Identification of Nutrition-Focused Physical Exam and Other Nutrition Assessment Components Specific to Bariatric Surgery: A Modified Delphi Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Bariatric surgery (BS) includes a group of surgical procedures used to promote weight loss for individuals with severe obesity by altering gastrointestinal anatomy and physiology. Although effective for weight reduction and metabolic improvement, patients frequently develop micronutrient deficiencies, loss of skeletal muscle mass, and other physiological complications following surgery. Standard Nutrition-Focused Physical Examination (NFPE) methods may not adequately account for the unique anatomical and metabolic changes in this population. This study introduces the first evidence-informed BS-NFPE tool specifically developed to address the limitations of conventional NFPE. The findings are expected to be of significant interest to both clinical practitioners and researchers working in nutrition, metabolic health, and bariatric care.

Comments:

Table 1. Why were the six domains and those components selected?

Table 2. The sample size is too small and only includes one male.

Table 3. How long was the data obtained after surgeries?

Table 4. Are there any comparison between this table and table 3?

Table 5. Why does the item “Separating non-heme iron (including iron supplements) from tannins (coffee/tea, red wine)” have a low frequency and percent?

Table 6. Why were these nutrients selected?

Figure 1. Are there any clinical trials to prove BS NFPE is better than traditional NFPE?

Author Response

RE: Reviewers Comments on Identification of Nutrition-Focused Physical Exam and Other Nutrition Assessment Components Specific to Bariatric Surgery: A Modified Delphi Study

Thank you to the reviewers for providing thoughtful feedback on our manuscript. Your comments were very helpful and have improved this paper. We have addressed the feedback below in red and made modifications as highlighted in yellow on the paper.

 

 

Comments and Suggestions for Authors

Bariatric surgery (BS) includes a group of surgical procedures used to promote weight loss for individuals with severe obesity by altering gastrointestinal anatomy and physiology. Although effective for weight reduction and metabolic improvement, patients frequently develop micronutrient deficiencies, loss of skeletal muscle mass, and other physiological complications following surgery. Standard Nutrition-Focused Physical Examination (NFPE) methods may not adequately account for the unique anatomical and metabolic changes in this population. This study introduces the first evidence-informed BS-NFPE tool specifically developed to address the limitations of conventional NFPE. The findings are expected to be of significant interest to both clinical practitioners and researchers working in nutrition, metabolic health, and bariatric care.

Comments:

Table 1. Why were the six domains and those components selected? The six domains were developed through a comprehensive literature review of nutritional complications and clinical manifestations associated with bariatric surgery. Reported physical findings, symptoms, and indicators affecting nutritional status were identified and systematically grouped into conceptually related categories, resulting in six domains representing major areas of nutritional risk in bariatric patients.

Table 2. The sample size is too small and only includes one male. Although the panel size (N = 25) may appear modest, it is consistent with recommended sample sizes for Delphi methodology, which prioritize the inclusion of knowledgeable experts rather than large sample sizes. Furthermore, the predominance of female participants, including only one male, reflects the demographic composition of the dietetics profession, which is overwhelmingly female.

Table 3. How long was the data obtained after surgeries? In this study, we surveyed experts in the field of bariatric surgery. Participants were questioned on components that may influence the nutritional status of this patient population. The data was not specific to a time post-surgery.

Table 4. Are there any comparisons between this table and table 3? There was no comparison because there were different components. Table 3 was the initial components and table 4 included the additional recommended components in the following round.

Table 5. Why does the item “Separating non-heme iron (including iron supplements) from tannins (coffee/tea, red wine)” have a low frequency and percent? These data reflected the number of participants who address each specific interaction. There just happened to be a lower number of dietitians who address separating non-heme iron from tannins in practice.

Table 6. Why were these nutrients selected? These were recommendations for inclusion from panelists in their open responses for vitamin, mineral and drug interactions.

 

Figure 1. Are there any clinical trials to prove BS NFPE is better than traditional NFPE? Excellent point! I added the following statement to the discussion:  Future clinical trials could compare the effectiveness of a BS NFPE to the traditional NFPE. Currently, no clinical trials have evaluated whether a bariatric surgery–specific nutrition-focused physical exam (BS-NFPE) improves the identification of nutritional complications compared with the traditional NFPE. The purpose of this study was to address this gap by developing an evidence-informed BS-NFPE tool using expert consensus.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses an important and clinically relevant gap: the lack of a bariatric surgery–specific Nutrition-Focused Physical Exam (BS-NFPE). The use of a modified Delphi process to develop consensus among bariatric RDN experts is appropriate, and the topic is timely given the continued volume of bariatric procedures.

