|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2023 | Volume
: 2
| Issue : 1 | Page : 26-30 |
|
Perioperative nutritional practices in patients undergoing bariatric surgery in India: A delphi consensus
Sarfaraz Jalil Baig1, Pallawi Priya1, Abhishek Katakwar2, Aparna Govil Bhasker3, Atul N. C. Peters4, Carlyne Remedios5, Deeba Siddiqui6, Kankona Dey7, Madhu Goel8, Manish Khaitan9, Mariam Lakdawala3, Rajkumar Palaniappan10, Ramen Goel11, Randeep Wadhawan12, Ritika Samaddar13
1 Belle Vue Clinic, Kolkata, West Bengal, India
2 Center for Obesity and Metabolic Therapy, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
3 Department of Bariatric Surgery, Saifee Hospital, Mumbai, Maharashtra, India
4 Department of Bariatric, MAS and Gen. Surgery, Max Smart Super Speciality Hospital, New Delhi, India
5 Department of Bariatric Surgery, Digestive Health Institute, Mumbai, Maharashtra, India
6 Department of Bariatric Surgery, Indraprastha Apollo Hospital, New Delhi, India
7 Department of Nutrition and Dietetics, The Maharaja Sayajirao University of Baroda, Vadodara, Gujarat, India
8 Center for Metabolic Surgery, Wockhardt Hospital, Mumbai, Maharashtra, India
9 Department of Bariatric Surgery, KD Hospital, Ahmedabad, Gujarat, India
10 Department of Bariatric Surgery, Institute of Bariatrics, Apollo Hospitals, Chennai, Tamil Nadu, India
11 Center of Metabolic Surgery, Wockhardt Hospitals, Mumbai, Maharashtra, India
12 Department of GI, MAS and Bariatric Surgery, Manipal Hospitals, New Delhi, India
13 Department of Bariatric Surgery, Max Healthcare, New Delhi, India
| Date of Submission | 30-Aug-2022 |
| Date of Acceptance | 23-Dec-2022 |
| Date of Web Publication | 20-Feb-2023 |
Correspondence Address:
Pallawi Priya
Belle Vue Clinic, Kolkata, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jbs.jbs_14_22
Introduction: Variations in cultural practices, diet, socioeconomic factors, genetics, and procedure selection have a potential impact on nutritional outcomes after bariatric surgery. There are no updated guidelines from India on clinical practice on the nutritional management of patients undergoing bariatric surgery. This is the first attempt to have a consensus on the subject. Methods: An expert committee was constituted which voted for three rounds on 20 statements/questions based on a Delphi method. Results: There was consensus regarding preoperative screening of hemoglobin, packed cell volume, albumin, iron, ferritin, Vitamin D, Vitamin B12, preoperative weight loss, postoperative prophylactic protein supplementations, therapeutic supplementation of iron, B12, and Vitamin D, postoperative testing, and frequency of follow-up visits. Experts did not agree on the routine preoperative testing of serum folate and thiamine. There was no consensus on lifelong supplementation with bariatric formulation, difference of supplementation dosages for Roux-en-Y gastric bypass and one anastomosis gastric bypass, or postponement of surgery pending correction of nutritional deficiencies. Conclusion: We need a better-quality regional data to formulate guidelines that can provide evidence-based guidance for the clinical practice.
Keywords: Bariatric surgery, Delphi consensus, gastric bypass, nutrition, sleeve gastrectomy, supplementation
How to cite this article:
Baig SJ, Priya P, Katakwar A, Bhasker AG, Peters AN, Remedios C, Siddiqui D, Dey K, Goel M, Khaitan M, Lakdawala M, Palaniappan R, Goel R, Wadhawan R, Samaddar R. Perioperative nutritional practices in patients undergoing bariatric surgery in India: A delphi consensus. J Bariatr Surg 2023;2:26-30 |
How to cite this URL:
Baig SJ, Priya P, Katakwar A, Bhasker AG, Peters AN, Remedios C, Siddiqui D, Dey K, Goel M, Khaitan M, Lakdawala M, Palaniappan R, Goel R, Wadhawan R, Samaddar R. Perioperative nutritional practices in patients undergoing bariatric surgery in India: A delphi consensus. J Bariatr Surg [serial online] 2023 [cited 2023 Mar 22];2:26-30. Available from: http://www.jbsonline.org/text.asp?2023/2/1/26/370080 |
| Introduction | |  |
Nutritional management is an important part of bariatric practice. The aim is perioperative nutritional optimization to achieve the maximum metabolic benefits while minimizing the nutritional complications as well as preventing the nutritional complications in the long term. Multiple guidelines exist for perioperative nutritional optimization from different societies.[1],[2]
Since there are variations in cultural practices, dietary habits, metabolic profile, and bariatric procedures across the globe, it is important to have guidelines suitable to the local clinical practice. For instance, majority of the bariatric patients are vegetarians in India. Even people who are nonvegetarians do not consume as much meat as the western population. Therefore, this population may need a higher protein supplementation and more stringent monitoring.
