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Hassan M, Barajas-Gamboa JS, Kanwar O, Lee-St John T, Tannous D, Corcelles R, Rodriguez J, Kroh M. The role of dietitian follow-ups on nutritional outcomes post-bariatric surgery. Surg Obes Relat Dis 2024; 20:407-412. [PMID: 38158312 DOI: 10.1016/j.soard.2023.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/18/2023] [Accepted: 10/29/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND Current evidence recommends dietary counselling with a registered dietitian (RD) for successful weight loss after metabolic bariatric surgery; however, there are limited data on the effect of RD follow-ups on micronutrient deficiencies. This study evaluated the effects of the number of postoperative RD visits on nutritional outcomes, including weight loss and micronutrient deficiencies. OBJECTIVES The aim of this study was to evaluate the effects of the number of postoperative registered dietitian visits on nutritional outcomes, including weight loss and micronutrient deficiencies after metabolic and bariatric surgery. SETTING Cleveland Clinic Abu Dhabi, United Arab Emirates METHODS: This retrospective study included patients who underwent bariatric surgery between September 2015 and June 2020. Demographics, weight loss, micronutrients, and the number of postoperative RD visits were evaluated. Baseline and 12-month postsurgery outcomes were compared based on the number of RD follow-ups. RESULTS A total of 174 primary and 46 revisions were included. Patients were 73.6% female, with a mean age of 40 years. The initial mean body mass index was 42.8 kg/m2. Number of RD visits were as follows: 0-1 (39 patients), 2 (59 patients), 3 (55 patients), and 4 or more (67 patients). Baseline (pre-operative) micronutrient values were within normal range. In comparison with the reference group (REF = 0-1 post-op RD visits), patients with 3 RD visits had 7% higher total body weight loss (P < .001) and maintained micronutrients within the normal range at 12 months postoperative. Mean differences in postoperative values were statistically significant (P < .05) for weight, vitamin B12, and vitamin D but not for hemoglobin, ferritin, calcium, folate, vitamin B1, copper, and zinc. CONCLUSION Our study suggests that three or more RD visits during the first 12 months after bariatric surgery are associated with improved outcomes, including significant percent total body weight loss and lower rates of micronutrient deficiencies.
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Affiliation(s)
- Mariam Hassan
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Juan S Barajas-Gamboa
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Oshin Kanwar
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Terrence Lee-St John
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Diana Tannous
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Ricard Corcelles
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - John Rodriguez
- Department of General Surgery, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio
| | - Matthew Kroh
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio; Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio.
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2
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Ford K, Huggins E, Sheean P. Characterising body composition and bone health in transgender individuals receiving gender-affirming hormone therapy. J Hum Nutr Diet 2022; 35:1105-1114. [PMID: 35509260 PMCID: PMC9790536 DOI: 10.1111/jhn.13027] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/26/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Gender-affirming hormone therapy (GAHT) is prescribed to produce secondary sex characteristics aligning external anatomy with gender identity to mitigate gender dysphoria. Transgender women are generally treated with oestrogens and anti-androgens, whereas transgender men are treated with testosterone. The objective of this narrative review was to characterise the influence of GAHT on body composition and bone health in the transgender population to help address weight concerns and chronic disease risk. METHODS Studies were extracted from PubMed and Scopus and limited to only those utilising imaging technologies for precise adipose tissue, lean mass, and bone mineral density (BMD) quantification. RESULTS Although methodologies differed across the 20 investigations that qualified for inclusion, clear relationships emerged. Specifically, among transgender women, most studies supported associations between oestrogen therapy and decreases in lean mass and increases in both, fat mass and body mass index (BMI). Within transgender men, all studies reported associations between testosterone therapy and increases in lean mass, and although not as consistent, increases in BMI and decreases in fat mass. No consistent changes in BMD noted for either group. CONCLUSIONS Additional research is needed to appropriately assess and evaluate the implications of these body composition changes over time (beyond 1 year) in larger, more diverse groups across all BMI categories. Future studies should also seek to evaluate nutrient intake, energy expenditure and other important lifestyle habits to diminish health disparities within this vulnerable population. Policies are needed to help integrate registered dietitians into the routine care of transgender individuals.
