Overview on nutritional issues in bariatric surgery

Translation and Validation of the Arabic Version of the Eating Behavior After Bariatric Surgery (EBBS) Questionnaire

PURPOSE

Complications after metabolic and bariatric surgery are common due to the patient's poor commitment to postoperative lifestyle changes. Therefore, intensive follow-up from a multidisciplinary team might improve outcomes. The present study aimed to translate and validate the Eating Behavior after Bariatric Surgery (EBBS) questionnaire into Arabic for use in clinical and research settings.

MATERIALS AND METHODS

The study followed World Health Organization guidelines for translation and questionnaire adaptation, including forward translation, back translation, pilot testing, and the creation of the final version of the tool. A total of 390 patients who had undergone metabolic and bariatric surgery 3 years ago or more were involved in testing the questionnaire's validity and reliability.

RESULTS

The mean age of participants was 36 years (range: 20 to 70 years), 56% were females, 94.1% were Saudis, and 56% had bachelor's degrees. The internal consistency of the questionnaire was tested using Cronbach's alpha. One item (alcohol consumption) was excluded during the reliability analysis due to low variance. The reliability analysis results showed that the 10 items were internally consistent, with a Cronbach's α of 0.851.

CONCLUSION

The validation and reliability of the Arabic-language version of the EBBS questionnaire were found to be satisfactory. The presence of a validated Arabic version of this instrument may help practitioners estimate patients' adherence to dietary and lifestyle recommendations after metabolic and bariatric surgery. Furthermore, the questionnaire may aid in identifying factors that influence the efficacy of these procedures.

Environmental Factors Determining Body Mass Index (BMI) within 9 Months of Therapy Post Bariatric Surgery-Sleeve Gastrectomy (SG)

Treatment of obesity should be multidirectional and include, in addition to bariatric surgery, changing the key factors of lifestyle and eating habits. The study aimed to assess the impact of bariatric surgery and dietary care on anthropometric measurements, blood pressure, changes in lifestyle, and eating habits of patients within 9 months after the procedure, with the selection of environmental factors determining BMI variation. The study included 30 SG patients before surgery (month zero) and at 1, 3, 6, and 9 months after SG. Patients completed a questionnaire regarding age, sex, place of residence, education, professional activity, number of family members, financial situation, family history of obesity, previous forms of therapy, self-assessment of nutritional knowledge, receiving and following nutritional recommendations, eating habits, frequency of body weight control, leisure time. Body weight, height, waist and hip circumference, and systolic and diastolic pressure were measured, and BMI and WHR (Waist to Hip Ratio) were calculated. Within 9 months after the procedure, the patients' body weight and BMI decreased on average by 26%. Post bariatric surgery, patients changed their eating habits. The influence of bariatric SG surgery and time after surgery was decisive for the normalization of BMI and explained the 33% variation in BMI up to 9 months after the procedure. Other factors important for the normalization of BMI after surgery were: male gender, older age of patients, family obesity (non-modifiable factors), as well as previous forms of therapy related to weight loss before surgery, shortening the intervals between meals and stopping eating at night (modifiable factors). The tested model explained 68% of the BMI variation after SG surgery for all assessed factors. Changes in lifestyle and eating habits in bariatric patients are crucial to maintaining the effect of bariatric surgery.

Pre-Operative Bariatric Surgery Imparts An Increased Risk of Infection, Re-Admission and Operative Intervention Following Elective Instrumented Lumbar Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

To evaluate the impact of bariatric surgery on patient outcomes following elective instrumented lumbar fusion.

METHODS

A retrospective review of a prospectively collected database was performed. Patients who underwent a bariatric procedure prior to an elective instrumented lumbar fusion were evaluated. Lumbar procedures were performed at a large academic medical center from 1/1/2012 to 1/1/2018. The primary outcome was surgical site infection (SSI) requiring surgical debridement. Secondary outcomes were prolonged wound drainage requiring treatment, implant failure requiring revision, revision secondary to adjacent segment disease (ASD), and chronic pain states. A randomly selected, surgeon and comorbidity-matched group of 59 patients that underwent an elective lumbar fusion during that period was used as a control. Statistical analysis was performed using Student's two-way t-tests for continuous data, with significance defined as P < .05.

