Optimisation of follow-up after metabolic surgery

Adherence to Dietary Behavior Recommendations Moderates the Effect Between Time Since Metabolic and Bariatric Surgery and Percentage Total Weight Loss

PURPOSE

Metabolic and bariatric surgery (MBS) is the gold standard in treating severe obesity. Previous research implies that different psychological and behavior-related factors might be critical for MBS' sustained success. Yet adherence to dietary behavior recommendations and its impact on weight development is rarely examined. This study investigated the relationship between adherence to dietary behavior recommendations and the percentage of total weight loss (%TWL) after MBS.

MATERIALS AND METHODS

This study is a cohort study (acquisition in Germany). N = 485 patients after MBS, being in grade III of obesity (body mass index (BMI) ≥ 40 kg/m2) pre-MBS, were included. Participants answered a standardized assessment on the relevant constructs, including adherence to dietary behavior recommendations, depression symptoms, weight, diet, and MBS characteristics.

RESULTS

BMI pre-MBS, type of MBS, age, regularity of physical activity, and depression symptoms were identified as significant covariates of %TWL and adherence. Within 6 months after MBS, adherence seems to peak, F(5,352) = 12.35, p < .001. Adherence and time since MBS predict %TWL. A higher adherence (moderator) is related to a higher %TWL, R2 = 52.65%, F(13,344) = 31.54, p < .001.

CONCLUSION

After MBS, adherence to dietary behavior recommendations seems crucial for maximizing its success. Implications for the optimization of MBS' success in aftercare management arise. In particular, behavior modification interventions should be routinely implemented.

Cross-Talk of NADPH Oxidases and Inflammation in Obesity

Obesity is a major risk factor for cardiovascular and metabolic diseases. Multiple experimental and clinical studies have shown increased oxidative stress and inflammation linked to obesity. NADPH oxidases are major sources of reactive oxygen species in the cardiovascular system and in metabolically active cells and organs. An impaired balance due to the increased formation of reactive oxygen species and a reduced antioxidative capacity contributes to the pathophysiology of cardiovascular and metabolic diseases and is linked to inflammation as a major pathomechanism in cardiometabolic diseases. Non-alcoholic fatty liver disease is particularly characterized by increased oxidative stress and inflammation. In recent years, COVID-19 infections have also increased oxidative stress and inflammation in infected cells and tissues. Increasing evidence supports the idea of an increased risk for severe clinical complications of cardiometabolic diseases after COVID-19. In this review, we discuss the role of oxidative stress and inflammation in experimental models and clinical studies of obesity, cardiovascular diseases, COVID-19 infections and potential therapeutic strategies.

Long-term weight loss and metabolic benefit from Roux-en-Y gastric bypass in patients with superobesity

BACKGROUND

Although Roux-en-Y gastric bypass (RYGB) is widely performed worldwide, its efficacy in patients with a body mass index (BMI) greater than 50 kg/m2 remains controversial. The aim of the present paper was to assess long-term (10 years or more) weight loss and metabolic results of RYGB in patients with superobesity (SO; BMI > 50 kg/m2), compared with patients with morbid obesity (MO; BMI 35-50 kg/m2).

METHODS

This study involved retrospective analysis of a prospectively followed cohort of adult patients operated on for a primary RYGB between 1999 and 2008. Long-term weight loss and metabolic parameters were compared between SO and MO patients, with a sex-specific subgroup analysis in SO patients. Multiple logistic regression assessed independent predictors of poor long-term weight loss.

RESULTS

Among the 957 included patients, 193 (20.2 per cent) were SO (mean BMI 55.3 kg/m2versus 43.3 kg/m2 in MO). Upon 10-year follow-up, which was complete in 86.3 per cent of patients, BMI remained higher in SO patients (mean 39.1 kg/m2versus 30.8 kg/m2, P < 0.001) although total bodyweight loss (per cent TBWL) was similar (28.3 per cent versus 28.8 per cent, P = 0.644). Male SO patients had a trend to higher 10-year per cent TBWL, while initial BMI greater than 50 kg/m2 and low 5-year per cent TBWL were independent predictors of long-term TBWL less than 20 per cent. Diabetes remission was observed in 39 per cent SO and 40.9 per cent MO patients (P = 0.335) at 10 years, and all patients had a significant lipid profile improvement.

CONCLUSION

Substantial improvement in co-morbidities was observed in all patients 10 years after RYGB. Total weight loss was similar in SO and MO patients, leaving SO patients with higher BMI. Suboptimal TBWL 5 years after surgery in SO, especially female patients, may warrant prompt reassessment to improve long-term outcomes.