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Affiliation(s)
- Ky Ford
- Department of Applied Health SciencesLoyola University ChicagoMaywoodIllinoisUSA
| | | | - Patricia Sheean
- Department of Applied Health SciencesLoyola University ChicagoMaywoodIllinoisUSA
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3
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Tewksbury C, Isom KA. Behavioral Interventions After Bariatric Surgery. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2022; 20:366-375. [PMID: 35789675 PMCID: PMC9244319 DOI: 10.1007/s11938-022-00388-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/21/2022] [Indexed: 11/28/2022]
Abstract
Purpose of Review Bariatric surgery is the most effective and durable treatment for severe obesity. Postoperative behavioral weight management approaches are available for optimizing weight change for both short- and long-term outcomes. Recent Findings Varying settings such as groups and telemedicine along with techniques such as cognitive behavioral therapy have been assessed in the post-bariatric surgery population. The assessment and application of these programs have been limited due to methodological, financial, and attrition-related constraints. Summary This review aims to summarize the current evidence for different postoperative behavioral interventions on postoperative outcomes, specifically highlighting weight loss. Future opportunities for study include mechanisms for overcoming some of the barriers to implementing these programs in clinical, non-research settings.
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Affiliation(s)
- Colleen Tewksbury
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, 3400 Spruce Street, Silverstein Building, 4th Floor, Philadelphia, PA 19104 USA
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Samaan JS, Srinivasan N, Mirocha J, Premkumar A, Toubat O, Qian E, Subramanyam C, Malik Y, Lee N, Sandhu K, Dobrowolsky A, Samakar K. Association of Postoperative Dieting, Exercise, Dietitian, and Surgeon Follow up With Bariatric Surgery Outcomes. Am Surg 2022; 88:2445-2450. [PMID: 35575161 DOI: 10.1177/00031348221101491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Although postoperative diet modification, exercise, and regular dietitian and surgeon follow-up are often recommended after bariatric surgery (BS), their impact on weight loss is unclear. A Retrospective chart review was conducted for patients who received sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) between August 2000 and November 2017 with telephone follow-up. Multivariable logistic regression models were used for analyses. There were 514 patients included in our study. Most were female (76.3%), mean age was 46.9 years (Standard Deviation [SD] = 11.8), and mean weight loss was 11.6 (SD = 6.5) BMI points at a mean follow-up of 7 years (SD = 4.3). Current surgeon follow-up OR = 2.08 (P < .01) was positively associated with postoperative weight loss, while current dietitian follow-up=OR .41 (P < .01) was negatively associated. Current weight loss supplement use OR = .45 (P = .03) was associated with reduced willingness to undergo surgery again. Increasing preoperative BMI OR = 1.06 (P = .04) and increasing age OR = 1.04 (P = .02) were associated with improved quality of life (QoL) due to BS. Lack of surgeon follow-up and regular dietician consultation was associated with suboptimal weight loss after BS. Older age was positively associated with improved QoL, while current weight loss supplement use was associated with lower likelihood of undergoing surgery again, both independent of weight loss.
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Affiliation(s)
- Jamil S Samaan
- Department of Medicine, 22494Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Nitin Srinivasan
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - James Mirocha
- Cedars-Sinai Medical Center, Biostatistics and Bioinformatics Research Center, Los Angeles, CA, USA
| | - Agnes Premkumar
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Omar Toubat
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Elaine Qian
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Chaitra Subramanyam
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Yousaf Malik
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Nayun Lee
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Kulmeet Sandhu
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Adrian Dobrowolsky
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Kamran Samakar
- Division of Upper GI & General Surgery, Department of Surgery, 12223Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
