Introductory Certificate in Obesity, Malnutrition and Health

Slide set for Workshop 3Bariatric follow up in Primary Care

Acknowledgments H Parretti and C Nwosu

WORKBOOK PAGES 21 - 25

Workshop 3Bariatric follow up in

Primary Care

Aims

To review types and frequency of bariatric procedures

To understand essential aspects of long term follow up after bariatric surgery

To explore the role of audit in improving the quality of routine care in primary care

NICE Guidance CG 189

NICE guidance updated 2014Expedited assessment for bariatric surgery if BMI greater than or equal to 35 and recent onset type 2 DM

Consider bariatric surgery if BMI between 30 and 35 and recent onset diabetes

First line option for those with a BMI more than 50kg/m2 in whom surgical intervention is considered appropriate

Lower BMI threshold if of Asian origin

Bariatric surgery types

Types of surgeryRestrictive

• Gastric banding• Sleeve gastrectomy

Malabsorptive and restrictive• Gastric bypass

Malabsorptive• Duodenal switch

Bariatric surgery procedures

20

00

/20

01

20

01

/20

02

20

02

/20

03

20

03

/20

04

20

04

/20

05

20

05

/20

06

20

06

/20

07

20

07

/20

08

20

08

/20

09

20

09

/20

10

20

10

/20

11

20

12

/20

13

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Data: Health and Social Care Information Centre 2012 and Health Survey England 2012-13

Bariatric surgery procedures

NBSR data 2011-2013

53.9% procedures were gastric bypass

21.4% procedures were gastric band

21.4% procedures were sleeve gastrectomy

0.06% procedures were duodenal switch

Bariatric surgery patient characteristics

• Average BMI pre-surgery 48.8kg/m2

• 26% patients are male (increase from 16% in 2006)• 26% women and 45% men have type 2 diabetes pre-

surgery• 71.5% women and 73.2% men have some functional

impairment• Average number of co-morbidities 3.4 for women and 3.7

for men (2.3 and 2.6 in 2006)• 54% of men and 41% women have 4 or more co-

morbidities• Average number of co-morbidities increases with age and

pre-surgery BMI

Funding and follow up

Patients who have had their procedure carried out under the NHS have follow up within specialist services for the first 1-2 years post surgery

Patients who have moved area or who undergo a private procedure are at risk of being lost to specialist follow up

76% procedures NHS funded and 22.6% privately funded

Publicly funded Privately funded

Gastric band 1879 1686

Gastric bypass 7750 1350

Gastrectomy 2795 819

Duodenal switch 6 5

RCGP Top Tips

These guidelines are aimed at all non-specialist clinicians, dietitians and nurses to aid management within primary care or where follow up guidance by the surgical team was not issued. National guidance not currently available for primary care

Patchy commissioning of local Tier 3 weight management services means many post-bariatric surgery patients may be lost to follow-up, risking nutritional deficiencies and metabolic complications

New concerns should always trigger referral to a Tier 3 weight management service (if available) or the local bariatric surgical team for further advice

Top Tip One

Keep a register of bariatric surgery patients and record the type of procedure in the register

Note that follow up varies according to the type of surgery

Top Tip Two

Encourage patients to check their own weight regularly and to attend an annual BMI and diet review with a health professional

Top Tip Three

Arrange emergency admission under the local surgical team if symptoms of

continuous vomiting

dysphagia

intestinal obstruction (gastric bypass)

severe abdominal pain

Top Tip Four

Continue to review co-morbidities post surgery such as

diabetes mellitus

hypertension

hypercholesterolaemia

sleep apnoea

mental health

Top Tip Four - A

Medication needs are likely to fall with post-operative weight loss, but may increase later if weight loss is not maintainedKeep on QOF diabetes register. Continue routine diabetes follow-up even if diabetes is in remission

Cardiovascular and metabolic risk factors – continue to monitor and adjust treatments as required

Patients on CPAP should continue to use their machines until repeat sleep studies are performed post surgery

Mental health should be reviewed regularly. There is a higher rate of mental health problems in patients with severe and complex obesity surgery compared to the general population

Top Tip Five

Review the patient’s regular medications. The formulations may need adjusting post-surgery to allow for changes in bio-availability and swallowing post surgery.