Bariatric surgery, gastrointestinal hormones, and the microbiome: An Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) 2022

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) is intended to provide clinicians an overview of bariatric surgery (i.e., bariatric procedures that improve metabolic disease are often termed "metabolic and bariatric surgery"), gastrointestinal hormones, and the microbiome as they relate to patients with obesity.

Methods

The scientific information for this CPS is based upon published scientific citations, clinical perspectives of OMA authors, and peer review by the Obesity Medicine Association leadership.

Results

This CPS includes the pros and cons of the most common types of bariatric procedures; the roles of gastrointestinal (GI) hormones in regulating hunger, digestion, and postabsorptive nutrient metabolism; and the microbiome's function and relationship with body weight. This CPS also describes patient screening for bariatric surgery, patient care after bariatric surgery, and treatment of potential nutrient deficiencies before and after bariatric surgery. Finally, this CPS explores the interactions between bariatric surgery, GI hormones, and the microbiome.

Conclusions

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) regarding bariatric surgery, gastrointestinal hormones, and the microbiome is one of a series of OMA CPSs designed to assist clinicians in the care of patients with the disease of obesity. Implementation of appropriate care before and after bariatric surgery, as well as an awareness of GI hormones and the microbiome, may improve the health of patients with obesity, especially patients with adverse fat mass and adiposopathic metabolic consequences.

Resistance Training Improves Muscle Strength and Function, Regardless of Protein Supplementation, in the Mid- to Long-Term Period after Gastric Bypass

Inadequate protein intake and low levels of physical activity are common long-term sequelae after bariatric surgery and can negatively affect muscle strength (MS) and physical function (PF). The study investigated the effects of resistance training with or without protein supplementation on MS and PF. The study, which involved a 12-week controlled trial (n = 61) of individuals 2-7 years post-Roux-en-Y gastric bypass (RYGB), comprised four groups: whey protein supplementation (PRO; n = 18), maltodextrin placebo (control [CON]; n = 17), resistance training combined with placebo (RTP; n = 11), and resistance training combined with whey protein supplementation (RTP+PRO; n = 15). An isokinetic dynamometer was used to measure MS (peak torque at 60°/s and 180°/s). PF was measured with the 30-s sit-to-stand (30-STS), 6-min walk (6-MWT), and timed up-and-go (TUG) tests. There were improvements in the absolute and relative-to-bodyweight peak torque at 60°/s and 180°/s, TUG, 6-MWT and 30-STS in the RTP and RTP+PRO groups, but not in the CON and PRO groups. Changes in MS were significantly correlated with changes in PF between the pre- and post-intervention periods. A supervised resistance training program, regardless of protein supplementation, improved MS and PF in the mid-to-long-term period after RYGB and can lead to clinical benefits and improved quality of life.

A randomized clinical trial on the effects of exercise on muscle remodelling following bariatric surgery

BACKGROUND

Muscle atrophy and strength loss are common adverse outcomes following bariatric surgery. This randomized, controlled trial investigated the effects of exercise training on bariatric surgery-induced loss of muscle mass and function. Additionally, we investigated the effects of the intervention on molecular and histological mediators of muscle remodelling.

METHODS

Eighty women with obesity were randomly assigned to a Roux-en-Y gastric bypass (RYGB: n = 40, age = 42 ± 8 years) or RYGB plus exercise training group (RYGB + ET: n = 40, age = 38 ± 7 years). Clinical and laboratory parameters were assessed at baseline, and 3 (POST3) and 9 months (POST9) after surgery. The 6 month, three-times-a-week, exercise intervention (resistance plus aerobic exercise) was initiated 3 months post-surgery (for RYGB + ET). A healthy, lean, age-matched control group was recruited to provide reference values for selected variables.

RESULTS

Surgery resulted in a similar (P = 0.66) reduction in lower-limb muscle strength in RYGB and RYGB+ET (-26% vs. -31%), which was rescued to baseline values in RYGB + ET (P = 0.21 vs. baseline) but not in RYGB (P < 0.01 vs. baseline). Patients in RYGB+ET had greater absolute (214 vs. 120 kg, P < 0.01) and relative (2.4 vs. 1.4 kg/body mass, P < 0.01) muscle strength compared with RYGB alone at POST9. Exercise resulted in better performance in timed-up-and-go (6.3 vs. 7.1 s, P = 0.05) and timed-stand-test (18 vs. 14 repetitions, P < 0.01) compared with RYGB. Fat-free mass was lower (POST9-PRE) after RYBG than RYGB + ET (total: -7.9 vs. -4.9 kg, P < 0.01; lower-limb: -3.8 vs. -2.7 kg, P = 0.02). Surgery reduced Types I (~ - 21%; P = 0.99 between-group comparison) and II fibre cross-sectional areas (~ - 27%; P = 0.88 between-group comparison), which were rescued to baseline values in RYGB+ET (P > 0.05 vs. baseline) but not RYGB (P > 0.01 vs. baseline). RYGB + ET showed greater Type I (5187 vs. 3898 μm² , P < 0.01) and Type II (5165 vs. 3565 μm² , P < 0.01) fCSA than RYGB at POST9. RYGB + ET also resulted in increased capillarization (P < 0.01) and satellite cell content (P < 0.01) than RYGB at POST9. Gene-set normalized enrichment scores for the muscle transcriptome revealed that the ubiquitin-mediated proteolysis pathway was suppressed in RYGB + ET at POST9 vs. PRE (NES: -1.7; P < 0.01), but not in RYGB. Atrogin-1 gene expression was lower in RYGB + ET vs. RYGB at POST9 (0.18 vs. 0.71-fold change, P < 0.01). From both genotypic and phenotypic perspectives, the muscle of exercised patients resembled that of healthy lean individuals.

