Researchers from the Netherlands have identified five major themes involved in patient adherence to multivitamin supplementation (MVS) intake after bariatric surgery, namely: gastrointestinal side effects to MVS intake, negative features of MVS, satisfaction with advice on MVS, dissatisfaction with service provision and costs of specialised MVS. The findings were reported in the paper, ‘Factors Affecting Patient Adherence to Multivitamin Intake After Bariatric Surgery: Thematic Analysis of Qualitative Data From a Multicenter Study’, published in Cureus.
They noted that poor adherence to MVS intake after surgery can ‘potentially’ led to nutritional complications including anaemia, bone loss or even neurological problems. For this multicenter thematic analysis of qualitative data, they conducted an anonymous survey study among patients after bariatric surgery from four high-volume bariatric centers in the Netherlands: Catharina Hospital Eindhoven, Rijnstate Arnhem, Franciscus Gasthuis and Vlietland, and Onze Lieve Vrouwe Gasthuis (OLVG) Amsterdam.
The questionnaire consisted of 41 multiple-choice questions and one open-ended question at the end. In total, answers from 1,246 patients were included in this study and they reported that five key themes emerged regarding participants’ suggestions on adherence to daily MVS intake. These themes were:
Gastrointestinal side effects related to MVS intake
Nausea was the most commonly reported side effect (n=236, 18.9%) and led to vomiting in some patients (n=55, 4.4%). This was followed by stomach or abdominal pain (n=110, 8.8%). Other complaints that occurred less often are gastroesophageal reflux disease, belching, or burping (n=44, 3.5%), dumping (n=8, 0.6%), hunger (n=3, 0.2%), diarrhoea (n=7, 0.6%), flatulence (n=3, 0.2%) and constipation (n=1, 0.1%). Furthermore, there were many patients with general malaise or gastrointestinal symptoms, which were not specified in the answer (n=87, 7%). In addition, 296 (23.8%) patients experienced gastrointestinal complaints by basic features of the supplements.
Negative features of MVS
Many patients experienced complaints such as nausea or emesis due to the size (n=92, 7.4%) or smell (n=39, 3.1%). The smell of the WLS MVS was described as foul and repulsive, which led to feelings of nausea and triggered the gag reflex (n=8 for WLS capsule, n=2 for WLS chewable and n=29 for unknown). Patients reported the taste as bad (n=165, 13.2%), because of the sweet taste (n=14, 1.1%) or sour taste (n=4, 0.3%), dumping complaints (n=5, 0.4%) and a very nasty aftertaste or halitosis that lasted for hours (n=147, 11.8%). MVS users of regular “over-the-counter” MVS reported no problems with the taste of their supplement. Some patients experienced swallowing difficulties and a sensation of the MVS being stuck in the throat (n=70 for WLS capsule, n=21 for WLS chewable tablets, and n=1 for regular MVS).
Satisfaction with advice on MVS
In the past, only one brand of WLS MVS was prescribed in many obesity centres in the Netherlands. Many patients reported being dissatisfied with this advice and aspired to alternative options for various reasons such as personal circumstances or preferences (e.g., costs and side effects). Six of them hoped that WLS MVS could be administered in injection form with a less frequent schedule in the future.
Many patients described problems with the timing of taking the MVS. The most commonly cited reason was that the MVS had to be taken separately from calcium supplements or calcium-rich foods. Most patients did not really know what to do in practice and frequently forgot to take calcium. Additionally, they received no or only limited advice about this subject. Some patients were not aware that separate intake was necessary or had never been advised to take calcium. The less frequently cited reasons were the insufficient support for the interaction of MVS or calcium supplements with other medications. Patients did not know the best time to take the supplements due to this interaction.
Dissatisfaction with service provision
Patients were dissatisfied with the duration and frequency of the aftercare program. They particularly experienced good support in the first year and only limited guidance from the second to fifth year (n=51, 4.1%). The negative attitude toward aftercare during the corona pandemic was striking (n=14, 1.1%). Most face-to-face consultations were converted to online consultations, which caused dissatisfaction. The short consultation time of 10-15 minutes yearly was also described as inadequate. Some patients did not think the high healthcare costs for a 10-minute consultation including a blood test were worth it. Several patients also indicated that postoperative group meetings were not suitable for them. They did not feel heard or did not dare to discuss their problem, fearing it would cause trouble in their self-confidence when another patient lost much more weight.
Some patients felt unheard during the consultations at the obesity center. The most frequently reported reason was that gastrointestinal complaints and the request to switch to another type of MVS were not taken seriously (n=26, 2.1%). The follow-up consultations did not meet their needs or preferences. Other less frequently reported reasons were weight regain (n=23, 1.9%), excess skin surplus (n=14, 1.1%), unrecognised vitamin B12 deficiency (n=3, 0.2%), and disturbed eating behaviour or alcohol addiction (n=2, 0.2%). Patients missed personal attention, personalized MVS advice, and sufficient time to discuss gastrointestinal complaints or personal questions.
Psychological counselling was inadequate, and patients often did not feel comfortable bringing up mental health issues themselves. Patients missed a standard checkup with a plastic surgeon or were disappointed that skin correction procedures were not reimbursed despite successful weight loss.
It was notable that patients believed that the obesity centre had shares in WLS MVS or that there was commercial interest in using WLS MVS. Patients frequently reported difficulties in cancelling a subscription with the WLS MVS company due to rigidity and pushiness. After surgery, patients were sometimes contacted earlier by the WLS MVS producer than by the professionals of the obesity centre, which was perceived as disruptive.
Costs of the WLS MVS
Many patients considered the costs of the WLS MVS to be a problem as they could not afford these supplements. Consequently, patients were tempted to use supplements from other brands or regular over-the-counter MVS that were more affordable for them. The majority of patients believed that it is crucial that specialised WLS MVS be covered by healthcare insurance.
“The specialised WLS MVS should be further optimised by manufacturers to enhance tolerability and reduce costs. However, the main challenges lie in improving the care pathway within obesity centres by healthcare professionals. Medical consultations should be organized in a way that focuses more on what the patient wants to discuss, rather than simply checking off a medical list in the electronic patient file,” the authors concluded. “Stronger education for healthcare professionals is necessary, and communication skills should be improved. Giving attention to the patient’s story is crucial to providing more personalised aftercare. More personalised aftercare has the potential to increase patients, which is probably the key to improving adherence to MVS intake. There is no doubt that adherence to MVS intake after BS is a multifactorial problem, and a multifactorial approach is essential.”
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