The study is well structured and clearly written; however, there are important methodological, conceptual, and interpretive issues that should be addressed before publication.

1. Extremely High Consensus in Round 1: All original domains and components reached consensus in Round 1 (100% of domains; 93–100% of components). This raises concerns about:

Whether items were too broadly defined

Whether the Likert threshold (≥3) was too permissive

Whether selection bias influenced homogeneity of responses

Whether true disagreement was possible within survey design

Suggestion:

Provide a deeper justification for the 75% consensus threshold combined with “≥3 on Likert scale.”

Consider reporting how many panelists rated items as 4–5 versus 3.

Discuss whether using ≥4 would have changed findings.

Address potential acquiescence bias.

2. The manuscript acknowledges difficulty defining expertise, but this needs stronger treatment. Concerns:

All panelists were White and non-Hispanic.

Most had 5–15 years of experience.

Half were only eligible to sit for CSOWM rather than credentialed.

Many reported low comfort and low frequency performing NFPE, which is highly concerning given this is an NFPE tool development study.

This creates tension:

If panelists are uncomfortable performing NFPE, how valid is consensus on modifying it?

Suggestion:

 

Provide justification for inclusion criteria (≥5 years in BS).

Discuss explicitly how low NFPE comfort impacts tool validity.

Consider reframing this as development of a conceptual framework rather than a validated clinical tool.

 

3. Several domains include components outside traditional RDN physical exam scope:

• DVT/PE
• Anastomotic leaks
• GI fistulas
• Surgical complications
• Hypoglycemia diagnosis
• Frailty assessment
• Mental health disorders
• Panelists themselves questioned scope.

Major conceptual issue….Is this an NFPE tool, or a comprehensive bariatric risk screening checklist?

The NFPE traditionally involves inspection/palpation/clinical nutrition signs — not diagnostic surveillance of surgical or psychiatric conditions.

Suggestion: Clarify whether this is: A modified NFPE,

A bariatric nutrition assessment framework, Or a multidisciplinary screening tool.

Consider renaming to avoid conceptual drift from standard NFPE definition.

4. Inclusion of Social Determinants of Health (SDOH): SDOH is conceptually important but does not align with NFPE methodology (inspection/palpation findings).This further suggests the tool is broader than physical examination.

 Provide conceptual model explaining how physical exam, psychosocial screening, and social determinants integrate. Consider presenting the tool as a layered assessment model rather than an expanded physical exam.

5. Frailty remains vaguely operationalized. Panelists selected various criteria, but no validated frailty tool was chosen. Concerns:

No standardized measure (e.g., Fried phenotype, Rockwood frailty index).

Reliance on subjective consensus rather than validated metrics.

Suggestion: Anchor frailty domain to an established frailty model.

Or clearly state this is a bariatric-adapted frailty conceptualization requiring validation.

6. The manuscript repeatedly refers to this as a “tool,” but: No reliability testing/ No pilot testing / No inter-rater agreement /No feasibility assessment /No predictive validity testing

Thus, it is a consensus framework, not yet a validated tool. Suggestion:

Modify language from “tool” to “proposed framework” or “consensus-derived assessment structure.”

Strengthen future research section to include:

• Inter-rater reliability
• Construct validity
• Clinical impact testing
• Time burden evaluation

 

7. Likert Scale Interpretation-Consensus defined as ≥3 (neutral or higher) may inflate agreement. Recommend reporting:

Distribution of responses

Median in addition to mean

Percent strongly agree (5)

8. Attrition Reporting-You report: 27 → 26 → 25 participants.  This is excellent retention, but clarify:

Were dropouts analyzed?

Any systematic differences?

9. The literature search strategy is under-described.Missing:

Search strings /PRISMA diagram

Number of studies screened/included

Quality appraisal/ Given that literature review informed the initial domains, greater transparency is needed.

10. Vitamin C Emphasis- The discussion devotes substantial space to Vitamin C deficiency and machine learning findings, but this component was rated lower in clinical relevance by panelists. Balance the discussion to reflect panel consensus rather than overemphasizing literature justification.
11. Transfer Addiction= The manuscript appropriately acknowledges controversy, but:

Consider softening language.

Clarify that evidence remains mixed.

 

Avoid implying causality.

12. Terminology: Dumping Syndrome vs PBH-The manuscript does a good job outlining confusion in terminology. However:

The final adopted terminology should be clearly stated in one consolidated table.

Provide operational definitions within the tool appendix.

13. Clarify whether “Hypoglycemia” refers specifically to Post-Bariatric Hypoglycemia (PBH).
14. Consider consolidating Tables 5 and 6 (very detailed, possibly excessive for main text).
15. Some repetition in Discussion regarding Delphi strengths and weaknesses.
16. Figure 1 (Venn diagram) should be described more explicitly in text.
17. Consider tightening manuscript length; currently quite long for consensus paper.

