Patient adherence to multivitamin supplementation after bariatric surgery: a narrative review

A Comparison of the Health Benefits of Customized Multivitamins and Standard Supplementation Post-bariatric Surgery: A Systematic Review

Rates of obesity increase worldwide year after year. This review explored if customized multivitamins (CMV) resulted in less micronutrient deficiency and higher serum levels of vitamins and minerals when compared to standard multivitamins (SMV) post-bariatric surgery in adults. Vitamins investigated were vitamins B1, B6, B12, D, parathyroid hormone (PTH), calcium, iron, hemoglobin, ferritin, folic acid, zinc, and magnesium. In Roux-en-Y gastric bypass (RYGB) patients weight loss surgeries (WLS) Forte or chewable CMV were studied, while in sleeve gastrectomy (SG) patients, WLS Optimum 1.0 (Opt. 1.0) or WLS Optimum 2.0 (Opt. 2.0) multivitamins were studied. An electronic search was performed on three databases (PubMed (n=28), Embase (n=120), and Cochrane (n=106)) to identify clinical trials and cohort studies. The inclusion criteria focused on studies since 2011 for adults ≥18 years old post-GB and SG. The keywords included bypass, sleeve, WLS, and multivitamins. Four clinical trials and three cohort studies were included. Jadad Scale was used to assess the quality and the bias risk in the clinical trials and the Newcastle-Ottawa scale (NOS) was used for the cohort studies. The PICO model and PRISMA rules were followed, where the outcomes targeted certain vitamin serum levels and the levels of deficiencies. The results of WLS Forte were better than SMV. The chewable CMV and Opt. 1.0 results were comparable to SMV. Opt. 2.0 was slightly better than Opt. 1.0. Further modifications would enhance the CMV presented in this systemic review. SMV would still be recommended until CMV are modified and tested. Multi-center trials that monitor the effect of the modified CMV on the serum levels of vitamins and minerals in the longer term in different wider populations are needed.

Beyond Obesity and Overweight: The Clinical Assessment and Treatment of Excess Body Fat in Children : Part 1 - Insulin Resistance as the Root Cause of Pediatric Obesity

PURPOSE OF REVIEW

Pediatric obesity and comorbidities related to insulin resistance continue to be a growing public health crisis. If lifestyle measures are unsuccessful, pharmacological and surgical interventions are offered. In this paper, we describe the driving force of the obesity crisis: hyperinsulinemia and the development of insulin resistance. We give historical background of key policy issues which have contributed to this pandemic as well as the physiologic mechanisms of insulin resistance. The prevalence of obesity will continue to rise unless the root cause of hyperinsulinemia is addressed.

RECENT FINDINGS

Current research on insulin resistance demonstrates that a decreased consumption of carbohydrates is an effective first-line dietary intervention for the treatment of obesity and related metabolic diseases. Evidence shows it is safe and beneficial. A low-carbohydrate eating pattern can be helpful to address pediatric obesity. However, there must be policy guardrails in place to ensure that this is a sustainable and viable option for children and their families. There must be a change in the nutritional environment to help individuals battle the chronic disease of obesity.

Efficacy of multivitamin support following bariatric surgery in patients with obesity: a prospective observational study

PURPOSE

Bariatric surgery (BS), an effective treatment for severe obesity and its comorbidities, may result in micronutrient and vitamin deficiencies. This monocentric prospective observational study aimed at evaluating the efficacy of a specifically designed vitamin/mineral formula (Bariatrifast, BIOITALIA S.r.l., Italy) for preventing and treating micronutrient deficiencies in patients submitted to BS.

METHODS

Twenty patients with severe obesity (mean weight and BMI: 123.5 kg (range 88-174) and 43.3 kg/m2 (range 37-54) respectively) underwent BS (10 vertical sleeve gastrectomy VSG, 10 Roux-en-Y gastric bypass, RYGB). The mean age was 49.9 years (range 27-68). After a presurgical visit (V0), follow-up visits were performed at 1, 3, 6 and 12 months after surgery (V1-V4). Recorded data included weight, height and BMI. A complete blood count, measurement of ferritin, folic acid, vitamin B12, ionized calcium, 25 OH vitamin D, parathyroid hormone (PTH) were obtained. Following BS, patients started the daily oral multivitamin and mineral supplement.

RESULTS

All patients achieved a significant weight loss (mean - 34.7 ± 11.8 kg). No deficiencies of various vitamins/micronutrients were detected during the entire study period. The serum concentrations of vitamin B12, 25-OH Vitamin D and folic acid increased over the follow-up period compared with V0 (mean increase 243 ng/L, 23 µg /L, 8 µg/L, respectively). Compared to RYGB, patients who underwent sleeve gastrectomy showed higher levels of 25-OH vitamin D at V2, V3 and V4 (all p < 0.05), and higher levels of Vitamin B12 and folic acid at V4 (p < 0.05 and p < 0.005, respectively). No adverse events were reported.

CONCLUSION

Following VSG or RYGB, Bariatrifast administration was associated with normal values of essential micronutrients, and it was well-tolerated without evidence of gastrointestinal side effects. Clinical Trial Registration ClinicalTrials.gov, identifiers NCT06152965.

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

BACKGROUND

Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy.

METHODS

In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n = 59 [gastric bypass surgery n = 26, sleeve gastrectomy n = 31, missing n = 2] and controls n = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17-20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5).

