INCLUDES GUIDELINES ON • Annual review after surgery • Drug therapy during weight-loss David W Haslam Colin Waine Anthony R Leeds Medical Management During Effective Weight-loss National Obesity Forum www.nationalobesityforum.org.uk Medical Management During Effective Weight-loss National Obesity Forum 2010 Reprinted with corrections 2010 Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss Foreword
Since the advent in the UK of surgery for obesity, and with an increasingly strong evidence base
Options for achieving weight-loss in medical practice
for use of formula low calorie and very low calorie diets, more healthcare practitioners in bothprimary and secondary care are seeing patients who are losing larger amounts of weight than
Medical management after bariatric surgery
The patient undergoing therapeutic weight-loss requires management of all the other aspects of
bodily function that are affected by reduced dietary energy, modified gut function (after surgery),
and altered hormonal and metabolic processes.
The healthcare practitioner needs a clearly presented set of guidelines, based on sound science
Metabolic complications after bariatric surgery (bypass)
and medical evidence, to enable changes to drug therapy and guidance on diet and lifestyle tobe made, and advice to be given with confidence.
The purpose of this publication is twofold:
• To provide outline guidance for healthcare practitioners caring for patients after
bariatric surgery, following discharge from the surgical unit.
Changes in therapy for other conditions during weight-loss
• To provide outline guidance on management of other medical conditions during
effective weight-loss, whether following surgery or following non-surgical methods,
such as very low calorie diets, part-formula low calorie diets and drugs.
This short handbook is based on current guidelines, published research and current practice, but may change as new information becomes available. Practitioners are advised to check for
later versions at www.nationalobesityforum.org.uk for any recent revisions.
Acknowledgements, biographical notes and declarations of interest
Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss Options for achieving weight-loss in medical practice
Body weight reduction can be achieved by reducing dietary energy intake, increasingactivity and by altering a number of behaviours relating to eating and activity andinactivity. In practice this means following an energy restricted diet and increasing physicalactivity as a first step. When first reviewed by the dietitian, there may be scope for changeor the patient may already have learned from many sources over many years. Behavioursassociated with being overweight, such as comfort eating, may be acknowledged by thepatient or may be denied. Drug therapy in the UK is at present limited to the use of onedrug: orlistat (Xenical®). Many other drugs are under investigation and within five yearsseveral others will be available. Drug types which are known to limit dietary energy intakein some patients, but for which the licensing is not yet specifically for weight-loss, such asGLP-1 analogues, may become available. Special diets for which there is scientificevidence for effective weight-loss have a place in practice – among these are formulavery low calorie diets (VLCD) and part-food-part-formula low calorie diets (Riecke BF et al. 2010, Johansson K et al. 2009). For the patient who meets NICE criteria (or the patient whoarranges a procedure privately), bariatric surgery is now increasingly available.
During effective weight-loss the amounts of weight lost may have appreciable effects on other conditions and the need for therapy. Following bariatric surgery there is arequirement for long-term follow-up and the account below outlines some of the needs. Weight-loss with formula diets will be used increasingly in the coming years, and peoplewho achieve weight-loss in this way require medical reviews at intervals and reappraisalof their medication needs. Medical management after bariatric surgery
Bariatric surgery is undertaken in order to achieve clinically meaningful weight-loss toreduce obesity-related conditions to more manageable levels. A range of metabolicchanges occurs after surgery, including increased insulin sensitivity, increased adiponectinlevels (an indicator of reduced risk of vascular disease) and decreased pro-inflammatorycytokines. Decreased amounts of fat in specific places may improve or ‘cure’ specificconditions: obstructive sleep apnoea, gastro-oesophageal reflux and urinaryincontinence. Decreased total body weight reduces cardiac work, load on joints andimproves posture and walking ability. Procedures which bypass the foregut adjust therelease of gut hormones, which stimulate (ghrelin) and suppress appetite (GLP-1 and PYY),resulting in improved appetite control. Psychological status and social status oftenimprove, as do measures of quality of life.
In practice, the variety of procedures and the absence of guidelines for long-term management present difficulties in primary care. Ultimately, all patients will be dischargedback into the general practitioner’s care, whether from a UK NHS bariatric unit or followinga procedure in the private sector abroad or in the UK. Medical Management During Effective Weight-loss Medical Management During Effective Weight-loss Types of surgery Roux-en-Y gastric bypass Gastric banding
Figure 2. Roux-en-Y bypass Dugal Heath FRCS reproduced with permission.