 

Comments for author File: Comments.docx

Author Response

RE: Reviewers Comments on Identification of Nutrition-Focused Physical Exam and Other Nutrition Assessment Components Specific to Bariatric Surgery: A Modified Delphi Study

Thank you to the reviewers for providing thoughtful feedback on our manuscript. Your comments were very helpful and have improved this paper. We have addressed the feedback below in red and made modifications as highlighted in yellow on the paper.

This manuscript addresses an important and clinically relevant gap: the lack of a bariatric surgery–specific Nutrition-Focused Physical Exam (BS-NFPE). The use of a modified Delphi process to develop consensus among bariatric RDN experts is appropriate, and the topic is timely given the continued volume of bariatric procedures.

The study is well structured and clearly written; however, there are important methodological, conceptual, and interpretive issues that should be addressed before publication.

1. Extremely High Consensus in Round 1: All original domains and components reached consensus in Round 1 (100% of domains; 93–100% of components). This raises concerns about:

Whether items were too broadly defined

Whether the Likert threshold (≥3) was too permissive

Whether selection bias influenced homogeneity of responses

Whether true disagreement was possible within survey design

This questionnaire was developed based on evidence-based research, and results were determined through expert consensus. The purpose of the modified Delphi process was to survey experts to confirm that the identified components are useful and relevant for bariatric surgery patient assessment. The goal was to have a high consensus. 

Suggestion:

Provide a deeper justification for the 75% consensus threshold combined with “≥3 on Likert scale.” Added to paper (lines 137, 406-412)

Consider reporting how many panelists rated items as 4–5 versus 3.

We added this to the paper (see lines 140-142):  The only components of the final 43 that did not meet consensus when evaluated for ratings of 4 or 5.

• Vitamin E relevance
• Vitamin C relevance
• Selenium relevance
• Vitamin K toxicity usefulness
• Vitamin K toxicity relevance
• B-toxicity usefulness
• B-Toxicity relevance

Discuss whether using ≥4 would have changed findings. Added to paper (lines 140-142)

Address potential acquiescence bias. Added to paper (lines 450-456)

1. The manuscript acknowledges difficulty defining expertise, but this needs stronger treatment. Concerns:

All panelists were White and non-Hispanic.

Most had 5–15 years of experience.

Half were only eligible to sit for CSOWM rather than credentialed.

Many reported low comfort and low frequency performing NFPE, which is highly concerning given this is an NFPE tool development study.

This creates tension:

If panelists are uncomfortable performing NFPE, how valid is consensus on modifying it?

Suggestion:

 

Provide justification for inclusion criteria (≥5 years in BS). We added additional justification to  paper based on reference below: (lines 152-154)

Jünger S, Payne SA, Brine J, Radbruch L, Brearley SG. Guidance on Conducting and REporting DElphi Studies (CREDES) in palliative care: Recommendations based on a methodological systematic review. Palliat Med. 2017;31(8):684-706. doi:10.1177/0269216317690685

Selection of experts The most prominent criteria for the identification and selection of experts were (1) representation of a particular profession or stakeholder group (n=24), (2) affiliation to a particular setting or work field (n=23) and (3) relevant clinical and/or academic expertise (n=20; Table 5). Other criteria included membership of an organization or professional board (n=11), being a recognized authority in the field (n=11) and geographical origin (n=13), with several studies paying particular attention to a balanced composition of the expert panel with representation from different regions and socio-economic backgrounds, or a relevant participation of experts from developing countries.32–34,50

Discuss explicitly how low NFPE comfort impacts tool validity. We added a discussion to explicitly explain this. (lines 455-456)

Consider reframing this as development of a conceptual framework rather than a validated clinical tool. Adjusted in the paper (lines 83-86)

 

1. Several domains include components outside traditional RDN physical exam scope:

• DVT/PE
• Anastomotic leaks
• GI fistulas
• Surgical complications
• Hypoglycemia diagnosis
• Frailty assessment
• Mental health disorders
• Panelists themselves questioned scope.

Major conceptual issue….Is this an NFPE tool, or a comprehensive bariatric risk screening checklist?

The NFPE traditionally involves inspection/palpation/clinical nutrition signs — not diagnostic surveillance of surgical or psychiatric conditions.

Suggestion: Clarify whether this is: A modified NFPE, Adjusted paper to explain the BS-NFPE as an expanded and modified NFPE (Great idea!) (lines14 & 82)

A bariatric nutrition assessment framework, Or a multidisciplinary screening tool.