RESULTS

Twenty-five patients were identified who underwent bariatric surgery prior to elective lumbar fusion. Mean follow-up was 2.4 ± 1.9 years in the bariatric group vs. 1.5 ± 1.3 years in the control group. Patients with a history of bariatric surgery had an increased incidence of SSI that required operative debridement, revision surgery due to ASD, and a higher incidence of chronic pain. Prolonged wound drainage and implant failure were equivalent between groups.

CONCLUSION

In the present study, bariatric surgery prior to elective instrumented lumbar fusion was associated increased risk of surgical site infection, adjacent segment disease and chronic pain when compared to non-bariatric patients.

Nutrient Intake and Deficiency of Patients 1 Year After Bariatric Surgery: Tehran Obesity Treatment Study (TOTS)

PURPOSE

This study aimed at assessing nutrient adequacy after 1 year in patients who had undergone gastric bypass (GB) surgery or sleeve gastrectomy (SG) and to investigate the association of nutrient adequacy with anthropometric indices.

METHODS

A total of 180 severely obese patients (BMI ≥ 35 kg/m²) were selected among the participants of Tehran Obesity Treatment Study. Nutritional assessments were performed over 3 days of 24-h dietary recall. To evaluate the nutrient adequacy ratio (NAR), the subject's nutrient intake was divided by the dietary reference intakes. The mean adequacy ratio (MAR) was also determined as the sum of NARs divided by the number of involved nutrients (n = 11).

RESULTS

The mean age of SG (67%) and GB (32%) patients was 39.2 ± 12 and 41.4 ± 10 years, respectively. SG patients had more postoperative fat-free mass (52.0 ± 12 kg) than GB patients (49.7 ± 8 kg) (P < 0.05). The most common postoperative serum nutrient deficiencies were related to vitamin B12 (30%), ferritin (19%), and 25-hydroxyvitamin D (16.2%). Moreover, high inadequacy of protein (> 80%) and total fat (> 70%) intake was reported. The MAR score showed that almost 45% of the patients had possibly adequate intakes of some nutrients. The adequacy of nutrients was positively associated with fat-free mass (β = 8.67, P < 0.05).

CONCLUSION

These findings revealed that patients had inadequate nutrient intakes 1 year after bariatric surgery, which was accompanied by serum nutritional deficiencies. Compared to GB patients, SG patients had a better body composition. Overall, compliance of patients with dietary guidelines and supplementations needs to be carefully monitored in the postoperative period.

MANAGEMENT OF ENDOCRINE DISEASE: Bone complications of bariatric surgery: updates on sleeve gastrectomy, fractures, and interventions

Despite well recognized improvements in obesity-related comorbidities, increasing evidence implicates bariatric surgery in the onset of adverse skeletal health outcomes. The purpose of this review is to provide a focused update in three critical areas: (i) emergent data on sleeve gastrectomy and bone loss, (ii) evidence linking bariatric surgery to incident fracture, and (iii) intervention strategies designed to mitigate surgical bone loss. Better understanding of these issues will inform our treatment of skeletal health for patients planning bariatric surgery.

[Quality of indications in bariatric surgery]

Bariatric and metabolic surgery is increasingly being utilized in Germany and also worldwide. Due to the increased perioperative risk compared to non-obese patients, a detailed and accurate preoperative assessment of the patient is pivotal to improve postoperative and long-term outcomes. The indications for bariatric surgery have shifted in recent years from a certain body mass index (BMI) to comorbidity-based indications. In 2018 the German S3 guidelines for metabolic surgery defined the indications for bariatric surgery as well as the preoperative assessment. The indications for bariatric metabolic operations should be assessed by an interdisciplinary team consisting of surgeons, internists, diabetologists, psychologists and dietitians. It is paramount that surgeon and patient define realistic goals of these operations. Also, the different types of bariatric operation and their long-term consequences should be discussed. Additionally, a thorough endocrinological assessment by an internist or diabetologist with respect to relevant comorbidities of obesity as well as the adjustment of existing therapies are important. An assessment by a mental health professional is also mandatory; however, psychological comorbidities are not a contraindication as long as the patient is being treated and the disease is controlled. A preoperative short-term high-protein and low-carbohydrate fluid nutrition helps to reduce the risk of postoperative complications, especially for patients with a high BMI. A preoperative weight loss in the sense of a mandatory loss of a defined proportion of the body weight is not useful.

