Am I a Candidate for ESG? Eligibility Criteria, Contraindications, and Who Should Wait

Where the criteria come from, and what counts as a related condition

BMI is weight in kilograms divided by height in metres squared: 85 kg at 165 cm is about 31.2. The threshold is not a clinic policy: it comes from the 2024 ASGE–ESGE guideline, which graded the evidence using GRADE before recommending [1], and it matches the populations actually studied. The MERIT randomised controlled trial (*The Lancet*, 2022) enrolled 209 adults with class 1 and 2 obesity and reported 13.6% total body weight loss at 52 weeks with ESG plus lifestyle, against 0.8% with lifestyle alone [2]; the five-year cohort of 216 patients had a mean baseline BMI of 39 [3].

For the 27.0–29.9 band, one related condition is what brings you within the guideline. MERIT tracked hypertension, diabetes, dyslipidaemia, and fatty liver disease, reporting 80% of the ESG group with at least one metabolic comorbidity improved by 52 weeks against 45% of controls [2]. The medical team also weighs other weight-related conditions such as sleep apnoea or load-bearing joint pain, from your history and results rather than a tick-box form.

Do Asian patients use the same thresholds?

Metabolic risk is widely recognised to appear at lower BMI values in Asia-Pacific populations, so obesity assessment here often applies lower thresholds alongside waist circumference and metabolic bloodwork. But the 2024 ASGE–ESGE guideline this article relies on sets no separate numerical threshold for Asian populations [1]. YOUNIFY therefore does not publish an "Asian cut-off" as settled fact. We assess each person individually: BMI alongside body composition, blood and metabolic results, weight-loss history, and gastroscopy findings.

Self-assessment checklist

Not a diagnosis, and no substitute for assessment by the medical team.

(a) Likely suitable

• BMI 30 or above, or 27.0–29.9 with at least one obesity-related condition
• Followed a structured eating and activity programme without reaching your goal, or regained afterwards
• No active digestive disease, no previous stomach surgery
• Able to change how you eat and attend follow-up through the first year
• BMI 27.0–29.9 but unsure whether you have a qualifying condition (bloodwork settles it)
• Chronic reflux, frequent heartburn, or difficulty swallowing; gastroscopy checks for hiatal hernia or inflammation
• On anticoagulant or antiplatelet medication
• Poorly controlled cardiac, respiratory, or blood-sugar conditions, which affect sedation planning
• Currently on, or recently stopped, a GLP-1 receptor agonist (timing needs planning)
• Previous stomach surgery or endoscopic stomach procedures, including a previous balloon
• Eating patterns needing dedicated support, or ongoing mental health treatment; assess with the team already caring for you
• BMI below 27, generally under the procedural threshold; start with a medical weight-management programme
• Any condition in the table below
• Expecting a one-time fix with no ongoing self-management
• Unable to attend follow-up in the first year, when outcomes are largely determined
• Pregnant, or planning pregnancy in the near term

(b) Needs further assessment first

(c) Not currently suitable, or contraindicated

Contraindications, and why each matters

From the international standards of practice and published safety data [4][5]. Each relates directly to the anatomy of suturing.

Overall, meta-analysis reports a pooled severe adverse event rate of 2.2% [5], and the 2024 IFSO position statement, pooling 15,398 procedures, reports 1.25% [6]. Detail in Is ESG safe? Side effects and risks.

The non-numerical factors that decide results

Readiness to change how you eat. The guideline is explicit that the procedure works *with* lifestyle intervention [1]; in MERIT both arms had the same programme, and the difference was the procedure added on top [2].

Grazing and emotional eating. ESG reduces stomach volume by roughly 70%, so you feel full sooner and stay full longer within a meal [4]. That works on *portion size*, not on appetite drive or eating for stress relief. Someone grazing on energy-dense snacks or sugary drinks through the day can still take in excess energy with a smaller stomach, which is why the consultation asks about eating patterns, not only weight.

Attending follow-up. The first year carries most of the dietary planning, symptom management, and metabolic monitoring. If your schedule cannot take it, plan for that before deciding. See ESG recovery and diet timeline.

Realistic expectations. Published figures: 13.6% mean total body weight loss at 52 weeks [2], and 15.9% at five years among those followed, with 61% maintaining at least 10% [3]. YOUNIFY's wording to patients is typically around 15–18% of body weight over one year; individual results may vary. If your target sits well above that, raise it before deciding.

What the assessment involves, and what you can do before flying

1. History and examination. Height and weight for BMI, body composition, previous weight-loss attempts, full medication list, existing conditions, surgical history, and how you actually eat.

2. Blood tests and metabolic assessment. Glucose and glycated haemoglobin, lipids, liver and kidney function, clotting parameters. For the 27.0–29.9 band, this is what confirms a qualifying condition.

3. Gastroscopy first, always. Not optional. The international standards of practice, written by endoscopists who had each performed more than 300 ESG procedures, require contraindications to be assessed before proceeding [4]. Large hiatal hernia, gastric ulcer, severe gastritis and gastric varices are detectable only on endoscopy. This is why some people who meet the BMI criteria still cannot go ahead.

Steps 1 and 2 can largely be prepared remotely: send your height and weight, medication list, diagnoses, and any bloodwork or endoscopy reports from the last 12 months, and we can tell you before you book flights whether you are broadly within criteria. Step 3 has to happen in Bangkok: build the trip so gastroscopy, procedure, and early follow-up sit in one visit, and know that if the gastroscopy finds something needing treatment first, the plan changes.

If the answer is not yet, what are the alternatives?

• A medically supervised weight-management programme. The starting point if you have not yet followed a structured one, and the foundation under every other route. See Obesity and weight management.
• Intragastric balloon. A temporary device placed endoscopically and removed on schedule. Meta-regression finds ESG produces significantly greater weight loss (mean difference 2.541; 95% CI 0.754–4.327; p=0.005), widening over longer follow-up, with no significant difference in overall adverse events, though balloons are more often removed early for intolerance [7]. See ESG vs gastric balloon.
• GLP-1 receptor agonists. STEP-1 (*NEJM*, 2021) reported a 14.9% weight change at 68 weeks with semaglutide 2.4 mg against 2.4% with placebo [8]. That was a different study with a different baseline population, so not directly comparable with ESG. On continuity, a 2026 analysis reports up to 65% stop within a year, with roughly two-thirds of the loss regained within a year of stopping [9].
• Bariatric surgery. For starting weights above the range ESG covers, traded against a permanent anatomical change and a longer recovery.
• After stopping a GLP-1 medication. Data presented at DDW in May 2026 (ATTAIN, n=59) reported 17% total body weight loss at 12 months with ESG plus lifestyle, against 0.1% with lifestyle alone [10]. Preliminary conference data, not yet peer reviewed in full.

In summary

Entry is a BMI of 30 or above, or 27.0–29.9 with a related condition, alongside a lifestyle programme [1]. The number is the first gate; gastroscopy is the one that decides. Eating patterns, follow-up, and realistic expectations separate two people who meet identical criteria. If the assessment says not yet, our medical team will say so plainly and set out the alternatives. Screening people out is part of caring for them properly.