CONCLUSIONS

This study provides compelling evidence-from gene to function-that strongly supports the incorporation of exercise into the recovery algorithm for bariatric patients so as to counteract the post-surgical loss of muscle mass and function.

[Physical exercise and loss of weight and body mass index in bariatric surgery: a systematic review]

INTRODUCTION

bariatric surgery is considered successful when the percentage of weight loss is equal to or higher than 25 %, or when the percentage loss of body mass index occurs above 50 % long-term.

OBJECTIVE

to analyze the effect of physical exercise on body weight and body mass index before and/or after bariatric surgery.

METHODOLOGY

articles registered in the PudMed, Scopus and Web of Science databases were searched for original papers with open access in English and Spanish that compared one or more physical exercise programs as treatment before and/or after bariatric surgery, with results on initial and final weight and body mass index, muscle mass, and fat mass from January to April 2021.

RESULTS

a total of 730 articles were obtained in the different databases and only 7 were selected for the analysis. Aerobic exercise combined with resistance training showed a greater decrease in the percentage of weight loss (% PP) and the percentage of loss of body mass index (% PBMI).

CONCLUSIONS

aerobic physical exercise in combination with endurance training is the most applied program in subjects with bariatric surgery, and the most important effects are an increase in percentage of weight loss and a decrease in body mass index.

Nutritional Deficiencies Among Adolescents Before and After Sleeve Gastrectomy: First Study with 9-Year Follow-up

BACKGROUND

Globally, only two studies appraised the long-term nutritional status of adolescents after laparoscopic sleeve gastrectomy (LSG).

METHODS

Retrospective chart review of all adolescents aged ≤ 18 years who underwent LSG with ≥ 5 years follow-up and had no subsequent revisional surgery (N = 146). We assessed 15 nutritional parameters preoperatively and at 1, 3, 5, 7, and 9 years post surgery.

RESULTS

Mean age was 16.51 ± 1.29 years, 51% were males. We identified three patterns: 1) Significant worsening of preoperative deficiencies: 4.7% and 0.8% of the sample exhibited zinc and vitamin B12 deficiencies, worsening to 20.8% and 12.8% at 1 year, respectively. Likewise, 0.7% of the sample had low total protein, worsening to 8.3% at year 3. A total of 32.4% of females had preoperative low hemoglobin worsening to 57.9% at year 5. 2) Significant improvement: the percentage of males with preoperative low hemoglobin (5.6%) was reduced to 4.1% and 5.1% at years 1 and 3, respectively. 3) Persistent deficiency: all (100%) of adolescents had preoperative vitamin D deficiency that persisted through years 3 and 9 at 90.5% and 100%, respectively. The most common complications were food intolerance (51%), vomiting (47.5%), gastritis/ esophagitis (35.7%), and gastroesophageal reflux disease (20.3%). We observed one case of Wernicke's encephalopathy. Across the 9 years, 15.4% of the adolescents underwent intra-abdominal surgeries where 12.6% had cholecystectomy and one patient had appendectomy.

CONCLUSION

Adolescents had several preoperative nutritional deficiencies, most of which worsened or persisted on the long term. This is the first study among adolescents to assess such deficiencies beyond 5 years.

Late complications of biliopancreatic diversion in an older patient: a case report

BACKGROUND

In the mid-seventies, biliopancreatic diversion became popular as weight-loss surgery procedure. This bariatric procedure combines distal gastric resection and intestinal malabsorption, leading to greater weight loss and improvement of co-morbidities than other bariatric procedures. Nowadays, biliopancreatic diversion has become obsolete due to the high risk of nutritional complications. However, current patients with biliopancreatic diversions are aging. Consequently, geriatricians and general practitioners will encounter them more often and will be faced with the consequences of late complications.

