Perspectives
Metabolic diseases Surgery
Volume 200 - Issue 2

Guidelines fall short on bariatric surgery

Author:  John B Dixon

Med J Aust 2014; 200 (2): 70. || doi: 10.5694/mja13.10861
Published online: 3 February 2014
Appropriate guidance is lacking in long-term nutritional monitoring and support
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Appropriate guidance is lacking in long-term nutritional monitoring and support

The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of overweight and obesity were released in early June 2013, replacing the 2003 version, intended for use by specialists and general practitioners.1 A multidisciplinary committee oversaw the guideline development process, aiming to systematically identify and evaluate evidence. In my view, this process has failed with regard to the section dealing with bariatric surgery, thereby failing severely obese Australians and those caring for them.

My greatest concern is the section about nutrition and supplementation after bariatric surgery. Nutritional issues are a critical downside to bariatric surgery and should be front of mind whenever doctors, nurses, dietitians or any other health professionals interact with a patient after surgery. High-quality guidance is required in the care of the thousands of patients who have had bariatric surgery. After bariatric surgery, energy intake is markedly reduced, food choices and diet quality often change, absorption of micronutrients such as iron, calcium, vitamin D and vitamin B12 can be impaired with some procedures and, more rarely, protein malnutrition and more complex deficiencies occur. All bariatric procedures require excellent nutritional support, monitoring and supplementation.

The guidelines’ suggestion that nutritional issues should be assessed through clinically manifest disease, including neuropathy, weakness and muscle wasting, bone pain and oral lesions, is dangerous, reflecting an “after the horse has bolted” mentality. Progressive nerve damage related to nutritional deficiency can be catastrophic and only partially reversible;2 metabolic bone disease related to nutritional deficiency is symptomatic only when it is generally too late to take any effective preventive action; and it is definitely too late when a pregnant woman’s baby is diagnosed with a neural tube defect. Anaemia, metabolic bone disease, and neuropathy are reported at much higher levels after bariatric surgery than in the community. Nutritional issues are predictable, and also preventable with appropriate monitoring.

These nutritional guidelines contrast starkly with the broader literature and the recently released United States guidelines for pre- and post-bariatric surgical care developed conjointly by the American Association of Clinical Endocrinologists, the Obesity Society, and the American Society for Metabolic and Bariatric Surgery.3 Their detailed literature review comes to very different conclusions. However, the recent NHMRC document1 does not detail any critical appraisal of the literature about nutritional support, monitoring or supplementation after bariatric surgery. What was the evidence base for the guidance provided, given its inconsistency with known nutritional deficiencies and the available literature on prevention? As soon as I became aware of the guidelines, I alerted the NHMRC and colleagues who were members of the relevant committees to the specific issues that worried me.

The greatest concern is the process that led to this unsatisfactory section of the guidelines. The review process is described as rigorous and transparent, yet the result, in my view, is not evidence-based, and is potentially dangerous. Rigour and transparency were used when looking at the weight loss extent and duration, the changes in obesity-related comorbid conditions and the overall mortality advantage after bariatric surgery. However, the guidelines are intended to provide practical assistance to health professionals managing chronic disease in patients with severe complex obesity who have undergone bariatric surgery. Surgery does not cure obesity or obesity-related comorbid conditions. Lifelong follow-up and support are required.

I recommended that the NHMRC consider revising the section on nutrition and nutritional supplementation after bariatric surgery. In addition, the NHMRC should review its aims and processes before conducting evidence-based reviews to ensure that guidelines provide the most relevant practical information for the target audience rather than a detailed formal review with limited practical relevance to patient selection and care. The NHMRC has recently confirmed that the section of concern will be revised. Meanwhile, I urge bariatric surgeons and their multidisciplinary teams to follow high-quality guidelines,3 provide individualised advice to patients and their key health care providers. Additional support for practitioners is available in two recent reviews detailing the nutritional aspects of bariatric surgery.4,5

Author

  • John B Dixon MB BS, PhD, FRACGP1
  • 1. Baker IDI Heart and Diabetes Institute, Melbourne, VIC.

Correspondence: john.dixon@bakeridi.edu.au

Competing interests

I act as a consultant for Allergan, Inc. and Metagenics. I am a member of the Optifast medical advisory board for Nestlè Australia; I have received honoraria from iNova Pharmaceuticals for organising an obesity summit, and I have received research grants from Allergan, Inc. for investigator-initiated research. None of these entities had any input into the current perspective.

References

Provenance: Not commissioned; externally peer reviewed.

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