A small 30ml gastric pouch is created by cutting across the stomach and is connected to
Figure 1. Laparoscopic band procedure Dugal Heath FRCS reproduced with permission.
the small bowel, which has been divided 80-100 cm below the pylorus. The ‘blind loop’,with the remaining stomach at its head and with bile and pancreatic juice draining into
A gastric band creates a small pouch with a narrow outlet. The band is adjustable (it is
the duodenum followed by about 50-60 cm of jejunum, is then connected via a new
usually not filled until six weeks after surgery). The patient needs to be fully prepared for
jejuno-jejunostomy about 80cm below the gastro-jejunostomy. The effect is to divert the
the reduction of food intake and educated about choices needed to achieve an adequate
food-stream, bypassing important absorptive areas and creating a possible mistiming
dietary intake. The patient needs to work with the procedure to eat appropriately and
of substrate and enzyme mixing after the jejuno-jejunostomy.
follow exercise and lifestyle choices appropriate for a weight-losing regimen, rather than try to follow the former lifestyle and eating habits.
The efficiency of absorption is reduced, but there are also specific risks of iron, B12 and calcium deficiency. There are also risks of early and late dumping syndrome.
Since this procedure does not interfere with digestion and absorption, nutritional status
Early dumping syndrome may occur if hypertonic food leaves the gastric pouch rapidly
ought not to be impaired, but commonly occurring problems (iron, vitamin D and calcium
(thus a sugar-containing drink may cause this), and results in a rapid rise of glucose
deficiency) may still occur. If the quality of the diet is believed to be poor after surgery,
followed by a rebound hypoglycaemia, causing nausea, sweating and faintness.
there may well be an inadequate intake of micronutrients.
The hypertonic gut content may draw fluid from the vascular space into the gut causingtransient tachycardia. Rapid movement of this meal through the gut may then cause an
During weight-loss, medications which are continued (see below) may need to be given
in liquid form, since tablets and capsules may not pass easily through the stricture. Biliopancreatic diversion (BPD)
The gut is dynamic and does change in response to the reduced food intake, but themajor changes of gut hormones seen after bypass surgery do not occur and there maybe little effect on appetite control. Patients may not feel full after eating. They may betroubled by hunger after gastric banding and may need help to overcome this.
Figure 3. Duodenal switch procedure Dugal Heath FRCS reproduced with permission. Medical Management During Effective Weight-loss Medical Management During Effective Weight-loss
As with Roux-en-Y, this procedure combines both restrictive (creation of a gastric pouch)
After Roux-en-Y bypass, 80-90% of people with type 2 diabetes may go into remission,
and malabsorptive components, but creates a greater reduction of absorptive efficiency
while after banding 40-80% may enter remission. Hypertension and sleep apnoea may
by leaving a much shorter length of small gut (50-60cm), within which digestion and
go into remission in some patients and dyslipidaemias, especially secondary
absorption occurs. After BPD, patients are more likely to show overt features of
malabsorption, diarrhoea and offensive stools. The range of potential long-term effects after BPD is similar to that following Roux-en-Y, but more so. Drug therapy after bariatric surgery
A review of drug therapy for co-morbidities in 114 patients treated with gastric bypass
showed that the greatest changes in medication use occurred in drugs for diabetes
Duodenal switch is a modified biliopancreatic diversion, where a long gastric sleeve and
and hypertension (Malone and Alger-Mayer 2005). Out of 28 patients using insulin
the first part of the duodenum act as the proximal pouch and are connected to the ileum.
preoperatively, 22 discontinued its use by two years. Metformin and sulphonylurea use was
The remaining duodenum and jejunum, the bypassed loop, is connected at the ileum.
reduced from 25 to four cases, and 27 to one case from preoperative to two years post-op.
This procedure severely restricts digestion and absorption and 80% of patients achieve
Thiazolidinedione use was halved. ACE inhibitor or receptor blocker use was reduced from
33 to 15 cases, beta-blocker use from 21 to 11 cases, calcium channel blocker use from 21 to ten cases and diuretic use from 54 to 19 cases from preoperative to two years
post-op. Most of these changes appear to have been made by the three-month review.
In other areas the patterns were different. For depression, SSRI use was reduced from 49 to 35 cases, but tricyclic antidepressants and benzodiazepine use was down from 19 to six cases from preoperative to two years post-op. For osteoarthritis, use of NAIDsand COX-2inhibitors was down from 59 to 33 cases from preoperative to two years post-op.