RESULTS

The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p = 0.228) or development of gestational diabetes (n = 3 [5%] vs. n = 7 [5%], p = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p = 0.030).

CONCLUSION

Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Adherence to liraglutide among individuals with overweight and obesity: Patient characteristics and clinical measures

AIM

To identify the sociodemographic, clinical and laboratory determinants relating to patient adherence to liraglutide treatment among individuals with overweight or obesity.

METHODS

We retrospectively analysed patients with overweight or obesity who were treated with liraglutide between 2019 and 2022. Over a 6-month follow-up period, measurements of body mass index, sociodemographic characteristics, clinical and laboratory data, and prescription records for liraglutide were collected. Treatment adherence was assessed using the proportion of days covered (PDC) measure, with a PDC ≥80% indicating high adherence.

RESULTS

The study population included 1890 participants (78.1% female, mean age 46 ± 12 years). At the end of the follow-up period, 84.9% of the participants exhibited low adherence to liraglutide treatment. Adherence to treatment improved with age (p = 0.04, odds ratio [OR] 1.013, confidence interval [CI] 1.001-1.025). Significant weight loss during treatment increased the likelihood of high adherence (p < 0.001, OR 1.251, CI 1.167-1.341). Individuals with a higher socioeconomic status displayed greater adherence (p = 0.023, OR 1.906, CI 1.091-3.328). Greater adherence was also seen in non-smokers (p = 0.047, OR 0.725, CI 0.528-0.996).

CONCLUSIONS

Only 15.1% of study participants exhibited high adherence to treatment (PDC ≥80%) after 6 months of follow-up. Further research is needed to explore approaches to enhance adherence to liraglutide, including strategies to educate and support patients in their efforts to achieve and maintain weight loss with the use of this drug.

The science of micronutrients in clinical practice - Report on the ESPEN symposium

BACKGROUND & AIMS

The European Society for Clinical Nutrition and Metabolism published its first clinical guidelines for use of micronutrients (MNs) in 2022. A two-day web symposium was organized in November 2022 discussing how to apply the guidelines in clinical practice. The present paper reports the main findings of this symposium.

METHODS

Current evidence was discussed, the first day being devoted to clarifying the biology underlying the guidelines, especially regarding the definition of deficiency, the impact of inflammation, and the roles in antioxidant defences and immunity. The second day focused on clinical situations with high prevalence of MN depletion and deficiency.

RESULTS

The importance of the determination of MN status in patients at risk and diagnosis of deficiencies is still insufficiently perceived, considering the essential role of MNs in immune and antioxidant defences. Epidemiological data show that deficiencies of several MNs (iron, iodine, vitamin D) are a global problem that affects human health and well-being including immune responses such as to vaccination. Clinical conditions frequently associated with MN deficiencies were discussed including cancer, obesity with impact of bariatric surgery, diseases of the gastrointestinal tract, critical illness, and aging. In all these conditions, MN deficiency is associated with worsening of outcomes. The recurrent problem of shortage of MN products, but also lack of individual MN-products is a worldwide problem.

CONCLUSION

Despite important progress in epidemiology and clinical nutrition, numerous gaps in practice persist. MN depletion and deficiency are frequently insufficiently searched for in clinical conditions, leading to inadequate treatment. The symposium concluded that more research and continued education are required to improve patient outcome.

Development and complications of nutritional deficiencies after bariatric surgery

The clinical effectiveness of bariatric surgery has encouraged the use of bariatric procedures for the treatment of morbid obesity and its comorbidities, with sleeve gastrectomy and Roux-en-Y gastric bypass being the most common procedures. Notwithstanding its success, bariatric procedures are recognised to predispose the development of nutritional deficiencies. A framework is proposed that provides clarity regarding the immediate role of diet, the gastrointestinal tract and the medical state of the patient in the development of nutritional deficiencies after bariatric surgery, while highlighting different enabling resources that may contribute. Untreated, these nutritional deficiencies can progress in the short term into haematological, muscular and neurological complications and in the long term into skeletal complications. In this review, we explore the development of nutritional deficiencies after bariatric surgery through a newly developed conceptual framework. An in-depth understanding will enable the optimisation of the post-operative follow-up, including detecting clinical signs of complications, screening for laboratory abnormalities and treating nutritional deficiencies.

PROMISE: effect of protein supplementation on fat-free mass preservation after bariatric surgery, a randomized double-blind placebo-controlled trial

INTRODUCTION

Protein malnutrition after bariatric surgery is a severe complication and leads to significant morbidity. Previous studies have shown that protein intake and physical activity are the most important factors in the preservation of fat-free mass during weight loss. Low protein intake is very common in patients undergoing bariatric surgery despite dietary counseling. Protein powder supplements might help patients to achieve the protein intake recommendations after bariatric surgery and could therefore contribute to preserve fat-free mass. This double-blind randomized placebo-controlled intervention study aims to assess the effect of a daily consumed clear protein powder shake during the first 6 months after bariatric surgery on fat-free mass loss in the first 12 months after laparoscopic Roux-en-Y gastric bypass (LRYGB).

