title: A dietitian-led Pre-Surgical Very Low Calorie Diet Clinic model of care - is it feasible and effective?
Creators: name: Griffin, Sally B
Publisher: name: Griffith University
Year: 2020
Subjects: subject: Very Low Calorie Diets
subject: dietitian-led VLCD Clinic

description: Background: Elective surgery in obese adults carries higher risk of post-operative infection, respiratory and cardiac events, and prolonged hospital stays. Consequently, surgeons often request that obese patients lose weight prior to surgery. Very Low Calorie Diets (VLCDs) are the most effective non-surgical, non-pharmacological approach to weight loss, and could be the choice of intervention prior to non-bariatric elective surgery, but there is a lack of literature available to prove their efficacy specifically for this patient group. The inappropriate administration of VLCDs in the pre-operative period carries risks, such as malnutrition, which can increase risk of surgical complications. Dietitians are the most suitably qualified health professionals to provide comprehensive, safe and evidence-based care for obese patients on restrictive diets. The dietitian-led Pre-Surgical VLCD Clinic model of care at Logan Hospital, Queensland, Australia was established to support obese elective surgical patients to lose weight pre-operatively. In this clinic, the dietitian is well-equipped to lead the patients’ care by being accredited with extended scope of practice to order blood tests and being an Accredited Optifast® Healthcare Professional to prescribe and manage VLCDs in medically complex patients. The model of care which underpins the dietitian-led VLCD Clinic includes a strict eligibility criterion with weight loss targets, interdisciplinary team involvement from anaesthesiologists and surgeons, and prompt surgery dates post weight loss. This model of care has not been evaluated previously. Aim: To evaluate the feasibility and effectiveness of the dietitian-led Pre-Surgical VLCD Clinic model of care by examining pre-surgical weight loss in obese patients prior to non-bariatric elective surgery, whether patients were able to proceed to surgery, patient engagement, and patient and surgeon satisfaction with the service. Surgeons’ reported perceived positive changes in surgical procedures due to the dietitian-led VLCD Clinic treatment were also noted. Methods: Eligible participants were adult patients referred to the dietitian-led VLCD Clinic and engaged in VLCD treatment from September 2017 to September 2018. The dietitian prescribed a VLCD based on VLCD meal replacement products, patients’ individual protein requirements and preferences. Patients attended fortnightly dietitian appointments where their weight, adherence to diet, barriers to adherence, and side effects were monitored. Target weights were set achieve to proceed to surgery by the referring surgeon, or, if a surgery date was already booked, no target weight was set. Interventions, education, counselling and coordination of care were also provided at each appointment by the dietitian in line with the structured evidence-based Nutrition Care Process. Data retrospectively collected from medical charts included weight and BMI changes, time to reach targeted or adequate weight loss, attendance rates, and pathology results. Additionally, patients who had been treated from April to October 2019 were surveyed using a paper-based survey. Surgeons who had referred patient(s) were surveyed using an online survey in June 2019. Descriptive analyses were used for quantitative data, and open-ended survey responses were reported descriptively. Results: Forty-five patients were treated in the dietitian-led VLCD Clinic (46±12.7yrs, 89% female, BMI 44.9±6.2kg/m2) between September 2017 and September 2018 inclusively. Average weight loss was 8.7kg (7% body weight) from baseline (p&lt;0.05). Twenty-nine patients (71%, n=29/41) who were given a weight loss target achieved adequate weight loss to proceed to surgery as per clinical judgement of their surgeon, and time taken to achieve this was 10.8±4.4 weeks. Fifty percent of patients (n=22/44) reported side effects from VLCD, with 93% of these resolving, and none leading to cessation of VLCD treatment. Overall failure to attend rate was 9% (n=28/302 appointments). Pathology showed no changes in kidney and liver function from baseline to completion (p&gt;0.05). All patients (overall response rate 59%, n=24/41) reported they were satisfied with the service. Their most common responses to what they liked about their experience were: weight loss success; contact with the dietitian; and ability to receive feedback. Surgeons agreed that the dietitian-led VLCD Clinic treatment had assisted with ease of operation (83%, n=10/12) and shortened operating time (75%, n=9/12). All surgeons (n=16) agreed that they would recommend this service be implemented in other facilities. Conclusion: This dietitian-led Pre-surgical VLCD Clinic and the unique model of care that underpins it is feasible and effective in supporting obese adults to safely lose weight prior to elective surgery, patients are satisfied with the treatment provided, and surgeons agree it is a valuable service and believe that the treatment provided has a positive impact on surgical procedures. A larger study with a control group is planned to add rigour to these results and to adequately evaluate surgical risk reduction outcomes. If successful, a plan for implementation of the model in other facilities will be developed.