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NICE proposes lowering threshold for bariatric surgery

NICE has proposed to lower the threshold for gastric band operations on patients newly diagnosed with type 2 diabetes to a BMI of 30, in a move welcomed by GP leaders and specialists.

The guidance, which is now under consultation, updates the 2006 advice in several areas including a suggestion that patients should receive at least two years of follow-up care after bariatric surgery within a specialist secondary care team and are offered ‘at least annual monitoring’ thereafter.

GP leaders and specialists have welcomed the move, saying that there is a need for GPs to ‘upskill’ on obesity.

The new guidelines state bariatric surgery assessment should be considered in ‘people who have recent-onset type 2 diabetes and who are obese (BMI of 35 and over).’

It adds: ‘Consider an assessment for bariatric surgery to people who have recent onset type 2 diabetes with a BMI of 30–34.9’ and that patients of Asian family origin with a lower BMI should also be considered.

The guidance also says that ‘very low calorie diets’ – which consist of 800kcal/day or less and are being increasingly used – should only be considered ‘as part of a multicomponent weight management strategy for a maximum of 12 weeks (continuously or intermittently) in people who are obese who have a clinically-assessed need to rapidly lose weight’, such as before joint surgery.

It also states risk benefits and psychological assessments and counselling should be considered before starting the diet, as well as explaining that weight loss is unlikely to be long-term.

Dr Andrew Brewster, a GPSI in obesity and diabetes in Reading, and an honorary research fellow at Reading University, explained there is an ‘unmet need’ to improve obesity medicine training for GPs.

Dr Brewster said: ‘I think the crux of the matter is up-skilling healthcare professionals in obesity medicine, so we all know what we’re doing.

‘We’re not very experienced at picking up all the potential metabolic complications, post-bariatric surgery. So I think it’s good that there is secondary care support, and two years is important because a lot of people do get lost to follow up.’

Dr Brewster added: ‘Bariatric surgery is the most powerful treatment there is for diabetes, and it’s not on the guidelines. It means people would end up with very, very expensive complications. They’re young people; they’re going to have a long history of hypoglycaemia, and retinopathy.

‘Not everybody will want [surgery] of course, but we’ve got to make it available to people, we’re not even particularly discussing it in consultations. There’s a big issue there.’

Professor Mark Baker, a director at NICE’s Centre for Clinical Practice, said: ‘Very low-calorie diets have grown in popularity in recent years, so we now have more evidence to consider  how well they work, if the weight loss can be sustained and the safety concerns, than we did in 2006.’

 

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Readers' comments (8)

  • Vinci Ho

    Absolutely right BUT
    Funding is always an argument even from the guidance in 2006 on bariatric surgery .
    Would you really believe the short sighted NHSE and hence CCGs will be more liberal than current practices ?

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  • Works to reverse Diabetes - and the cost savings are real.

    Definitely worth doing in patients with BMI >40, but the PCT would barely fund anyone with a BMI >50.

    They played the system, making you fill out bureaucratic cr@p - pages of funding applications with completely inappropriate requests, needing pictures of the problem to be sent to funding panel meetings full of mangers and lay people.

    They took so long to do anything with the paperwork, then months later tell you you filled a box wrong, or they have 'misplaced it' so you have to do it again.

    They thrived on the hope that you or the patient would loose yours and give up.

    Short sighted managers and politicians, who aren't going to be in post long enough to see the benefits come in clinically or financially.

    Start funding the BMI >40 before spreading the circle too wide, prove the benefits beyond doubt.

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  • good ..then lets put this unarguable evidence to work without delay..bariatric surgery is now safe and one of the most cost effective interventions in medicine..we will not be able to fund type 2 diabetic trearment in future if not.i doubt the bureausclerotic part privatised current nhs will..as obsessed with short term cost saving(and vital executive bonuses) not evident reality...........
    i agree not for all obese but definitely all over forty bmi as barring one per cent exceptions this medical condition is in reality incurable and irreversible.
    i know from personal experience..i funded my op privately but enabled probably twenty years more as a productive gp.
    morbid obesity is a seperate issue from more global lesser obesity for which i agree global public health and tax policy is vital ..fat chance(!) with the present contemtible corrupt loathsome shower in government.
    we need all the nhs deforms of past twenty years to be smashed ..and the ten billion saved by cutting current nhs admin costs of 14 per cent back to previous genuine nhs of 5 per cent...the truth of this waste is an extreme national scandal causing untold human suffering at the altar of failed dogma that bma should be screaming from the rooftops umtil hoarse....