METHODS AND ANALYSIS

Inclusion will take place at the outpatient clinic of the bariatric expertise center for obesity of the Maasstad Hospital. Patients will be randomly assigned to either the intervention or control group before surgery. The intervention group will receive a clear protein powder shake of 200 ml containing 20 g of whey protein dissolved in water which should be taken daily during the first 6 months after LRYGB on top of their normal postoperative diet. The control group will receive an isocaloric, clear, placebo shake containing maltodextrine. Postoperative rehabilitation and physiotherapeutical guidance will be standardized and similar in both groups. Also, both groups will receive the same dietary advice from specialized dieticians. The main study parameter is the percentage of fat-free mass loss 6 months after surgery, assessed by multi-frequency bioelectrical impedance analysis (MF-BIA).

ETHICS AND DISSEMINATION

The protocol, version 2 (February 20, 2022) has been approved by the Medical Research Ethics Committees United (MEC-U) (NL 80414.100.22). The results of this study will be submitted to peer-reviewed journals.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05570474. Registered on October 5, 2022.

Postoperative micronutrient changes in bariatric surgery patients compliant with nutritional supplementation

BACKGROUND

Bariatric surgery is commonly used in patients with body mass indexes over 35 kg/m and obesity-related comorbidities. Despite the significant clinical benefits of bariatric surgery, nutritional deficiencies post-surgery remain a challenge for both patient and healthcare provider [Toninello et al. in Nutrients 13:1565, 2021, Gasmi et al. in Eur J Nutr 61:55-67, 2022]. Nutritional supplementation is a way of reducing the likelihood of postoperative deficiencies; however, prior studies have shown varying degrees of mostly poor to moderate patient adherence [Spetz et al. in Obes Res Clin Pract 16:407-412, 2022, Mahawar et al. in Obes Surg 29:1551-1556, 2019, Santonicola et al. in J Am Nutr Assoc 41:11-19, 2022, Sherf Dagan et al. in Obes Surg 27:2258-2271, 2017]. Our present study aims to provide insights into the micronutrient biochemical profile in patients previously found to be compliant with supplementation following roux-en-y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG).

METHODS

An 11-point outpatient survey was administered to consecutive patients ≥ 18 years who had undergone either RYGB or VSG to determine adherence with nutritional supplementation. Medical records were retrospectively reviewed to determine preoperative and postoperative lab values, including vitamins A, B1, B12, and D, thyroid stimulating hormone (TSH), iron binding capacity, transferrin, ferritin, folate, iron, albumin, hemoglobin A1C, zinc, glomerular filtration rate (GFR, and liver function values. Values were classified as "abnormal" or "normal." Preoperative and postoperative values were compared for differences. Postoperative values were also compared between RYGB and VSG.

RESULTS

There were no significant differences between preoperative and postoperative values for any nutritional marker aside from vitamin B12. A total of 51/60 patients (85.0%) had normal preoperative B12 measurements, compared with 40/65 (61.5%) patients postoperatively (P = 0.03). Notably, of 25 "abnormal" postoperative measurements, 20 (80%) were elevated values. There were no differences in postoperative deficiencies between RYGB and VSG.

CONCLUSIONS

Patients in our sample did not have worsened micronutrient deficiencies following bariatric surgery, and there were no differences in micronutrient deficiencies between surgical technique.

Towards precision medicine in bariatric surgery prescription

Obesity is a complex, multifactorial and chronic disease. Bariatric surgery is a safe and effective treatment intervention for obesity and obesity-related diseases. However, weight loss after surgery can be highly heterogeneous and is not entirely predictable, particularly in the long-term after intervention. In this review, we present and discuss the available data on patient-related and procedure-related factors that were previously appointed as putative predictors of bariatric surgery outcomes. In addition, we present a critical appraisal of the available evidence on which factors could be taken into account when recommending and deciding which bariatric procedure to perform. Several patient-related features were identified as having a potential impact on weight loss after bariatric surgery, including age, gender, anthropometrics, obesity co-morbidities, eating behavior, genetic background, circulating biomarkers (microRNAs, metabolites and hormones), psychological and socioeconomic factors. However, none of these factors are sufficiently robust to be used as predictive factors. Overall, there is no doubt that before we long for precision medicine, there is the unmet need for a better understanding of the socio-biological drivers of weight gain, weight loss failure and weight-regain after bariatric interventions. Machine learning models targeting preoperative factors and effectiveness measurements of specific bariatric surgery interventions, would enable a more precise identification of the causal links between determinants of weight gain and weight loss. Artificial intelligence algorithms to be used in clinical practice to predict the response to bariatric surgery interventions could then be created, which would ultimately allow to move forward into precision medicine in bariatric surgery prescription.

Evaluating the Compliance, Efficacy, and Cost of Formulated Vitamins Versus Separate Supplements in Post-bariatric Surgery Patients

OBJECTIVE

Micronutrient deficiencies are common complications after bariatric surgery as alterations to the gastrointestinal tract change absorption. Patients are recommended to take supplements including multivitamins, B complex, calcium, vitamin D, and iron after bariatric surgery, and can take these as specifically formulated vitamins for post-bariatric patients or separate vitamin supplements. We investigated the compliance, efficacy, and cost of specifically formulated vitamins for post-bariatric patients in comparison to separate vitamin supplements.

METHODS

We surveyed 126 post-bariatric adult patients between February 1, 2022, and August 31, 2022, who had undergone bariatric surgery between 2014 and 2021 to assess the type of supplements taken, compliance, and cost. Demographics, type of bariatric surgery, and serum micronutrient levels were evaluated for all patients.

