British Obesity and Metabolic Surgery Society Guidelines on perioperative and postoperative biochemical monitoring and micronutrient replacement for patients undergoing bariatric surgery-2020 update

Beyond Insulin: Modified OAGB in Low-BMI Insulin-Resistant and Non-compliant Type 2 Diabetic Patients

BACKGROUND

Metabolic surgery's role in lower-BMI patients with type 2 diabetes mellitus (T2DM) remains debated, particularly regarding long-term outcomes.

METHODS

This retrospective study analyzed 54 patients (BMI 24-30 kg/m2) with poorly controlled T2DM (HbA1c ≥ 10%) who underwent modified one anastomosis gastric bypass between 2016 and 2017. Primary outcomes included glycemic control, weight loss, and complications at 7 years.

RESULTS

Mean preoperative BMI was 26.76 ± 1.82 kg/m2, and HbA1c was 12.63 ± 1.67%. Follow-up rates were year 1 (54/54, 100%), year 3 (52/54, 96.3%), year 5 (48/54, 88.9%), and year 7 (36/38, 94.7% of eligible patients). At 7-year follow-up, mean HbA1c decreased to 6.17 ± 0.71% (p < 0.001), and %TWL was 13.1 ± 2.4%. Complete medication elimination occurred in 45 of 54 patients (83.3%) achieving HbA1c < 6.5%. No mortality or major complications were reported.

CONCLUSIONS

Modified OAGB demonstrates sustained glycemic control and safety in lower-BMI patients with severe T2DM through 7 years with potential benefits of early surgical intervention.

Optimizing Nutritional Management Before and After Bariatric Surgery: A Comprehensive Guide for Sustained Weight Loss and Metabolic Health

Obesity is associated with multiple comorbidities that contribute to increased mortality among affected individuals. There are multiple treatments for this condition, including nutritional interventions, pharmacological therapies, and surgical procedures. Within these, bariatric surgery is an effective treatment option that requires a multidisciplinary approach, both before and after surgery. Nutritional management prior to surgery aims to achieve metabolic control and reduce comorbidities associated with the procedure. Postoperative nutritional management focuses on preventing complications, ensuring adequate nourishment, and providing necessary supplementation for optimal recovery and long-term success. This narrative review examines all these critical aspects of nutritional management in bariatric surgery, including preoperative nutrition, postoperative nutrition and physical activity recommendation, different nutritional aspects according to the type of bariatric surgery, and future directions for investigation.

Effects of Weight Loss on Endothelium and Vascular Homeostasis: Impact on Cardiovascular Risk

Available knowledge shows that obesity is associated with an impaired endothelial function and an increase in cardiovascular risk, but the mechanisms of this association are not yet fully understood. Adipose tissue dysfunction, adipocytokines production, along with systemic inflammation and associated comorbidities (e.g., diabetes and hypertension), are regarded as the primary physiological and pathological factors. Various strategies are now available for the control of excess body weight. Dietary regimens alone, or in association with bariatric surgery when indicated, are now widely used. Of particular interest is the understanding of the effect of these interventions on endothelial homeostasis in relation to cardiovascular health. Substantial weight loss resulting from both diet and bariatric surgery decreases circulating biomarkers and improves endothelial function. Extensive clinical trials and meta-analyses show that bariatric surgery (particularly gastric bypass) has more substantial and long-lasting effect on weight loss and glucose regulation, as well as on distinct circulating biomarkers of cardiovascular risk. This review summarizes the current understanding of the distinct effects of diet-induced and surgery-induced weight loss on endothelial function, focusing on the key mechanisms involved in these effects.

Preoperative Nutrition in Bariatric Surgery: A Narrative Review on Enhancing Surgical Success and Patient Outcomes

Bariatric surgery has become the preferred treatment for individuals with morbid obesity. Nutrition is key in optimizing surgical outcomes by reducing risks and enhancing recovery. Preoperative strategies, such as reducing body fat, decreasing liver size, and improving metabolic profiles, have been shown to facilitate safer surgical procedures with fewer complications. This narrative review aims to provide an analysis of the fundamental role of preoperative nutritional management in improving bariatric surgery outcomes, emphasizing the importance of addressing specific nutritional challenges to enhance surgical safety, recovery, and overall health. Preoperative nutritional interventions focus on correcting comorbidities and nutritional deficiencies, particularly hypovitaminosis and micronutrient imbalances, through a multidisciplinary approach involving nutritionists and other healthcare professionals. These interventions not only prepare patients for the physiological demands of surgery but also initiate a period of adaptation to new dietary habits, aiming to improve long-term compliance and mitigate risks such as postoperative weight regain and dumping syndrome. Adopting dietary changes, such as very low-calorie or ketogenic diets 6-12 weeks before surgery, enhances adherence to postoperative restrictions and overall surgical success. Future research should focus on developing comprehensive guidelines for preoperative nutritional care to improve patient outcomes globally.

Boosting Dietary Compliance After Bariatric Surgery: Winning Tactics for Patients

BACKGROUND

Bariatric metabolic surgery has emerged as a pivotal intervention for managing obesity, with strict adherence to postoperative nutritional guidelines being paramount for patient outcomes. This study seeks to evaluate dietary compliance levels and the factors that influence them among patients who have undergone bariatric surgery, offering insights to enhance clinical strategies.

METHOD

Our research encompassed patients who underwent bariatric metabolic surgery at our institution from February 2022 to December 2023. We utilised a validated dietary compliance scale to assess how well patients followed postoperative nutritional advice. To determine factors linked to dietary compliance, we conducted Pearson correlation and logistic regression analyses.

RESULTS

The study comprised 176 individuals who underwent bariatric metabolic surgery, with a concerning 60.23% exhibiting inadequate dietary compliance. The Pearson correlation analysis revealed significant correlations between poor dietary compliance and several demographic factors: age (r = -0.516), gender (r = 0.467), educational attainment (r = -0.605) and monthly household income (r = -0.558). Logistic regression analysis confirmed age (OR = -2.157, 95% CI: -3.120 to -1.403), gender (OR = 2.006, 95% CI: 1.821-2.665), education level (OR = -3.081, 95% CI: -4.147 to -1.679), and average monthly family income (OR = -2.847, 95% CI: -3.516 to -1.225) as independent predictors of poor dietary compliance in post-bariatric metabolic surgery patients.

CONCLUSION

The high incidence of poor dietary compliance among patients following bariatric metabolic surgery is a significant concern and is notably influenced by demographic variables such as age, gender, education and economic status. It is imperative for healthcare professionals to consider these variables when developing personalised interventions aimed at improving dietary compliance within this patient group.