Top Tip Five - A

Review co-morbidity medications post surgery, such as anti-hypertensives, diabetes medications, analgesics

Use diuretics with caution due to the increased risk of hypokalaemia

Replace extended release formulations with immediate release formulations

Consider pill size – patients may need liquid formulations or syrups in the immediate post-operative period. Usual medication formulations should be tolerated by around 6 week post-op

Top Tip Five - B

Avoid bisphosphonates

Avoid NSAIDS: if no alternative use with PPI

Monitor anticoagulants carefully

Psychiatric medications may need increased or divided doses

Avoid effervescent medications for patients with gastric bands

Top Tip Six

Bariatric surgery patients require lifelong annual monitoring blood tests, including micronutrients.

Encourage patients to attend for their annual blood tests.

Gastric band patients only require FBC, U&Es and LFTs annually, or sooner if there are concerns about the band.

Blood test Surgical procedure

Gastric bypass Sleeve gastrectomy Duodenal switch

LFTs Yes Yes Yes

FBC Yes Yes Yes

Ferritin Yes Yes Yes

Folate Yes Yes Yes

Vitamin B12 Yes* Yes* Yes*

Calcium Yes Yes Yes

Vitamin D Yes Yes Yes

PTH Yes Yes Yes

Vitamin A Possibly** No Yes

Zinc, copper Yes Possibly*** Yes

Selenium No*** No*** No***

* If patient is having three monthly intramuscular injections of vitamin B12, there may be no need for annual checks.

**If the patient has a long limbed bypass, symptoms of steatorrhoea or night blindness.***Measure when concerns

Top Tip Seven

Be aware of potential nutritional deficiencies that may occur and their signs and symptoms.

If a patient is deficient in one nutrient, then screen for other deficiencies too.

In particular, consider risk of anaemia

vitamin D deficiency

protein malnutrition

other vitamin and micronutrient deficiencies.

Top Tip Seven - A

Protein malnutritionOedema - need urgent referral back to the bariatric team

Anaemia iron, folate and vitamin B12 deficiencies all possible.

unexplained anaemia may result from less common causes such as zinc, copper and selenium deficiencies

some patients may need parenteral iron or blood transfusions if oral iron does not correct the deficiency

Calcium and vitamin D deficiency may result in secondary hyperparathyroidism

Vitamin A deficiency suspect in patients with changes in night vision

patients with steatorrhoea or those who have had a duodenal switch are at high risk

Top Tip Seven - B

Zinc, copper and selenium

unexplained anaemia, poor wound healing, hair loss, neutropenia, peripheral neuropathy and cardiomyopathy

ask about OTC supplements and liaise with bariatric unit as zinc supplements can induce copper deficiency and vice versa

Thiamine deficiency

suspect in patients with poor intake, persistent regurgitation or vomiting

may be caused by anastomotic stricture in the early postoperative phase, food intolerances or an overtight band

start thiamine supplementation immediately and refer urgently to the local bariatric unit - risk of Wernicke’s encephalopathy (ophthalmoplegia, ataxia and confusion)

do not give sugary drinks as this may precipitate Wernicke’s encephalopathy

Top Tip Eight

Ensure the patient is taking the appropriate lifelong nutritional supplements, as recommended by the bariatric centre.

Ensure guidance regarding vitamin supplementation has been issued by the bariatric surgery team.

Request a copy for the patient’s GP records if this has not been included in the discharge information.

More details: “GP Guidance for the Management of Nutrition following Bariatric Surgery” http://www.bomss.org.uk/nutritional-guidelines/

Top Tip Eight - A

Gastric band

No supplements should be needed, but a comprehensive multivitamin and mineral supplement od, (Sanatogen A to Z or Forceval) is recommended

Gastric bypass

multivitamin and mineral (OTC comprehensive multivitamin preparation bd or Forceval od)

3 monthly vitamin B12 injections

calcium and vitamin D (i.e. Adcal D3 Forte, Calceos or Calcichew D3 Forte) plus additional vitamin D as required

iron (start at 200mg od and monitor as may need to increase dose), especially for women of menstruating age