RESULTS

There were 51 patients taking formulated vitamins and 75 patients taking separate vitamins. The formulated vitamin group demonstrated greater adherence to optimal vitamin dosage (formulated vitamin group, 76.5% vs. separate supplement group, 30.7%; p < 0.001) and higher compliance (formulated vitamin group, 90.2% vs. separate supplement group, 66.7%; p = 0.002). The costs associated with both groups were comparable. No significant difference was observed in the incidence of micronutrient deficiency between the groups.

CONCLUSIONS

Our study shows that formulated vitamins do not offer significant difference in micronutrient levels or cost compared to separate standard vitamin supplements. However, formulated bariatric vitamins have improved compliance compared to separate vitamin supplements.

The effect of bariatric surgery on dietary Behaviour, dietary recommendation Adherence, and micronutrient deficiencies one year after surgery

Bariatric surgery (BS) is associated with vitamin and mineral deficiencies, which might be augmented by low adherence to dietary guidelines and inappropriate dietary behaviours. The aim of this study was to determine the influence of BS on eating behaviour, prevalence of nutrient deficiency, level of commitment to diet, and lifestyle recommendations one-year post-BS. A cross-sectional study was conducted among adult patients who underwent BS in 2019 and had follow-up for a year. Age, gender, and clinical data were collected from the hospital system and other information was obtained from questionnaires during phone interviews. A total of 160 patients participated in the study. At 12 months, a significant increase from the baseline values in plasma levels of vitamin B12, folate, vitamin D, iron, corrected calcium, albumin, CRP, and MCV, as well as a significant decrease in BMI was observed. Adherence to dietary and lifestyle recommendations was moderate to high. Emotional, and restrained eating behaviours were moderate with 64.4%, and 77.5%, respectively. External eating was low at 58.1%. The study concluded that pre-and post-bariatric surgery nutrients should be closely monitored.

Factors Affecting Patient Adherence to Multivitamin Intake After Bariatric Surgery: Thematic Analysis of Qualitative Data From a Multicenter Study

Introduction Adherence to daily intake of multivitamin supplementation (MVS) is a major challenge after bariatric surgery (BS). The aim of this study was to identify insights into patients' beliefs and experiences on adherence to MVS intake. Methods A thematic analysis of qualitative data from four high-volume bariatric centers in the Netherlands was conducted. A series of texts from the open-ended question of 1,246 patients were thematically analyzed for common or overarching themes, ideas, and patterns. Results Five key themes emerged regarding participants' suggestions on adherence to daily MVS intake: "gastrointestinal side effects to MVS intake" (n = 850, 68.2%), "negative features of MVS" (n = 296, 23.8%), "satisfaction with advice on MVS" (n = 272, 21.8%), "dissatisfaction with service provision" (n = 160, 12.8%), and "costs" (n = 93, 7.5%). Most problems were experienced when using specialized weight loss surgery (WLS) MVS. These supplements may cause gastrointestinal side effects, and costs are too high. After bariatric surgery, numerous patients strongly felt that information provision was poor in several aspects, and the aftercare pathway process did not provide sufficient support. Conclusion This study found five major themes involved in patient adherence to multivitamin intake after BS: gastrointestinal side effects to MVS intake, negative features of MVS, satisfaction with advice on MVS, dissatisfaction with service provision, and costs of specialized MVS. Challenges lie in stronger education for both patients and healthcare professionals. More personalized care could probably increase patient satisfaction, and MVS companies should look at further optimizing supplements for better tolerability and reducing costs.

Nutritional Status of Vegetarian Patients Before and After Bariatric Surgery: a Monocentric Retrospective Observational Case-Control Study

The obesity pandemic is associated with an increasing number of bariatric surgeries which allow improvement in obesity-related comorbidities and life expectancy but potentially induce nutritional deficiencies. Vegetarianism becomes more and more popular and exposes as well to vitamin and micronutrient deficiencies. Only one study has explored the impact of vegetarianism on the preoperative nutritional status of eligible patients for bariatric surgery, but none in postoperative care.

MATERIALS AND METHODS

We conducted a retrospective case-control study in our cohort of bariatric patients, matching 5 omnivores for each vegetarian. We compared their biological profile regarding vitamin and micronutrient blood levels before and 3, 6, 12, and 30 months after surgery.

RESULTS

We included 7 vegetarians including 4 lacto-ovo-vegetarians (57%), 2 lacto-vegetarians (29%), and one lacto-ovo-pesco-vegetarian (14%). Three years after surgery with equivalent daily standard vitamin supplementation, the two groups showed a similar biological profile including blood levels of ferritin (p = 0.6), vitamin B1 (p = 0.1), and B12 (p = 0.7), while the total median weight loss at 3 years was comparable (39.1% [27.0-46.6] in vegetarians vs 35.7% [10.5-46.5] in omnivores, p = 0.8). We observed no significant difference between vegetarians and omnivores before surgery regarding comorbidities and nutritional status.

CONCLUSION

It seems that, after bariatric surgery, vegetarian patients taking a standard vitamin supplementation do not show an increased risk of nutritional deficiencies compared to omnivores. However, a larger study with a longer follow-up is needed to confirm these data, including an evaluation of different types of vegetarianism such as veganism.