Copper Deficiency: A Frequently Overlooked Complication After MBS-A Systematic Review and Meta-analysis

This study reviews the prevalence of copper (Cu) deficiency in patients for metabolic and bariatric surgery (MBS), as well as the long-term outcomes related to the prevalence of Cu deficiency after undergoing MBS. A systematic literature search and meta-analysis were conducted in PubMed, Web of Science, and Scopus for articles published by August 31, 2024. The search terms included metabolic and bariatric surgery, weight loss surgery, metabolic surgery, obesity surgery, sleeve gastrectomy, gastric banding, gastric bypass, duodenal switch, duodenojejunal bypass, copper, copper deficiency, and hypocuposemia. After PRISMA screening, 43 studies with a total of 49 patients with obesity were included in this meta-analysis. The results demonstrated that the prevalence of Cu deficiency after MBS at 1-, 2-, 3-, and 4-year follow-up was found to be 16%, 28%, 21%, and 16%, respectively. Additionally, hypocuposemia was observed to be more prevalent in patients with BPD compared with other types of surgery. Copper deficiency is frequently observed in patients following MBS, particularly those who have undergone BPD procedures. Therefore, it is imperative for patients to undergo postoperative follow-up and nutritional monitoring, along with targeted interventions.

Current Clinical Practice Guidelines for Nutritional Screening Before and After Sleeve Gastrectomy and Roux-En-Y Gastric Bypass: A Scoping Review

INTRODUCTION

Long-term data indicate that patients who underwent metabolic bariatric surgery have a higher risk of developing nutritional complications. Therefore, it is of utmost importance to monitor their nutritional status.

METHODS

A scoping literature search was conducted in MEDLINE, EMBASE, CINAHL, and TRIP database to identify clinical practice guidelines for nutritional screening before and after metabolic bariatric surgery from learned societies. For full coverage, all websites of learned societies affiliated with the World Obesity Federation were searched. Clinical practice guidelines were eligible if they contained recommendations for nutritional screening before and after sleeve gastrectomy or Roux-en-Y gastric bypass. Content was screened by two reviewers for timing, biochemical markers and cut-off values, and biochemical assays for nutritional screening.

RESULTS

Nine eligible clinical practice guidelines co-authored by 26 learned societies were identified. All guidelines provided recommendations for both bariatric procedures except for one. Majority of guidelines endorsed nutritional screening before surgery and at 3, 6, 12, and 24 months after surgery, and annually thereafter. Pre- and postoperative screening recommendations were available for iron, vitamin B12, folate, calcium and vitamin D, but in a lesser extent for vitamin A, vitamin E, vitamin K, zinc, vitamin B1, copper and magnesium. Two clinical practice guidelines provided cut-off values for the diagnosis of nutritional deficiencies.

DISCUSSION

The clinical practice guidelines exhibited a high level of consistency for timing of screening, but not for the applied biochemical markers. Going forward, the primary focus should be on harmonizing recommendations for biochemical markers, and cut-off values.

Is There a Need to Reassess Protein Intake Recommendations Following Metabolic Bariatric Surgery?

PURPOSE OF REVIEW

Protein intake is recognized as a key nutritional factor crucial for optimizing Metabolic Bariatric Surgery (MBS) outcomes by preventing protein malnutrition, preserving fat-free mass, and inducing satiety. This paper discusses the current evidence regarding protein intake and its impact on clinical outcomes following MBS.

RECENT FINDINGS

There are considerable gaps in the understanding of protein requirements following MBS, as existing guidelines are based on limited and inconsistent reports. This highlights the urgent need for updated clinical practice recommendations grounded in high-quality evidence. Further investigation using robust methodologies is essential to address existing research gaps related to the individualization of protein requirements following MBS. Future research should consider factors such as the time elapsed since surgery, the form and quantity of protein consumed, and necessary adjustments for physical activity. Ultimately, in alignment with recent literature, a more specific and personalized dietary protein approach should be examined.

Measuring Dietary Intake of Pregnant Women Post-Bariatric Surgery: Do Women Meet Recommendations?

Background: Bariatric surgery is increasingly offered to women of childbearing age and significantly reduces food intake and nutrient absorption. During pregnancy, associated risks, including micronutrient deficiency, are accentuated. This study describes maternal dietary intake and adherence to dietary recommendations in pregnant women with a history of bariatric surgery. Methods: Women aged 18-45 with singleton pregnancies post-bariatric surgery were recruited at <23 weeks of gestation and followed until birth. Dietary intake was measured using three non-consecutive 24 h recalls at enrolment and at 28 and 36 weeks using the standardized tool ASA24-Australia. Micronutrient supplementation dose and adherence was reported using the Brief Medication Adherence Questionnaire. Mean macronutrient intake was calculated from all diet recalls. Micronutrient intake was determined from diet recalls and from supplementation. Intake was compared to the recommended daily intakes for pregnancy. Results: Sixty-three women participated in the study. The participants met 65 ± 17.3% (mean ± SD) of estimated energy requirements, 53(23)% (median(IQR)) of fiber requirements, and exceeded fat and saturated fat recommendations. Dietary intake levels of iron, folate, zinc, calcium, and vitamin A were below recommended levels. Gastric bypass recipients consumed significantly less folate (p = 0.008), vitamin A (p = 0.035), and vitamin E (p = 0.027) than women post-gastric sleeve or gastric band. Multivitamins were used by 80% (n = 55) of participants at study enrolment, which increased their mean intake of all micronutrients to meet recommendations. Conclusions: Women who conceive post-bariatric surgery may require targeted support to meet the recommended nutrient intake. Micronutrient supplementation enables women to meet nutrient recommendations for pregnancy and is particularly important for gastric bypass recipients.

The approach to a pregnancy after bariatric surgery

With a rising worldwide incidence of obesity, particularly in the young, bariatric surgery offers an effective method of meaningful and sustained weight loss. At present, most bariatric procedures are carried out in women and increasingly in younger age groups. In line with the fertility benefits associated with weight loss, pregnancy after bariatric surgery is now a very common scenario. Although there is limited evidence to support optimal care in this group, most women appear to have good pregnancy outcomes, with reduced rates of pre-eclampsia and gestational diabetes (GDM). However, rates of stillbirth and small-for-gestational-age (SGA) babies are increased, suggesting that screening and supplementation of micronutrients is likely to be very important in this cohort. The risks and benefits that bariatric surgery may pose to pregnancy outcomes, both maternal and fetal, are largely dependent upon the degree of weight loss, weight stability upon entering pregnancy, surgical complications and the time interval between bariatric surgery and pregnancy. Ideally, preconception care would be more widely available, helping to assess and address micronutrient deficiencies and support preparation for pregnancy.

