The bariatric patient’s journey

Sorry for such a long time between posts! I can only attribute my absence to finally getting a job (yay!), you see all of those job hunting tricks I wrote about can pay off 😛

So in tribute to my new job role working within a weight management and bariatric consultancy service I thought I would focus this post on the bariatric patient’s journey to surgery, and which guidelines, as dietitians, we should be familiar with.

Firstly, patients wanting NHS surgery (private practices may vary) must meet the designated criteria, as stipulated in the NICE CG43 guidelines for obesity:

Bariatric surgery is recommended as a treatment option for adults with obesity if all of the following criteria are fulfilled:
− they have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 40 kg/m2 and other significant disease (for example, type 2 diabetes or high blood pressure) that could be improved if they lost weight
− all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months
− the person has been receiving or will receive intensive management in a specialist obesity service
− the person is generally fit for anaesthesia and surgery
− the person commits to the need for long-term follow-up.
• Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.

When the guideline talks of trying all appropriate non-surgical measures for at least 6 months, and receiving intensive management in a specialist obesity service, that’s my job! The diagram below shows the patient’s journey in good detail, from tiers 1-4 of intervention:

obesity image 5

As you can see, there’s a lot to consider and be implemented before the patient is considered ready for surgery, many assessments must be made from councillors, dietitians, exercise therapists, clinicians, specialist nurses and surgeons before a final decision is made, which can take a very long time and a lot of effort from the patient and all health care professionals involved. The patient must be seen to be engaging with all parts of the process, and have the motivation to make changes along the way. This is because the operation itself is not the be all and end all to weight loss, the patient must make many changes to their lifestyle to lose weight, of which the surgery is just an additional tool. I’m sure we have all heard stories of patients receiving gastric bands or sleeves, which have eventually stretched and caused them to regain the weight…proof that surgery alone will not result in long term weight loss.

Another huge consideration which must be made by the patient is the potential after effects of surgery, and the fact that their rose tinted view of it may not be reality. Some potential consequences are:

  • Loose skin
  • Malabsorption of essential nutrients resulting in supplementation for life
  • Scarring
  • The fact they may never be as slim as they want
  • Surgery complications (infection, hernia)
  • Reflux
  • Vomiting
  • Never being able to eat a normal size meal again
  • Dumping syndrome
  • Psychological changes (body image, friends and families views)

And in fact, probably unsurprisingly, a lot of patients after going through this pathway and being educated in the process decide that they do not wish for surgery any longer. My view is that it definitely works for some people, especially those with co-morbidities such as diabetes in which the surgery can result in them no longer having to inject insulin, and those with such a high BMI that the likelihood of losing the amount of weight they would with surgery with diet and exercise alone is small. However there are patients on the cusp of the threshold, such as having a BMI of 41 with no co-morbidities, that I really think could benefit much more in the long run with achieving the weight loss alone. Especially when they are young and relatively fit, doing it without the malabsorption and restriction for the rest of their life looks like a much better process. I think bariatric surgery should be considered not as a quick fix for weight loss, but a serious operation that could and probably will have consequences for the patient later on in life. Especially since the bariatric surgery service itself has not been around long enough in order for the long term effects to be scientifically studied.



(Diagram shown above thanks to

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