Pre-bariatric surgery weight loss: Useful, Necessary, or a Waste of Time?


Pre-bariatric surgery weight loss: Useful, Necessary, or a Waste of Time?

Bariatric Surgery is the most effective method of achieving sustained weight loss over the long term in patients with obesity when compared to lifestyle interventions and pharmacotherapy.

Despite the strong evidence, from clinical studies and randomised controlled trials, of the benefits of bariatric surgery on weight and metabolism, access to bariatric surgery remains limited in many health care systems including the UK.

In the UK, patients seeking bariatric surgery are mandated to go through tier 3 weight management services (typically community based, non-surgical weight management services) before referrals are made to tier 4 (i.e. bariatric surgery). Tier 3 is supposed to consist of a multidisciplinary team including but not limited to bariatric physicians, weight management dietitians, psychologists, specialist nurses and physiotherapists.

There are several objectives of tier 3 services and some services focus on specific objectives. One of the objectives of tier 3 services is to ‘prepare’ patients for tier 4 services, although the nature and meaning of this preparation vary between tier 3 services. In addition, tier 3 services have a role to select patients for bariatric surgery in some localities (i.e. selecting those who are more likely to have favourable outcomes after bariatric surgery and not referring those who are unlikely to do as well after surgery).

Previously, patients in the UK had to spend 6-12 months in tier 3 services before being referred to bariatric surgery. While recent commissioning guidelines made the length of this ‘preparatory’ period shorter/ more flexible, the length of this period varies across the country due to the local commissioning processes.

Tier 3 weight management services educate patients in regards to nutrition, diet, physical activity and lifestyle and support them to make positive changes in these areas. In addition, tier 3 services should address mental health issues, eating disorders and metabolic disorders before referral to bariatric surgery.

One of the challenges that make the ‘selection role into bariatric surgery’ of tier 3 services difficult and/or problematic  is the lack of reliable pre-surgical ‘selection criteria’ that predict post bariatric surgery outcomes as the literature is conflicting in that regards. The only consistent predictor of long-term weight loss after bariatric surgery is early weight change post bariatric surgery; pre-surgical predictors remain controversial. Despite that, tier 3 services are supposed to/requested to make a judgement regarding who will do better after bariatric surgery.

Some tier 3 services demand that patients lose a significant proportion of weight during the tier 3 service (this is separate from the weight loss achieved on the pre-bariatric surgery low calorie diet). Such mandatory weight loss during the tier 3 period is typically between 5-10% of body weight. While there is no doubt that 5-10% weight loss has significant benefits to health, whether this help to improve the outcomes after bariatric surgery or even predict weight loss after surgery remains controversial (particularly considering that many of our patients have managed to lose 5% of their weight during multiple dieting attempts previously but regained the weight).

Hence, the opinions are divided. While some see such weight loss as an important aspect of patients’ preparation and an important predictor of better outcomes after bariatric surgery; others feel that this is another hurdle in the path of patients towards bariatric surgery and just a process to restrict access.

What makes all of this more complicated is the fact that bariatric surgery is an expensive procedure (though cost effective) and hence in a financially restricted health care system there is a lot of pressure on selecting patients who are likely to achieve the most benefit to improve the cost effectiveness of the intervention.

In this Twitter chat we would like to discuss whether such mandatory weight loss before bariatric surgery is necessary and can predict the outcomes post bariatric surgery or whether it is just another hurdle that patients must pass and is mainly used to restrict access to bariatric surgery.

In this chat we would like to discuss:
  1.        What are your views about mandatory weight loss before bariatric surgery (not the pre-operative diet)? Useful or useless? Beneficial or harmful? Essential or just a hurdle?
  2.        Is pre-operative weight loss a predictor of post bariatric surgery weight loss?
  3.        Does enforcing pre-operative weight loss (via lifestyle or pharmacotherapy) improve weight loss after bariatric surgery?
  4.        Does pre-operative weight loss really show patient ‘commitment and readiness’ for bariatric surgery?
  5.        Is there still a role of tier 3 for patients who want to undergo bariatric surgery if preoperative weight loss and preparation is not as important?
By Dr Abd Tahrani, NIHR Clinician Scientist and Honorary Consultant Endocrinologist 



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