Based on Propensity Matching Scores: Comparison of the Mid-term Outcomes of Two Bariatric Surgeries for the Treatment of Obesity and its Complications

BACKGROUND

To compare the mid-term efficacy and postoperative complications of two common bariatric procedures-single anastomotic duodeno-ileal bypass with sleeve gastrectomy (SADI-S) and sleeve gastrectomy (SG)-in treating obesity and metabolic syndrome.

METHODS

Data from 186 patients undergoing SADI-S or SG between September 2013 and October 2021 were retrospectively analyzed. Propensity score matching (PSM) was applied in a 1:1 ratio, resulting in 78 patients included in the final analysis (39 per group). Differences between groups were compared regarding weight loss outcomes (weight, BMI, waist circumference, waist-to-height ratio, %TWL, %EWL), metabolic syndrome remission rates (diabetes, hypertension, hyperuricemia, dyslipidemia, fatty liver), and postoperative complications (bone density abnormalities, anemia, gallstones).

RESULTS

Following matching, the SADI-S group achieved significantly greater weight loss (P < 0.05), particularly in %TWL and %EWL. Additionally, the SADI-S group exhibited greater efficacy in metabolic syndrome remission (diabetes, hypertension, dyslipidemia). However, the SADI-S group showed a higher incidence of postoperative bone mineral density abnormalities (P < 0.05) and more severe anemia compared to the SG group.

CONCLUSION

While SADI-S demonstrates superior weight loss and metabolic disease remission, SG may be preferable for patients with concurrent bone density issues,a higher risk of anemia,or nutritional deficiencies. Further optimization of postoperative management is recommended to reduce these complications.

Micronutrient Deficiency and Wernicke's Encephalopathy in the Setting of Over the Counter Transcutaneous Multivitamin Patch Use Following Bariatric Surgery

Background/Objective

Thiamine deficiency, which may occur following bariatric surgery, can lead to the development of Wernicke's encephalopathy (WE). This case report describes a patient developing WE postbariatric surgery, due to the use of over-the-counter transcutaneous multivitamin patch rather than recommended vitamin tablets.

Case Report

A 61-year-old female presented with 45 pounds of weight gain over the past year with a body mass index of 39.58 kg/m2. She underwent lifestyle modification and treatment with dulaglutide with limited success. After evaluation and counseling, the patient underwent Roux-en-Y gastric bypass surgery and was prescribed thiamine, cholecalciferol, vitamin B12, and multivitamin tablets postoperatively. Eight months later, she presented to the emergency room with confusion, bilateral lower extremity weakness, paresthesia, and ataxia. Neurological examination revealed disorientation, nystagmus, and bilateral lateral rectus palsies. She reported using transcutaneous multivitamin patches instead of the recommended oral supplementation. The clinical features, low serum thiamine level of 1.28 μg/dL (reference 2.5-7.5 μg/dL), and resolution of symptoms following supplementation confirmed the diagnosis of WE.

Discussion

Obesity often predisposes individuals to multiple nutritional deficiencies. It is critical that these patients take adequate vitamin supplementation before and after bariatric surgery. Thiamine deficiency can present as WE due to inappropriate supplementation such as use of a transcutaneous patch as seen in our patient.

Conclusion

Adequate nutritional counseling and supplementation before and after bariatric surgery is required to prevent complications. Transcutaneous patch as a mode of multivitamin supplementation is questionable in its current state and should be avoided.

Micronutrient Status in Patients with Severe Obesity Before and After Laparoscopic Sleeve Gastrectomy

Background: Micronutrient deficiencies (MNDs) are commonly reported after bariatric and metabolic surgery, including laparoscopic sleeve gastrectomy (LSG). Nevertheless, the micronutrient status changes over time and the influence of sex or initial body mass index (BMI) on these changes are less explored. This study aims to investigate the changes in micronutrient levels at 6 and 12 months after LSG and the potential influence of sex or baseline BMI (≥40 kg/m2) on these changes in patients submitted to LSG. Additionally, the frequency of MNDs before and at 12 months after the procedure was investigated. Materials and methods: Fifty patients with obesity underwent LSG and were assessed anthropometrically and nutritionally at baseline and at 6 and 12 months, respectively, after LSG. The changes in micronutrients levels over time were tested by a linear mixed model. Results: Vitamin B12 and vitamin D [25(OH)D] did not change significantly, while iron (p < 0.001), calcium (p = 0.01), and parathormone (p < 0.001) differed significantly from baseline to 12 months after LSG. Ferritin significantly decreased from baseline to 6 months and 12 months after LSG (LS-means, 95% CI: 202 [163, 240] vs. 160 [130, 191] vs. 150 [115, 185]). Sex or initial severe obesity (BMI ≥ 40 kg/m2) exhibited significant modifying effects for 25(OH)D and calcium, respectively. The 25(OH)D levels increased significantly in men, but not in women, while the calcium plasma concentration changed significantly only in patients with initial severe obesity. No significant changes over time were found for MNDs' frequency (p > 0.05). The most consistent deficiency frequency was observed for 25(OH)D both before and after LSG. Conclusions: Overall, our findings revealed changes in micronutrient status across the follow-up period, except for vitamin B12. Variations in 25(OH)D levels were reported exclusively in men, suggesting that they depend on sex. The calcium plasma concentration showed significant changes exclusively in patients with BMI ≥ 40 kg/m2. MNDs' frequency was not significantly altered during the study follow-up. Our results reinforce the need for developing national dietary guidelines tailored for Romanian patients following LSG.

Iron homeostasis in obesity and metabolic and bariatric surgery: a narrative review

Iron deficiency has been recognized as a potentially modifiable nutritional complication of metabolic and bariatric surgery (MBS) since prior to the turn of the century. Despite this, it remains the most common and clinically significant nutritional complication of this surgery with the potential to negate quality of life and the health benefits of surgical weight loss. This narrative review summarizes the current literature regarding iron deficiency as it relates to patients with severe obesity and those who undergo MBS. Advances in the clinical knowledge of iron homeostasis in severe obesity as a chronic disease, current diagnostic criteria for the diagnosis of iron deficiency in this patient population, the significance of preoperative iron deficiency, postoperative iron deficiency, and the status of supplementation and treatment will be reviewed with emphasis on gaps in knowledge and needed areas of further study.

