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Education and nutrition

The importance of education and nutrition for patients

Further studies were needed to determine if gastric banding is detrimental to micronutrient status
The incidence of copper deficiency increases with time post bariatric surgery, but the incidence of copper deficiency pre-operatively is low
The implementation of a Dietetic led nutrition education session is associated with significant improvements
Preparing patients for bariatric surgery is now needed so that education becomes evidence rather than experience based

Malnutrition and vitamin deficiency is prevalent in both the obese population and surgical patients, and it is important to educate them on the importance of adhering to their supplement regime post-surgery. Several papers presented at the 6th Annual Meeting of the British Obesity and Metabolic Surgical Society 21-23 January, in Newcastle, UK, examined the impact surgery has on micronutrient deficiency and the role education can play in trying to prevent its occurrence. 

In a study examining the impact gastric banding on nutrient deficiency, Anita Attala from the Northumbria Healthcare NHS Foundation Trust, Tyne and Wear, UK, said that although gastric banding does not cause malabsorption of nutrients from food, some units do not routinely perform micronutrient surveillance on gastric band patients. In addition, they do not tend to recommend vitamin and mineral supplementation for gastric band patients.

However, through observation it has been noted that often patients restrict nutrient dense foods such as beef, pork, lamb, bread etc and, by nature of the surgery, portion size is restricted.

The researchers 18 randomly selected patients from their unit who had had their gastric band placed for over a year and who subsequently gave consent to have their micronutrient status measured. The micronutrients measured were the same as those monitored in the roux-en-y gastric bypass patients and sleeve gastrectomy patients including B12, Magnesium, Phosphate, Folate, Copper, Zinc, Selenium, Haemoglobin, Calcium and Vitamin D.

They reported that only two patients did not have any micronutrient deficiencies, with the remaining patients showing deficiencies in one or more micronutrients.

She said that further studies were needed to determine if gastric banding is detrimental to micronutrient status or if these are deficiencies to be expected in the obese population as a whole in the hospital’s region.

“In the meantime, based on this audit, a literature search and BOMSS recommendations, it may be prudent to supplement and survey the micronutrients in the gastric band population as it is in all other bariatric procedures,” she added

Co-authors of the study were Terry Sergeant, Amy Jamieson, Sue Colley

Copper deficiency

Aimee Newton from York Teaching Hospital NHS Foundation Trust, York, UK, and colleagues said that the frequency of copper deficiency in bariatric patients is unknown and research is limited, probably because copper levels are not routinely measured in patients following bariatric surgery. Copper deficiency can cause anaemia, myelopathy, and neuropathy, although routine vitamin and mineral supplementation following bariatric surgery should meet copper requirements.

Nevertheless, some clinical cases of bariatric patients experiencing symptoms of neuropathy highlighted severe deficiencies in copper, therefore the researchers examined the copper levels preoperatively and post-operatively, at three, six, nine, 12, 18 and 24 months. 

She explained that the normal range for copper is 11-22umol/L and 12.6-24.4umol/L for males and females, respectively, with low levels classified as <10umol/L. Data were obtained between October 2013 and April 2014. Patients were evaluated within three groups: 1) Pre-operative, 2) Post-operatively < 2 years from surgery and 3) Post operatively >2 years from surgery. None of these patients had received additional copper supplementation. Results are shown in Table 1.

Pre-op (n=32)


Post op <2 yrs (n=133)


Post op >2 years (n =97)


Low Cu

High Cu

Low Cu

High Cu

Low Cu

High Cu

1 (3%)

9 (28%)

10 (7.5%)

22 (16.5 %)

12 (12.4

%) 8 (8.2%)

Table 1: Levels of copper pre- and post-surgery

She concluded that the incidence of copper deficiency increases with time post bariatric surgery, but the incidence of copper deficiency pre-operatively is low but this may be due to the small sample size. 

“The cost of copper testing is £23 per test. Based on 80 procedures completed annually the total cost would equate to £12,880 for that cohort of patients over the two year follow up period,” she explained. “Based on these results, copper testing is warranted however, we propose testing is only required pre-operatively, post operatively at six and 12 months, and then annually thereafter. This would reduce cost to £7,360. This would be a cost saving of £5520.”

The co-author of this study was David Locker

Dietary education

Rochelle Blacklock from King’s College Hospital, London, UK, began by stating that self-management education before bariatric surgery is widely recognised as a key component of high quality care. Therefore, equipping patients with the knowledge and confidence to implement postoperative dietary changes is essential to reduce risk of post eating complications and improve nutritional well-being. 

“However, little is known about the impact of such education on patients’ perceived knowledge and confidence,” she added.

She explained that at her institution patients attended a one hour education session delivered by the dietitian that covered five domains: texture progression, healthy foods, optimal eating behaviours, vitamins and minerals and post eating symptoms. Attendees scored their perceived knowledge of these domains before and after the education session using a 5 point scale (1=low, 5=high). Confidence to implement changes after surgery and satisfaction with training were assessed using the same scale. Results were presented as median scores used to compare pre and post education scores.

A total of 38 patients (59% of invitees) attended the education sessions and 97% completed the evaluation. Pre-education, low perceived knowledge scores (<3 on the 5 point scale) were found in three of the five domains; vitamin and mineral supplements, post eating symptoms and healthy food choices. However a disparity existed with confidence levels which were high (median 4; IQR 2-5) despite low perceived knowledge.

After the education session significant improvements in knowledge were reported for each domain (p<0.01) and confidence also increased (p<0.01). The median overall satisfaction score was 5 (IQR 5-5).

“The implementation of a Dietetic led nutrition education session is associated with significant improvements in patients’ perceived knowledge and confidence and very high overall patient satisfaction,” she concluded.  “Low pre-operative dietary knowledge emphasises the importance of providing education to optimise patients understanding of how to self-manage their condition following bariatric surgery.”

Co-authors of this study were Sara Kitching and Clare Grace

Pre-operative educational course

There are currently no standardised pre-operative educational course for bariatric surgery patients exists in the UK (BOMSS survey conducted 2014), with pre-operative education ibased mainly on clinical experience, with little evidence based research to support its design. The researchers including Corinne Owers from the Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK, designed an educational course using qualitative research and a structured framework to include information that patients feel are the most important aspects of bariatric surgery and are most keen to be taught about.

The team undertook qualitative interviews on 12 previous bariatric surgery patients, asking their opinion of pre-operative bariatric education. An interpretative phenomenological analysis (IPA) was performed to identify master and subthemes. Once complete, a previously designed educational course was analysed, and content added to include any missing subthemes identified from the (IPA). Patient and public involvement (PPI) was then used to assess and evaluate this newly designed educational course.

The results revealed the master factors as physical health, psychological health, diet and social influences. New topics not previously included within pre-operative education included: side effects (not complications) of surgery, guilt and shame, accessing psychological support, social life/ eating out, public perception of bariatric surgery, addiction transference and clothing issues.

“Although each trust within the UK provides educational material for patients pre-operatively, this is not standardised, and is not always performed in the private sector. In order to give patients equal access to education and preparation around the UK, a standardised educational course would be useful both for research and educational courses,” she concluded. “Using qualitative research and patient and public involvement to design such a course would ensure that it is both useful and of maximum benefit to patients. Further research to evaluate the utility of courses such as this in preparing patients for bariatric surgery is now needed so that education becomes evidence rather than experience based.”

Co-authors of this study were Roger Ackroyd1 Vanessa Halliday2 (1Sheffield Teaching Hospitals NHS Foundation Trust, and  2School of Health and Related Research, University of Sheffield, Sheffield, UK).

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