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:
- 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?
- Is pre-operative weight loss a predictor of post bariatric surgery weight loss?
- Does enforcing pre-operative weight loss (via lifestyle or pharmacotherapy) improve weight loss after bariatric surgery?
- Does pre-operative weight loss really show patient ‘commitment and readiness’ for bariatric surgery?
- 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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