Outcomes of Single Anastomosis Duodeno-Ileal Bypass With Sleeve Gastrectomy (SADI-S): A Single Bariatric Center Experience

Introduction Bariatric surgery is increasingly employed to address the global burden of morbid obesity, with Roux-en-Y gastric bypass (RYGB) representing the predominant procedure. However, some patients, particularly those with extreme obesity (BMI >50 kg/m²), may experience unsatisfactory weight-related outcomes following RYGB. While biliopancreatic diversion with duodenal switch (BPD-DS) offers superior weight reduction for this population, its complexity and associated risks limit its widespread use. Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S) was developed as a simpler substitue to BPD-DS, aiming to gain equivalent weight loss with improved safety profile. This analysis examined the efficacy of SADI-S in facilitating weight loss and ameliorating concomitant conditions (type 2 diabetes mellitus, hypertension, and obstructive sleep apnea) at various time points up to nine years post-procedure. Additionally, the study assessed the incidence of nutritional deficiencies following SADI-S. Material and methods This retrospective analysis utilized data obtained from patients undergoing SADI-S at a high-volume specialized bariatric centre between January 2016 and December 2022. Inclusion criteria encompassed individuals with high BMI and uncontrolled obesity-related comorbidities who had experienced insufficient weight-related outcomes following a previous bariatric surgery and demonstrated good compliance within a Tier 3 weight management program. Patients were excluded if they were non-compliant, unfit for surgery, or under 18 years old. Participants were followed up quarterly in the first year, every four months in the second year, and yearly thereafter. Nutritional assessments were performed in accordance with British Obesity and Metabolic Surgery Society (BOMSS) guidelines. Relevant data were extracted from patient clinical records and institutional electronic databases and analyzed using Microsoft Excel. Results There were 4000+ bariatric procedures conducted during this time. Seventeen patients were deemed as suitable candidates for SADI-S after multidisciplinary team discussion. The surgeries were performed by various surgeons. Most participants were women, with an age range of 23 to 64 years. The median BMI was 63.4 kg/m² (range: 35 kg/m² to 96.2 kg/m²). Mean percentage excess weight loss (%EWL) was 32% (range: 15% to 53%) at six months, 69.6% (range: 34% to 90%) at one year, and 86.2% (range: 43% to 109%) at two years post-procedure. Extended follow-up data (six to nine years) were available for 16 patients, with one patient lost to subsequent assessments. At this stage, the mean %EWL was 76% (range: 62% to 96%). No patients developed protein-energy malnutrition. However, micronutrient deficiencies were observed, with four patients (23.53%) exhibiting zinc deficiency and three (17.65%) presenting with calcium deficiency. All deficiencies were successfully managed with oral supplementation. Conclusion SADI-S effectively achieves substantial and sustained weight loss with high comorbidity resolution in individuals with high BMI. While micronutrient deficiencies require proactive management, SADI-S appears safe and yields favourable outcomes comparable to, or exceeding, those reported in larger studies. Long-term weight maintenance is promising. This study contributes valuable real-world evidence supporting the efficacy and safety of SADI-S, though larger studies are needed for further validation.

A systematic review on clinical practice guidelines for managing pregnancy following metabolic-bariatric surgery

OBJECTIVE

The ongoing pandemic of obesity is associated with an increase of weight loss surgeries in women of reproductive age. This study was conducted to review clinical practice guidelines (CPGs) for managing pregnancy following metabolic-bariatric surgery.

METHODS

We conducted a comprehensive literature search of all CPGs that covered the management of pregnancy following metabolic-bariatric surgery, 2010 through 2022, and that were published in English. Two authors independently scored the quality and usefulness of CPGs using the Appraisal of Guidelines for Research and Evaluation II tool (AGREE II).

RESULTS

From a total of 20 CPGs, consistent recommendations included the following: 1) contraception with long-acting reversible contraceptives before surgery until the optimal time of pregnancy; 2) nutritional care by a dietitian; 3) considering gastrointestinal discomforts during pregnancy as a potential surgical complication; and 4) modified screening for gestational diabetes instead of glucose tolerance tests preventing post-bariatric hypoglycemia. There was a lack of uniformity concerning surgery-to-conception interval and dose of supplements, as well as research gaps regarding the surgical type, mental health, delivery type, breastfeeding, neonatal care, and weight retention.

CONCLUSIONS

All recommendations for managing pregnancy after metabolic-bariatric surgery were deemed clinically useful. Although consistent recommendations should be implemented, inconsistencies should be the focus of research.

Therapeutic Options for Recurrence of Weight and Obesity Related Complications After Metabolic and Bariatric Surgery: An IFSO Position Statement

Obesity is a chronic disease that may require multiple interventions and escalation of therapy throughout the years. Until recently, no universal definition existed for recurrent weight gain and insufficient weight loss. Standardization of reporting is key so outcomes can be compared and data can be pooled. The recent IFSO consensus provided standard terminology and definitions that will likely resolve this in the future, and publishers will need to enforce for authors to use these definitions. This current IFSO position statement provides guidance for the management of recurrent weight gain after bariatric surgery.

Health Benefits Beyond the Scale: The Role of Diet and Nutrition During Weight Loss Programmes

INTRODUCTION

Obesity management strategies such as caloric restriction, very-low-calorie diets (VLCDs), and meal replacements can lead to moderate short-term weight loss. However, many patients face significant challenges in maintaining these results. Personalized interventions, including behavioral counseling and physical activity, have been shown to improve long-term adherence and success. Current clinical guidelines emphasize the pivotal role of dietitians in enhancing patient outcomes through nutritional therapy. When combined with pharmacotherapy and bariatric surgery, the focus shifts from mere weight loss to broader health improvements.

METHODS

This review explores the evolving role of dietitians in obesity management, advocating for a shift from a weight-centric approach to a more holistic model that prioritizes overall health gains. Key areas of interest include dietetic interventions' impact on metabolic health, cardiovascular function, gut microbiome balance, inflammation, and psychological well-being.

RESULTS

Dietetic interventions have been shown to provide significant health improvements beyond weight loss. These include enhanced metabolic and cardiovascular health, better gut microbiome balance, reduced inflammation, improved sleep quality, mental well-being, and overall quality of life. By focusing on non-scale victories such as improved insulin sensitivity, lipid profiles, and mental health, dietitians play a crucial role in driving long-term success in obesity management. These outcomes highlight the need to shift the focus from short-term weight loss to a more comprehensive view of health gains.

CONCLUSIONS

The role of dietitians in obesity management is expanding to encompass a more comprehensive and individualized approach. Moving beyond a focus on weight reduction, this paradigm promotes long-term, patient-centered strategies that address the multifactorial nature of obesity. By combining dietary changes with regular physical activity and behavioral support, dietitians can contribute to sustained health improvements, treating obesity as a chronic, complex disease.