Moreover, Indians have a higher visceral fat and are constitutionally more prone to developing metabolic syndrome at a lower body mass index. Further, mini-gastric bypass (MGB)-one anastomosis gastric bypass (OAGB) is the second-most performed procedure in India which is more malabsorptive than Roux-en-Y gastric bypass (RYGB).[3] These factors may influence nutritional outcomes after bariatric surgery.
Some guidelines exist from the Indian subcontinent;[4] however, they have not been updated. Many articles with nutritional outcome have been published since. In addition, a registry has been recently launched for a comprehensive data collection and collaboration by bariatric surgeons of India. Efforts to make evidence-based guidelines for bariatric practice suitable to Indian population are underway. In the meantime, the Obesity Surgery Society of India (OSSI) has issued a consensus statement based on a Delphi Survey during its annual conference. The consensus was conducted using the Delphi method[5] and currently available evidence. We present the finding of the consensus in this article.
| Methods | | |
This was a consensus based on Delphi method.[5] The OSSI assigned a facilitator for the consensus (SJB). The facilitator, with another author (PP), prepared a questionnaire. SJB and PP prepared the initial set of questions, conducted the voting, modified the statements based on the feedback, analyzed data, and wrote the manuscript [Figure 1].
A total of 13 experts were selected based on their expertise in bariatric nutrition, publications, and patient volume.
An initial mail was sent to individual experts sharing the Delphi protocols. After they agreed to participate, the questionnaire for round 1 [Appendix 1][Additional file 1] was sent through a Google survey form with a field to express their opinion regarding each question.
Any statement achieving 80% or more agreement between experts was taken as a consensus.
In the second round, statements which did not achieve a consensus were resent with the results of the first round and available literature. Experts were asked if they would like to reconsider the responses in light of this information. Some of the questions which did not achieve consensus were also rephrased, and experts were asked if they would agree to the new statements. The second-round survey was sent in the form of a PowerPoint file [Appendix 2][Additional file 2] asking the experts to highlight their preferred response and add any comment.
The same process was repeated for the third round with a PowerPoint file [Appendix 3][Additional file 3].
| Results | | |
Q1. Preoperative testing before sleeve gastrectomy
There was consensus on measuring hemoglobin (Hb), packed cell volume (PCV), serum iron, Vitamin D, Vitamin B12, and albumin before sleeve gastrectomy in the first round. Round 2 failed to achieve additional consensus on other lab indices. In round 3, experts also agreed to measure serum ferritin. There was no consensus on measuring TSAT, serum calcium, phosphorus, thiamine, urinary calcium, Vitamin A, copper, zinc, and parathyroid hormone (PTH) as preoperative screening tests before sleeve gastrectomy.
Q2. Preoperative testing before gastric bypass
There was consensus on measuring Hb, PCV, serum iron, Vitamin D and B12, and albumin before gastric bypass in the first round. In round 2, there was additional consensus on routine preoperative screening of ferritin, TSAT, calcium, phosphorus, and PTH. There was no consensus on thiamine, urinary calcium, Vitamin A, copper, and zinc.
Q3. Preoperative correction of nutritional deficiencies before bariatric surgery
There was no consensus on postponing surgeries pending correction of nutritional deficiencies detected in the preoperative period. However, in round 2, most people agreed that corrections should be started preoperatively and should be continued in the postoperative period except for severe deficiencies.
