Guidelines for Medical Care of Postbariatric Patients

Nicola M. Parry, DVM

December 22, 2017

The European Association for the Study of Obesity has released new guidelines providing practical recommendations to help clinicians manage patients after bariatric surgery.

The evidence-based recommendations were published online December 6 in Obesity Facts and highlight data from current evidence and existing guidelines.

The guidelines focus, in particular, on the management of issues such as nutrition, medical and psychological comorbidities, pregnancy, and weight regain.

Although the recommendations target general practitioners, they will also help other healthcare providers who are not specifically trained in bariatric medicine, but who manage patients after bariatric surgery.

As the number of bariatric procedures performed annually worldwide continues to increase, so does the need for clinicians in primary care to follow up and care for these patients after surgery.

"[B]ariatric patients may face new specific multifaceted clinical problems after surgery," write Luca Busetto, MD, from the University of Padova, Italy, and colleagues.

As a consequence, clinicians need special knowledge and skills "in order to deliver appropriate and effective care to the post-bariatric patient," the authors add.

Nutritional management is one key area of need for patients after bariatric surgery, the authors emphasize. After the procedure, these individuals must develop new nutritional habits and eating behaviors, transitioning to eating smaller amounts of food as they adjust to living with a smaller-volume stomach.

The guidelines recommend that primary care clinicians advise patients about the optimum quantity and frequency of food intake and about the importance of consuming a healthy, nutrient-dense diet that contains adequate amounts of lean proteins, fruits, and vegetables. In particular, patients must eat sufficient protein (at least 60 g/day) to preserve muscle mass during weight loss.

Many bariatric patients experience nutritional deficits as they adjust to the smaller intake of their stomach or digestive tract, as well as to the reduced amounts of food they need to eat. Thus, the guidelines advise clinicians to monitor patients' nutritional blood parameters every 3 to 6 months during the first year after surgery, and every 12 months thereafter.

Some of the most common nutrient deficiencies that occur in these patients involve vitamins B and D, calcium, and iron, the authors say. Clinicians should therefore also advise patients about the need to also take supplementary forms of such nutrients.

The guidelines also address mental health and psychosocial issues of bariatric patients, especially because psychiatric comorbidities, including suicidal ideation, substance abuse, or eating disorders, are common among these individuals.

And although bariatric candidates receive a perioperative psychological evaluation, mental illness may be under-recognized or undertreated before and after surgery.

The guidelines thus advise clinicians to also perform postoperative psychological evaluations to monitor patients for mental health issues, including unrealistic expectations from surgery. Patients should also receive education about the risk for alcohol abuse after surgery.

They also need counseling about the importance of adopting and maintaining a healthy lifestyle over the long-term to prevent weight regain. This requires combining regular physical activity with nutritional adherence, the authors say.

Pregnancy management is another key area of need for bariatric patients, especially because most of these patients are women, and up to 80% are of child-bearing age.

Because weight loss leads to improved sex hormone profiles and improved metabolic and hormonal changes, a woman's fertility can quickly increase after bariatric surgery.

The guidelines recommend primary care clinicians educate women about these changes in fertility changes. They should advise women against becoming pregnant in the first 12 to 24 months after bariatric surgery, however, because of an increased risk for nutritional deficiencies and obstetric complications during this period.

And because the efficacy of oral contraceptives is reduced after gastric bypass and bilio-pancreatic diversion, women should be switched to nonoral contraceptives after these procedures.

For women who become pregnant after bariatric surgery, clinicians should prescribe a prenatal multivitamin preparation, vitamin B12 injections, and oral calcium supplements. Clinicians should also screen pregnant women for gestational diabetes, but using serial capillary glucose monitoring instead of the conventional oral glucose tolerance test, which can precipitate dumping syndrome and hypoglycemia.

Clinicians should also ensure that pregnant women receive multidisciplinary antenatal care at a specialized center with experience in pregnancy after bariatric surgery.

During follow-up, the guidelines advise clinicians to also routinely monitor patients' blood pressure and blood glucose levels, as well as their lipid profiles and cardiovascular risk status. In this way, clinicians can adjust medications according to new therapeutic needs.

Although bariatric patients should be offered multidisciplinary follow-up care after their surgery, given the growing number of these patients, follow-up should be at least in part transferred to primary care over time, say the authors explain.

There is thus "a growing need for dissemination of first-level knowledge in managing bariatric patients" in primary care, they conclude.

The authors have reported no relevant financial relationships.

Obesity Facts. Published online December 6, 2017. Full text

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