Instead of the WHO BMI standards, different standards need to be developed according to culture, says the IOTF, which now suggests that the BMI standard for Asians should be lowered to 23.3 as one means of assessing obesity-related health risks.

Calling it "a bitter irony that as developing countries continue their efforts to reduce hunger, some are also facing the opposing problem of obesity", the IOTF is now evaluating issues of per-cent body fat and waist-to-hip ratios.

With the global obesity epidemic, Dr. Miller expects 20 to 30 patients a month by the end of this year, and 40 to 50 from all over Asia in two years. The centre will also eventually act as a centre for training surgeons and nurses from Asian countries. Whether a gastric bypass or banding, whether laparoscopic or traditional, bariatric surgery will not help every obese person.

LBS and other responsible clinics carefully screen potential patients and eliminate habitual drug users and people with compulsive eating disorders. Patients must be morbidly obese, at least 45kg over optimum weight, and their BMI at least 30.

In addition, patients are accepted for surgery only after they’ve exhausted all other options. "That stereotype of a lazy, fat person – forget it. These people are desperate and depressed by the failure of all the other methods they’ve tried", says Dr. Miller. "And their life is at risk."

Shedell easily qualified. "I’ve always been overweight, say, around nine kilograms too much", says the nurse, who works in the labour and delivery department of a hospital near Los Angeles. Her 12-hour shifts should have kept her active, but her love of sweets did her in.

"Give me candy, cake, chocolates, I’ll eat them all. They’re my comfort food", she says.

As the kilograms piled on, she turned to fad diets and pills. Some helped, but as soon as she stopped, the weight marched right back on. She couldn’t even walk comfortably because her feet hurt all the time.

When her sister had triple bypass surgery at age 38, warning bells rang. "I knew I had to do something", she says, "and I began researching options."

Her research led her to nearby LBS and to Dr. Miller, who was looking for Piyavate’s first bariatric patient. Although she had considered other surgeries and other clinics, Shedell was immediately attracted. She had already visited Thailand three times.

"It’s my favourite country, along with Ireland", she says.

Cost is another consideration. Charges, including medicine, surgery, treatment and hospital stay, come to US$ 11,500.- (Baht 449,000.-), a third of what patients in the US pay.

A few hours after surgery, she is sitting up and instructing the nurses on procedures (a good sign in a recovering patient who’s also a nurse).

“I had some mild pain on the first day, but nothing I couldn’t handle,” she reports. After seven days in Thailand, she flew home.

The new Shedell will develop slowly. "I know that the surgery is not a weight-reduction technique in itself, but a life-long hunger-management regime", she says.

With her smaller stomach, her food intake will be reduced. Eventually, she’ll be able to eat almost anything, but in much lower quantities. She’ll no longer snack between meals. She’ll have to exercise regularly. In addition to routine physical examinations, she’ll take vitamin and mineral supplements for the rest of her life to avoid deficiencies. She should reach her optimum weight of around 49 kg in a year to 18 months.