Assessment of education effects on patient involvement and bariatric treatment outcome: an observational study

Introduction

As a result of the growing number of people with obesity, the popularity of bariatric surgery has been systematically increasing. It has not yet been explored whether individual education of the patient can contribute to long-term success in weight reduction after bariatric treatment.

Aim

To implement and compare the effects of different education methods, versus receiving one-time written information in the form of a guidebook, on patient involvement in abiding by lifestyle recommendations after laparoscopic sleeve gastrectomy (LSG) bariatric treatment.

Material and methods

The study included 160 patients with morbid obesity. The education session study participants were 100 patients after sleeve gastrectomy, with whom three education sessions were planned, and who were enrolled in the study. The control group consisted of 60 patients who underwent sleeve gastrectomy, and before discharge from the department, they received one-time written recommendations in the form of a guidebook.

Results

We confirmed that the three education sessions we conducted with the study group after LSG had a significant impact on weight loss. The control group, which received only written information, achieved weight loss and abided by the written recommendations, although to a lesser extent than the study group. The differences were evident particularly in motivation to adhere to recommendations and check-ups, which was significantly lower (p < 0.001) after a year of observation in the control group.

Conclusions

This study results should encourage the establishment of education as a permanent element of the LSG procedure.

The Efficacy of Energy-Restricted Diets in Achieving Preoperative Weight Loss for Bariatric Patients: a Systematic Review

In bariatric practice, a preoperative weight loss of at least 5% is recommended. However, the hypocaloric diets prescribed vary and no consensus exists. This study examined the efficacy of preoperative diets in achieving 5% weight loss. From a systematic literature search, eight randomised controlled trials (n = 862) were identified. Half of the trials used a "very-low-calorie diet" whilst the rest employed a "low-calorie diet". Only five diets achieved ≥ 5% weight loss over varying durations and energy intakes. By inference, compliance with a 700-1050 kcal (2929-4393 kJ) diet, consisting of moderate carbohydrate, high protein and low/moderate fat, for 3 weeks is likely to achieve 5% weight loss. A low-carbohydrate diet (< 20 g/day) may achieve this target within a shorter duration. Additional research is required to validate these conclusions.

Bariatric surgery as a treatment for metabolic syndrome

Obesity is the pandemic of the 21st century. Obesity comorbidities, including hypertension, dyslipidaemia and glucose intolerance define metabolic syndrome, which increases mortality risk and decreases the quality of life. Compared with lifestyles (diet and physical activity) and pharmacological interventions, bariatric surgery is by far the most effective treatment for obesity and its comorbidities. This minimally invasive surgical treatment is based on an increase of satiety (by hormonal regulation and decreasing stomach volume) or a decrease in nutrient retention (gastric and/or intestinal resection). Bariatric surgery has widely demonstrated a beneficial effect on excess body weight loss, cardiovascular risk, dyslipidaemia, non-alcoholic fatty liver disease or glucose homeostasis, among other obesity-related metabolic diseases. This review describes current efforts for the implementation of bariatric surgery in metabolic syndrome, which are mainly focused on the formulation of key definition criteria for targeting the most suitable population for this therapeutic approach. Patients should undergo appropriate nutritional and psychological follow up in order to achieve and maintain weight loss milestones and a healthy metabolic status.

Do Bariatric Patients Follow Dietary and Lifestyle Recommendations during the First Postoperative Year?

BACKGROUND

Data on adherence to postoperative lifestyle recommendations by bariatric patients are scarce. Thus, the aim of this study was to evaluate adherence to selected recommendations during the first year following laparoscopic sleeve gastrectomy (LSG) surgery.