Iron Treatment in Patients with Iron Deficiency Before and After Metabolic and Bariatric Surgery: A Narrative Review

Iron is an essential nutrient in living organisms with multiple vital functions. Iron deficiency (ID) can cause long term health consequences beyond iron deficiency anemia (IDA). The high prevalence of ID and its long-term effects in patients with obesity and after metabolic and bariatric surgery (MBS) is recognized. Nevertheless, there is limited knowledge of the optimal route or dose for treatment of patients with obesity and post-MBS, and an evidence-based universal guideline for prevention and treatment of ID in short- and long-term post-MBS (PMBS) is not yet available. ID in the general population is currently treated with oral or parenteral iron, where oral iron treatment is considered the preferred option with parenteral iron as a second-line treatment in case there is intolerance or lack of response to oral iron. In patients with obesity with chronic low-grade inflammation and PMBS patients with altered gut anatomy and function, there are also alterations in the bioavailability and higher risks of side effects of available oral irons. The conclusions of current studies exploring effective treatment of iron deficiency in this population have been inconsistent and further well-planned randomized and prospective studies are needed. This is a narrative review of the literature on the available treatment options and strategies for treatment of ID in PMBS patients to recognize the knowledge gaps and provides topics of future research.

Perioperative Care for Bariatric Surgery

This review will start with a brief pathophysiology of obesity and the requirement for bariatric surgery, and it continues with a preoperative assessment, which includes a surgical mortality risk assessment, respiratory and cardiovascular assessments, and a psychological assessment. In-hospital postoperative care will be discussed, including which patients need a surgical intensive care unit and the monitoring tools required. The need for postoperative medications, postoperative complications, strategies for management, and a follow-up plan are also reviewed. This manuscript is written in a narrative review form with a chance of bias as a possible limitation.

Preoperative Micronutrient Repletion Strategies in Metabolic and Bariatric Surgery: A Systematic Review

BACKGROUND

Evidence is lacking to inform how micronutrient deficiencies should be prevented and treated before metabolic-bariatric surgery to optimize patient outcomes.

OBJECTIVE

This systematic review aimed to examine the effect of preoperative repletion strategies for micronutrient deficiencies on micronutrient biochemistry, quality of life, and complication rates among candidates for metabolic and bariatric surgery compared with usual care, alternate strategies, or no treatment.

METHODS

PubMed, Embase, CINAHL, and CENTRAL was searched in April 2024. A grey literature search was updated in April 2024 via Google search. Eligible observational and interventional studies were those that provided micronutrient repletion before the surgery and measured micronutrient status pre- and/or postsurgery. Studies with participants who were pregnant, lactating, or elected jejunocolic bypass, jejunoileal bypass, vertical banded gastroplasty, and biliopancreatic diversion were excluded. Risk of bias was assessed using the Academy of Nutrition and Dietetics Quality Criteria Checklist. Findings were narratively synthesized and the Grading of Recommendation, Assessment, Development and Evaluations was adopted when applicable. Twenty studies (n = 27 groups) were included (n = 15 observational; n = 5 interventional).

RESULTS

Strategies targeted vitamins A, D, E, B6, B12, C, thiamin, folate, calcium, iron, selenium, and zinc, including chronic dosing of oral supplements and multivitamins (n = 21), megadoses of oral supplements (n = 1), intramuscular injection (n = 1), intravenous infusion (n = 1), and a mix of injection and oral supplements (n = 3). Preoperative repletion strategies varied in efficacy. Chronic dosing of oral supplements increased vitamin D levels (n = 4 interventional studies; Grading of Recommendation, Assessment, Development and Evaluations rating: moderate). Multivitamins did not improve vitamin B12 status but improved status of vitamin B6, vitamin C, and folate. Iron infusion (n = 1) increased ferritin levels, despite small sample size and low adherence rate, whereas oral iron supplementation resulted in unchanged (n = 4) or decreased (n = 1) ferritin levels.

CONCLUSIONS

Proactive and personalized micronutrient repletion schedules may decrease the risk of preoperative and early postoperative deficiency.

Trends and development in perioperative enteral nutrition: a systematic bibliometric analysis

Background

This research aims to explore the intellectual landscape of studies in perioperative enteral nutrition (PEN) and identify trends and research frontiers in the field.

Methods

Scientometric research was conducted through the analysis of bibliographic records from the Web of Science Core Collection Database for the period 2014-2023. Analyses performed using CiteSpace software included cooperation network analysis, reference co-citation analysis, and keywords co-occurrence analysis.

Results

The analysis included 3,671 valid records in the final dataset. Findings indicate an upward trend in annual publications, with the United States leading in research output and Harvard University as the top publishing institution. The Journal of Parenteral and Enteral Nutrition was identified as the most productive journal. Notable research hotspots include enhanced recovery after surgery, early enteral nutrition, intestinal failure, short bowel syndrome, abdominal surgery. Evidence-based articles have emerged as the predominant literature type. Future research trends are anticipated to focus on gut microbiota and patients with congenital heart disease.

Conclusion

Our study provides a comprehensive analysis of the publication volume, contributions by country/region and institutions, journal outlets, and reference and keyword clusters in the field of PEN over the decade. The findings provide valuable insights for researchers, policymakers, and clinicians, helping them comprehend the research landscape, identify gaps, and shape future research directions in this field.

Obesity influencing circulating levels of nutrients: Evidence from Mendelian randomization study

Observational studies have established that obesity is associated with nutritional deficiencies, but the exact causality remains uncertain. Thus, this Mendelian randomization (MR) study aimed to identify the causal associations between obesity and circulating levels of nutrients. Single-nucleotide polymorphisms associated with obesity (body mass index and waist-hip ratio), were extracted from a genome-wide association study of 694,649 European ancestry. Summary-level data for minerals (copper, selenium, zinc, calcium, magnesium, and potassium), and vitamins (folate, vitamins A, C, E, B6, and B12), albumin were obtained from the publicly available integrative epidemiology unit OpenGWAS database psychiatric genomics consortium. Inverse-variance weighted method several sensitivity analyses were conducted. Genetically predicted higher body mass index significantly decreased circulating levels of magnesium (β = -0.07, 95% confidence interval [CI]: -0.10 to -0.03, P = 1.47 × 10-4), folate (β = -0.07, 95% CI: -0.10 to -0.04, P = 5.61 × 10-5), vitamin A (β = -0.11, 95% CI: -0.14 to -0.07, P = 3.10 × 10-9), vitamin E (β = -0.10, 95% CI: -0.13 to -0.06, P = 1.84 × 10-8), albumin (β = -0.15, 95% CI: -0.17 to -0.12, P = 9.89 × 10-28); whereas genetically predicted higher waist-hip ratio decreased circulating levels of magnesium (β = -0.07, 95% CI: -0.11 to -0.02, P = 1.87 × 10-3), folate (β = -0.07, 95% CI: -0.11 to -0.03, P = 9.87 × 10-4), vitamin C (β = -0.08, 95% CI: -0.12 to -0.04, P = 2.40 × 10-4), albumin (β = -0.08, 95% CI: -0.11 to -0.04, P = 3.72 × 10-5). The study supports a causal effect of obesity on lower circulating levels of nutrients. Our findings highlight the necessity of adjuvant nutrients in obesity management.