CASE PRESENTATION

A 74-year old female presented with weakness, recurrent falls, confusion, episodes of irresponsiveness, anorexia and weight loss. Her medical history included osteoporosis, herpes encephalitis 8 years prior and a biliopancreatic diversion (Scopinaro surgery) at age 52. Cerebral imaging showed herpes sequelae without major atrophy. Delirium was diagnosed with underlying nutritional deficiencies. Biochemical screening indicated vitamin A deficiency, vitamin E deficiency, zinc deficiency and severe hypoalbuminemia. While thiamin level and fasting blood glucose were normal. However, postprandial hyperinsulinemic hypoglycemia was observed with concomitant signs of confusion and blurred consciousness. After initiating parenteral nutrition with additional micronutrient supplementation, a marked improvement was observed in cognitive and physical functioning.

CONCLUSIONS

Long-term effects of biliopancreatic diversion remain relatively underreported in older patients. However, the anatomical and physiological changes of the gastrointestinal tract can contribute to the development of metabolic and nutritional complications that may culminate in cognitive impairment, functional decline and delirium. Therefore, it is warranted to evaluate the presence of metabolic disturbances and nutritional complications in older patients after biliopancreatic diversion.

Patients' experiences of telenursing follow-up care after bariatric surgery

AIM

To explore the postsurgical management experiences of bariatric patients after receiving telenursing follow-up care, using a telemonitoring platform for approximately 1 month.

BACKGROUND

Obesity prevalence rates among adult Canadians are increasing, and as such the number of bariatric surgeries. Adapting to life following bariatric surgery is challenging, and patients are often experiencing difficulties to adhere to the postsurgical behavioural recommendations. The use of technology has been introduced in bariatric aftercare programmes, yet patients voiced a desire to communicate with a clinician between routine visits to improve continuity of care. To our knowledge, there is a lack of research on emerging practice of telenursing to provide monitoring, support and aftercare to bariatric patients remotely.

DESIGN

A qualitative descriptive design was used.

METHODS

A total of 22 semi-structured interviews were thematically analysed. The SRQR checklist was used.

RESULTS

Participants embraced the idea of integrating telenursing care in bariatric aftercare programmes, as they viewed this novel approach to care as a way to overcome the current challenges of accessing bariatric services. The most salient benefit reported by participants was the timely advice and care provided by the telenurse. The provision of tailored nursing care and the accessibility to a first-line professional empowered participants to exercise greater control over their recovery process, which promotes self-management and enhances feelings of security and reassurance. Lastly, participants voiced areas of improvement to better the system and to render it most accessible and user-friendly.

CONCLUSION

Despite its novelty in bariatric aftercare, our findings indicated that patients are eager to integrate telenursing in mainstream services. Discussions are needed regarding patient adherence to telemonitoring, and the need to develop clinical follow-up protocols.

RELEVANCE TO CLINICAL PRACTICE

Results provide new insights into the importance of a telenurse in providing individualised care to bariatric patients.

Effect of exercise training before and after bariatric surgery: A systematic review and meta-analysis

We aimed to assess the effectiveness of exercise training programs in adults with severe obesity undergoing bariatric surgery. A systematic search of controlled trials published up to October 2019 that assigned participants to either a preoperative or postoperative exercise training group or a nonexercise group was performed. Meta-analyses were conducted using random-effects models. Twenty-two training programs were assessed (18 performed after bariatric surgery). The effect of preoperative exercise training on postsurgery outcomes was reported in only one study. Compared with the control condition without exercise, postoperative exercise training led to higher weight loss (N = 14, mean difference [95% CI] = -1.8 [-3.2; -0.4] kg, P = 0.01), fat loss (N = 9, P = 0.01), increase in VO₂ max (N = 8, P < 0.0001), and increase in muscle strength (N = 9, P < 0.0001). No significant effect was found on lean body mass (N = 11). Preliminary evidence suggests a beneficial effect of postoperative exercise training on bone mineral density (N = 3, P < 0.001) and weight maintenance after the end of the intervention (N = 2, P < 0.001) but no significant effect on quality of life (N = 2), habitual physical activity (N = 2), or cardiometabolic outcomes (N < 4). In conclusion, exercise training performed after bariatric surgery improves physical fitness and leads to a small additional weight and fat loss and may prevent bone loss and weight regain after bariatric surgery.

Sleeve Gastrectomy Attenuates Diabetic Nephropathy by Upregulating Nephrin Expressions in Diabetic Obese Rats

PURPOSE

Diabetic nephropathy (DN) is the leading cause of end-stage renal disease, and sleeve gastrectomy (SG) is considered to be an effective strategy to improve pre-existing DN. However, the mechanism remains unknown.