METHODS

A prospective cohort study with 12 months of follow-up on 100 LSG patients was conducted. Data were collected at baseline and at 3 (M3), 6 (M6), and 12 (M12) months post-surgery and included anthropometrics, biochemical tests, food intake, food tolerance, common surgery-related side effects, physical activity (PA), supplementation, and number of follow-up meetings with a dietitian.

RESULTS

Data were available for 77 patients (57.1% women, mean age 43.1 ± 9.3 years and preoperative BMI 42.1 ± 4.8 kg/m²). Only a minority of the patients adhered to the recommended protein intake ≥60 g/day at all time points (≤40.3%) and ≥6 meetings with a dietitian at M12 (41.6%). Half of the patients performed ≥150 min/week of PA at all time points (≤50.6%) as recommended. PA of ≥150 min/week was associated with better lipid and glucose changes at M6 and M12 (P ≤ 0.044). Most of the patients adhered to the recommended supplementation at all time points (≥57.1%). Adherence to supplementation at M12 was significantly associated with higher serum levels of folic acid, iron, hemoglobin, and vitamins D and B12 (P ≤ 0.056 for all). Adherence to all recommendations was not significantly associated with excess weight loss ≥60% at M12 (P ≥ 0.195 for all).

CONCLUSION

Bariatric patients have medium to high adherence to the major lifestyle recommendations during the first year following LSG; however, adherence to those recommendations was not related to better weight loss at short-term follow-up. Adherence to recommended supplementation was associated with better micronutrient status 1 year postoperatively.

Weight Loss and Timing of J Tube Removal in Biliopancreatic Diversion with Duodenal Switch Patients Who Report Physical or Sexual Abuse

BACKGROUND

Bariatric surgery patients who report physical or sexual abuse form a sizeable cohort that stands out due to psychological comorbidity. Their possible vulnerability to suboptimal weight loss remains of interest. Their risk for malnutrition due to inadequate oral intake following surgery is underexplored.

OBJECTIVES

Study aims were to determine the effect of self-reported physical or sexual abuse in patients undergoing open biliopancreatic diversion with duodenal switch (BPD/DS) on (a) 3-year weight loss trajectories and (b) timing of feeding jejunostomy tube (J tube) removal. Delayed J tube removal served as an indicator for inadequate oral intake.

METHODS

In this retrospective cohort study, the sample (N = 189) consisted of all patients who underwent primary BPD/DS by the same surgeon during 2009 and 2010 at a Midwestern health system. All patients had a J tube placed during surgery. Longitudinal mixed models were used for testing differences in weight loss trajectories by abuse status.

RESULTS

There were no significant differences in weight loss trajectories by abuse status. The abused group had the J tube in place a mean of 61.9 days (SD = 39.5) compared to 44.8 days (SD = 32.8) for the not abused group, a significant difference.

CONCLUSIONS

Our use of the best available statistical methods lends validity to previous findings that suggest physical or sexual abuse does not affect weight loss after bariatric surgery. Increased likelihood of persistent inadequate oral intake in the abused group suggests the need for early multidisciplinary interventions that include mental health and nutrition experts.

Problems in bariatric patient care - challenges for dieticians

Obesity management options include a low-calorie diet, behavioral therapy, regular physical activity and pharmacological therapy. However, treatment failure is frequently encountered, most of these methods are ineffective, and a positive outcome is rarely maintained in the long term. In morbidly obese patients, bariatric surgery is considered the most effective treatment for obesity as well as the accompanying diseases. Bariatric surgery promotes much greater weight loss than conservative treatment, regardless of the applied surgical technique. Bariatric surgery patients should receive professional perioperative (preoperative, intraoperative and postoperative) care from a multidisciplinary team of specialists, including a bariatric surgeon, a general practitioner, a dietitian and a health psychologist. Patients require postoperative nutritional counseling to be able to stabilize their weight and maintain long-term weight loss after surgery. Patients are guided by bariatric dietitians through the process of adopting new eating habits and behavior, learning how to make healthy food choices.