sectional audit. Adults aged ≥18 years undergoing primary MBS at 4 high-volume tertiary centers in UK, Spain, France, and Brazil. Excluded: patients undergoing revisional procedures or multiple bariatric operations within the same year.. Intervention: Classification as clinical obesity or preclinical obesity using pragmatic operationalization of the Lancet Diabetes and Endocrinology Commission framework. Compared with: Clinical obesity versus preclinical obesity. n = 2,316. 4 high-volume tertiary centers: UK, Spain, France, Brazil.
Clinical obesity prevalence 73.8% (1709/2316) across all centers, ranging from 62.7% in Brazil to 79.3% in UK Patients with clinical obesity were significantly older: UK 48.9 vs 39.5 years (P<0.001), France 45.6 vs 34.7 years (P<0.001), Spain 47.1 vs 40.0 years (P<0.001), Brazil 48.3 vs 40.0 years (P<0.001) Clinical obesity associated with higher ASA classification across cohorts (all P<0.001)
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For MBS practitioners, this framework suggests that BMI-based patient selection may miss important heterogeneity in comorbidity burden and operative risk. Classification of candidates as clinical versus preclinical obesity could improve risk stratification and patient counseling, though prospective validation and longer-term outcome assessment are needed before adoption into routine selection criteria.
A rigorous multicenter cross-sectional study applying a new clinical classification framework to a large, real-world MBS cohort, demonstrating differential risk profiles; results support the framework's potential but require prospective validation and longer-term outcome data.
As stated by the source record.
Quoted from the source exactly as published.
For MBS practitioners, this framework suggests that BMI-based patient selection may miss important heterogeneity in comorbidity burden and operative risk. Classification of candidates as clinical versus preclinical obesity could improve risk stratification and patient counseling, though prospective validation and longer-term outcome assessment are needed before adoption into routine selection criteria.
Graded across the dimensions that decide whether you should act, each from what the source actually supports. There is no single score, and where a dimension was not assessed it says so.
Importance: Metabolic bariatric surgery (MBS) is the most effective treatment for severe obesity, yet patient selection and prioritization remain largely based on body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) thresholds rather than clinical conditions. The Lancet Diabetes and Endocrinology Commission recently proposed distinguishing clinical obesity (adiposity with obesity-related organ dysfunction) from preclinical obesity (excess adiposity with preserved function). The implications of this framework for MBS practice have not been evaluated. Objective: To assess the prevalence of clinical and preclinical obesity among MBS candidates and examine their demographic and clinical profiles, perioperative risk, and long-term prognosis. Design, Setting, and Participants: This retrospective, multicenter, cross-sectional study audited data of adults (aged ≥18 years) undergoing primary MBS (laparoscopic gastric bypass or sleeve gastrectomy) between January 1, 2014, and December 31, 2025, at 4 high-volume tertiary centers in the UK, Spain, France, and Brazil. Patients who underwent revisional procedures or multiple bariatric operations within the same year were excluded. Exposures: Classification of obesity as clinical or preclinical using a pragmatic operationalization. Main Outcomes and Measures: The primary outcome was the prevalence of clinical obesity. Secondary outcomes were patterns of organ dysfunction, BMI levels, baseline American Society of Anesthesiologists classification and Charlson Comorbidity Index, estimated 10-year cardiovascular risk (Framingham risk score), and 30-day major postoperative complications (Clavien-Dindo grade ≥3). Comparative analyses between patients with clinical obesity vs those with preclinical obesity were performed only within each individual cohort. No direct statistical comparisons were performed between centers as patient-level data were not shared across cohorts. Results: Among the 2316 patients included, 1709 (73.8%) had clinical obesity (mean [SD] age across cohorts, 45.6 [11.0] to 48.9 [11.7] years; 1149 women [67.2%]) and 607 (26.2%) had preclinical obesity (mean [SD] age across cohorts, 34.7 [10.4] to 40.0 [9.8] years; 486 women [80.1%]). Clinical obesity was the most prevalent category across all centers (from 62.7% in the Brazilian cohort to 79.3% in the UK cohort). Mean (SD) BMI ranged from 40.2 (4.9) (preclinical obesity in the Brazilian cohort) to 48.5 (9.0) (preclinical obesity in the UK cohort), and BMI levels and BMI category distributions (<40, 40-49, ≥50) were similar between clinical and preclinical obesity. Patients with clinical obesity were significantly older compared with those with preclinical obesity (UK cohort: mean [SD], 48.9 [11.7] vs 39.5 [9.7] years; French cohort: mean [SD], 45.6 [11.0] vs 34.7 [10.4] years; Spanish cohort: mean [SD], 47.1 [9.3] vs 40.0 [9.8] years; Brazilian cohort: mean [SD], 48.3 [11.7] vs 40.0 [9.4] years (all P <.001) and had a higher American Society of Anesthesiologists classification (UK cohort: median [IQR], 3 [2-3] vs 2 [2-3]; P <.001; French cohort: median [IQR], 3 [3-3] vs 2 [2-3]; P <.001; Spanish cohort: median [IQR], 2 [2-3] vs 2 [1-2]; P <.001; Brazilian cohort: median [IQR], 2 [2-2] vs 2 [2-2]; P =.02), as well as higher estimated cardiovascular Framingham risk score (Spanish cohort: median [IQR], 1.31 [0.20-4.34] vs 0.20 [0.20-1.68]; Brazilian cohort: median [IQR], 1.57 [0.20-5.28] vs 0.20 [0.20-0.20]; French cohort: median [IQR], 8.00 [3.00-13.00] vs 2.00 [1.00-4.00]) (all P <.001) and all-cause mortality risk (Charlson Comorbidity Index score) (UK cohort: median [IQR], 1 [0-2] vs 0 [0-0]; Spanish cohort: median [IQR], 1 [0-1] vs 0; Brazilian cohort: median [IQR], 1 [1-3] vs 1 [0-1]) (all P <.001). Clinical obesity was associated with increased 30-day major postoperative complications (Clavien-Dindo grade ≥3) compared with preclinical obesity in the French cohort (4.0% vs 1.1%; P =.04). Conclusions and Relevance: This international, multicenter cross-sectional study found that the majority of MBS candidates met criteria for clinical obesity, while a substantial minority were classified as having preclinical obesity. Despite similar BMI distributions, patients with clinical obesity may have a greater disease burden, higher operative risk, and higher estimated cardiovascular risk, supporting its potential value as a clinically meaningful framework for surgical practice.
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