Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Saolta Health Care Group, Galway, Ireland; HRB Clinical Research Facility, University of Galway and Saolta University Health Care Group, Ireland; Cúram, University of Galway, Ireland.
Centre for Diabetes, Endocrinology and Metabolism, Galway University Hospitals, Saolta Health Care Group, Galway, Ireland; HRB Clinical Research Facility, University of Galway and Saolta University Health Care Group, Ireland; Cúram, University of Galway, Ireland.
Metabolism. 2024 Feb;151:155739. doi: 10.1016/j.metabol.2023.155739. Epub 2023 Nov 18.
There is good evidence that structured lifestyle modification programmes improve health in patients with metabolic and cardiovascular disorders, but there is no specific evidence that they improve outcomes in patients undergoing metabolic or obesity surgery. Despite expert consensus guidelines stating this fact, some healthcare systems still compel patients to participate in a structured lifestyle modification programme prior to metabolic or obesity surgery. There is a well-established need for individualised multidisciplinary dietetic and physical activity care for metabolic and obesity surgery patients, and the benefits of intentional weight loss prior to surgery are well proven, but these are distinct from potentially harmful requirements for patients to undertake compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery and reinforce obesity stigma. A critical step in rejuvenating metabolic surgery is to reframe patient participation in structured lifestyle modification programmes as an opportunity for education and empowerment, not as an indicator of motivation or suitability for metabolic surgery. Large, well-designed and adequately powered clinical trials are needed to address uncertainties in the evidence base for these programmes. Given genuine equipoise, they will need to determine whether "surgery plus lifestyle" is superior to "surgery plus placebo". Moreover, they will need to determine the cost-effectiveness of these programmes and identify some of the factors giving rise to the substantial heterogeneity in responses to structured lifestyle modification.
有充分的证据表明，结构化的生活方式改变计划可以改善代谢和心血管疾病患者的健康，但没有具体证据表明它们可以改善代谢或肥胖症手术患者的预后。尽管专家共识指南指出了这一事实，但一些医疗保健系统仍迫使患者在接受代谢或肥胖症手术前参加结构化的生活方式改变计划。对于代谢和肥胖症手术患者，个体化的多学科饮食和体育活动护理有明确的需求，并且术前有计划的体重减轻的益处已得到充分证明，但与患者必须进行强制性的结构化生活方式计划的固定持续时间、频率和强度的潜在有害要求不同，这可能会延迟手术并加剧肥胖耻辱感。复兴代谢手术的关键步骤是将患者参与结构化生活方式改变计划重新定义为教育和赋权的机会，而不是作为对代谢手术的动机或适宜性的指标。需要进行大型、精心设计和充分有力的临床试验，以解决这些计划证据基础中的不确定性。鉴于真正的平衡，他们将需要确定“手术加生活方式”是否优于“手术加安慰剂”。此外，他们还需要确定这些计划的成本效益，并确定导致对结构化生活方式改变反应存在显著异质性的一些因素。