Drugs for surgery related problems were, not surprisingly, increased. Gastric acidityreducing drugs (H2 receptor anatagonists and proton-pump inhibitors) increased fourfold. In this series of US cases, ursodeoxycholic acid (to inhibit cholesterol gallstoneformation or reduce stone size) was not used preoperatively, but was used in 45 casesaround the time of surgery and in only ten cases at two years. Allopurinol to reduce uric
Figure 4. Sleeve gastrectomy Dugal Heath FRCS reproduced with permission.
acid levels, used in 24 cases preoperatively, was used by only ten cases by two years. Nutritional supplements were increased fourfold from preop to two years post-op,
This reduction of stomach volume is usually done as the first of two stages offered to
though surprisingly nearly 10% were not taking a supplement at two years.
super-obese patients. Stomach volume is reduced, but the small gut is left intact at this first stage. This is thus a restrictive procedure. Subsequently a bypass procedure is added.
This particular US pattern of drug use change after surgery may not be replicated in other
By the time the patient is followed up in primary care, the issues will be the same as for
settings but, with the exception of use of ursodeoxycholic acid, there are likely to be
similarities between US and UK experience. Gastric balloons and gastric and duodenal sleeves Metabolic Complications after bariatric surgery (bypass)
Gastric balloon insertion is not a common procedure in the UK. The insertion of gastric
The risk of complications is dependent on the nature of the surgery and the degree
and duodenal sleeves to bypass the upper gut internally are experimental procedures
of bypass and the relative lengths of the small intestinal loops, either bypassed or
at the present time and are not yet approved by regulatory agencies.
functioning for absorption. All are likely to develop vitamin B12 and iron deficiency. Many UK patients have low or deficient vitamin D status preoperatively, due to low
Effects of bariatric surgery
exposure to sunlight (between October and March most people in the UK do not
Weight reduction is likely to be greatest after BPD, followed by Roux-en-Y bypass, where
synthesise vitamin D, unless they take a winter holiday in the sun), low dietary intake and
up to 80% of excess weight may be lost by four years post-operatively. Gastric banding
effects of their previous experience of weight-losing regimens. Vitamin D status and bone
generally can result in up to 60% of excess weight-loss.
health, therefore, need to be watched. Serum trace elements such as Zinc, Selenium andCopper levels have been shown to fall in the majority of patients post-bariatric surgery.
Effects of surgery on co-morbidities are also weight-loss and procedure dependent.
The serum levels of trace elements may not accurately reflect tissue and organ stores, so reliance on blood levels may be misleading. Medical Management During Effective Weight-loss Medical Management During Effective Weight-loss
Table 1: Metabolic complications of bypass bariatric surgery
From one year and onwards, all bariatric surgery patients should be followed up annually,
Complication Clinical features Management
even where there are metabolic co-morbidities (the exception is the post BPD patient who
should be seen six-monthly: AACE/TOS/ASMBS Bariateric Surgery guidelines). After two
years this care would usually be transferred to primary care, provided that the primary
care setting can supply adequate support.
Table 2: Recommended investigations of nutritional status after bypass and band
procedures at annual review after two years post-op
Roux-en-Y gastric bypass Gastric band (and duodenal switch)
Adapted (in part) from Table 13 AACE/TOS/ASMBS Bariatric Surgery guidelines, Endocr Pract 2008; 14 (Suppl 1) 1-83.
For BPD, an extended list of investigations is suggested (see the AACE/TOSA/ASMBS guidelines). *the frequency of DEXA scans should be annual after BPD, but the frequency after gastric bypass
Adapted from Table 8 AACE/TOS/ASMBS Bariatric Surgery guidelines, Endocr Pract 2008; 14 (Suppl 1) 1-83. Post-operative guidance on diet
Each surgical unit will give guidance on the diet to be followed in stages after surgery. By the time of return to primary care at the two years post-operative time point, the lowfood intake is selected from a healthy balanced diet chosen from adequate proteinsources, fruits, vegetables and whole grains. Use of small plates may help to controlportion size. The energy (calorie) needs are based on height, weight and age. Since totalfood intake is relatively low, a vitamin and mineral supplement has to be taken dailyindefinitely.