Obesity in adults

Obesity has increased in prevalence worldwide and WHO has declared it a global epidemic. Population-level preventive interventions have been insufficient to slow down this trajectory. Obesity is a complex, heterogeneous, chronic, and progressive disease, which substantially affects health, quality of life, and mortality. Lifestyle and behavioural interventions are key components of obesity management; however, when used alone, they provide substantial and durable response in a minority of people. Bariatric (metabolic) surgery remains the most effective and durable treatment, with proven benefits beyond weight loss, including for cardiovascular and renal health, and decreased rates of obesity-related cancers and mortality. Considerable progress has been made in the development of pharmacological agents that approach the weight loss efficacy of metabolic surgery, and relevant outcome data related to these agents' use are accumulating. However, all treatment approaches to obesity have been vastly underutilised.

Assessment of guidelines for bariatric and metabolic surgery: a systematic review and evaluation using appraisal of guidelines for research and evaluation II (AGREE II)

BACKGROUND

In recent years, multiple guidelines on bariatric and metabolic surgery were published, however, their quality remains unknown, leaving providers with uncertainty when using them to make perioperative decisions. This study aims to evaluate the quality of existing guidelines for perioperative bariatric surgery care.

METHODS

A comprehensive search of MEDLINE and EMBASE were conducted from January 2010 to October 2022 for bariatric clinical practice guidelines. Guideline evaluation was carried out using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework.

RESULTS

The initial search yielded 1483 citations, of which, 26 were included in final analysis. The overall median domain scores for guidelines were: (1) scope and purpose: 87.5% (IQR: 57-94%), (2) stakeholder involvement: 49% (IQR: 40-64%), (3) rigor of development: 42.5% (IQR: 22-68%), (4) clarity of presentation: 85% (IQR: 81-90%), (5) applicability: 6% (IQR: 3-16%), (6) editorial independence: 50% (IQR: 48-67%), (7) overall impressions: 48% (IQR: 33-67%). Only six guidelines achieved an overall score >70%.

CONCLUSIONS

Bariatric surgery guidelines effectively outlined their aim and presented recommendations. However, many did not adequately seek patient input, state search criteria, use evidence rating tools, and consider resource implications. Future guidelines should reference the AGREE II framework in study design.

Nutritional Challenges and Treatment After Bariatric Surgery

Bariatric surgery is an important weight loss tool in individuals with severe obesity. It is currently the most effective long-term weight loss treatment that lowers obesity-related comorbidities. It also has significant physiological and nutritional consequences that can result in gastrointestinal complications and micronutrient deficiencies. After gastric bypass, clinical events that negatively affect nutritional status include malabsorption, dumping syndrome, kidney stones, altered intestinal bile acid availability, bowel obstruction, ulcers, gastroesophageal reflux, and bacterial overgrowth. Risk factors for poor nutritional status and excessive loss of lean body mass and bone include reduced dietary quality and inadequate intake, altered nutrient absorption, and poor patient compliance with nutrient supplementation. There are unique concerns in adolescents, older individuals, and individuals who become pregnant postoperatively. With careful management, health-care professionals can assist with long-term weight loss success and minimize the risk of acute and long-term nutrition complications after bariatric surgery.

Thyroid function and iodine intake: global recommendations and relevant dietary trends

Iodine is a micronutrient that is essential for thyroid hormone production. Adequate iodine intake is especially important during pregnancy and early life, when brain development is dependent on thyroid hormones. Iodine intake recommendations vary around the world, but most recommendations generally reflect the increased requirements during pregnancy and lactation, although adequate iodine intake before pregnancy is also important. Tremendous progress has been made in improving iodine intake across the world over the past 30 years, mainly through salt-iodization programmes. However, in countries without strong iodine fortification programmes, and with shifts in dietary patterns, a need has arisen for health organizations, governments and clinicians to ensure that adequate iodine is consumed by everyone in the population. For example, in countries in which adequate iodine intake depends on individual food choice, particularly of iodine-rich milk and dairy products, intake can be highly variable and is also vulnerable to changing dietary patterns. In this Review, iodine is considered in the wider context of the increasing prevalence of overweight and obesity, the dietary trends for salt restriction for cardiovascular health and the increasing uptake of plant-based diets.

Short-term effects of Roux-en-Y gastric bypass or gastric sleeve on bone mineral density and calciotropic hormones: a systematic review and meta-analysis

Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS) have been associated with significant reductions in bone mineral density (BMD) and fluctuations in serum levels of calciotropic hormones. These changes pose a risk to bone health. The study assessed the short-term (12 and 24 months) effects of RYGB and GS on BMD and calciotropic hormones. PubMed, Embase, and Cochrane Library databases were searched. Analyses considered follow-up (12 and 24 months) with BMD as main outcome at three sites (femoral neck, total hip, and lumbar spine) and one for each calciotropic hormone (25 OH vitamin D and parathyroid hormone [PTH]). Estimated effect sizes were calculated as standardized mean differences (SMD), confidence interval of 95%, and P value. Nine studies totaling 473 participants (RYGB = 261 and GS = 212) were included. RYGB resulted in lower BMD than GS at 12 months for femoral neck (SMD = -0.485, 95% CI [-0.768, -0.202], P = .001), lumbar spine (SMD = -0.471, 95% CI [-0.851, -0.092], P = .015), and total hip (SMD = -0.616, 95% CI [-0.972, -0.259], P = .001), and at 24 months for total hip (SMD = -0.572, 95% CI [-0.907, -0.238], P = .001). At 24 months, 25 OH vitamin D was lower in RYGB than GS (SMD = -0.958 [-1.670, -0.245], P = .008) and PTH levels were higher in RYGB than in GS (SMD = 0.968 [0.132, 1.804, P = .023]). RYGB demonstrated significant reduction in regional BMD. It also induces lower serum 25 OH vitamin D and higher PTH levels than GS. The results support the need for preventive bone health measures in the short-term postoperative period, especially in the case of RYGB.

