Energy and macronutrient intake after gastric bypass for morbid obesity: a 3-y observational study focused on protein consumption

Perception of Hunger/Satiety and Nutrient Intake in Women Who Regain Weight in the Postoperative Period After Bariatric Surgery

OBJECTIVE

To investigate the perception of hunger and satiety and its association with nutrient intake in women who regain weight in the postoperative period after bariatric surgery.

METHODS

Cross-sectional study of adult women divided into three groups: weight regain (n = 20), stable weight (n = 20) (both at least 24 months after Roux-en-Y gastric bypass surgery), and non-operated obesity (n = 20). A visual analogue scale measured hunger/satiety perception while fasting, immediately after finishing a test meal, and 180 min after finishing the test meal. The incremental area above or under the curve was calculated. Food intake was analyzed by 3 days of food recall and adjusted for intraindividual variation. To make between-group comparisons, Mann-Whitney, ANOVA, Kruskal-Wallis, and independent-samples T tests and Pearson's correlation were used.

RESULTS

There were no between-group differences in incremental areas of hunger/satiety, but protein intake was significantly lower among patients who regained weight compared with those who had stable body weight (0.99 ± 0.23 g/kg body weight vs. 1.17 ± 0.21 g/kg body weight, p = 0.047). In the group that regained weight, satiety was correlated positively with usual dietary protein density (r = 0.541; p = 0.017) and negatively with usual carbohydrate intake (r = - 0.663; p = 0.002).

CONCLUSION

Women who regained weight presented similar perceptions of hunger/satiety to those of patients without weight regain and with non-operated obesity. In patients who regained weight postoperatively, satiety perception was correlated positively with usual dietary protein density and inversely with usual carbohydrate intake.

Functional and systemic effects of whole body electrical stimulation post bariatric surgery: study protocol for a randomized controlled trial

Background

Obesity represents a major public health problem and is the fifth leading risk factor for mortality. Morbid obesity is associated with chronic systemic inflammation which increases the risk of comorbidities. Bariatric surgery (BS) is considered an effective intervention for obese patients. However, BS is associated with dietary restriction, potentially limiting physical activity. Whole-body neuromuscular electrical stimulation (WBS) could represent an innovative option for the rehabilitation of BS patients, especially during the early postoperative phase when other conventional techniques are contraindicated. WBS is a safe and effective tool to combat sarcopenia and metabolic risk as well as increasing muscle mass, producing greater glucose uptake, and reducing the proinflammatory state. Therefore, the objective of this study is to evaluate the effects of WBS on body composition, functional capacity, muscle strength and endurance, insulin resistance, and pro- and anti-inflammatory circulating markers in obese patients undergoing BS.

Methods/design

The present study is a randomized, double-blind, placebo-controlled, parallel groups clinical trial approved by the Ethics Committee of our Institution. Thirty-six volunteers (body mass index (BMI) > 35 kg/m²) between 18 and 45 years of age will be randomized to the WBS group (WBSG) or control (Sham) group (ShamG) after being submitted to BS. Preoperative assessments will include maximal and submaximal exercise testing, body composition, blood inflammatory markers, and quadriceps strength and endurance. The second day after discharge, body composition will be evaluated and a 6-min walk test (6MWT) will be performed. The WBS or Sham protocol will consist of 30 daily sessions for 6 consecutive weeks. Afterwards, the same assessments that were performed in the preoperative period will be repeated.

Discussion

Considering the important role of WBS in skeletal muscle conditioning and its value as an aid in exercise performance, the proposed study will investigate this technique as a tool to promote early rehabilitation in these patients, and as a strategy to enhance exercise capacity, weight loss, and peripheral muscle strength with positive systemic effects. The present study is still ongoing, and data will be published after its conclusion.

Trial registration

REBEC, RBR-99qw5h. Registered on 20 February 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2844-8) contains supplementary material, which is available to authorized users.

Diabetes management before, during, and after bariatric and metabolic surgery

Metabolic surgery is unrivaled by other therapeutic modalities due to its ability to foster diabetes remission. Metabolic surgery is an integral therapeutic modality in obese and morbidly obese populations because pharmacological and behavioral therapy often fail to effectively manage type II diabetes. However, given the invasiveness of the metabolic surgery relative to behavioral therapy and the need to conform to preparatory and discharge guidelines, patients must adhere to strict nutritional and diabetes management protocols. Also, the pharmacological regimen that is instituted upon discharge is distinct from the preoperative regimen. Oftentimes, the dose for insulin and oral medications are significantly decreased or withdrawn. As time elapses and depending on several factors (e.g., exercise adherence), diabetes control becomes tenuous in a small portion of the patients because there is weight regain and on-going beta cell failure. At this time interval, intensification of diabetes therapy becomes prudent. Indeed, pharmacotherapy from the preoperative to the postoperative phase is labile and may be complex. Therefore, by discussing pharmacology options during the preoperative, perioperative, and postoperative period, the goal is to guide clinician-driven care.

