When surgery is the better answer

Where surgery still wins

• Size and durability of the result. Sleeve gastrectomy and gastric bypass typically produce 25 to 30 per cent total body weight loss, sustained at five and ten years. Head to head comparisons continue to show greater loss with surgery than with medicine, although these comparisons are observational and the randomised trials are only now beginning.
• It is one intervention rather than an indefinite one. This is the argument that matters most in India. Where cost is the binding constraint, a single procedure can work out cheaper than two or three years of continuous medicine, and it does not stop working when the money does.
• The longest follow-up data in the field. The Swedish Obese Subjects study and others show benefits in mortality and cancer over ten to twenty years. No medicine has anything close to that duration.
• Higher rates of diabetes remission.
• Insurance covers it. Under an IRDAI direction, bariatric surgery is covered by health insurance policies in India, subject to criteria and waiting periods. Weight loss medicines are not covered by any IRDAI-regulated policy for weight management. This inverts what most people assume.

Where medicine is preferable

• It is reversible, and carries no operative risk and no permanent change to your anatomy.
• For people unwilling or medically unfit for an operation.
• At lower BMI ranges, where surgery is not indicated.
• Where the specific benefit you are after has outcome trial evidence behind it, such as cardiovascular or kidney protection.
• Before surgery, to reduce operative risk, and after surgery where the weight loss was inadequate or has returned. Both of these are now common and evidence-supported, and it is worth knowing that the two are not alternatives.

The Indian thresholds are lower than you think

The 2025 Indian guideline suggests considering bariatric surgery from a BMI of 27.5 to 35, depending on comorbidities and on the response to previous treatment. Western guidance generally starts at 35 or 40. The reason is the same thin-fat phenotype that runs through this whole section: an Indian at BMI 32 carries the metabolic burden of a European considerably heavier.

How the decision is actually made

The old question, drug or surgery, is not the useful one. The useful questions are which one, in what sequence, for this person, at what cost, and over what period. What we do at Caspian is the assessment and the medical management, and where the picture points towards surgery we say so and refer you for a surgical opinion. Getting an opinion does not commit you to anything.

The surgeon we refer to is Dr. Aslam Baba, DrNB Surgical Gastroenterology, at Renova Century Hospital, Banjara Hills. The operation is not done at Caspian and we take nothing from it. If you would rather see a different surgeon, or have it done somewhere else entirely, that is yours to decide and it changes nothing about your care here. What we do is the assessment before it and the care afterwards, either way.

Things that push the balance towards surgery in a real conversation: a very high BMI, diabetes that is difficult to control, an inadequate response to medicine, and above all not being able to afford indefinite treatment. Things that push against it: a strong preference against an operation, a BMI in the lower range, and significant surgical risk from something else.

Sources: Revised Indian obesity guideline, 2025. ASMBS and network meta-analysis comparisons of surgical and medical treatment, Obesity, 2026. IRDAI circular on bariatric surgery cover, 2019.