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Chen JH, Lee HM, Chen CY, Chen YC, Lin CC, Su CY, Tsai CF, Tu WL. 6M50LSG Scoring System Increased the Proportion of Adequate Excess Body Weight Loss for Suspected Poor Responders After Laparoscopic Sleeve Gastrectomy in Asian Population. Obes Surg 2021; 32:398-405. [PMID: 34817795 DOI: 10.1007/s11695-021-05776-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/14/2021] [Accepted: 11/03/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE We aimed to evaluate the efficacy of the predictive tool, 6M50LSG scoring system, to identify suspected poor responders after laparoscopic sleeve gastrectomy (LSG). METHODS The 6M50LSG scoring system has been applied since 2019. Suspected poor responders are defined by EBWL at 1 month < 19.5% or EBWL at 3 months < 37.7% based on the 6M50LSG scoring system. Our analysis included 109 suspected poor responders. Based on the date of LSG, the patients were separated into two groups: the 2016-2018 group (before group, BG, with regular care) and the 2019-2020 group (after group, AG, with upgrade medical nutrition therapy). RESULTS At the end of the study, the AG group had a significantly higher proportion of adequate weight loss, which was defined as EBWL ≥ 50% at 6 months after LSG, than that in the BG group (18.92% in BG vs. 48.57% in AG, p = 0.003). The AG group demonstrated significantly more 3-months-TWL (BG: 15.22% vs. AG: 17.54%, p < 0.001) and 6-months-TWL (BG: 21.08% vs. AG: 25.65%, p < 0.001). In multivariate analyses and adjustments, the scoring system (AG) resulted in significantly higher chances of adequate weight loss in suspected poor responders (adjusted OR 3.392, 95% CI = 1.345-8.5564, p = 0.010). One year after LSG, suspected poor responders in AG had a significantly higher weight loss than those in BG (BG vs. AG: TWL 27.17% vs. 32.20%, p = 0.014) . CONCLUSION This study confirmed that the 6M50LSG scoring system with upgraded medical nutrition therapy increased the proportion of suspected poor responders with adequate weight loss after LSG.
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Affiliation(s)
- Jian-Han Chen
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan. .,Division of General Surgery, E-Da Hospital, Kaohsiung, Taiwan. .,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.
| | - Hui-Ming Lee
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan.,Division of General Surgery, E-Da Cancer Hospital, Kaohsiung, Taiwan
| | - Chung-Yen Chen
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.,Division of General Surgery, E-Da Hospital, Kaohsiung, Taiwan.,School of Medicine, College of Medicine, I-Shou University, Kaohsiung, Taiwan
| | - Ying-Chen Chen
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.,Department of Nutrition Therapy, E-Da Hospital, Kaohsiung, Taiwan
| | - Chia-Chen Lin
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
| | - Ching-Yi Su
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
| | - Cheng-Fei Tsai
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan
| | - Wan-Ling Tu
- Bariatric and Metabolism International Surgery Center, E-Da Hospital, Kaohsiung, Taiwan.,Department of Nutrition Therapy, E-Da Hospital, Kaohsiung, Taiwan
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Bielawska B, Ouellette-Kuntz H, Zevin B, Anvari M, Patel SV. Early postoperative follow-up reduces risk of late severe nutritional complications after Roux-En-Y gastric bypass: a population based study. Surg Obes Relat Dis 2021; 17:1740-1750. [PMID: 34229936 DOI: 10.1016/j.soard.2021.05.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 04/16/2021] [Accepted: 05/30/2021] [Indexed: 01/19/2023]
Abstract
BACKGROUND Severe nutritional complications can occur following Roux-en-Y gastric bypass (RYGB). Adherence to follow-up visits can reduce the risk of many bariatric surgery complications, but whether this applies to severe nutritional complications is unknown. OBJECTIVES Determine the association between adherence to follow-up visits after RYGB and risk of severe nutritional complications. SETTING Multicenter publicly-funded Ontario Bariatric Network. METHODS Retrospective cohort study of Ontario adults participating in the Ontario Bariatric Registry who underwent RYGB between January 1, 2009, and December 31, 2015. The primary outcome was a severe nutritional complication (hospital admission with malnutrition or nutrient deficiency) occurring 1 year or more after RYGB. The primary exposure was adherence to postoperative follow-up visits, occurring at 3, 6, and 12 months postoperatively, and categorized as perfect (3 visits), partial (1-2 visits), or none. Cox proportional hazards modeling quantified the association between adherence to follow-up visits and the primary outcome using hazard ratios (HR). RESULTS In total, 9105 adults (84% female, age 44.7 ± 10.3 yr) met study criteria. Mean preoperative body mass index (BMI) was 48.6 kg/m2. First year follow-up attendance was: 51.7% perfect, 31.6% partial, and 16.7% none. Median time in the study was 3.4 years. Severe nutritional complications occurred in 1.1% of patients. Compared with perfect follow-up, patients with no follow-up (HR 3.09, 95% CI 1.74-5.50) and partial follow-up (HR 1.94, 95% CI 1.25-3.03) had an increased risk of severe nutritional complications. CONCLUSION Adherence to follow-up visits during the first year after RYGB is independently associated with reduction in the risk of subsequent severe nutritional complications.