New insights into apolipoprotein A5 in controlling lipoprotein metabolism in obesity and the metabolic syndrome patients

Apolipoprotein A5 (apoA5) has been identified to play an important role in lipid metabolism, specifically in triglyceride (TG) and TG-rich lipoproteins (TRLs) metabolism. Numerous evidence has demonstrated for an association between apoA5 and the increased risk of obesity and metabolic syndrome, but the mechanism remains to be fully elucidated. Recently, several studies verified that apoA5 could significantly reduce plasma TG level by stimulating lipoprotein lipase (LPL) activity, and the intracellular role of apoA5 has also been proved since apoA5 is associated with cytoplasmic lipid droplets (LDs) and affects intrahepatic TG accumulation. Furthermore, since adipocytes provide the largest storage depot for TG and play a crucial role in the development of obesity, we could infer that apoA5 also acts as a novel regulator to modulate TG storage in adipocytes. In this review, we focus on the association of gene and protein of apoA5 with obesity and metabolic syndrome, and provide new insights into the physiological role of apoA5 in humans, giving a potential therapeutic target for obesity and associated disorders.

The relevance of dietary protein after bariatric surgery: what do we know?

PURPOSE OF REVIEW

The growing obesity epidemic is associated with an increased demand for bariatric surgery with Roux-en-Y Gastric Bypass and Sleeve Gastrectomy as the most widely performed procedures. Despite beneficial consequences, nutritional complications may arise because of anatomical and physiological changes of the gastrointestinal tract. The purpose of this review is to provide an update of the recent additions to our understanding of the impact of bariatric surgery on the intake, digestion and absorption of dietary protein.

RECENT FINDINGS

After bariatric surgery, protein intake is compromised because of reduced gastric capacity and aversion for certain foods. A minority of patients reaches the recommended protein intake of minimal 60 g per day, which results in the loss of fat-free mass rather than the desired loss of fat mass. Despite inadequate protein intake, protein digestion and absorption do not seem to be impaired suggesting that other mechanisms could counteract the reduced secretion of digestive enzymes and their delayed inlet.

SUMMARY

After bariatric surgery, protein supplementation or diet enrichment could attribute to achieve the minimal recommended protein intake and benefit the amount and composition of postoperative weight loss.

Effect of Protein Intake on the Protein Status and Lean Mass of Post-Bariatric Surgery Patients: a Systematic Review

BACKGROUND

Post-bariatric surgery may compromise nutritional status due to energy and protein intake restriction.

METHODS

Systematic review was performed to synthesize evidence on the amount of protein intake and its association with lean mass and serum proteins during at least 6 months following Roux-en-Y gastric bypass or sleeve gastrectomy.

RESULTS

Twelve studies (n = 739) were identified in the search. Protein intake below 60 g/day and significant lean mass loss were observed in majority of these studies. Of the four studies that measured association between protein intake and lean mass retention, only two supported this hypothesis.

CONCLUSION

There is insufficient evidence of the effect of dietary protein on serum protein levels. Further studies are needed to better estimate the protein intake that supports a healthy nutritional status in this population.

Functional Foods and Lifestyle Approaches for Diabetes Prevention and Management

Functional foods contain biologically active ingredients associated with physiological health benefits for preventing and managing chronic diseases, such as type 2 diabetes mellitus (T2DM). A regular consumption of functional foods may be associated with enhanced anti-oxidant, anti-inflammatory, insulin sensitivity, and anti-cholesterol functions, which are considered integral to prevent and manage T2DM. Components of the Mediterranean diet (MD)-such as fruits, vegetables, oily fish, olive oil, and tree nuts-serve as a model for functional foods based on their natural contents of nutraceuticals, including polyphenols, terpenoids, flavonoids, alkaloids, sterols, pigments, and unsaturated fatty acids. Polyphenols within MD and polyphenol-rich herbs-such as coffee, green tea, black tea, and yerba maté-have shown clinically-meaningful benefits on metabolic and microvascular activities, cholesterol and fasting glucose lowering, and anti-inflammation and anti-oxidation in high-risk and T2DM patients. However, combining exercise with functional food consumption can trigger and augment several metabolic and cardiovascular protective benefits, but it is under-investigated in people with T2DM and bariatric surgery patients. Detecting functional food benefits can now rely on an "omics" biological profiling of individuals' molecular, genetics, transcriptomics, proteomics, and metabolomics, but is under-investigated in multi-component interventions. A personalized approach for preventing and managing T2DM should consider biological and behavioral models, and embed nutrition education as part of lifestyle diabetes prevention studies. Functional foods may provide additional benefits in such an approach.

