Bariatric Practice Guidelines

These guidelines provide suggestions for the work-up and follow-up of the bariatric patient. They are not intended to replace, and indeed cannot replace, the bariatrician’s judgment regarding a particular patient’s treatment. Neither are they intended to represent legal requirements for providing “good medical practice.” The bariatrician is the one most capable of determining what is or is not appropriate for an individual patient.

A. Initial Patient Work-Up
The course of treatment should be based on the patient’s history, physical examination, laboratory work and ECG (when indicated).

  1. History: A history of each patient should be taken and recorded. It should include an evaluation of dietary status, a weight history and a history of mental status. Whenever this is a self-fill-in, or computerized history, or one taken by assistants, the bariatrician should personally evaluate significant positive responses and make appropriate notations.
     
  2. Physical Examination: The physical examination should include the following:

a. Height, weight, blood pressure and pulse.

b. Additional examinations should be done which are appropriate for the patient’s age and state of health. Usually this would include examinations of the head, neck, thyroid, heart, lungs, abdomen and extremities. The patient’s records should indicate the status of observations made.

  1. Diagnostic Studies: When prior medical records can be obtained indicating any of the above procedures have recently been completed, the bariatrician may avoid unnecessary duplication by performing only those exams needed to complete the bariatric work-up.
    • Laboratory Work: An “executive-type” profile including testing for thyroid function (TSH suggested) should be completed in addition to other laboratory work if indicated.
    • Electrocardiogram: Required if there is reasonable evidence of present or past significant cardiac disease. In addition, the potential value of an ECG should be considered if coronary heart risk factors are present; e.g., hypertension, hyperglycemia, dyslipidemias or a strong family history of cardiac disease.
    • Optional Tests: Body composition using skinfolds, infrared or impedance testing may be performed as additional testing. Other tests may be included at the discretion of the bariatrician
  2. Patient Counseling: Appropriate counseling should be given to patients on proper eating habits, exercise, behavior modification, medications and other aspects of therapy, prior to and during the weight loss program.
     
  3. Return Visits: The bariatrician should provide adequate periodic follow-up and counseling for the patient.

B. Medications and Other Therapeutic Modalities

  1. The bariatrician should weigh the potential benefits and risks of any medication or modality used. Significant sources of such information include journal articles, experience of colleagues, labeling, textbooks, The ASBP Anorectic Usage Guidelines, and personal education, training and experience. Each of these sources may provide valuable information, and no single source should be used to the exclusion of others.
  2. When appropriate, the bariatrician should provide information on the benefits and risks of the proposed treatment modalities to be used and should inquire as to the patient’s understanding of the benefits and risks.
  3. When medications are dispensed, they should be packaged and labeled in accordance with applicable laws and appropriate records should be kept.

C. Maintenance
A program, as developed by the individual bariatrician, should be provided for helping the patient in maintaining the weight loss that has been achieved.

Bibliography

  1. Azar ST, Zantout MS. Evaluation and treatment of obesity. J Med Liban. 2000 Sep-Oct; 48(5):310-4.
  2. Bray G. Evaluation of total and regional body composition. In: Bray GA, Bouchard C, James WPT, eds. Handbook of Obesity. New York-Basel: Marcel Dekker, Inc., 1998, 831-54.
  3. National Heart, Lung, and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. September, 1998, NIH Publication No. 98-4083.
  4. Shape Up America and The American Obesity Association; Guidance for the Treatment of Adult Obesity, November, 1996.