Medical Management During Effective Weight-loss Medical Management During Effective Weight-loss
Table 3: Routine nutrient supplementation after bypass surgery
For patients who have had a bypass procedure:
Supplement Product examples
A medical review, a referral to the dietitian (particularly where there is a known history of eating disorder) and measurement of a limited list of variables is indicated (Table 2).
A reassessment of cardiac risk factors (it must be remembered that conventional formulae
for calculation of risk are not valid following bariatric surgery) and a reappraisal of needfor drug therapy are indicated. A check on aspects of lifestyle, including physical activity,
is indicated. At a suitable point in time, referral for plastic surgery may be appropriate.
The medical review should include questions about eating habits, speed of eating,
dysphagia, hunger and difficulty with eating particular types of foods.
The patient should be referred back to the specialist unit if there is:
Adapted from Table 14 AACE/TOS/ASMBS Bariatric Surgery guidelines, Endocr Pract 2008; 14 (Suppl 1)
1-83 and from material prepared by Ella Segaran of NLOSS for BOSS Dietitians, November 2008.
*recommendations for B12 and iron are higher in the US than in the UK, for B12 1mg/3mo may be
Patients who become pregnant after bariatric surgery should be managed within an
regarded as sufficient and iron up to 45mg/d may be sufficient.
obstetric unit in a centre which also has a bariatric surgical unit.
As the number of people treated with bariatric surgery in the UK rises, the numberspassing the two-year follow-up in secondary care will rise and there will be a need forannual follow-up in primary care. Formal protocols will be developed by individualbariatric units and national guidelines will be published. In the meantime, the followingpoints of guidance may be useful at the annual review at two and three years andsubsequently.
Does the surgical unit issue guidelines for management beyond two years?
Do you have the report and final set of biochemical tests at two years?
Have any problems developed during that time?
What percentage of excess body weight has been lost?
Have all adjustments to therapy for co-morbidities been made?
For patients who have had gastric banding:
A medical review, a referral to the dietitian (particularly where there is a known history of eating disorder) and measurement of a limited list of variables is indicated. A reassessment of cardiac risk factors (it must be remembered that conventional formulaefor calculation of risk are not valid following bariatric surgery) and a reappraisal of needfor drug therapy are indicated. A check on aspects of lifestyle, including physical activity, is indicated. At a suitable point in time, referral for plastic surgery may be appropriate. Medical Management During Effective Weight-loss Medical Management During Effective Weight-loss
be as good as they were immediately after weight-loss (Lanz et al. 2003). There is a
Weight-loss using non-surgical methods
developing scientific literature on the potential role for chronic dietary energy restriction on
Body weight reductions are characteristically of the order of 8-10 kg following drug
prolonged improvement of disease risk factors and weight maintenance (with implications
therapy in responders after six months of treatment and of the order of 18kg after
for prolonged longevity). New drug, dietary and surgical methods to achieve chronic
six months of a formula diet programme beginning with VLCD (Franz et al. 2007).
dietary energy intake restriction will be used to help achieve weight maintenance.
VLCD (400-800 kcal/d) are diets formulated to provide the daily requirement of vitamins,minerals, essential fatty acids and dietary fibre. Low energy diets (800-1200 kcal/d) may
Changes in therapy for other conditions during weight-loss
be food-based or part-formula-part-food-based, or may be liquid formula diets. There isa place for removal of all conventional food in some patients (who have previously
Diabetes (Type 2)
struggled to comply with a food-based restricted diet) and substitution with formula diet
Following bariatric surgery
for a period of time prior to the gradual reintroduction of conventional food, with education about healthy eating and lifestyle as energy intake rises to a new lower
After gastric banding oral medications for diabetes are continued at the preoperative
maintenance level [25kcal/d lower than the baseline dietary energy intake for each
dose and then reduced according to indicators of glucose control. The immediate
kilogram of weight lost]. The NICE guidance on use of VLCD recommends that
reduction of dietary energy intake is likely to reduce glucose levels and hypoglycaemia
uninterrupted use should not continue for more than 12 weeks. Many individuals following
needs to be avoided. Self-testing of blood glucose and recording of values in a diary
a VLCD develop a physiological ketosis which may help to suppress hunger, improve
and making a note of any episode of hypoglycaemia (with a request for a check on
mood and facilitate dietary compliance. VLCD formula diets contain all required
blood glucose levels at the time of the hypo, where this is possible) are essential during
micronutrients so nutritional status may be improved after weight-loss, especially in those
weight-loss after surgery. During weight-loss the patient should be in close contact with
with marginal baseline status, in contrast to the impairment of nutritional status seen after
the managing team and the diabetes specialist nurse or practice nurse must be made
fully aware of the patient’s surgical timetable.