MATERIALS AND METHODS

Animal model of DN was induced by high-fat diet (HFD) and streptozotocin (STZ). SG or sham surgery was performed and rats were sacrificed at 4, 8, and 12 weeks after surgery. The basic parameters (blood glucose, body weight, kidney weight), indicators of renal function including serum creatinine (Scr), blood urea nitrogen (BUN), urine microalbumin, urine creatinine (Ucr), microalbumin creatinine ratio (UACR), ultrastructural changes of glomerulus, and the expression of nephrin gene and protein in glomerular podocytes were compared among groups.

RESULTS

Blood glucose and body weight of SG rats were significantly lower than those of the sham-operated rats, and renal function of SG groups were also significantly improved within the postoperative period of 12 weeks. The results of periodic acid-Schiff staining (PAS) and transmission electron microscopy (TEM) showed that glomerular hypertrophy and accumulation of extracellular matrix proteins were significantly alleviated after SG, and the thickness of basement membrane and the fusion or effacement of foot processes were also significantly improved. The mRNA and protein expression of nephrin in SG groups was significantly higher than that in the sham group.

CONCLUSION

These results suggest that SG attenuates DN by upregulating the expression of nephrin and improving the ultrastructure of glomerular filtration membrane. This study indicates that SG can be used as an available therapeutic intervention for DN.

Effects of Resistance Training With or Without Protein Supplementation on Body Composition and Resting Energy Expenditure in Patients 2-7 Years PostRoux-en-Y Gastric Bypass: a Controlled Clinical Trial

BACKGROUND

Resistance training (RT) and adequate protein intake are recommended as strategies to preserve fat-free mass (FFM) and resting metabolic demand after bariatric surgery. However, the effect of both interventions combined in the late postoperative period is unclear. This study investigated the effects of RT, isolated and combined with protein supplementation, on body composition and resting energy expenditure (REE) in the late postoperative period of Roux-en-Y gastric bypass (RYGB).

METHODS

This controlled trial involved patients who were 2-7 years postRYGB. Participants were partially matched on body mass index (BMI), age, sex, and years after surgery, and divided into four groups, placebo maltodextrin (control [CON]; n = 17), whey protein supplementation (PRO; n = 18), RT combined with placebo (RTP; n = 13), and RT combined with whey protein supplementation (RTP + PRO; n = 15)-considering the participants who completed the protocol. REE was measured by indirect calorimetry and body composition by multifrequency electrical bioimpedance.

RESULTS

Participant characteristics (40.3 ± 8.3 years old; average BMI 29.7 ± 5.3 kg/m²; 88.9% females) were similar among groups. The RTP+PRO group showed an increase of 1.46 ± 1.02 kg in FFM and 0.91 ± 0.64 kg in skeletal muscle mass (SMM), which was greater than the equivalent values in the CON group (- 0.24 ± 1.64 kg, p = 0.006 and - 0.08 ± 0.96 kg, p = 0.008, respectively). There was no significant time-by-group interaction for absolute or relative REE.

CONCLUSION

Combined RT and adequate protein intake via supplementation can increase FFM and SMM in the late postoperative period without changing REE. These associated strategies were effective in improving muscle-related parameters and potentially in improving the patients' physical function.

Development and Validation of a Nomogram for Predicting Obstructive Sleep Apnea in Bariatric Surgery Candidates

BACKGROUND

Obstructive sleep apnea (OSA) is highly prevalent in bariatric surgery patients and can lead to potential perioperative risks, but some screening tools lack adequate performance in this population. Thus, we aimed to develop and validate a clinical nomogram for predicting OSA in bariatric surgery candidates.

METHODS

We retrospectively collected the data of 482 bariatric surgery patients between September 2015 and January 2020. Patients were randomly classified into training cohort (n=338) and validation cohort (n=144). The Lasso regression was used to select potentially relevant features; then, multivariable logistic regression analysis was used to establish the nomogram. Discrimination, calibration and clinical usefulness of the nomogram were assessed using the C-index, calibration curve and decision curve analysis (DCA).

RESULTS

The overall prevalence of OSA was 71.0% and higher in males (88.2%) compared to females (60.1%). Of these, 26.1% had mild OSA, 14.9% had moderate OSA, and 44.8% had severe OSA. The nomogram consisted of gender, habitual snoring, type 2 diabetes mellitus (T2DM), neck circumference, body mass index (BMI) and age. The nomogram provided favorable discrimination, with a C-indexes for the training and validation cohort of 0.856 (95% CI: 0.816-0.897) and 0.829 (95% CI: 0.76-0.895), respectively, and good calibration. The DCA displayed that the nomogram was clinically useful.

CONCLUSION

We established a concise and practical nomogram that could facilitate the preoperative individualized prediction of OSA before bariatric surgery, which may help clinicians select bariatric surgery patients with high-risk OSA for polysomnography (PSG).

The Optimal Nutritional Programme for Bariatric and Metabolic Surgery

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.