Consider renaming to avoid conceptual drift from standard NFPE definition.

1. Inclusion of Social Determinants of Health (SDOH): SDOH is conceptually important but does not align with NFPE methodology (inspection/palpation findings).This further suggests the tool is broader than physical examination.

 Provide conceptual model explaining how physical exam, psychosocial screening, and social determinants integrate. Consider presenting the tool as a layered assessment model rather than an expanded physical exam. This is a great suggestion to integrate a conceptual model; however, the predetermined aims of the study were to develop a bariatric-specific NFPE (BS-NFPE) tool informed by a comprehensive literature review. The second objective was to utilize a modified Delphi methodology to achieve expert consensus among bariatric RDNs on the essential components of this tool.

1. Frailty remains vaguely operationalized. Panelists selected various criteria, but no validated frailty tool was chosen. Concerns:

No standardized measure (e.g., Fried phenotype, Rockwood frailty index).

Reliance on subjective consensus rather than validated metrics.

Suggestion: Anchor frailty domain to an established frailty model.

Or clearly state this is a bariatric-adapted frailty conceptualization requiring validation. We added this statement to the paper. Great idea! (lines 297-299)

1. The manuscript repeatedly refers to this as a “tool,” but: No reliability testing/ No pilot testing / No inter-rater agreement /No feasibility assessment /No predictive validity testing.

Thus, it is a consensus framework, not yet a validated tool. Suggestion:

Modify language from “tool” to “proposed framework” or “consensus-derived assessment structure.” Addressed in #2

Strengthen future research section to include:  Added to paper (lines 479-491)

• Inter-rater reliability
• Construct validity
• Clinical impact testing
• Time burden evaluation

 

1. Likert Scale Interpretation-Consensus defined as ≥3 (neutral or higher) may inflate agreement. Recommend reporting: We added data on those who demonstrated agreement of 4 or higher as recommended above. Tables 3 and 4 do include not only the mean, but the standard deviation and interquartile range. Information collected was a priori methodology and approved by the IRB.

Distribution of responses

Median in addition to mean

Percent strongly agree (5)  

1. Attrition Reporting-You report: 27 → 26 → 25 participants. This is excellent retention, but clarify:

Were dropouts analyzed?

Any systematic differences? We did not conduct a non-response or bias analysis.

1. The literature search strategy is under-described.Missing:

Search strings /PRISMA diagram   We included search terms in the paper, but not specific search strings because we searched separately for the many potential topics associated with BS. We did not complete a PRISMA because this was not a systematic review or meta-analysis. We collaborated closely with the medical librarian (added to paper) utilizing PubMed, CINAHL, Scopus, and Web of Science electronic databases. The primary investigator is also an expert in the field, and the Delphi process utilized other experts to ensure the information was comprehensive. We also added the following to the paper: After a thorough review of the literature, a total of 418 articles were obtained that supported the research (see lines 91 and 99-100)

Number of studies screened/included 

Quality appraisal/ Given that literature review informed the initial domains, greater transparency is needed.

1. Vitamin C Emphasis- The discussion devotes substantial space to Vitamin C deficiency and machine learning findings, but this component was rated lower in clinical relevance by panelists. Balance the discussion to reflect panel consensus rather than overemphasizing literature justification. We shortened this section as suggested. However, we did want to explain the emerging literature on vitamin C and how it has deficiency has been underdiagnosed (as represented in our Delphi study). (see lines 382-392)
2. Transfer Addiction= The manuscript appropriately acknowledges controversy, but:

Consider softening language. Adjusted- see line 433

Clarify that evidence remains mixed.  Clarified (see lines 440-442)

 

Avoid implying causality. Adjusted- see line 433

Great points!  

1. Terminology: Dumping Syndrome vs PBH-The manuscript does a good job outlining confusion in terminology. However:

The final adopted terminology should be clearly stated in one consolidated table. The final terminology is represented in Figure 1 which includes all final domains and associated components with newly defined wording.

Provide operational definitions within the tool appendix. Added to appendix G

13. Clarify whether “Hypoglycemia” refers specifically to Post-Bariatric Hypoglycemia (PBH). Adjusted throughout the paper
14. Consider consolidating Tables 5 and 6 (very detailed, possibly excessive for main text). Consolidated the tables. (see lines 262-271)
15. Some repetitions in Discussion regarding Delphi strengths and weaknesses. Consolidated the paragraphs. (see lines 443-473)
16. Figure 1 (Venn diagram) should be described more explicitly in text. Completed (lines 374-377)
17. Consider tightening manuscript length; currently quite long for consensus paper. Tightened up the paper as able.

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Acceptance