Weight reductions of this order of magnitude [8-18kg and above] cause improvement
As dietary energy intake falls, the drugs most likely to cause episodes of hypoglycaemia
in insulin sensitivity, reduction of blood pressure and symptom improvement in
should be reduced in dose and stopped first (e.g. sulphonylureas), whereas metformin
can be left in place. The need for metformin to be left in place can be reviewed two tothree months after surgery.
Other medical conditions need to be reviewed and medication requirements need to be reassessed during effective weight-loss. Medications for diabetes require regular review
After a gastric bypass or following BPD, all oral medications for diabetes would be
and adjustment. Therapy for hypertension may likewise change and practitioners should
stopped at the time of surgery and the need for any therapy to be reinstated judged some
look out for symptoms of hypotension. Other forms of therapy are likely to remain
months later. Whether this is good practice is yet to be determined. Glucose monitoring
unchanged or possibly reduced in dose.
gives an important record for judging response to surgery. Change of body weight versus reduced dietary energy intake
Patients on insulin therapy ought, depending on dose and the duration of the disease(time since diagnosis of diabetes), to reduce dose according to blood glucose response.
A weight-reducing regimen reduces two primary variables: body weight and dietary
A big drop in insulin requirement can be anticipated with the drop in dietary energy
energy intake. Metabolic effects of weight-loss may be related to weight-loss or reduced
supply immediately following surgery, although some of this reduction ought to have
dietary intake or both. A reduction of dietary energy intake increases flux along some
occurred preoperatively during the preoperative dietary preparation when energy is
pathways and reduces it along others. There is little doubt that pro-inflammatory cytokine
restricted in order to achieve liver shrinkage. Where the preoperative dose was low, it is
production is reduced during energy intake restriction and clinicians know that caloric
likely that this could be stopped altogether at the time of surgery. Patients on much higher
restriction reduces pain in both rheumatoid and osteo-arthritis. Chronic caloric restriction
doses ought perhaps to be prepared preoperatively for a longer period to achieve some
improves biomarkers of longevity and oxidative stress (Heilbronn et al. 2006) as well as
loss of visceral adipose tissue as well as liver mass and reduced insulin resistance. Blood
classical cardiac risk factors. Reduced energy supply to the liver reduces triglyceride
glucose monitoring and close contact and monitoring by the diabetes team is essential.
synthesis, in turn reducing plasma triglyceride and LDL cholesterol.
GLP-1 analogues and related drugs would be discontinued at the time of surgery.
At the end of a three or six month weight-loss programme, blood lipids and bloodpressure may well be lower than at baseline and adjustment of therapy may beappropriate (see below). At two years body weights may be significantly reduced belowbaseline and the patient may have fewer symptoms, but risk factors need to be reviewedagain at one year and two years since some patients may be on a slow weight regainwith a slightly higher dietary energy intake than is desirable and markers of risk may not
Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss During weight-loss with VLCD, LED and drugs
but also by indicators of renal function (in the patient who is also diabetic), includingserum creatinine and urine albumin-creatinine ratio.
The fall in dietary energy supply would usually be expected to reduce requirement forboth oral therapy and insulin if these are being used. It is essential to avoid episodes of
A recently published meta-analysis on blood pressure responses to drug therapy
hypoglycaemia. Sulphonylureas and thiazolidendiones would best be reduced in dose
indicates that there is benefit in lowering blood pressure in anyone at sufficient
and discontinued as soon as possible, in line with blood glucose results, but it is wise to
cardiovascular risk, regardless of blood pressure (Law et al. 2009). Hypertension therapy
drop the dose of sulphonylureas or discontinue them altogether at the time of
after weight-loss is therefore probably best judged on the basis of home monitoring of
commencement of the diet, rather than wait for episodes of hypoglycaemia.
blood pressure, rather than doctor’s office measurements (if possible) and presence orabsence of side effects or symptoms of hypotension. There is no lower threshold below
Insulin requirements are likely to be reduced rapidly when patients follow formula low
which lowering blood pressure gives no further benefit in terms of cardiovascular risk
energy diets or VLCD, and pre-emptive reduction of dosage by 25% at the time of
(within the ranges studied and currently reported in the literature).