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Affiliation(s)
- Barbara Bielawska
- University of Ottawa, Department of Medicine, Ottawa, Ontario, Canada; Queen's University, Department of Public Health Sciences, Kingston, Ontario, Canada.
| | | | - Boris Zevin
- Queen's University, Department of Surgery, Kingston, Ontario, Canada
| | | | - Sunil V Patel
- Queen's University, Department of Surgery, Kingston, Ontario, Canada
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7
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Zanley E, Shah ND, Craig C, Lau JN, Rivas H, McLaughlin T. Guidelines for gastrostomy tube placement and enteral nutrition in patients with severe, refractory hypoglycemia after gastric bypass. Surg Obes Relat Dis 2020; 17:456-465. [PMID: 33160876 DOI: 10.1016/j.soard.2020.09.026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/29/2020] [Accepted: 09/14/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Postbariatric hypoglycemia (PBH) affects up to 38% of Roux-en-Y gastric bypass (RYGB) patients. Severe cases are refractory to diet and medications. Surgical treatments including bypass reversal and pancreatectomy are highly morbid and hypoglycemia often recurs. We have developed a highly effective method of treatment by which enteral nutrition administered through a gastrostomy (G) tube placed in the remnant stomach replaces oral diet: if done correctly this reverses hyperinsulinemia and hypoglycemia, yielding substantial health and quality of life benefits for severely affected patients. OBJECTIVES To provide clinical guidelines for placement of a G-tube to treat postRYGB hypoglycemia, including candidate selection, preoperative evaluation, surgical considerations, and post-RYGB management. SETTING Stanford University Hospital and Clinics. METHODS Based on our relatively large experience with placing and managing G-tubes for PBH treatment, an interdisciplinary task force developed guidelines for practitioners. RESULTS A team approach (endocrinologist, dietitian, surgeon, psychologist) is recommended. Appropriate candidates have a history of RYGB, severe hypoglycemia refractory to medical-nutrition therapy, and significantly affected quality of life. Preoperative requirements include education and expectation setting, determination of initial enteral feeding program, and establishing service with a home enteral provider. Close postoperative follow-up is needed to ensure success and may require adjustments in formula and mode/rate of delivery to optimize tolerance and meet nutritional goals. G-tube nutrition must fully replace oral nutrition to prevent hypoglycemia. CONCLUSIONS G-tube placement in the remnant stomach represents a relatively well-tolerated and effective treatment for severe, refractory hypoglycemia after RYGB.
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Affiliation(s)
- Elizabeth Zanley
- Department of Medicine, Stanford University, Stanford, California
| | - Neha D Shah
- Department of Clinical Nutrition, Stanford Health Care, Stanford, California
| | - Colleen Craig
- Department of Medicine, Stanford University, Stanford, California
| | - James N Lau
- Department of General Surgery, Stanford University, Stanford, California
| | - Homero Rivas
- Department of General Surgery, Stanford University, Stanford, California
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8
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O'Kane M, Parretti HM, Pinkney J, Welbourn R, Hughes CA, Mok J, Walker N, Thomas D, Devin J, Coulman KD, Pinnock G, Batterham RL, Mahawar KK, Sharma M, Blakemore AI, McMillan I, Barth JH. British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update. Obes Rev 2020; 21:e13087. [PMID: 32743907 PMCID: PMC7583474 DOI: 10.1111/obr.13087] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/21/2020] [Accepted: 05/31/2020] [Indexed: 02/06/2023]
Abstract
Bariatric surgery is recognized as the most clinically and cost-effective treatment for people with severe and complex obesity. Many people presenting for surgery have pre-existing low vitamin and mineral concentrations. The incidence of these may increase after bariatric surgery as all procedures potentially cause clinically significant micronutrient deficiencies. Therefore, preparation for surgery and long-term nutritional monitoring and follow-up are essential components of bariatric surgical care. These guidelines update the 2014 British Obesity and Metabolic Surgery Society nutritional guidelines. Since the 2014 guidelines, the working group has been expanded to include healthcare professionals working in specialist and non-specialist care as well as patient representatives. In addition, in these updated guidelines, the current evidence has been systematically reviewed for adults and adolescents undergoing the following procedures: adjustable gastric band, sleeve gastrectomy, Roux-en-Y gastric bypass and biliopancreatic diversion/duodenal switch. Using methods based on Scottish Intercollegiate Guidelines Network methodology, the levels of evidence and recommendations have been graded. These guidelines are comprehensive, encompassing preoperative and postoperative biochemical monitoring, vitamin and mineral supplementation and correction of nutrition deficiencies before, and following bariatric surgery, and make recommendations for safe clinical practice in the U.K. setting.
