Patients should no longer have to attempt weight loss by non-surgical interventions before referral to bariatric surgery, under new NICE guidance published today.
They also no longer have to be ‘generally fit for anaesthesia and surgery’ before referral to a specialist weight management service, which will instead undertake this assessment.
A new update to the clinical guideline for obesity identification, assessment and management removes a number of barriers for GPs to refer patients to be assessed for weight-loss surgery.
This follows a previous update to the guideline this year to the section on pharmacological interventions to include recommendations from NICE technology appraisal guidance on liraglutide, semaglutide and naltrexone-bupropion.
The previous guidance, first published nine years ago, had stipulated that referral for bariatric surgery should only be considered once ‘all appropriate non-surgical measures have been tried but the person has not achieved or maintained adequate, clinically beneficial weight loss’.
But this has now been removed, alongside a requirement for the person to have gone through intensive weight management treatment in a tier 3 service.
The new guideline instead uses the term specialist weight management centre – which requires the necessary expertise to assess patients but does not necessarily need to be tier 3.
Professor Alex Miras, professor of endocrinology at Ulster University, who participated in developing the new guidance, said: ‘If the team decide that the patient needs optimisation, this can take place before surgery is undertaken. If the team decide that there is no need for optimisation, then the patient can proceed to surgery much faster.’
The guidance also highlights that ‘drug treatments may be used to maintain or reduce weight before surgery for people who have been recommended surgery’.
And it further aims to clarify in which patents bariatric surgery interventions may be most beneficial.
Professor Miras said: ‘We have made it a bit more clear as to which obesity complications have a high level of evidence in terms of response to surgery (e.g. diabetes and fatty liver disease), while clarifying that the list is not exhaustive. In the previous guidance the language used was more vague.’
GP referral criteria will also be subject to local commissioners which may limit opportunities for bariatric surgery.
‘What we have done is make the patient’s journey towards bariatric surgery less cumbersome and removed some of the obstacles,’ said Professor Miras.
‘These changes may not necessarily increase the number of operations funded by the ICBs, but it will make the journey of the individual patient much more efficient.’
According to NICE, removing these barriers to referral 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,’ a spokesperson said.
Professor Azeem Majeed, a GP professor of primary care and public health at Imperial College London, said the new guideline ‘potentially has significant implications for general practices in England’.
He argued it will bring ‘additional work in discussing weight management with patients’ and that ‘suitable referral pathways would need to be in place with sufficient capacity to deal with an increase in patient numbers’.
Highlight 2023 updates to NICE’s obesity referral guideline
July 2023 updated guidance:
1.10.1 Offer 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). 
1.10.2 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 recommendation 1.10.1 to account for the fact that these groups are prone to central adiposity and their cardiometabolic risk occurs at a lower BMI. 
1.10.5 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 ) than in recommendation 1.10.4, to account for the fact that these groups are prone to central adiposity and their cardiometabolic risk occurs at a lower BMI. [2014, amended 2023]
1.10.6 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. 
1.10.7 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. 
1.10.12 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. See the sections on pharmacological interventions and continued prescribing and withdrawal. [2006, amended 2023]
April 2023 updated guidance:
1.8.1 Consider pharmacological treatment (see table 1) only after dietary, exercise and behavioural approaches have been started and evaluated. NICE has not recommended naltrexone–bupropion (see NICE’s technology appraisal guidance on naltrexone–bupropion for managing overweight and obesity). [2006, amended 2023]