commencement may be appropriate. However, it is important to note that a gradualtitration of dietary energy intake downwards, through a series of steps (1500, 1200, 1000,
maybe 800 kcal/d) with daily monitoring of blood glucose and regular contact with thediabetes management team to determine a gradual reduction of dosage, may be
Weight-loss influences thyroid hormone levels, but in routine practice no replacement
preferred by some physicians over a sudden drop in dietary energy requiring a rapid
therapy is introduced, unless biochemical hypothyroidism is demonstrated. Functional
hypothyroidism with high levels of reverse T3 may occur, but in the UK we have nostandard approach in place to address this. It is likely that clinical trials currently underway
There are no formal guidelines on the use of metformin at low dietary energy intake
in the US may provide an indication of when and how any thyroid adaptation to weight-
levels, but even at baseline, some patients may be using a relatively high and possibly
loss can be corrected pharmacologically, but in the meantime conventional criteria must
ineffective dose above 2g/d and may be taking it when markers of renal function suggest
be used. Any existing thyroid medications must remain in place and unchanged after
that it should be discontinued. Hydration state may influence the potential threat to renal
bariatric surgery and during weight-loss with VLCD, low energy diets or drugs. A review
function posed by metformin and it may be wise to discontinue metformin below
of thyroid status at three, six and/or nine months after commencement of the weight-loss
800kcal/d or when, after surgery, there may be concern about adequate hydration.
The need for metformin could then be reassessed afresh two or three months aftercommencement of the diet or after surgery. Blood lipid lowering drugs
Total blood cholesterol, LDL cholesterol and blood triglyceride often improve after weight-
loss, but careful examination of the published literature shows that the lipid lowering
Following bariatric surgery
effect is often not sustained at six months or one year after treatment, perhaps becauseof weight gain or perhaps because dietary energy intake has risen sufficiently to drive up
Body weight reduction and reduced dietary energy intake lower blood pressure.
Medications for hypertension should remain in place after surgery, except when dosereduction is indicated by repeated blood pressure measurements or where electrolyte
A conservative approach is to leave lipid-lowering therapy in place and remeasure blood
measurements suggest reduction of diuretic use. Beta-blocker use may be reduced or
lipids three and/or six months later, before withdrawing any drugs.
stopped fairly soon, if not at the time of surgery, especially if it is believed to be limitingphysical activity. This is subject to satisfactory blood pressure readings, which ought to
Statins are probably best left in place, but fibrates and other triglyceride lowering drugs
be done weekly during the early phases of weight-loss after bypass (more frequently
might be withdrawn if a sustained adequate reduction of triglyceride to low levels is
if needed), but perhaps every two to three weeks after banding.
achieved following weight-loss. Even partial weight regain or a return to higher dietaryenergy intake levels may result in a rebound of triglyceride levels. During weight-loss with VLCD, LED and drugs
The electrolyte and water changes on commencement of a VLCD can be quite marked,
Conventional formulae for calculation of cardiac risk are not valid after bariatric surgery.
and if the patient is only using a diuretic, there may be merit in stopping this or reducingdosage on commencement of the diet. Frequent (weekly) measurements of blood
Aspirin, anti-platelet drugs, warfarin and heparin
pressure are indicated (more frequently if there is concern), falling to fortnightly when the
Aspirin should be continued but the inhibitory effects of aspirin and ketones on
The longer-term need for therapy can be reassessed at three and/or six months, when the
renal uric acid handling need to be considered for those on very low calorie
merits of continuing ACE inhibitors and AR blockers can be judged, not just by blood pressure,
Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss Anti-platelet drugs
There is no evidence that oral contraceptives are less effective after weight-loss, but the patient should be advised of these possible changes and may care to make appropriate
Clopidogrel and related drugs should be continued.
choices, and consider other methods of contraception. Warfarin Drugs for arthritis
Warfarin dose response is influenced by dietary vitamin K. There are few
Reduced dietary energy intake or absorption often results in an improvement in
reported cases of problems arising during weight-loss and these relate to
symptoms in rheumatoid arthritis, possibly due to a reduction of inflammatory cytokine
extreme changes of diet not usually seen (see below).
production. Recently published evidence suggests that similar changes may occur inosteoarthritis with symptom reduction after effective weight-loss.