Q4. Preoperative weight loss before bariatric Surgery
In round 1, experts did not agree on recommending weight loss for all patients as a routine preoperative optimization. However, in round 2, they did agree on recommending selective preoperative weight loss to reduce the liver volume and for achieving preoperative glycemic control.
Q5. Use of bariatric versus over-the-counter formulations
Experts did not agree on specialized bariatric formulations as the only method of multivitamin-multimineral supplementation after bariatric surgery (round 1 and round 2). However, they did agree that bariatric formulations are more suited for postbariatric patients (round 3).
Q6. Duration of supplementation
When asked if they would recommend lifelong supplements as a routine after bariatric surgery, experts did not reach a consensus (round 1). However, there was an agreement on the need for long-term supplementation after diversionary procedures (round 2).
Q7. Difference in supplementation dosage between gastric bypass and sleeve gastrectomy patients
There was no consensus on prescribing double-dose supplements in gastric bypass patients compared to sleeve patients. However, experts agreed on using a higher dose of supplements in patients undergoing gastric bypass compared to sleeve gastrectomy.
Q8. Protein supplementation after bariatric Surgery
There was consensus among experts on providing more than 60 g of protein to patients after bariatric surgery.
Q9. Type of protein supplementation after bariatric surgery
There was consensus on using whey/soy protein in the early postoperative period as a source of protein supplement.
Q10. Route of prophylactic iron supplementation
When asked about the route of prophylactic iron supplementation, there was a mixed response. However, there was consensus in using the oral route as the preferred approach.
Q11. Nutritional screening tests after sleeve gastrectomy
Experts agreed on routine postoperative screening of Hb, PCV, iron, ferritin, Vitamin D, B12, and albumin after sleeve gastrectomy (round 1). In round 2, there was additional consensus on screening of TSAT, serum calcium, phosphorus, and PTH. No consensus was achieved for routine screening of urinary calcium, serum thiamine, Vitamin A, copper, and zinc.
Q12. Nutritional screening tests after gastric bypass
Experts agreed on routine postoperative screening of Hb, PCV, iron, ferritin, Vitamin D, B12, and albumin after gastric bypass (round 1). In round 2, there was additional consensus on screening of TSAT, serum calcium, phosphorus, and PTH. No consensus was achieved for routine screening of urinary calcium, serum thiamine, Vitamin A, copper, and zinc.
Q13. Frequency of nutritional screening after sleeve gastrectomy
There was consensus on doing tests during the follow-up 2–3 times in the first 2 years and then annually.
Q14. Frequency of nutritional screening tests after gastric bypass
There was a consensus on doing tests during follow-up 2–3 times in the first 2 years and then annually.
Q15. Anthropometric tests after bariatric surgery
There was a variable response to the routine anthropometric tests for bariatric patients (round 1). However, experts agreed that their preferred method of anthropometric analysis was body composition analysis.
Q16. Protein supplementation in vegetarians
Experts agreed that vegetarians need a higher protein supplementation than nonvegetarians.
Q17. Difference in supplementation dosage between Roux-en-Y gastric bypass and one anastomosis gastric bypass- mini-gastric bypass patients
Experts did not agree on routinely prescribing higher supplementation dosage for OAGB-MGB patients compared to RYGB. However, there was consensus on prescribing higher supplementation dosages based on the limb length.
Q18. Route of Vitamin B12 for postoperative therapeutic supplementation
There was no agreement on the preferred route of therapeutic supplementation of Vitamin B12. Experts were divided between the oral and parenteral routes.
Q19. Route and dosage of iron for postoperative therapeutic supplementation
Experts agreed on the adequacy of oral iron 50–200 mg per day for 3 months odds ratio 500–1000 mg of IV iron as therapeutic supplementation of postoperative iron deficiency or IDA.