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  • The following is the convoluted bullcrap that we GPs are expected to do BEFORE referring these patients onto the bariatic service.I hope these guidelines remove this red tape allowing referrals to better resourced bariatric services which can do all the preliminary workup:

    Regional Obesity Surgery Service Referral Form























    WE ARE NOT PERMITTED TO ACCEPT ANY
    REFERRALS WITH INCOMPLETE INFORMATION


    HEIGHT (metres) Calculated BMI kg/m2
    Must be >50 or
    WEIGHT (kg) >45 with a co morbidity*
    Actual not recall Date of measurements
    *listed on page 5

    EVIDENCE OF FAILURE TO LOSE WEIGHT OVER 6 MONTHS OR MORE


    PREVIOUS WEIGHT (kg) DATE: ……………………………….
    Actual not recall must be >6 months ago

    CONFIRMATION OF NON-SMOKING STATUS.
    We cannot accept patients who are currently smoking

    NEVER SMOKED

    CEASED SMOKING DATE: ……………………………….
    Completely = 0/day must be >6 weeks ago
    EPWORTH SLEEPINESS SCALE


    How likely is the patient to doze off or fall asleep in the following situations - in contrast to just feeling tired? This refers to their usual way in recent times. Even if they have not done some of these things recently, try to work out how they would have been affected. Use the following scale to choose the most appropriate number for each situation


    0 = would never doze

    1 = slight chance of dozing

    2 = moderate chance of dozing

    3 = high chance of dozing



    Situation
    Chance of dozing
    Sitting and reading


    Watching television


    Sitting inactively in a public place


    Riding as a passenger in a car for one hour without a break

    Lying down to rest in the afternoon when circumstances permit

    Sitting and talking with someone


    Sitting quietly after lunch without alcohol


    Sitting in a car as the driver, while stopped for a few minutes in traffic


    Epworth Questionnaire Total Score
    must be 10 or more, or the patient should have a history of sleepiness in a dangerous situation.




    PLEASE NOTE THAT IF A PATIENT SCORES > 10 THEN THEY MUST BE REFERRED FOR SLEEP STUDIES BEFORE AN OBESITY REFERRAL IS MADE.























































































    CONFIRMATION OF DIETETIC & BEHAVIOURAL INTERVENTIONS

    Describe efforts to lose weight by dieting, which must include consultation with a registered dietician. A dietician’s report would greatly assist.

    Describe any efforts to lose weight by psychological therapy such as cognitive behavioural therapy. A report or contact details would greatly assist if such a referral has been made.

    Describe efforts to lose weight using exercise as able. Describe current exercise regimen. Has an exercise referral programme been trialled?



    Specify
    weight loss activity

    Date and duration of activity
    Outcome
    weight loss

    State Registered Dietician





    Psychological intervention



    Exercise schedule/programme



    Other: please
    specify




    Comments:

    …………………………………………………………………………………………

    …………………………………………………………………………………………

    …………………………………………………………………………………………

    …………………………………………………………………………………………

    CONFIRMATION OF FAILED MEDICAL THERAPY
    All patients should have had an adequate trial of currently or previously available Oral anti-obesity medication. Please provide details.












    THANKS FOR COMPLETING THIS REFERRAL

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  • Vinci Ho

    Let's face it:
    Sincerity , conviction and commitment of DoH/NHS/hence CCGs to save money :10/10, to save people, 1/10(only because of some of our colleagues in CCGs).
    Call me cynical if you want ........

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  • Vinci Ho

    For those of you who have been involving in writing up this guidance since 2006 , ladies and gentlemen, do you not feel you have been betrayed by these bureaucrats ?

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  • Vinci Ho

    I mean
    0/10 if no colleague of ours were in CCGs......

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  • Surgery is not the only option for obese type 2 diabetics. Endobarrier Therapy, which is now funded becoming in other EU countries is a non surgical intervention for those T2D who are obese. it shows on ave a 20% AWL @ 12 months and a 2% point drop in HbA1c. I'd be interested to hear what GP's think of this non surgical intervention which is currently being reviewed by NICE.

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