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Updated guidelines

UK body recommends rapid assessment for surgery

NICE updates weight loss surgery criteria for people with type 2 diabetes
Guidelines also includes recommendations on very-low-calorie diets and follow up after surgery

Patients who are diagnosed with type 2 diabetes and who have a BMI>35 will be quickly assessed for bariatric surgery, according to finalised guidelines from the UK’s National Institute for Health and Care Excellence (NICE). This newly updated NICE guideline also states that very-low-calorie diets should only be used in certain circumstances and includes new recommendations on follow up after surgery.

“The financial implications of obesity are huge – 10% of the NHS budget is used to treat diabetes and its complications alone. It is a major issue, if not the major issue, for the health service in the coming years,” Professor Mark Baker, Centre for Clinical Practice director. “NICE has published a range of guidelines to help prevent obesity and to help people lose weight. This guideline focuses on the clinical aspects – what a doctor should do to help an obese or overweight person. It sets out clearly what help and treatments should be offered and in what order.”

The updated guidelines include:

Very-low-calorie diets

  • Do not routinely use very-low-calorie diets (800 kcal/day or less) to manage obesity (defined as BMI over 30)
  • Only consider very-low-calorie diets, as part of a multicomponent weight management strategy, for people who are obese and who have a clinically-assessed need to rapidly lose weight (for example, people who need joint replacement surgery or who are seeking fertility services). Ensure that: the diet is nutritionally complete; the diet is followed for a maximum of 12 weeks (continuously or intermittently); the person following the diet is given ongoing clinical support.

Bariatric surgery for people with recent-onset type 2 diabetes

  • Offer an expedited assessment for bariatric surgery to people with a BMI of 35 or over who have recent-onset type 2 diabetes  as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent)
  • Consider an assessment for bariatric surgery for people with a BMI of 30–34.9 who have recent-onset type 2 diabetes as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent)
  • Consider an assessment for bariatric surgery for people of Asian family origin who have recent-onset type 2 diabetes  at a lower BMI than other populations (see recommendation 1.2.8) as long as they are also receiving or will receive assessment in a tier 3 service (or equivalent).

Follow-up care - offer people who have had bariatric surgery a follow-up care package for a minimum of 2 years within the bariatric service. This should include:

  • monitoring nutritional intake (including protein and vitamins) and mineral deficiencies
  • monitoring for comorbidities
  • medication review
  • dietary and nutritional assessment, advice and support
  • physical activity advice and support
  • psychological support tailored to the individual
  • information about professionally-led or peer-support groups

“Obesity has different causes – for some people it is down to lifestyle, for others it is genetics, but for most it is somewhere in between. But, whatever the reason, everyone who has a weight problem should be focusing on making changes to their diet and lifestyle,” said Professor John Wilding, Professor of Medicine and Honorary Consultant Physician in Diabetes, Endocrinology and General Medicine, University of Liverpool and Aintree University Hospitals NHS Foundation Trust. “Weight loss surgery is not a quick fix or easy option, and although effective, it isn’t the answer for everyone. At the moment only 1% of people eligible for surgery actually have it; most people should try diet and exercise first. However, if someone is obese and they are diagnosed with type 2 diabetes it is really important that their doctor talks to them about the benefits undergoing surgery could provide for them. The new guideline also looked at very-low-calorie diets – after considering how well they work and if the weight loss can be sustained, we have recommended that they should not be used routinely for people who are obese. But we are not ruling them out entirely, they may be considered for people who have a clinical need to lose weight quickly, such as before joint replacement surgery.”

“NICE already recommends that weight loss surgery should be available as an option for people with a BMI over 35, who have failed to lose weight through medical weight loss programmes and if they have another medical condition that could be improved if they lost weight,” said Dr Rachel Batterham, Head of Obesity and Bariatric services at University College London Hospital NHS Trust; and Head of the Centre for Obesity Research, University College London, UK. “However, we now know that surgery can make a real difference for people with recently diagnosed type 2 diabetes, so the new guideline now recommends that if someone is diagnosed with type 2 diabetes and their BMI is 35 or over then they should be offered an early, rapid assessment for weight loss surgery.”

The British Obesity and Metabolic Surgery Society (BOMSS) has welcomed the updated guidance.

“Surgery can be a powerful treatment for diabetes. There are published data on 26,000 surgical patients with impressive recovery from diabetes and functional status with those who have had diabetes for the shortest period recovering quickest,” said Mr Richard Welbourn, president of BOMSS. “Bariatric surgery improves people’s health and also saves on healthcare costs.”

To access the guidance document, please click here

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