Q20. Route and dosage of Vitamin D for postoperative therapeutic supplementation
Experts agreed on using oral Vitamin D supplements 60,000 units once or twice weekly for 6–8 weeks for treating deficiency states during follow-up.
| Discussion | | |
Consensus from the Indian experts was similar to most international guidelines[1],[2] regarding preoperative screening of Hb, PCV, albumin, iron, ferritin, Vitamin D, Vitamin B12, preoperative weight loss, postoperative prophylactic protein supplementations, therapeutic supplementation of iron, B12 and Vitamin D, postoperative testing, and frequency of follow-up visits [Table 1]. | Table 1: Consensus regarding pre- and postoperative nutritional screening
Click here to view |
However, there were differences on a few issues. Experts did not agree on the routine preoperative testing of serum folate and thiamine. When experts were asked to comment on the topic, the reasons given were high cost and low yield rate. However, data from Indian general population suggest a high deficiency of folate and thiamine in the general population.[6] We need more data from Indian bariatric population to understand the magnitude of the problem and guide clinical practice.
Experts did not agree on universal lifelong supplementation with bariatric formulations either after SG or GB. However, they did agree on the need for “long-term” supplementation after GB without defining “long-term.” The ASMBS guidelines also suggest long-term supplementation for all postbariatric patients.[1] On discussion, most experts agreed that after 5–7 years, the supplementation should be individualized according to the need and profile of the patients. Of course, to do this, more long-term data need to be available. Till that time, it may be prudent to continue with the ASMBS-recommended dosage in the long term for these patients.
They also said that formulations, whether bariatric or over-the-counter, are acceptable if they supply adequate dosages as per the recommendations. This is especially important to understand and adapt for countries with cost restraints like ours. Prescribing low-cost supplements may improve compliance in patients who have problems affording bariatric formulation.[7],[8]
Experts did not agree that the supplementation of OAGB-MGB needs to be different from RYGB. However, they agreed that supplementation after both RYGB and OAGB-MGB should depend on the limb length. This is backed up by some data in the literature. A study compared a biliopancreatic limb of 150 versus 250 cm in OAGB and demonstrated that deficiencies were more prevalent in the latter.[9] Similarly, the limb lengths in RYGB have been shown to affect the malnutrition rates.[10] However, a multicenter study from India reported a higher protein deficiency and anemia in OAGB-MGB compared to RYGB without mentioning the limb lengths.[11] Although it is not the scope of this consensus, we would like to highlight that OAGB needs to be offered carefully to a vegetarian population, given these findings. A recent publication from a Delphi consensus said that OAGB can be offered safely to a vegetarian population.[12] However, clearly, more research on this subject is needed before establishing the safety of the procedure in a vegetarian and/or sarcopenic population.
Experts did not agree on postponement of surgery for the correction of deficiencies detected preoperatively. However, they did agree that all therapeutic supplementations should be started in the preoperative period and should be continued postoperatively. Experts also said that a preoperative correction to a reasonable level should be aimed for in case of severe deficiencies. Few societies like BOMSS recommend correction of nutritional deficiencies before the surge.[2] However, it is less evidence based and is categorized as a “Good Practice Point.”
This is the first consensus statement on perioperative nutritional practices from India. Delphi has several advantages over face-to-face meetings. The anonymity of the experts leads to uninfluenced response and reduces conflict between experts. In addition, controlled feedback allows participants to reconsider their responses without undue pressure.
There are certain limitations of the study. The expert selection and an 80% cutoff for consensus can be considered arbitrary. In addition, the size of the expert panel was small, making the consensus less reproducible. We would also like to highlight that any lack of consensus does not mean an agreement to the contrary. In fact, even with the statements where we could not achieve an 80% agreement, 60%–70% of the experts voted in favor of the statements.
Future research should focus on producing high-quality prospective data, so we can formulate regional guidelines backed up by evidence.
| Conclusion | | |
To summarize, experts in India agree regarding preoperative screening tests, postoperative monitoring, and nutritional management on follow-up. There is a lack of consensus on duration of supplementation, perioperative screening for folate and thiamine, and dosage of supplements in OAGB. The lack of consensus in this process is reflective of inadequate data available on the subject. We need a better-quality regional data to formulate guidelines that can provide evidence-based guidance for the clinical practice.
Data availability
Data are available with the authors and can be provided on request.
Financial support and sponsorship
Nil.
Conflicts of interest
Author 1, Author 2, Author 3, Author 4, Author 5, Author 6, Author 7, Author 8, Author 9, Author 10, Author 11, Author 12, Author 13, Author 14, and Author 15 have no conflicts of interests to declare. The corresponding Author is submitting a CoI form on behalf of all the authors.