Bariatric Surgery and Its Complications in Inflammatory Bowel Disease Patients

Recent data have suggested that bariatric procedures, especially laparoscopic sleeve gastrectomy (SG), are safe and effective weight loss measures in patients with inflammatory bowel disease (IBD). But most of the studies have looked at short-term outcomes, and there is a general lack of awareness of underlying disease processes and baseline comorbidities in IBD patients undergoing bariatric procedures. Postbariatric issues in IBD patients including diarrhea from dumping syndrome, choleretic diarrhea, a high prevalence of small intestinal bacterial overgrowth, gastroesophageal reflux disease, Barrett's esophagus, stomal ulcerations, stenosis, and renal and gallstones can complicate the natural history of IBD. This could lead to unnecessary hospitalizations, change of medical therapy, and poor surgical and quality of life outcomes. In this review, we will discuss major complications after common bariatric procedures (SG, Roux-en-Y gastric bypass, and gastric banding) and suggest possible management strategies.

Recommendations Based on Evidence by the Andalusian Group for Nutrition Reflection and Investigation (GARIN) for the Pre- and Postoperative Management of Patients Undergoing Obesity Surgery

In order to develop evidence-based recommendations and expert consensus for nutrition management of patients undergoing bariatric surgery and postoperative follow-up, we conducted a systematic literature search using PRISMA methodology plus critical appraisal following the SIGN and AGREE-II procedures. The results were discussed among all members of the GARIN group, and all members answered a Likert scale questionnaire to assess the degree of support for every recommendation. Patients undergoing bariatric surgery should be screened preoperatively for some micronutrient deficiencies and treated accordingly. A VLCD (Very Low-Calorie Diet) should be used for 4–8 weeks prior to surgery. Postoperatively, a liquid diet should be maintained for a month, followed by a semi-solid diet also for one month. Protein requirements (1–1.5 g/kg) should be estimated using adjusted weight. Systematic use of specific multivitamin supplements is encouraged. Calcium citrate and vitamin D supplements should be used at higher doses than are currently recommended. The use of proton-pump inhibitors should be individualised, and vitamin B12 and iron should be supplemented in case of deficit. All patients, especially pregnant women, teenagers, and elderly patients require a multidisciplinary approach and specialised follow-up. These recommendations and suggestions regarding nutrition management when undergoing bariatric surgery and postoperative follow-up have direct clinical applicability.

Associations of Bariatric Interventions With Micronutrient and Endocrine Disturbances

IMPORTANCE

Few studies have described the longitudinal trajectories of serum levels of micronutrients whose deficiencies are associated with serious sequelae following bariatric procedures, such as anemia, osteoporotic fractures, and neuropathies. Furthermore, previous studies comparing laparoscopic sleeve gastrectomy (LSG) vs Roux-en-Y gastric bypass (LRYGB) or one-anastomosis gastric bypass (OAGB) procedures may have been limited by selection and confounding biases.

OBJECTIVE

To appraise the spectrum and temporal course of micronutrient deficiencies associated with bone metabolism and erythropoiesis after LSG vs OAGB or LRYGB procedures, using the propensity score as a balancing score.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, longitudinal comparative effectiveness study was conducted at a high-volume bariatric unit in Singapore from September 1, 2008, to November 30, 2017, with a cutoff date for analysis of September 2018. Patients who underwent adjustable gastric banding, biliopancreatic diversion procedures, and intragastric balloon procedures were excluded. All other patients who underwent bariatric procedures were included. Data were analyzed from September 23 to 30, 2018.

MAIN OUTCOMES AND MEASURES

Serial assessment of 13 biochemical parameters at 12 time points for up to 5 years after bariatric procedure. Inverse probability-of-treatment weights were used to obtain estimates of the mean associations of variables assessed with the bariatric surgical interventions. Longitudinal trajectories were analyzed using mixed-effects generalized linear models to apportion the temporal variation of serum micronutrients into fixed-effects and random-effects components.