No RDA was given in EU Council Directive 90/496/EEC, but the generally accepted requirement for vitamin K is about 1µg/kg. Thus an 80kg man would
Drug regimens may need to be changed on a case-by-case basis, according to
require 80µg/d and a 65kg woman about 65µg/d. Vitamin K requirement in
symptoms and markers of disease activity. Some patients may be able to stop or reduce
morbidly obese individuals or during weight-loss has not been determined
Drugs for gastric hyperacidity
If intake or absorption of vitamin K were to change significantly, the dose of warfarin may need to change. Measurement of the INR at baseline and a few
Proton pump inhibitors and H2 receptor antagonists may be continued as previously.
days after each major dietary change is recommended. Where formula diets
With medical and dietary weight reduction, gastro-oesophageal reflux may be reduced,
are used (usually containing 40µg vitamin K per portion or sachet of product),
but the evidence for a benefit in reducing risk of oesophageal carcinoma needs to be
each change of dietary level with consequent change of vitamin K intake ought
considered before therapy is stopped. After surgery there may be a greater need for
to be followed by an INR test a few days later. Consistency of intake from
proton pump inhibitors in some cases.
day to day is important and those using formula diets should not change the amount of formula product consumed from day to day. Antipsychotics
Medication should continue unchanged unless adjusted in consultation with the patient’s
A case report (Quereshi GD et al. 1981) described warfarin resistance in
someone following a vegetable-rich weight reducing diet (calculated to contain 1270µg/d of vitamin K), who became less resistant to warfarin when moved to
a ‘regular’ diet (containing 360µg/d vitamin K).
Antidepressants should continue unchanged until a relatively stable steady state has
been achieved, when gradual dose reduction and cessation may be possible in somecases.
Indications for heparin use remain unchanged. Contraceptive pill
Blood lithium levels are likely to change and measurement of blood levels is indicated,
Weight-loss alters the hormonal milieu, often reduces insulin resistance and often allows
especially during rapid weight-loss.
pregnancy to occur in those who have long failed to achieve this. Any womancommencing an effective weight-loss programme, whether surgical or medical, needs to
be aware that fertility may change and that long-held assumptions about contraceptiveefficacy may no longer apply.
The effect of dietary energy restriction and/or weight reduction on suppression of pro-inflammatory signals may allow gradual dose-reduction. Anticonvulsants
Loss of abdominal fat may change pelvic anatomy – if barrier methods are used, reassessment of size and fit may be needed.
Anticonvulsant therapy must continue throughout weight reduction, following either
Liver steatosis may be decreased with a change of hepatic capacity for drug
surgery or diet. Changed body weight and hepatic function may change the dose
requirement and this may be judged by measuring blood levels or observing clinical
The dynamics of oestrogen cycling within the gut may change and the
response. Asking the patient to keep a diary of clinical events (fits) and notes on causes
efficacy of oral contraceptives may also change. Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss References
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metabolism. Blood uric acid levels tend to be higher in overweight and obese people and
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the process of weight-loss raises uric acid further. Any ketosis occurring during weight-
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meta-analysis of 147 randomised trials in the context of expectations from prospective epidemiological studies.
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BMJ 2009; 338; b1665; doi: 10.1136/bmj.b1685.
gout during weight-loss. Where appropriate, uric acid lowering therapy should be
Malone M, Alger-Mayer SA. Medication use patterns after gastric bypass surgery for weight management.
National Institute for Clinical Excellence Clinical Guidline 43 Obesity at:http://www.nice.org.uk/guidance/index.jsp?action=download&o=30365
Many overweight and obese patients have already developed gallstones, which in many
Qureshi GD, Reinders TP, Swint JJ, Slate MB. Acquired Warfarin Resistance and Weight-Reducing Diet.
cases may be asymptomatic. In many cases the gall bladder may be non-functioning.
During weight-loss the litho-genicity of the bile may increase, though scientific evidence
Riecke BF, Christensen R, Christensen P, Leeds AR, Boesen M, Lohmander LS, Astrup A, Bliddal H. Comparing two
supporting this idea is weak. An effective weight-loss regimen, whether surgical or
low-energy diets for the treatment of knee osteoarthritis symptoms in obese patients: a pragmatic randomized
medical, will perturb the physiological dietary fat-induced gall bladder filling and draining
clinical trial. Osteoarthritis and Cartilage 2010; 10/1016/j.joca. http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6WP3-4YDKK1R-
cycle and patients should be warned that there is an increased risk of developing
symptoms due to gallstones during an effective weight-loss programme.
