Bariatric surgery has gained wide acceptance as an effective treatment for morbid obesity, especially among those suffering with type 2 diabetes. In 2009, it’s estimated that 200,000 bariatric procedures were performed at a cost of about $5 billion, and these figures are likely to increase as the obesity epidemic continues to grow. Bariatric surgery, however, does not guarantee success, and patients require postoperative care. Approximately 20% of patients either fail to lose weight or regain weight post-surgery. To reduce this likelihood and to ensure that comorbid conditions are managed appropriately, all patients should receive careful medical follow-up after their surgery.
In the November 8, 2010 Journal of Clinical Endocrinology & Metabolism, the Endocrine Society published a clinical practice guideline on the nutritional and endocrine management of adults after bariatric surgery, including those with diabetes. The evidence-based recommendations (available online at http://jcem.endojournals.org) focus on the immediate postoperative period and long-term management to prevent complications, weight regain, and management of obesity-associated comorbidities.
The guidelines recommend that all patients undergo active nutritional patient education and clinical management to prevent and identify deficiencies after bariatric surgery. The management of nutritional deficiencies is especially important for patients undergoing malabsorptive procedures (eg, Roux-en-Y gastric bypass). To be most successful during and after surgery, a proficient surgical program—preferably one that has been accredited by a national certifying group—and an integrated medical support team that offers proven dietary and behavioral strategies should be available to patients postoperatively and during long-term follow-up. Postoperative treatment of weight regain should include diet instruction, increased physical activity, behavior modification, and possibly pharmacologic therapy.
An average daily protein intake of 60 g to 120 g is recommended to maintain lean body mass during weight loss and for the long term. This can help prevent protein malnutrition and its effects in patients who undergo malabsorptive procedures. To prevent nutritional deficiencies, long-term vitamin and mineral supplementation should be considered in all patients. Periodic clinical and biochemical monitoring after bariatric surgery are also recommended to detect micronutrient and macronutrient deficiencies.
Use a Multidisciplinary Team
A multidisciplinary team—including the primary care physician, endocrinologist, or gastroenterologist in addition to an obesity medicine specialist, dieticians, exercise physiologists, psychiatrists, and other mid-level providers—should be involved in the care of patients before and after undergoing bariatric procedures. This team is critical in helping optimize outcomes and avoid complications. It should be involved in efforts to educate patients, modify behaviors, provide additional weight loss therapies when needed, and refer patients for revisionary surgery whenever clinically indicated. Enrolling in a comprehensive program will hopefully give the patient the best chance of success after their surgery and possibly prevent weight regain.
Another important component of post-bariatric surgery care includes the significant improvement of comorbidities, especially type 2 diabetes and lipid abnormalities. Frequent monitoring of A1C, blood pressure, cholesterol, and triglyceride levels is paramount to achieving long-term success. Clinicians should also be cognizant of other surgical benefits on additional comorbidities like obstructive sleep apnea, fatty liver disease, polycystic ovarian disease, degenerative joint disease, or GERD, and adjusttheir therapies as these issues resolve.
In future research, it’s hoped that studies will seek to address the effectiveness of intensive postoperative nutritional and endocrine care in reducing morbidity and mortality from obesity-associated diseases. In the meantime, providers should review the Endocrine Society’s guidelines to ensure appropriate postoperative care that is based on available evidence in the literature.
Readings & Resources (click to view)
Heber D, Greenway FL, Kaplan LM, Livingston E, Salvador J, Still C. Endocrine and nutritional management of the post-bariatric surgery patient: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2010;95:4823-4843. Available at:http://jcem.endojournals.org/cgi/content/abstract/95/11/4823.
O’Brien PE. Bariatric surgery: mechanisms, indications and outcomes. J Gastroenterol Hepatol. 2010;25:1358-1365.
Furtado LC. Nutritional management after Roux-en-Y gastric bypass. Br J Nurs. 2010;19:428-436.
Moizé VL, Pi-Sunyer X, Mochari H, Vidal J. Nutritional pyramid for post-gastric bypass patients.Obes Surg. 2010;20:1133-1141.