Nutritional and Lifestyle Behaviors Reported Following One Anastomosis Gastric Bypass Based on a Multicenter Study

This study aimed to describe nutritional and lifestyle parameters following one-anastomosis gastric bypass (OAGB). A multicenter study among OAGB patients across Israel (n = 277) and Portugal (n = 111) was performed. Patients were approached according to the time elapsed since surgery. An online survey with information regarding demographics, anthropometrics, and nutritional and lifestyle aspects was administered in both countries simultaneously. Respondents from Israel (pre-surgery age of 41.6 ± 11.0 years, 75.8% females) and Portugal (pre-surgery age of 45.6 ± 12.3 years, 79.3% females) reported changes in their appetite (≤94.0% and ≤94.6%), changes in their taste (≤51.0 and ≤51.4%), and intolerance to specific foods (i.e., red meat, pasta, bread, and rice). Bariatric surgery-related eating recommendations were generally followed well, but a trend toward lower adherence was evident in groups with longer time elapsed since surgery in both countries. Most respondents from Israel and Portugal reported participation in follow-up meetings with a surgeon (≤94.0% and 100%) and a dietitian (≤92.6% and ≤100%), while far fewer reported participation in any follow-up meeting with a psychologist/social worker (≤37.9% and ≤56.1%). Patients following OAGB might experience changes in appetite, taste, and intolerance to specific foods. Adherence to bariatric surgery-related eating recommendations is not always satisfying, especially in the longer term post-surgery.

Associations of age, sex, and socioeconomic status with adherence to guideline recommendations on protein intake and micronutrient supplementation in patients with sleeve gastrectomy or Roux-en-Y gastric bypass

INTRODUCTION

Patients with bariatric surgery often show poor long-term compliance to recommendations for prevention of nutrient deficiency but it is unclear which factors contribute. We investigated the associations of age, sex, and socioeconomic status (SES) with adherence to guideline recommendations on protein intake and micronutrient supplementation.

METHODS

In a monocentric cross-sectional study we prospectively recruited patients with sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) and a minimum postoperative period of 6 months. Clinical and demographic data were obtained from the patients' medical files and by questionnaire. Patients reported on supplement usage, recorded their dietary intake for seven days and underwent physical examinations including blood testing.

RESULTS

We included 35 patients (SG: n = 25, RYGB: n = 10) with a mean (+SD) postoperative period of 20.2 (±10.4) months. Distributions of age, sex and SES were comparable between the SG and RYGB groups. Non-adherence to recommended protein intake was associated with age ≥ 50 years (p = 0.041) but not sex or SES. Protein intake inversely correlated with markers of obesity. There were no significant associations of age or sex with micronutrient supplementation. Only for vitamins A (p = 0.049) and B1 (p = 0.047) higher SES was associated with greater compliance. The only manifest deficiency associated with non-adherence to micronutrient supplementation was that for folic acid (p = 0.044).

CONCLUSION

In patients after bariatric surgery, those of older age and of lower SES might have a greater risk of unfavorable outcome and may require greater attention to micronutrient and protein supplementation.

A smartphone application to improve adherence to vitamin and mineral supplementation after bariatric surgery

OBJECTIVE

This trial evaluated a smartphone application's effectiveness in improving adherence to vitamin and mineral supplementation postoperatively.

METHODS

This study was a randomized controlled trial comprising 140 patients undergoing bariatric surgery (gastric bypass or sleeve gastrectomy). Participants were randomized 1:1 to the 12-week intervention, using the smartphone application PromMera, or to standard care. The primary end point was adherence to vitamin and mineral supplementation.

RESULTS

Initiation rate and overall adherence to supplementation were high in both groups. Change in objectively measured adherence rate from before the intervention to 1 year post surgery, measured with pharmacy refill data, did not differ between groups for vitamin B₁₂ (-9.6% [SD = 27%] vs. -9.3% [SD = 30%]; p = 0.48) or calcium/vitamin D (-12.3% [SD = 29%] vs. -11.5% [SD = 32%]; p = 0.44). A modest effect on the secondary end point (subjectively measured adherence, using the Medication Adherence Report Scale-5) was seen immediately after the intervention (intervention group 0.00 [SD = 1.3] vs. control group -1.2 [SD = 3.5]; p = 0.021), but this effect did not persist 1 year post surgery. No differences were detected in the prevalence of biochemical deficiencies.

CONCLUSIONS

The use of the smartphone application PromMera did not obtain a lasting improvement in adherence to vitamin and mineral supplementation 1 year post bariatric surgery.

Pregnant Women Following Bariatric Surgery: a Focus on Maternal Mental Health and Its Impact on Birth Outcomes

PURPOSE

Bariatric surgery is associated with elevated risks for adverse birth outcomes, such as small-for-gestational-age infants (SGA). Maternal mental health is a critical regulator of fetal growth, but it is largely overlooked in pregnant women post-surgery. This study aimed to examine the associations between maternal mental health and birth outcomes in pregnant women post-bariatric surgery.

MATERIALS AND METHODS

This was a retrospective analysis of medical records of women who had a singleton delivery following Roux-en-Y gastric bypass or sleeve gastrectomy. Mental health measures included depression/anxiety and substance use (cigarettes, alcohol, opioids, and marijuana). Birth outcomes were fetal growth restriction, SGA, low birthweight, and preterm birth. Logistic regressions were used to assess the associations between maternal mental health and each of the birth outcomes. A post hoc logistic regression was conducted to assess factors that influenced maternal marijuana use.