Sjöström L et al. Lifestyle, Diabetes and Cardiovascular Risk Factors 10 years after Bariatric Surgery. Vitamin D status
New England Journal of Medicine 2004; 351: 2683-93 [Swedish Obesity Subjects (SOS) Study]. See also:
A proportion of people entering the surgical pathway or about to commence a medical
Aills L et al., ASMBS Allied Health Nutritional guidelines for the surgical weight-loss patient. Surgery for Obesity and
weight-loss programme may be vitamin D deficient or have low-normal levels, possibly
Related diseases 2008; 4: S 73-S108.
due in part to repeated weight-loss attempts with dietary regimens, which result ininsufficient dietary vitamin D intake. At UK latitudes, vitamin D is not synthesised in the
Websites and resources
skin during autumn and winter (October to March). There may be merit in measuring
The National Obesity Forum is not responsible for the content of other websites.
blood levels before any weight-loss regimen. Vitamin D status should be checked after
National Institute for Clinical Excellence Obesity Guidelines: Dietitians in Obesity Management http://domuk.org/category/home/ http://domuk.org/wp-content/uploads/2007/11/gastric-by-pass-and-weightloss-patients-october-07.pdf British Obesity and Metabolic Surgery Association http://www.british-obesity-surgery.org/index.htm http://www.british-obesity-surgery.org/bariatric_surgery.htm Scottish Intercollegiate Guidelines Network – Management of Obesity (115) and Diabetes (116) http://www.sign.ac.uk/guidelines/fulltext/115/index.html http://www.sign.ac.uk/guidelines/fulltext/116/index.html British Obesity Surgery Patient Association http://www.bospa.org/Default.aspx http://domuk.org/category/sub-groups/surgery/ Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss Acknowledgements
We are grateful to colleagues for advice, guidance and criticism, especially from PratikSufi and Dugal Heath at the North London Obesity Surgery Service at the WhittingtonHospital, and Daniel Darko at the Jeffrey Kelson Diabetes Centre, Central MiddlesexHospital. Stephan Rössner at the Obesity unit, Karolinska Institute, Stockholm, Swedenand Henning Bliddal, Frederiksberg Hospital, Copenhagen, Denmark also kindlyreviewed the text. Figures 1-4 are reproduced with the kind permission of Dugal Heath,FRCS. Biographical Notes
David Haslam is a GP with a special interest in obesity and cardiometabolic disease. He is chair of the National Obesity Forum for which he is also clinical director, and alsoworks in the Centre for Obesity Research at the Luton and Dunstable Hospital. He previously led the formulation of guidelines for adult obesity management in primarycare and guidelines for management of childhood obesity with the Royal College ofPaediatrics and Child Health.
Colin Waine was formerly Chair of the National Obesity Forum and is Visiting Professor in Primary and Community Care at the University of Sunderland. He was chair of the Royal College of General Practitioners from 2000 to 2003 and Director of Primary Care in Sunderland from 1993 to 2003.
Anthony Leeds is Visiting Professor in the Faculty of Life Sciences at the University of Copenhagen, Visiting Senior Fellow at the University of Surrey and Physician within theNorth London Obesity Surgery Service at the Whittington and Central MiddlesexHospitals. He is Medical Director of the Cambridge Weight Plan. Declaration of Interests:
DH consults for LighterLife and ARL is employed as Medical Director by CambridgeWeight Plan.
Footnote: The US Endocrinology Society is preparing a document ‘Endocrine andNutritional Management of the Post-Bariatric Surgery Patient: An Endocrine SocietyClinical Practice Guideline’. Progress may be checked by visiting www.endo-society.org/towards the end of 2010. Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss National Obesity Forum www.nationalobesityforum.org.uk Medical Management During Effective Weight-Loss Medical Management During Effective Weight-Loss
Produced with an educational grant from Cambridge Weight Plan
Organism list not requested in this search BIOLOGICAL ACTIVITIES ISOLATED FOR XANTHOHUMOL% XANTHOHUMOL (FLAVONOID) PHARMACOLOGY OF COMPOUND - IN VITRO * IC50 31.4 MICROMOLS/ACTIVE * L10219 * VS.CDNA-EXPRESSED HUMAN CYP1A2. PHARMACOLOGY OF COMPOUND - IN VITRO * CONCENTRATION VARIABLE NOT STATED ACTIVE * SEE ARTICLE FOR OTHER TEST RESULTS. * L30201 *PHARMACOLOGY OF COMPOUND - IN VITRO * C
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