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Affiliation(s)
- Mary O'Kane
- Dietetic Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | | | - Jonathan Pinkney
- Faculty of Health and Human Sciences, Peninsula Schools of Medicine and Dentistry, Plymouth, UK.,Department of Endocrinology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Richard Welbourn
- Department of Upper GI and Bariatric Surgery, Musgrove Park Hospital, Taunton and Somerset NHS Foundation Trust, Taunton, UK
| | - Carly A Hughes
- Norwich Medical School, University of East Anglia, Norwich, UK.,Fakenham Weight Management Service, Fakenham Medical Practice, Fakenham, UK
| | - Jessica Mok
- Centre for Obesity Research, Rayne Institute, Department of Medicine, University College London, London, UK
| | - Nerissa Walker
- School of Biosciences, Sutton Bonington Campus, University of Nottingham, Nottingham, UK
| | - Denise Thomas
- Department of Nutrition and Dietetics, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Jennifer Devin
- Specialist Weight Management Service, Betsi Cadwaladr University Health Board, Wales, UK
| | - Karen D Coulman
- Population Health Sciences, Bristol Medical School. University of Bristol, Bristol, UK.,Obesity and Bariatric Surgery Service, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | | | - Rachel L Batterham
- Centre for Obesity Research, Rayne Institute, Department of Medicine, University College London, London, UK.,Bariatric Centre for Weight Management and Metabolic Surgery, UCLH, University College London Hospital (UCLH), London, UK.,National Institute of Health Research, UCLH Biomedical Research Centre, London, UK
| | - Kamal K Mahawar
- Department of General Surgery, Sunderland Royal Hospital, Sunderland, UK
| | - Manisha Sharma
- Department of Clinical Biochemistry & Bariatric Surgery, Homerton University Hospital NHS Trust, London, UK
| | - Alex I Blakemore
- Department of Life Sciences, Brunel University, London, UK.,Department of Medicine, Imperial College, London, UK
| | | | - Julian H Barth
- Department of Chemical Pathology & Metabolic Medicine, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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9
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Abstract
PURPOSE OF REVIEW Bariatric surgery is the most effective treatment for severe and complex obesity; however, the risk of developing nutrient deficiencies varies based upon the type of surgery, degree of malabsorption, and level of nutrition intervention. There are numerous factors that can impact the nutrition status of a patient during their pre- and postoperative journey. We review the critical components and considerations needed in order to provide optimal nutrition care for patients with bariatric surgery. RECENT FINDINGS A dietitian, specializing in bariatric surgery, is the best equipped healthcare provider to prepare and support patients in achieving and maintaining optimal nutrition status. We present best practices for both the pre- and postoperative nutrition-related phases of a patient's journey. The dietitian specialist is integral in the assessment and ongoing nutrition care of patients with bariatric surgery. Further consideration should be given to enable access for lifelong follow-up and monitoring.
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Affiliation(s)
- Julie M Parrott
- Metabolic and Bariatric Surgery Program, Penn Medicine, Clinical Practices of the University of Pennsylvania, Philadelphia, PA, 19104, USA
| | | | | | - Mary O'Kane
- Department of nutrition and dietetics, The General Infirmary at Leeds, Great George Street, Leeds, West Yorkshire, LS1 3EX, UK.