Top Tip Eight - BSleeve gastrectomy

multivitamin and mineral (OTC comprehensive multivitamin preparation bd or Forceval od)

3 monthly vitamin B12 injections, if low B12 levels at 12 months

calcium and vitamin D (i.e. Adcal D3 Forte, Calceos or Calcichew D3 Forte) plus additional vitamin D as required

possibly iron especially for women of menstruating age (dose as above)

Duodenal switch

As for gastric bypass, but additional fat soluble vitamins (A, D, E and K) also needed as well as possibly zinc and copper supplementation. Liaise with specialist local services for advice regarding these supplements

Top Tip Nine

Discuss contraception – ideally pregnancy should be avoided for at least 12-18 months post surgery

LARC of the patient’s choice would be appropriate.

Avoid OCP due to issues with absorption

Avoid Depo-Provera due to risk of weight gain

Top Tip Ten

If a patient plans to become pregnant after bariatric surgery alter their nutritional supplements to one suitable during pregnancy

Inform

the local bariatric unit of patient’s pregnancy

the obstetric team of the patient’s history of bariatric surgery

Top Tip Ten - A

Gastric band patients may need their band adjusting

Recommended changes before and during pregnancy are:Change forceval to a supplement appropriate in pregnancy such as Pregnacare or Boots Pregnancy Support

If a PPI is needed, omeprazole recommended

Continue vitamin D supplementation according to vitamin D levels and National Osteoporosis Society guidance

Continue vitamin B12 injections or monitor vitamin B12 levels for those not receiving vitamin B12 injections (for sleeve gastrectomy patients)

Iron 200mg od

Folic acid 5mg od

Thanks

Co-AuthorsDr CA Hughes

Ms M O’Kane

Mr S Woodcock

Dr R Pryke

Full guidance available on RCGP Nutrition Web Pages

References

Duke E and Finer N (2012) Bariatric Surgery: Pre-Operative and Post-Operative Care. Information for General Practitioners. UCLH Centre for Weight Loss, Metabolic and Endocrine Surgery, UK.

Francis R et al, (2013) Vitamin D and Bone Health: A practical clinical guideline for patient management. National Osteoporosis Society. [Online] Available from: http://www.nos.org.uk/document.doc?id=1352  

Heber D et al, (2010) Endocrine and Nutritional Management of the Post-Bariatric Surgery Patient: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology and Metabolism, 95 (11): 4823-4843.

Mechanick JI et al, (2013) Clinical Practice Guidelines for the Perioperative Nutritional Metabolic and Nonsurgical Support of the Bariatric Surgery Patient 2013 Update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery. Obesity 21: S1-S27.

National Institute for Health and Clinical Excellence (NICE) (2006) Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. National Institute for Health and Clinical Excellence. [Online] Available from: http://www.nice.org.uk/guidance/CG43.

O’Kane M, Pinkney J, Aasheim ET, Barth JH, Batterham RL and Welbourn R (2014) Management of nutrition following bariatric surgery: GP guidance. [Online] Available from: http://www.bomss.org.uk/nutritional-guidelines/.

Thomas CM et al. (2011) Monitoring for and Preventing the Long-term Sequelae of Bariatric Surgery. Journal of the American Academy of Nurse Practitioners 23: 449-458.

Woodcock S (2014) Primary care management of post operative bariatric patients. British Obesity and Metabolic Surgery Society. [Online] Available from: insert RCGP nutrition pages URL here

Workshop 3A

A Practical Guide to the Audit Tool Kit

Acknowledgments H Parretti and C Nwosu

WORKBOOK PAGES 26 - 32

Audit Tool for Managing Patients Post Bariatric Surgery in Primary Care

The Audit Tool Kit

Running the audit of patients 2 years post bariatric surgery highlights:-

Importance of coding

Medication and co-morbidity review

Annual blood monitoring

Nutritional Supplements

Annual health check

Concerning symptoms

Pregnancy

In the Real World!

Results of a practice audit in the north of England showed

Initial audit cycle - no patients had all their correct bloods done

55% of patients required an intervention based on blood results

How does your surgery compare?