Effects of Very Low-Calorie Diet versus Roux-en-Y Gastric Bypass Surgery on Body Composition in Patients with Obesity

Roux-en-Y gastric bypass (RYGB) is the most effective treatment for severe obesity. A very low-calorie diet (VLCD) is another effective dietary intervention to treat obesity. This study evaluated the effect of a VLCD versus RYGB on weight reduction, changes in body composition and the resolution of comorbidities during a 12-week period. Individuals with obesity at the obesity clinic, Ramathibodi Hospital, Mahidol University, Thailand with a body mass index (BMI) ≥ 37.5 kg/m2 or ≥32.5 kg/m2 with obesity-related complications were recruited. Treatment options, either RYGB or VLCD, were assigned depending on patients' preferences and physicians' judgment. The analysis included 16 participants in the RYGB group and 15 participants in the VLCD group. Baseline characteristics were similar between groups; nevertheless, the participants in the VLCD group were significantly younger than those in the RYGB group. The number of patients with type 2 diabetes (T2D) was slightly higher in the RYGB group (43.8% vs. 33.3%, p = 0.552). Additionally, patients in the RYGB group had a longer duration of T2D and were treated with anti-diabetic agents, while VLCD patients received only lifestyle modifications. At 12 weeks, total and percentage weight loss in the RYGB and VLCD groups, respectively, were as follows: -17.6 ± 6.0 kg vs. -15.6 ± 5.1 kg (p = 0.335) and -16.2% ± 4.3% vs. -14.1% ± 3.6% (p = 0.147). Changes in biochemical data and the resolution of comorbidities were similar between the groups at 12 weeks. A 12-week VLCD resulted in similar weight loss and metabolic improvement compared with RYGB. Large-scale studies with long follow-up periods are needed to elucidate whether VLCD is a viable alternative treatment to bariatric surgery.

When and How to Evaluate Vitamin D Status? A Viewpoint from the Belgian Bone Club

Low serum vitamin D levels have been associated with a variety of health conditions which has led the medical community but also the general population to evaluate vitamin D status quite liberally. Nevertheless, there remain questions about the efficacy and cost-effectiveness of such a broad and untargeted approach. This review therefore aims to summarize the current evidence and recommendations on when and how to evaluate vitamin D status in human health and disease. For the general population, most guidelines do not recommend universal screening but suggest a targeted approach in populations at risk. Also, some guidelines do not even recommend evaluating vitamin D status when vitamin D substitution is indicated anyway, such as in children or patients receiving anti-osteoporosis drugs. In those guidelines that recommend the screening of vitamin D status, serum 25(OH)D levels are universally proposed as the preferred screening tool. However, little attention is given to analytical considerations and almost no guidelines discuss the timing and frequency of screening. Finally, there is the known variability in diagnostic thresholds for defining vitamin D insufficiency and deficiency. Overall, the existing guidelines on the evaluation of vitamin D status differ broadly in screening strategy and screening implementation, and none of these guidelines discusses alternative screening modes, for instance, the vitamin metabolic ratio. Efforts to harmonize these different guidelines are needed to enhance their efficacy and cost-effectiveness.

Psychological Benefits of a Preoperative Educational Bridging Program for Bariatric Surgery: Does Face-to-Face versus Videoconference-Based Delivery Make a Difference?

INTRODUCTION

Short educational programs prior to metabolic and bariatric surgery (MBS) provide information to prepare patients adequately for surgery and subsequent changes. Our knowledge of the beneficial effects of these programs on stabilizing and improving mental health of patients with obesity awaiting surgery is incomplete. The objective of this study was to assess the effects of a group-based educational program before MBS on three key factors: (i) patients' mental health, (ii) the program's perceived helpfulness from the patients' perspective, and (iii) the effectiveness of delivering the program online via videoconferencing.

METHODS

Validated questionnaires for anxiety, depression, stress, and quality of life before and after the program were assessed. Additionally, participants' perspectives of benefits were assessed. Two subgroups, one participating in face-to-face classes, the other participating online via videoconferencing, were compared.

RESULTS

Three hundred five patients with obesity waiting for MBS participated in the program. The dropout rate was 3%. On mean average, symptoms of anxiety (-1.1 units [SD 4.6], p < 0.001), depression (-0.9 units [SD 4.6], p < 0.001), and stress (-4.6 units [SD 15.6], p < 0.001) improved, while physical quality of life (+1.7 units [SD 9.7], p = 0.016) and body weight (-0.3 kg [SD 8.7], p = 0.57) remained stable. Patients perceived the program as very beneficial. The results were similar between delivery methods (face-to-face vs. videoconferencing).

CONCLUSION

The educational program proved to be effective in bridging the gap in preoperative preparation while also stabilizing participants' mental health. In addition, participants perceived the program as supportive. Online participation via video conferencing can be offered as an equivalent option to face-to-face classes.

Assessing Nutritional Deficiencies in Bariatric Surgery Patients: A Comparative Study of Roux-en-Y Gastric Bypass versus Sleeve Gastrectomy

Obesity is a worldwide epidemic, and bariatric surgery is considered the primary treatment for long-term weight loss and managing obesity-related health issues. Sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) are the most performed procedures. Nutritional deficiencies are a significant concern following bariatric surgery and can have serious consequences. This study aims to compare the incidence of nutritional deficiencies in patients undergoing RYGB and SG. A retrospective analysis was conducted on the nutritional status of 505 consecutive patients who underwent either RYGB or SG between January and December 2019. Data were collected regarding vitamin B12, folic acid, vitamin D, calcium, PTH, magnesium, hemoglobin, iron, ferritin, and transferrin at preoperative, 6-month, and 12-month intervals post-surgery. The RYGB group showed significantly higher excess weight loss. Vitamin B12, hemoglobin, and ferritin levels were consistently higher in the SG group throughout the study. Vitamin D deficiency was prevalent, with no significant difference between the groups. Vitamin B12 deficiency was significantly more common in the RYGB group (6 months: 17.46% vs. 4.69%, p < 0.001; 12 months: 16.74% vs. 0.93%, p < 0.001). Despite differences in their mechanisms, bariatric surgeries were associated with nutritional deficiencies. It is crucial to efficiently assess, prevent, and manage these deficiencies tailored to each surgical procedure.

The Weight of Bariatric Surgery: Wernicke-Korsakoff Syndrome after Vertical Sleeve Gastrectomy-A Case Series

In this case series, the simultaneous occurrence of Wernicke's encephalopathy (WE) and dry beriberi was reported in three patients who underwent vertical sleeve gastrectomy (VSG) between May 2021 and May 2023. All patients were obese women who underwent vertical sleeve gastrectomy (VSG) without immediate postoperative complications, but two weeks later, hyperemesis and subsequent encephalopathy with ocular movement abnormalities and weakness were observed over the following thirty days. Patients were referred to neurology, where due to the high suspicion of WE, thiamine replacement therapy was initiated; meanwhile, diagnostic neuroimaging and blood tests were conducted. Neurological and psychiatric evaluations and neuroconduction studies were performed to assess the clinical evolution and present sequelae. One year after diagnosis, all patients exhibited affective and behavioral sequelae, anterograde memory impairment, and executive functioning deficits. Two patients met the criteria for Korsakoff syndrome. Additionally, peripheral nervous system sequelae were observed, with all patients presenting with sensorimotor polyneuropathy. In conclusion, Wernicke's encephalopathy requires a high diagnostic suspicion for timely intervention and prevention of irreversible sequelae, which can be devastating. Therefore, raising awareness among medical professionals regarding the significance of this disease is essential.