Caloric Restriction-Induced Decreases in Dopamine Receptor Availability are Associated with Leptin Concentration

OBJECTIVE

It has been previously reported that early after Roux-en-Y-gastric bypass, dopamine (DA) type 2 and 3 receptor (D2/3R) binding potential (BP_ND ) was decreased from preoperative levels. The current study aimed to determine whether calorie restriction without weight loss modifies D2/3R BP_ND and whether such changes are explained by neuroendocrine regulation.

METHODS

Fifteen females with obesity (BMI = 39 ± 6 kg/m² ) were studied before and after ∼10 days of a very-low-calorie-diet (VLCD). Outcome measures included fasting insulin, leptin, acyl ghrelin, and glucose, and insulin sensitivity and disposition index were estimated using the oral-minimal model (OMM) method. Participants underwent positron emission tomography scanning with the displaceable radioligand [¹⁸ F]fallypride to estimate available regional D2/3R levels. Regions of interest included the caudate, putamen, ventral striatum, hypothalamus, and substantia nigra (SN).

RESULTS

With the VLCD, weight decreased slightly (-3 kg). Insulin, glucose, and leptin decreased significantly, but there was no change in acyl ghrelin or measures from OMM. SN D2/3R BP_ND decreased significantly, with trends toward decreased levels in the remaining regions. The decrease in leptin concentration strongly predicted the change in D2/3R BP_ND in all regions (all P ≤ 0.004).

CONCLUSIONS

In obesity, reductions in regional D2/3R availability after VLCD are suggestive of increased endogenous DA competing with the radioligand. Changes in regional D2/3R availability were associated with decreases in leptin concentrations that occurred before clinically significant weight loss.

Sociodemographic and lifestyle factors as determinants of energy intake and macronutrient composition: a 10-year follow-up after bariatric surgery

BACKGROUND

Early identification of the potential to adopt a long-term unhealthy diet, could improve weight outcomes for patients having undergone bariatric surgery.

OBJECTIVES

We explored whether presurgical sociodemographic and lifestyle characteristics, together with the type of surgery, could predict 10-year changes in dietary intake after bariatric surgery.

SETTING

Surgical departments and primary healthcare centers, nationwide.

METHODS

Participants were from the Swedish Obese Subjects study, a matched (nonrandomized) prospective trial comparing bariatric surgery with standard care for obese patients. This study included the 1695 surgery patients with complete information on presurgery diet. Questionnaires were completed before and 6 months, 1-4, 6, 8, and 10 years after surgery. Analyses were conducted with linear mixed-model.

RESULTS

Dietary changes were observed in 1561, 1298, and 1243 participants, at the 2-, 6-, and 10-year follow-ups, respectively. Sex and treatment type predicted changes in energy, carbohydrate, protein, and fiber intake over the follow-up (P<.05). Furthermore, male sex, younger age, a sedentary behavior, and gastric bypass predicted increased alcohol consumption (P<.001). Two important phases for intervening bariatric patients' diet were identified. The first was 6 months after surgery, when the maximal changes in diet were achieved. The second, stretched from 6 months until 4 years after surgery, during which earlier commitments to dietary changes were largely abandoned.

CONCLUSIONS

Male sex and banding surgery in particular predicted unfavorable post-surgery changes in energy and macronutrient intake. Furthermore, gastric bypass, a younger age, and an unhealthy lifestyle presurgery, may predispose individuals to increased alcohol intake after surgery.

Overview on nutritional issues in bariatric surgery

PURPOSE OF REVIEW

In the context of the worldwide obesity epidemic, bariatric surgery is the only therapy associated with a sustainable weight loss and to midterm prevention of obesity-related complications. However, nutritional and behavioral multidisciplinary medical preparation, as well as long-term postoperative nutritional follow-up, is strongly advised to avoid postoperative surgical, nutritional, or psychiatric complications.

RECENT FINDINGS

Due to a long history of restrictive diets and large body weight fluctuations, preoperative nutritional assessment and correction of vitamin and trace elements deficiencies are mandatory. A rapid and massive weight loss induces the loss of muscle mass and fat-free mass that could lead to malnutrition and osteoporosis. Dietetic counseling is advised to prevent postoperative food intolerance syndrome, malnutrition, and weight regain. Protein intake should be at least 60 g/day. Planned and structured physical exercise should be systematically promoted to maintain muscle mass and bone health.

SUMMARY

Bariatric surgery is mostly successful if patients are well prepared and monitored. The perfect patients' selection remains difficult in the absence of well defined predictive criteria of success. Future research is needed to define optimal perioperative nutritional management and its influence on long-term outcome, including quality of life and healthcare-related costs.