RESULTS

Participants (N = 179) were mostly white (64.6%), non-Hispanic (84.5%), with a mean age of 32.7 ± 4.6 years, and mean body mass index of 37.2 ± 8.4 kg/m² at conception. Maternal marijuana use significantly increased the odds for fetal growth restriction, SGA, low birthweight, and preterm birth. Cigarette use increased the risk for low birthweight. Conversely, alcohol use was protective of low birthweight and preterm birth. A post hoc analysis revealed that married women were less likely to use marijuana than those who were single, divorced, or widowed.

CONCLUSION

This analysis identified marijuana and cigarette use as risk factors for adverse birth outcomes post-bariatric surgery. Future studies with larger sample sizes are needed to confirm study findings.

Self-care model and body image in adults after a bariatric surgery

OBJECTIVE

the aim of the present article was to test a self-care model explained by the relationship between self-efficacy, body image, obsessive-compulsive disorder, and depression in people with bariatric surgery in the city of Tijuana, Baja California, Mexico.

METHOD

this was a correlational cross-sectional study carried out between August and December 2020. Validated instruments were administered to 102 participants to measure their self-care capacity, general self-efficacy, psychopathological symptoms, and body image perception and satisfaction. The variables of interest were analyzed using descriptive statistics and the Pearson and Spearman correlation coefficients were used to develop a model using path analysis.

RESULT

a significant model was obtained with adequate goodness-of-fit indicators (chi-square χ2 (8) = 11.451, p = .177; root mean square error of approximation (RMSEA)= 0.000; goodness-of-fit index (GFI)= 0.965; comparative fit index (CFI)= 0.985; parsimonious normed fit index (PNFI)= 0.509, and Akaike information criterion (AIC)= 37.451). Self-efficacy (Zβ=0.294) and body image dissatisfaction (So= -0.376) were shown to influence self-care abilities while psychopathological symptoms influenced body dissatisfaction: obsessive-compulsive disorder (Zβ=0.370) and depression (Zβ=0.320).

CONCLUSION

adequate levels of self-efficacy and body satisfaction predict a high capacity for self-care.

Nutritional Status after Roux-En-Y (Rygb) and One Anastomosis Gastric Bypass (Oagb) at 6-Month Follow-Up: A Comparative Study

Introduction: Roux-en-Y gastric bypass (RYGB) and one anastomosis gastric bypass (OAGB) are two effective bariatric surgical procedures with positive outcomes in terms of weight loss, comorbidities remission, and adverse events profiles. OAGB seems to carry a higher risk of malnutrition, but existing data are controversial. The aim of this study is to objectively evaluate and compare malnutrition in patients undergoing RYGB and OAGB. Methods: Retrospective monocentric study of obese patients undergoing RYGB or OAGB between the 15 September 2020 and the 31 May 2021. Nutritional status was assessed using the Controlling Nutritional Status (CONUT) score and compared between groups. The primary outcome was the mean CONUT score at 6 months. The secondary outcomes included the incidence of malnutrition, comorbidities, including hypertension, insulin resistance and type II diabetes mellitus, and weight loss. Results: 78 patients were included: 30 underwent RYGB and 48 underwent OAGB. At 6-Month Follow-Up there was no difference between groups in the mean CONUT score nor in incidence of malnutrition. In both groups, the nutritional status significantly worsened 6 months after surgery (preoperative and postoperative score of 0.48 ± 0.9 and 1.38 ± 1.5; p = 0.0066 for RYGB and of 0.86 ± 1.5 and 1.45 ± 1.3; p = 0.0422 for OAGB). Type II Diabetes mellitus (DMII) and hypertension remission were significant in the OAGB group with a 100% relative remission in the DMII-OAGB group (p = 0.0265), and a 67% relative remission in the hypertension-OAGB group (p = 0.0031). Conclusions: No difference in nutritional status has been detected between patients undergoing RYGB or OAGB at the 6-Month Follow-Up. Both procedures may have significant mal-absorptive effects leading to decline in nutritional status. OAGB may be more efficacious in inducing DMII and hypertension remission. Larger prospective studies dedicated specifically to nutritional status after gastric bypass are needed to confirm the impact of different bypass procedures on nutritional status.

Complications in post-bariatric body contouring surgery using a practical treatment regime to optimise the nutritional state

Background

Post-bariatric body contouring surgery (BCS) treats redundant skin after massive weight loss; however, the complication risk is relatively high (23-70%). Most complications are wound-related, which may be partly due to a poor nutritional status after bariatric surgery. The objective of this observational study was to optimise nutrition preoperatively and assess the prevalence of wound-related complications after BCS.

Methods

This prospective cohort study included 140 patients. Patients were treated according to the post-bariatric BCS guideline. Nutritional parameters were collected via pre- and peri-operative blood sampling; any deficiencies were treated. A protein-enriched diet was prescribed by a dietician 4 weeks preoperatively up until closure of all wounds. Complications were recorded using the Clavien-Dindo classification. Univariate and multivariate regression analyses were performed to identify variables associated with wound-related complications.

