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EASO recommendations

EASO issues recommendations for bariatric surgery

The recommendations include basic information about nutrition, management of co-morbidities, pregnancy, psychological issues, as well as weight regain prevention and management

A post-bariatric multidisciplinary follow-up programme should be an integral part of the clinical pathway at centres delivering bariatric surgery and it should be offered to patients requiring it, according to practical clinical recommendations published by the European Association for the Study of Obesity. The recommendations, ‘Practical Recommendations of the Obesity Management Task Force of the European Association for the Study of Obesity for the Post-Bariatric Surgery Medical Management’, published online in the journal Obesity Facts, emphasises that post-bariatric patients should also be transferred to the primary care physicians and to obesity specialists, dieticians and nurses not primarily engaged in the bariatric programme.

The recommendations include basic information about nutrition, management of co-morbidities, pregnancy, psychological issues, as well as weight regain prevention and management. The paper also includes a short list of clinical practical recommendations is included for each item.

Nutritional Management

The recommendations state that nutritional management of the post-bariatric patients requires specific nutritional skills and the intervention of experienced nutritionists and dieticians – in particular for early, late and life-long nutritional management, protein intake and supplementation, as well as specific nutritional problems. One important aspect that should be emphasised to patients is that they should be trained to chew adequately and receive clear instruction about post-operative meal initiation and progression by an experienced bariatric dietician before discharge. Patients should also receive periodic counselling by a registered dietician about long-term dietary modifications in order to maximise the results of the bariatric procedure and reduce the risk of late weight regain. In particular, patients with gastric restriction should be counselled to eat three small meals during the day and chew small bites of food thoroughly before swallowing, without drinking beverages at the same time (more than 30mins apart).

In addition, regular physical activity should therefore be encouraged after bariatric surgery, starting immediately after the recovery from surgery. Patients should be advised to incorporate moderate aerobic physical activity, i.e., a minimum of 150 min/week (with a goal of 300min/week) as well as strength training 2-3 times/week.

Patients should also receive educational support from an experienced dietician may help patients to acquire a better behavioural adaptation and/or to use alternative foods. Food intolerances and behavioural errors may cause episodes of vomiting or food regurgitation during meals, such episodes are usually self-limiting, may occur occasionally in the first months after surgery and should be considered normal in a patient still adapting to his new gastric anatomy.

The paper states that the occurrence of vitamin and mineral deficiencies is one of the most common and compelling problems after bariatric surgery, and the prevention, detection and treatment of these deficiencies represent cornerstones of long-term follow-up in post-bariatric patients.

The anatomical characteristics and the mechanisms of action of the various procedures mostly dictate the frequency and severity of vitamin and mineral deficiencies after bariatric surgery (Table 1). Nutritional deficiencies are uncommon after purely gastric restrictive procedures not altering intestinal continuity and normal digestive processes, but more common after surgical procedures inducing some degree of malabsorption. However, the occurrence of nutritional deficits is also influenced by factors independent from the surgical technique, such as regular and nutrient-dense food intake and adherence with post-operative vitamin and mineral supplementation.

Table 1: Major vitamins and minerals deficiencies after bariatric surgery: clinical manifestations and estimated frequency according to the bariatric procedure

The suggested daily supplementation for patients with gastric bypass and sleeve gastrectomy includes two adult multivitamin plus mineral supplements (containing iron, folic acid and thiamine), 1,200-1,500mg of elemental calcium (in diet and as citrated supplement in divided doses), at least 3,000IU of vitamin D (titrated to therapeutic 25-hydroxyvitamin D levels >30ng/ml) and vitamin B12 titrated to maintain normal levels.

Routine supplementation with adequate amounts of fat-soluble vitamins should be added to this regimen after biliopancreatic diversion or duodenal switch. In case of gastric banding, the suggested daily supplementation may be reduced to adult multivitamin plus mineral supplement and at least 3,000IU of vitamin D (titrated to vitamin D levels) with or without 1,200-1,500mg of elemental calcium (in diet and as citrated supplement in divided doses).

The paper recommends periodic laboratory routine surveillance for nutritional deficiencies is recommended, and supplementation should be individualised accordingly in patients with demonstrated micronutrient insufficiencies or deficiencies. The authors propose a reasonable scheme for minimal periodic nutritional surveillance after bariatric procedures in Table 2.

Table 2: Minimal periodic surveillance for nutritional deficiencies after bariatric surgery

Co-morbidities

According to the latest IFSO Global Registry Report, 22% of patients undergoing bariatric surgery were on medications for type 2 diabetes before surgery (inter-country variation 7.4-63.2%). The authors state that good blood glucose control pre- and post-bariatric surgery is highly recommended, however, individual considerations and follow-up are needed for each patient.