RESULTS

A total of 688 patients were included in this study, of whom 499 underwent LSG (mean [SD] age, 41.5 [11.3] years; 318 [63.7%] women) and 189 underwent OAGB or LRYGB (mean [SD] age, 48.6 [9.4] years; 112 [59.3%] women). There were no differences during follow-up among patients who underwent LSG vs those who underwent OAGB or LRYGB in intact parathyroid hormone levels (mean difference, 7.05 [95% CI, -28.67 to 42.77] pg/mL; P = .70), serum 25-hydroxyvitamin D levels (mean difference, -0.72 [95% CI, -1.56 to 0.12] ng/mL; P = .09), or phosphate levels (mean difference, 0.006 [95% CI, -0.052 to 0.064] mg/dL; P = .83). Hemoglobin levels were a mean 0.63 (95% CI, 0.41 to 0.85) g/dL higher among patients who underwent LSG compared with those who underwent OAGB or LRYGB (P < .001), despite no differences in iron concentration levels (mean difference, 1.50 [95% CI, -1.39 to 4.39] µg/dL; P = .31), total iron-binding capacity (mean difference, 4.36 [95% CI, -5.25 to 13.98] µg/dL; P = .37), or ferritin levels (mean difference, 3.0 [95% CI, -13.0 to 18.9] ng/mL; P = .71). Compared with patients who underwent LSG procedures, patients who underwent OAGB or LRYGB had higher folate levels (mean difference, 2.376 [95% CI, 1.716 to 3.036] ng/mL; P < .001) but lower serum magnesium levels (mean difference, -0.25 [95% CI, -0.35 to -0.16] mg/dL; P < .001) and zinc levels (mean difference, -7.58 [95% CI, -9.92 to -5.24] µg/dL; P < .001).

CONCLUSIONS AND RELEVANCE

These findings suggest that LSG vs OAGB or LRYGB procedures have differential associations with various micronutrient and metabolic parameters. These differences should be recognized in guidelines for postbariatric nutritional surveillance and prevention.

A new sensitive and accurate model to predict moderate to severe obstructive sleep apnea in patients with obesity

Obstructive sleep apnea (OSA) has a high prevalence in patients with obesity. Only patients with clinical symptoms of OSA are admitted to polysomnography; however, many patients with OSA are asymptomatic. We aimed to create and validate a population-based risk score that predicts the severity of OSA in patients with obesity.We here report the cross-sectional analysis at baseline of an ongoing study investigating the long-term effect of bariatric surgery on OSA. One-hundred sixty-one patients of the Obesity Center of the Catholic University Hospital in Rome, Italy were included in the study. The patients underwent overnight cardiorespiratory monitoring, blood chemistry analyses, hepatic ultrasound, and anthropometric measurements. The patients were divided into 2 groups according OSA severity assessed by the apnea-hypopnea index (AHI): AHI < 15 = no or mild and AHI ≥ 15 moderate to severe OSA. A statistical prediction model was created and validated. C statistics was used to evaluate the discrimination performance of the model.The prevalence of OSA was 96.3% with 74.5% of the subjects having moderate/severe OSA. Sex, body mass index, diabetes, and age were included in the final prediction model that had excellent discrimination ability (C statistics equals to 83%). An OSA risk chart score for clinical use was created.Patients with severe obesity are at a very high risk for moderate or severe OSA in particular if they are men, older, more obese, and/or with type 2 diabetes. The OSA risk chart can be useful for general practitioners and patients as well as for bariatric surgeons to select patients with high risk of moderate to severe OSA for further polysomnography.

A Novel Mutation of the Calcium-Sensing Receptor Gene Causing Familial Hypocalciuric Hypercalcemia Complicates Medical Followup after Roux-en-Y Gastric Bypass: A Case Report and a Summary of Mutations Found in the Same Hospital Laboratory

Heterozygous inactivating mutations in the calcium-sensing receptor (CaSR) gene are known to cause familial hypocalciuric hypercalcemia (FHH), usually a benign form of hypercalcemia without symptoms of a disrupted calcium homeostasis. FHH can be mistaken for the more common primary hyperparathyroidism (PHPT), for which surgical treatment may be needed. We describe a case of a 36-year-old woman with hypercalcemia and elevated PTH, initially suspected of having PHPT. Sequencing of the CaSR-gene revealed a mutation in nucleotide 437, changing the amino acid in position 146 from Glycine to Aspartate. The mutation was previously undescribed in the literature, but a very low calcium:creatinine clearance ratio supported the diagnosis FHH. A few years later, the patient's two daughters were tested and the association between mutation and hypercalcemia could be confirmed. The patient was gastric bypass-operated and therefore, due to malabsorption and increased risk of fracture, was in need of adequate calcium supplementation. The chronically elevated calcium levels challenged medical followup, as calcium sufficiency could not be monitored in a traditional manner. Eventually the patient developed elevated alkaline phosphatase, a further increased PTH and a decreased DXA T-score indicating calcium deficiency and bone resorption. As a supplement, all CaSR-mutations found at our hospital, 2005-2018.

Validation of the Use of Electronic Medical Records for Identification of Post-gastric Bypass Hypoglycemia Cases

OBJECTIVE

We sought to validate an algorithm designed to identify patients with post-gastric bypass hypoglycemia (PGBH) using clinician chart review.

