Patients do not have to attempt weight loss by before referral to bariatric surgery, according to updated guidance issued by the National Institute for Health and Care Excellence (NICE). The previous guidance, published in 2014, mandated referral for bariatric surgery should only be considered after ‘all appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss’.
An update to the ‘Clinical Guideline for Obesity Identification, Assessment and Management’, removes the necessity for patients to undergo non-surgical measures, in addition to the requirement for the person to have gone through intensive weight management treatment in a tier 3 service.
It is expected that the new guidance will allow patients to proceed to surgery much sooner.
In brief, NICE’s obesity updated guidance includes:
Offering adults a referral for a comprehensive assessment by specialist weight management services providing multidisciplinary management of obesity to see whether bariatric surgery is suitable for them if they: - have a BMI of 40 kg/m2 or more, or between 35 kg/m2 and 39.9 kg/m2 with a significant health condition that could be improved if they lost weight (see box 2 for examples) and; agree to the necessary long-term follow up after surgery (for example, lifelong annual reviews).
Consider referral for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background using a lower BMI threshold (reduced by 2.5 kg/m2) than in the above recommendation to account for the fact that these groups are prone to central adiposity and their cardiometabolic risk occurs at a lower BMI.
Consider an expedited assessment for bariatric surgery for people of South Asian, Chinese, other Asian, Middle Eastern, Black African or African-Caribbean family background using a lower BMI threshold reduced by 2.5 kg/m2), to account for the fact that these groups are prone to central adiposity and their cardiometabolic risk occurs at a lower BMI.
Ensure the multidisciplinary team within a specialist weight management service includes or has access to health and social care professionals who have expertise in conducting medical, nutritional, psychological and surgical assessments in people living with obesity and are able to assess whether surgery is suitable.
Carry out a comprehensive, multidisciplinary assessment for bariatric surgery based on the person’s needs. As part of this, assess: - the person’s medical needs (for example, existing comorbidities) - their nutritional status (for example, dietary intake, and eating habits and behaviours) any psychological needs that, if addressed, would help ensure surgery is suitable and support adherence to postoperative care requirements - their previous attempts to manage their weight, and any past response to a weight management intervention (such as one provided by a specialist weight management service) - any other factors that may affect their response after surgery (for example, language barriers, learning disabilities and neurodevelopmental conditions, deprivation and other factors related to health inequalities) - whether any individual arrangements need to be made before the day of the surgery (for example, if they need additional dietary or psychological support, or support to manage existing or new comorbidities) - fitness for anaesthesia and surgery.
Drug treatments may be used to maintain or reduce weight before surgery for people who have been recommended surgery, if the waiting time is excessive.
Consider pharmacological treatment only after dietary, exercise and behavioural approaches have been started and evaluated. NICE has not recommended naltrexone–bupropion.
According to NICE, these updated guidelines will reduce variation in practice and increase uptake in previously overlooked groups: “This however does not mean more people will have bariatric surgery, because they may decide it is not right for them or they are not judged to be clinically suitable for surgery,” said a NICE spokesperson.