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10
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Mechanick JI, Apovian C, Brethauer S, Timothy Garvey W, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical Practice Guidelines for the Perioperative Nutrition, Metabolic, and Nonsurgical Support of Patients Undergoing Bariatric Procedures - 2019 Update: Cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic and Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Obesity (Silver Spring) 2020; 28:O1-O58. [PMID: 32202076 DOI: 10.1002/oby.22719] [Citation(s) in RCA: 142] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 10/09/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPGs) was commissioned by the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), American Society for Metabolic and Bariatric Surgery (ASMBS), Obesity Medicine Association (OMA), and American Society of Anesthesiologists (ASA) Boards of Directors in adherence with the AACE 2017 protocol for standardized production of CPGs, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include: contextualization in an adiposity-based chronic disease complications-centric model, nuance-based and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current health care arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence based within the context of a chronic disease. A team approach to perioperative care is mandatory, with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Guideline Task Force Chair (AACE); Professor of Medicine, Medical Director, Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart; Director, Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York; Past President, AACE and ACE
| | - Caroline Apovian
- Guideline Task Force Co-Chair (TOS); Professor of Medicine and Director, Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | - Stacy Brethauer
- Guideline Task Force Co-Chair (ASMBS); Professor of Surgery, Vice Chair of Surgery, Quality and Patient Safety; Medical Director, Supply Chain Management, Ohio State University, Columbus, Ohio
| | - W Timothy Garvey
- Guideline Task Force Co-Chair (AACE); Butterworth Professor, Department of Nutrition Sciences, GRECC Investigator and Staff Physician, Birmingham VAMC; Director, UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- Guideline Task Force Co-Chair (ASA); Professor of Anesthesiology, Service Chief, Otolaryngology, Oral, Maxillofacial, and Urologic Surgeries, Associate Medical Director, Respiratory Care, University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Guideline Task Force Co-Chair (ASMBS); Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Guideline Task Force Co-Chair (TOS); Professor of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Richard Lindquist
- Guideline Task Force Co-Chair (OMA); Director, Medical Weight Management, Swedish Medical Center; Director, Medical Weight Management, Providence Health Services; Obesity Medicine Consultant, Seattle, Washington
| | - Rachel Pessah-Pollack
- Guideline Task Force Co-Chair (AACE); Clinical Associate Professor of Medicine, Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Guideline Task Force Co-Chair (OMA); Adjunct Assistant Professor, Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | - Richard D Urman
- Guideline Task Force Co-Chair (ASA); Associate Professor of Anesthesia, Brigham and Women's Hospital, Boston, Massachusetts
| | - Stephanie Adams
- Writer (AACE); AACE Director of Clinical Practice Guidelines Development, Jacksonville, Florida
| | - John B Cleek
- Writer (TOS); Associate Professor, Department of Nutrition Sciences, University of Alabama, Birmingham, Alabama
| | - Riccardo Correa
- Technical Analysis (AACE); Assistant Professor of Medicine and Endocrinology, Diabetes and Metabolism Fellowship Director, University of Arizona College of Medicine, Phoenix, Arizona
| | - M Kathleen Figaro
- Technical Analysis (AACE); Board-certified Endocrinologist, Heartland Endocrine Group, Davenport, Iowa
| | - Karen Flanders
- Writer (ASMBS); Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Writer (AACE); Associate Professor, Department of Surgery, University of Alabama at Birmingham; Staff Surgeon, Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Writer (AACE); Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | - Shanu Kothari
- Writer (ASMBS); Fellowship Director of MIS/Bariatric Surgery, Gundersen Health System, La Crosse, Wisconsin
| | - Michael V Seger
- Writer (OMA); Bariatric Medical Institute of Texas, San Antonio, Texas, Clinical Assistant Professor, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Writer (TOS); Medical Director, Center for Nutrition and Weight Management Director, Geisinger Obesity Institute; Medical Director, Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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11
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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures - 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of Endocrinology, The Obesity Society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anesthesiologists. Surg Obes Relat Dis 2019; 16:175-247. [PMID: 31917200 DOI: 10.1016/j.soard.2019.10.025] [Citation(s) in RCA: 235] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The development of these updated clinical practice guidelines (CPG) was commissioned by the American Association of Clinical Endocrinologists, The Obesity Society, the American Society of Metabolic and Bariatric Surgery, the Obesity Medicine Association, and the American Society of Anesthesiologists boards of directors in adherence to the American Association of Clinical Endocrinologists 2017 protocol for standardized production of CPG, algorithms, and checklists. METHODS Each recommendation was evaluated and updated based on new evidence from 2013 to the present and subjective factors provided by experts. RESULTS New or updated topics in this CPG include contextualization in an adiposity-based, chronic disease complications-centric model, nuance-based, and algorithm/checklist-assisted clinical decision-making about procedure selection, novel bariatric procedures, enhanced recovery after bariatric surgery protocols, and logistical concerns (including cost factors) in the current healthcare arena. There are 85 numbered recommendations that have updated supporting evidence, of which 61 are revised and 12 are new. Noting that there can be multiple recommendation statements within a single numbered recommendation, there are 31 (13%) Grade A, 42 (17%) Grade B, 72 (29%) Grade C, and 101 (41%) Grade D recommendations. There are 858 citations, of which 81 (9.4%) are evidence level (EL) 1 (highest), 562 (65.5%) are EL 2, 72 (8.4%) are EL 3, and 143 (16.7%) are EL 4 (lowest). CONCLUSIONS Bariatric procedures remain a safe and effective intervention for higher-risk patients with obesity. Clinical decision-making should be evidence-based within the context of a chronic disease. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.