Results

The overall wound-related complication rate was 51%. Most complications were minor, with only 4.3% was considered major. No significant differences in patient characteristics were found between patients with and without complications. Variables indicating an optimised nutritional state were not significantly associated with a decreased risk of complications; the most influential factor was a sufficient post-operative protein intake (OR 0.27, 95% CI 0.07 – 1.02, p = 0.05).

Conclusion

The overall wound-related complication rate was in accordance with previous literature; however, major complications were few. This study showed a weak correlation between optimising nutritional state and better outcome after BCS, especially following a protein-enriched diet post-operatively. Therefore, we recommend continuing research on nutrition and wound-related complications, using homogeneous study populations and well-defined complications.

Compliance and Patients' Perspectives Towards Nutritional Supplementation Following Bariatric Surgery

BACKGROUND

Nutritional supplementation is recommended as a prophylactic strategy for nutritional deficiencies after bariatric surgery. Little is known regarding compliance and patients' perspectives. The purpose of the study was to explore supplement intake, compliance, and patients' perspectives (including barriers, facilitators, and beliefs) and to examine whether compliance to nutritional supplementation can be predicted after bariatric surgery. MATERIAL AND METHODS: A questionnaire was developed to explore supplement intake and patients' perspectives. The Probabilistic Medication Compliance Scale (ProMAS) was included and modified to measure behaviors related to supplementation compliance. Content validity was assessed with an expert and patient panel. Consequently, a cross-sectional survey was conducted among patients that underwent bariatric surgery, who were invited using social media. Descriptive statistics and Spearman correlations were applied. Multiple linear regression analysis was performed to predict compliance.

RESULTS

A 58-item questionnaire was developed and content validated, resulting in a scale-content validity index of 0.93. The questionnaire was completed by 402 subjects. Sixty-nine subjects reported not consuming any nutritional supplement (n = 69; 17.2%). For the supplement users (n = 333; 82.8%), a median ProMAS sum score of 11.0 (7.0-15.0) was observed. Increasing age and medicine intake were positive predictors of compliance (age: B = 0.058, p = 0.01; medicine intake: B = 0.39, p < 0.001), while experiencing barriers was identified as a negative predictor of compliance (B =  - 4.637, p < 0.001). Top three barriers for supplement use were forgetfulness (n = 118; 29.4%), too expensive (n = 91; 22.6%), and experiencing side effects (n = 61; 15.2%).

CONCLUSION

Lifelong nutritional supplementation is essential after bariatric surgery, but compliance can be affected by the presence of barriers.

Prebiotic to Improve Calcium Absorption in Postmenopausal Women After Gastric Bypass: A Randomized Controlled Trial

CONTEXT

The adverse skeletal effects of Roux-en-Y gastric bypass (RYGB) are partly caused by intestinal calcium absorption decline. Prebiotics, such as soluble corn fiber (SCF), augment colonic calcium absorption in healthy individuals.

OBJECTIVE

We tested the effects of SCF on fractional calcium absorption (FCA), biochemical parameters, and the fecal microbiome in a post-RYGB population.

METHODS

Randomized, double-blind, placebo-controlled trial of 20 postmenopausal women with history of RYGB a mean 5 years prior; a 2-month course of 20 g/day SCF or maltodextrin placebo was taken orally. The main outcome measure was between-group difference in absolute change in FCA (primary outcome) and was measured with a gold standard dual stable isotope method. Other measures included tolerability, adherence, serum calciotropic hormones and bone turnover markers, and fecal microbial composition via 16S rRNA gene sequencing.

RESULTS

Mean FCA ± SD at baseline was low at 5.5 ± 5.1%. Comparing SCF to placebo, there was no between-group difference in mean (95% CI) change in FCA (+3.4 [-6.7, +13.6]%), nor in calciotropic hormones or bone turnover markers. The SCF group had a wider variation in FCA change than placebo (SD 13.4% vs 7.0%). Those with greater change in microbial composition following SCF treatment had greater increase in FCA (r2 = 0.72, P = 0.05). SCF adherence was high, and gastrointestinal symptoms were similar between groups.

CONCLUSION

No between-group differences were observed in changes in FCA or calciotropic hormones, but wide CIs suggest a variable impact of SCF that may be due to the degree of gut microbiome alteration. Daily SCF consumption was well tolerated. Larger and longer-term studies are warranted.

Analysis of the Consumption of Non-Oncological Medicines: A Methodological Study on Patients of the Ada Cohort

Cancer patients are identified as fragile patients who are often immunodepressed and subject to secondary diseases. The Ada cohort comprises cancer survivors aged 15–39 years at diagnosis included in 34 Italian cancer registries. This study aimed to analyze the possible excess of non-cancer medicines use on the basis of the medicine database of the Ada cohort. Records of medicines present in the pharmaceutical flows collected by eight Lombardy cancer registries and used by patients with any type of cancer were extracted for the year 2012. Medicine consumption data were processed to assign a defined daily dose value and to evaluate the consumption of medicines belonging to different groups of the ATC (Anatomical Therapeutic Chemical) classification. The values were compared with values in the Lombardy population. Medicine consumption related to 8150 patients was analyzed, for a total of 632,675 records. ATC groups A and C for females and group N for both sexes showed significant increases. Group J for males and group M for females showed intermediate increases, and group H for both sexes showed smaller increases. This method allowed the identification of excess medicine use to reduce cancer therapy side effects and primary disease sequelae in this group of patients.