For patients still requiring insulin during their post-operative hospitalisation, basal insulin should be continued at discharge, with strict glucose monitoring and tapering of insulin units to avoid hypoglycaemia. Due to the complexity of diabetes treatment in these patients, treatment should be assessed and adjusted at 7-10 days after surgery by an experienced physician. In general, caution should be taken to avoid hypoglycaemia in these patients, especially during the night; therefore, insulin dosages should be as low as possible and corrected as necessary.

According to the recommendations, health providers should pay particular attention to patients in whom obstructive sleep apnoea (OSA) had been diagnosed before surgery and weight stabilisation after surgery is also important to prevent OSA or worsening of OSA. Patients should be reviewed by the respiratory physician in order to determine whether the bi-level positive airway pressure/continuous positive airway pressure pressures need to be adjusted and if a new sleep respiratory assessment should be undertaken.

Dyslipidaemia should be assessed through regular monitoring of serum lipids and therapeutic strategies to prevent cardiovascular disease are recommended, lipid-lowering medications should not be stopped unless clearly indicated. Patients with dyslipidaemia and on lipid-modifying medications should be re-assessed by performing fasting lipid profiles periodically, including re-assessment of cardiovascular risk status.

Treatment of hypertension in the long term should adhere to current general guidelines, possibly avoiding anti-hypertensive medications with a known unfavourable effect on body weight. In patients in whom hypertension have resolved, continued surveillance should be guided by recommended screening guidelines for the specific age group.

Increased awareness of pharmacotherapy after bariatric surgery must be instilled to medical professionals, including physicians, pharmacists, nurses and dieticians. Patients should be closely monitored in order to evaluate the short- and long-term safety and efficacy of their drug regimen.

Pregnancy

Currently available data suggests that pregnancy following bariatric surgery is associated with improved maternal and foetal outcomes, compared to women with untreated obesity. However, there are concerns with regard to conceiving during the period of rapid weight loss seen in the first 12-24 months following bariatric surgery, as this period has been associated with higher rates of nutritional deficiencies and obstetric complications. Therefore, pregnancy is not recommended during 12-18 months following surgery. Current data suggests that pregnancy after bariatric surgery is safe, although good antenatal care is essential.

Regarding contraception the recommendations state that women should be informed that their fertility is likely to increase immediately after surgery, and contraception should be discussed and offered - this is of particular importance in adolescents after bariatric surgery, where rates of unwanted pregnancy are higher than both in the general adolescent population and in the total post-bariatric surgery population. Decisions regarding the type of contraceptive should be made on an individualised basis, considering procedure type, age and medical history.

Psychological aspects

Although a peri-operative psychological evaluation of candidates to bariatric surgery is nowadays highly recommended, there may be under-recognition or under-treatment of the mental illness before and after surgery. Healthcare professionals should keep in mind that morbidly obese patients might have unrealistic expectations of body appearance post-operatively and are therefore constantly disappointed by the aesthetic outcome of their surgery. Therefore, it is essential to support these patients with psychological and/or psychiatric treatment if needed and help them to find a new way through life.

Bariatric surgery not only increases the risk of suicidal ideation and/or behaviour, it also elevates the risk for an alcoholic disease. Regardless of the alcohol history of the morbidly obese individual, all bariatric surgery-seeking candidates should be educated on the potential effects of this intervention, especially in the case of RYGB, in order to minimise the risk of alcohol misuse post-operatively.

The prevalence of compulsive eating patterns known as binge eating disorder is quite common among bariatric surgery-seeking patients. The recommendations state that it is imperative that treatment programmes are developed, which address the special needs of this patient group, focusing on both psycho-social factors and eating behaviours as well as on weight loss for a successful support.

Weight regain

Weight regain after bariatric surgery is a result of hormonal and metabolic alterations, surgical failure, nutritional non-adherence, mental health issues and physical inactivity. It is estimated that around 50% of post-bariatric patients regain around 5% of their body weight in two years after the procedure.

The multi-disciplinary team comprising of a nutritionist/dietician, a psychologist, a specialised physician and a bariatric surgeon should focus on leveraging lifestyle changes and encourage the patient to commit to those changes and to maintain them in the long-term.

“It remains clear that referral to a bariatric multi-disciplinary centre, preferably the one performing the original procedure, should be considered in case of more complex clinical situations,” the paper concludes.

To access this paper, please click here

https://www.karger.com/Article/FullText/481825

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