Keypoints
Important consensus achieved:
- Preoperative testing of Hb, PCV, serum iron, vitamin B12, vitamin D3, albumin, and serum ferritin before sleeve gastrectomy, and Hb, PCV, serum iron, vitamin B12, vitamin D3, albumin, serum ferritin, TSAT, serum calcium, phosphorus, and PTH before gastric bypass
- Postoperative testing of Hb, PCV, serum iron, ferritin, vitamin B12, vitamin D3, albumin, TSAT, serum calcium, phosphorus, and PTH after sleeve gastrectomy and gastric bypass
- For deficiencies detected in preoperative period, corrections should be started preoperatively and should be continued in the postoperative period except for severe deficiencies which should be corrected before surgery
- Specific bariatric formulation for supplementation is preferred over OTC formulations. A higher dose of supplementation is needed for gastric bypass patients compared to sleeve gastrectomy patients. Vegetarians need a higher protein supplement compared to nonvegetarians. The limb length should be considered when deciding supplementation dosage for diversionary procedures
- Nutritional tests should be done 2–3 times in the first two years and then annually.
| Appendixes | | |
Appendix 1: Round 1 questionnaire
Appendix 2: Round 2 questionnaire with round 1 responses
Appendix 3: Round 3 questionnaire with round 2 responses
| References | | |
| 1. | Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, et al. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: Cosponsored by American association of clinical endocrinologists/American college of endocrinology, the obesity society, American society for metabolic & bariatric surgery, obesity medicine association, and American society of anesthesiologists. Surg Obes Relat Dis 2020;16:175-247.  |
| 2. | O'Kane M, Parretti HM, Pinkney J, Welbourn R, Hughes CA, Mok J, et al. British obesity and metabolic surgery society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update. Obes Rev 2020;21:e13087. |
| 3. | Bhasker AG, Prasad A, Raj PP, Wadhawan R, Khaitan M, Agrawal AJ, et al. Trends and progress of bariatric and metabolic surgery in India. Updates Surg 2020;72:743-9. |
| 4. | Remedios C, Bhasker AG, Dhulla N, Dhar S, Lakdawala M. Bariatric nutrition guidelines for the Indian population. Obes Surg 2016;26:1057-68. |
| 5. | Niederberger M, Spranger J. Delphi technique in health sciences: A map. Front Public Health 2020;8:457. |
| 6. | Gonmei Z, Toteja GS. Micronutrient status of Indian population. Indian J Med Res 2018;148:511-21. [ PUBMED] [Full text] |
| 7. | Mahawar KK, Clare K, O'Kane M, Graham Y, Callejas-Diaz L, Carr WR. Patient perspectives on adherence with micronutrient supplementation after bariatric surgery. Obes Surg 2019;29:1551-6. |
| 8. | James H, Lorentz P, Collazo-Clavell ML. Patient-Reported adherence to empiric vitamin/mineral supplementation and related nutrient deficiencies after Roux-en-Y gastric bypass. Obes Surg 2016;26:2661-6. |
| 9. | Ahuja A, Tantia O, Goyal G, Chaudhuri T, Khanna S, Poddar A, et al. MGB-OAGB: Effect of biliopancreatic limb length on nutritional deficiency, weight loss, and comorbidity resolution. Obes Surg 2018;28:3439-45. |
| 10. | Wang A, Poliakin L, Sundaresan N, Vijayanagar V, Abdurakhmanov A, Thompson KJ, et al. The role of total alimentary limb length in Roux-en-Y gastric bypass: A systematic review. Surg Obes Relat Dis 2022;18:555-63. |
| 11. | Baig SJ, Priya P, Mahawar KK, Shah S, Indian Bariatric Surgery Outcome Reporting (IBSOR) Group. Weight regain after bariatric surgery-a multicentre study of 9617 patients from Indian bariatric surgery outcome reporting group. Obes Surg 2019;29:1583-92. |
| 12. | Kermansaravi M, Parmar C, Chiappetta S, Shahabi S, Abbass A, Abbas SI, et al. Patient selection in one anastomosis/mini gastric bypass-an expert modified Delphi consensus. Obes Surg 2022;32:2512-24. |
[Figure 1]
[Table 1]
|
Search Pubmed for