Factors Affecting Patient Adherence to Multivitamin Intake After Bariatric Surgery: a Multicentre Survey Study from the Patient's Perspective

Purpose

Lifelong multivitamin supplementation is recommended to prevent nutritional deficiencies. Despite this advice, deficiencies are common which may be due to poor adherence to MVS intake. The aim of this study was to identify which factors affect patient adherence to Multivitamin Supplement (MVS) intake after bariatric surgery.

Materials and Methods

A 42-item questionnaire was sent to 15,424 patients from four Dutch bariatric center. In total, 4975 patients wanted to participate of which 361 patients were excluded. A total of 4614 patients were included, and MVS users (n=4274, 92.6%) were compared to non-users (n=340, 7.4%). Most patients underwent Roux-en-Y gastric bypass (64.3%) or sleeve gastrectomy (32.3%).

Results

Seven hundred and ten patients (15.4%) reported inconsistent MVS use and 340 patients (7.4%) did not use any MVS at all. For inconsistent MVS users, most reported reasons included forgetting daily intake (68.3%), gastro-intestinal side effects (25.6%) and unpleasant taste or smell (22.7%), whereas for non-users gastro-intestinal side effects (58.5%), high costs (13.5%) and the absence of vitamin deficiencies (20.9%) were most frequently reported. Overall, 28.5% were dissatisfied about instructions on MVS use, attention paid to MVS use during medical consultation and the extent to which personal preferences were taken into account.

Conclusion

The attitude of bariatric patients towards MVS use is predominantly negative. It is important to provide accurate information on different options for MVS intake and collect information about patient’s personal preferences when prescribing supplements. Improving adherence to MVS intake is challenging and requires implementation of a shared decision-making process, further optimization of MVS formulas and exploring options for reimbursement.

Graphical abstract

The Effects of Bariatric Surgery on Vitamin B Status and Mental Health

Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.

Optimizing Multivitamin Supplementation for Sleeve Gastrectomy Patients

Purpose

Micronutrient deficiencies are frequently reported after sleeve gastrectomy (SG), and therefore lifelong daily multivitamin supplementation is highly recommended. Based on literature and the results of a previous randomized controlled trial, a specialized multivitamin supplement for SG patients was further optimized (WLS Optimum 2.0, FitForMe). The present study reports on its short-term effectiveness.

Materials and Methods

An open-label study was performed in which 76 patients were included to receive WLS Optimum 2.0 for 12 months (Opt 2.0 group). This group was compared with a group of 75 patients that had received WLS Optimum 1.0 for 12 months during a previous study (Opt 1.0 group).

Results

Intention-to-treat analysis (Opt 1.0, n = 69; Opt 2.0, n = 75) showed higher serum levels of vitamin B12, vitamin B6, and zinc, and a lower prevalence of deficiencies for vitamin B12 and phosphate in the Opt 2.0 group. MCV and serum folic acid levels were higher in the Opt 1.0 group. Over the 12-month study period, mean increase in serum levels of phosphate, vitamin B6, and zinc was higher in the Opt 2.0 group, and MCV and serum vitamin D levels increased more in the Opt 1.0 group.

Conclusion

The present study showed that the use of a specialized multivitamin supplement for SG patients is effective at preventing deficiencies for most vitamins and minerals, specifically in compliant patients. However, a strict follow-up regime remains necessary to monitor nutritional status and to improve patient compliance.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05282-4.

A Prospective Study of Association of Micronutrients Deficiencies during Pregnancy and Neonatal Outcome among Women after Bariatric Surgery

Little is known about the association of micronutrients deficiencies during pregnancy and neonatal outcome among women after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). We present a prospective study of 87 consecutive women with a history of RYGB (n = 37) or SG (n = 50) who underwent complete and regular clinical and biological nutritional assessments during pregnancy. Data on maternal characteristics, biological nutritional parameters, antenatal management, and perinatal outcome were collected. The objective was to evaluate serum levels of micronutrients at the second trimester, and to assess the association between micronutrients deficiencies and neonatal outcome. After RYGB, maternal age (34.3 ± 4.9 vs. 31.1 ± 4.6 years; p = 0.003) and pregnancy timing after surgery (64.5 ± 47.0 vs. 38.1 ± 28.1 months; p = 0.002) were significantly higher, and pre-pregnancy BMI was significantly lower (29.8 ± 5.6 vs. 32.9 ± 7.1 kg/m2; p = 0.03). Maternal and neonatal outcomes were similar. Additional supplementations after blood tests were similar in groups. Zinc, selenium, vitamins A1, B1, B6, C, and E levels were not different depending on the type of surgery. Zinc deficiency (7/87) was significantly more frequent after RYGP (18.9% vs. 0%; p = 0.02) and selenium deficiency (15/87) was similar in groups (21.6% after RYGB and 14.0% after SG; p = 0.36). The mean birth weight was significantly lower in selenium deficiency cases (3137 ± 550 vs. 3535 ± 737 g; p = 0.04). Selenium deficiency was negatively correlated with birth weight (r = -0.23; p = 0.03) and with birth weight z-score (r = -0.26; p = 0.01), but not correlated after adjustment for the procedure. The levels of micronutrients surveillance along pregnancy in women with a history of bariatric surgery is necessary to decrease the risk of inadequate fetal growth in the patients.