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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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