METHODS

We conducted a chart review study of non-diabetic patients who underwent Roux-en-Y gastric bypass (RYGB) at our institution from 2004 to 2013. The electronic medical record (EMR) algorithm was based on any post-operative glucose <60 mg/dl, diagnosis of hypoglycemia, or medication use for treatment of PGBH and identified 158 charts as PGBH and 1048 charts without PGBH. Two clinicians independently reviewed a random selection of 80 cases and 80 control charts and determined the presence or absence of PGBH by searching the chart using keywords and reviewing laboratory results, medications, and clinic notes.

RESULTS

Of the 160 charts reviewed, the EMR algorithm agreed with the chart review for 130 (accuracy = 80%, 95% CI = 75-87%) with sensitivity of 89% (95% CI = 83-96%) and specificity of 86% (95% CI = 78-93%). We improved the algorithm's accuracy to 90% by limiting the search to data obtained 3 months or more following RYGB.

CONCLUSION

The EMR algorithm has high sensitivity, specificity, and accuracy to identify post-gastric bypass hypoglycemia within our patient cohort. The use EMR-based algorithms may be a useful tool for future research to improve our understanding of epidemiology and risk factors for post-bariatric surgery hypoglycemia.

Management of hyperglycaemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter-2 (SGLT2) inhibitor or a glucagon-like peptide-1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Management of Hyperglycemia in Type 2 Diabetes, 2018. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association and the European Association for the Study of Diabetes convened a panel to update the prior position statements, published in 2012 and 2015, on the management of type 2 diabetes in adults. A systematic evaluation of the literature since 2014 informed new recommendations. These include additional focus on lifestyle management and diabetes self-management education and support. For those with obesity, efforts targeting weight loss, including lifestyle, medication, and surgical interventions, are recommended. With regards to medication management, for patients with clinical cardiovascular disease, a sodium-glucose cotransporter 2 (SGLT2) inhibitor or a glucagon-like peptide 1 (GLP-1) receptor agonist with proven cardiovascular benefit is recommended. For patients with chronic kidney disease or clinical heart failure and atherosclerotic cardiovascular disease, an SGLT2 inhibitor with proven benefit is recommended. GLP-1 receptor agonists are generally recommended as the first injectable medication.

Resistance Training and Protein Supplementation Increase Strength After Bariatric Surgery: A Randomized Controlled Trial

OBJECTIVE

Physical activity and dietary regimens to optimize health outcomes after bariatric surgery are not well known. This study aimed to determine whether resistance training with dietary protein supplementation is effective in maintaining body composition and physical fitness after obesity surgery.

METHODS

Seventy-six women with obesity undergoing Roux-en-Y gastric bypass were randomly assigned at the time of surgery to receive either usual care (controls [CON], n = 22), usual care and additional (whey) protein intake (PRO, n = 31), or usual care, additional protein intake, and supervised strength training for 18 weeks (PRO+EX, n = 23). The primary outcome was pre- to 6-month postsurgery change in lean body mass (by dual-energy x-ray absorptiometry). Secondary outcomes included changes in muscle strength (by one-repetition maximum testing).

RESULTS

Loss over time in lean body mass did not differ between groups (CON: mean,-8.8 kg; 95% CI: -10.1 to -7.5 kg; PRO: mean, -8.2 kg; 95% CI: -9.3 to -7.1 kg; PRO+EX: mean, -7.7 kg; 95% CI: -9.0 to -6.5 kg; P = 0.899). The increase in relative lower-limb muscle strength was higher in the PRO+EX group (+0.6 [0.3 to 0.8]) versus +0.1 (-0.1 to 0.4) and +0.2 (0.0 to 0.4) kg/kg body mass in CON and PRO groups, respectively (P = 0.021).

CONCLUSIONS

Loss in muscle strength observed after bariatric surgery can be overcome by resistance training with additional protein intake.

Long-term nutritional follow-up post bariatric surgery

PURPOSE OF REVIEW

Bariatric surgery is an effective treatment for classes II and III obesity and its associated diseases. However, many important long-term outcomes of bariatric surgery are still poorly understood, such as neurological and psychological complications, bone health, and so on. This review summarizes the current evidence and expert opinions on nutritional care in the long-term postoperative period.

RECENT FINDINGS

In the first section, we will provide an update of the main long-term complications: risk of anaemia, risk of bone fracture, neurological and psychological complications, and risk of developing Barrett's oesophagus after sleeve gastrectomy. We will also examine the current strategies used to increase weight loss or reduce weight regain. As adherence to long-term follow-up has been shown to decrease over time, the second section aims to identify all measures that improve follow-up rates, to get the maximum benefit from bariatric surgery, while minimizing long-term adverse effects and complications.

SUMMARY

There is still a significant level of uncertainty regarding the best clinical practices for maintaining the health benefits provided by bariatric surgery. The role of family physician in postsurgery care needs to be clearly defined. More effort is needed to improve psychological care, behaviour management, and therapeutic patient education after bariatric surgery. A more patient-centred approach should probably be considered.