Following a number of deaths and near-deaths in recent years among people who have undergone bariatric surgery to treat severe obesity by reducing the size of their stomachs, the Health Ministry has issued new directives to better regulate the procedures.Prof. Arnon Afek, the head of the ministry’s medical administration, wrote – in a document aimed at all relevant authorities – that Israel is one of 10 countries in the world with a significant increase in obesity. It has multiplied three-fold in the past 30 years, he said.As a result, the number of stomach reducing operations – which are included in the basket of health services if conducted for medical rather than aesthetic purposes – has also increased.The operations are also effective in relieving and often curing Type 2 diabetes.Afek’s document defines the minimum criteria necessary for medical centers to be allowed to perform bariatric surgery. They must set down guidelines on patient assessment and institutional reporting. It also determined what medical indications there are for performing the surgery on adults over 18.Such centers must have a multidisciplinary team with experts on morbid obesity and its complications, so they can assess each case. They also need a clinical dietitian; a psychiatrist, psychologist or social worker; an endocrinology and diabetes service; a gastroenterological institute and a general intensive care unit and CT and other imaging and invasive radiology institutes.In addition, the bariatric surgery center must be run by a general surgeon whose main activity has been treatment of the morbidly obese during the previous three years.The center must conduct a minimum of 100 bariatric operations annually and have expertise in at least two surgical techniques. It must also transfer data to the National Center for Disease Control.Surgeons must know how to perform repair surgery in case a problem arises from the original operation.A wide variety of medical tests must be performed before the would-be patient undergoes the operation, Afek said.The dietitian, who must have experience with bariatric patients, has to make an assessment of the person’s eating habits, willingness to undergo change, previous attempts at weight loss and reasons for failure. The stages before and after surgery must be explained to the patient and expectations for positive results must be discussed.Any candidate for bariatric surgery must say whether he is currently undergoing psychiatric treatment. He also needs a statement from his psychiatrist’s that he is able to cope with the surgery and its results.A multidisciplinary discussion must be held with regards to patients that are 65 years old and over, to consider the medical implications of such an operation.Once the surgery is performed, the medical institution must follow up in the community with at least six sessions during the first year after the operation.Just reducing the stomach is not enough; lifestyle changes must be made, Afek wrote.In the second year, one to three follow- up sessions must be held, either in person or online.The family physician must also send the patient for medical tests including blood sugar, lipid levels and bone density.