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Affiliation(s)
- Jeffrey I Mechanick
- Marie-Josée and Henry R. Kravis Center for Clinical Cardiovascular Health at Mount Sinai Heart, New York, New York; Metabolic Support Divisions of Cardiology and Endocrinology, Diabetes, and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York.
| | - Caroline Apovian
- Nutrition and Weight Management, Boston University School of Medicine and Boston Medical Center, Boston, Massachusetts
| | | | - W Timothy Garvey
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama; UAB Diabetes Research Center, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- University of Washington, Harborview Medical Center, Seattle, Washington
| | - Julie Kim
- Harvard Medical School, Mount Auburn Hospital, Cambridge, Massachusetts
| | - Robert F Kushner
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Rachel Pessah-Pollack
- Division of Endocrinology, Diabetes and Metabolism, NYU Langone Health, New York, New York
| | - Jennifer Seger
- Department of Family and Community Medicine, Long School of Medicine, UT Health Science Center, San Antonio, Texas
| | | | - Stephanie Adams
- American Association of Clinical Endocrinologists, Jacksonville, Florida
| | - John B Cleek
- Department of Nutrition Sciences, Birmingham VA Medical Center, Birmingham, Alabama
| | | | | | - Karen Flanders
- Massachusetts General Hospital Weight Center, Boston, Massachusetts
| | - Jayleen Grams
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama; Birmingham VA Medical Center, Birmingham, Alabama
| | - Daniel L Hurley
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, Minnesota
| | | | - Michael V Seger
- Bariatric Medical Institute of Texas, San Antonio, Texas, University of Texas Health Science Center, Houston, Texas
| | - Christopher D Still
- Center for Nutrition and Weight Management Director, Geisinger Obesity Institute, Danville, Pennsylvania; Employee Wellness, Geisinger Health System, Danville, Pennsylvania
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Abstract
The objective of this review is to examine advances in the development of combination therapies for the treatment of obesity beyond diet or lifestyle interventions. Experimental combination pharmacotherapies include combinations of pramlintide and phentermine as well as amylin and bupropion-naltrexone. Incretin and pancreatic hormones generally inhibit upper gastrointestinal motor functions, and combinations showing efficacy in obesity are coadministration of glucagon-like peptide-1 (GLP-1) with glucagon, a unimolecular dual incretin of PEGylated GLP-1/GIP coagonist, the combination of GLP-1 and PYY3-36, and, in proof of concept studies, combined infusions of GLP-1, peptide YY, and oxyntomodulin. Among bariatric procedures, repeat intragastric balloon (IGB) treatments are more efficacious than IGB plus diet, and endoscopic intervention can enhance the effects of Roux-en-Y gastric bypass when weight regain occurs. A first trial has provided promising results with combination of IGB plus the GLP-1 analog, liraglutide, compared to the balloon alone. Thus, combination therapies for the treatment of obesity hold promise for introduction into clinical practice.
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Affiliation(s)
- Michael Camilleri
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic , Rochester, Minnesota
| | - Andres Acosta
- Clinical Enteric Neuroscience Translational and Epidemiological Research (CENTER), Mayo Clinic , Rochester, Minnesota
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