Laparoscopic Roux-en-Y Versus Mini-Gastric Bypass on Liver Function at 6 Months in Morbid Obesity Patients: A Cross-Sectional Study

Background: Various weight loss surgeries exist, with no absolute superiority; each has pros and cons. Due to rising bariatric surgeries globally, it's vital to investigate comparisons between two-mini gastric bypass and Roux-en-Y gastric bypass (RYGB), especially regarding their impact on liver function. Objectives: The purpose of this study was to "draw comparisons between the effects of mini gastric bypass and laparoscopic Roux-en-Y gastric bypass on liver function at 6 months among patients with morbid obesity." Methods: This cross-sectional study included 90 bariatric surgery candidates (Body Mass Index (BMI) 35 - 50) from 2018 - 2021. Forty-five had laparoscopic mini gastric bypass surgery, while 45 had Roux-en-Y gastric bypass. Demographic, anthropometric, lab, and sonographic tests were conducted at baseline, 3-, and 6-months post-surgery. Data was analyzed using SPSS. Results: In a study of 90 patients (75.6% female, mean age 38.6 ± 10.4 years), both surgeries (Mini gastric bypass (MGB) and RYGB) effectively reduced body weight, BMI, and waist circumference at 3- and 6-months post-surgery. However, MGB showed significantly higher BMI and weight loss compared to RYGB (P = 0.003). In 90 patients, both surgeries reduced weight and BMI. However, MGB showed better BMI/weight loss. LFTs (ALT, AST, ALP) remained stable after MGB but worsened at 3 months after RYGB before recovering by 6 months. Mini gastric bypass also showed better GGT improvement. Both procedures improved fatty liver grading, FBS, and HbA1C levels equally. No significant differences were observed in blood pressure, platelet count, hemoglobin, or MCV. Ferritin levels increased in both groups but were higher in RYGB. CRP was higher in RYGB at 3 months. Conclusions: Roux-en-Y gastric bypass temporarily exacerbated liver enzymes and inflammation, but MGB resulted with more weight reduction. In comparison to RYGB, MGB improved LFTs more consistently.

Factors Impacting One-year Follow-up Visit Adherence after Bariatric Surgery in West China: A Mixed Methods Study

PURPOSE

Quality follow-up (FU) is crucial after bariatric surgery. However, poor adherence after surgery is prevalent. This research aimed to explore the factors related to FU adherence after bariatric surgery in West China.

MATERIALS AND METHODS

This study used a sequential explanatory mixed-methods research design. Participants (n = 177) were identified from the West China Hospital. Demographic information, disease profile, treatment information, and post-surgery FU information were obtained from the bariatric surgery database of the Division of Gastrointestinal Surgery of the West China Hospital. The survey data were analyzed using logistic regression. Semi-structured interviews with participants (n = 10) who had low adherence were conducted. The recording was transcribed verbatim and entered into qualitative data analysis software. Qualitative data were analyzed using a content analysis approach.

RESULTS

Multiple logistic regression revealed that living in Chengdu (OR, 2.308), being employed (OR, 2.532), non-smoking (OR, 2.805), and having less than five years of obesity (OR, 2.480) were positive predictors of FU adherence within one year. Semi-structured interviews suggested that factors related to adherence to FU were lack of motivation, lack of opportunity, insufficient ability, and beliefs regarding consequences.

CONCLUSION

Factors impacting one-year FU visit adherence after bariatric surgery include not only demographic and disease-related factors but also social and family factors. These results will provide evidence to support healthcare professionals in developing personalized postoperative FU management strategies.

Dietitian-led micronutrient management in a public bariatric surgery outpatient clinic

AIMS

This study aimed to explore the multidisciplinary team attitudes and knowledge of bariatric surgery micronutrient management (pre- and postoperative care) and to evaluate the implementation of an extended-scope of practice dietitian-led model of care for micronutrient monitoring and management.

METHODS

A mixed method study design included quantitative evaluation of micronutrient testing practices and deficiency rates. Qualitative reflexive thematic analysis was used to interpret multidisciplinary experience with micronutrient monitoring in a traditional and dietitian-led model of care. In addition, deductive analysis used normalisation process theory mapping of multidisciplinary experience with the implementation of the dietitian-led model of care.

RESULTS

In the traditional model, a lack of quality evidence to guide micronutrient management, and a tension in trust between surgeons and patients related to adherence to micronutrient prescriptions were described as challenges in current practice. The dietitian-led model was seen to overcome some of these challenges, increasing collaborative, and coordinated, consistent and personalised patient care that led to increased testing for and detection of micronutrient deficiencies. Barriers to sustainability of the dietitian-led model included a lack of workforce succession planning, and no clearly defined delegation for some aspects of care.

CONCLUSION

An extended scope dietitian-led model of care for micronutrient management after bariatric surgery improves clinical care. Challenges such as succession planning must be considered in design of extended scope services.

Micronutrient status 2 years after bariatric surgery: a prospective nutritional assessment

Background

Among commonly performed bariatric surgeries, biliopancreatic diversion with duodenal switch (BPD-DS) provides greater weight loss than Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG), with sustained metabolic improvements. However, the risk of long-term nutritional deficiencies due to the hypoabsorptive component of BPD-DS hinders its widespread use.

Objective

The aim of the study was to examine nutritional status over 2 years after BPD-DS, RYGB or SG.

Methods

Patients were recruited in the REMISSION trial (NCT02390973), a single-center, prospective study. Out of 215 patients, 73, 48 and 94, respectively, underwent BPD-DS, RYGB or SG. Weight loss, micronutrient serum levels (including iron, calcium, parathormone, vitamins A, B12 and D), and nutritional supplementation were assessed over 2 years. Patients were supplemented according to the type of surgery and individual micronutrient level evolution.

Results

At baseline, BPD-DS patients were younger than SG patients (p = 0.0051) and RYGB patients had lower body mass index (p < 0.001). Groups had similar micronutrient levels before surgery, with vitamin D insufficiency as the most prevalent nutritional problem (SG: 38.3%, RYGB: 39.9%, BPD-DS: 54.8%, p = 0.08). BPD-DS patients showed lower levels of iron, calcium and vitamin A than SG patients at 24 months. Groups had similar levels of vitamin D at 24 months. Prevalence of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiency was similar among groups at 24 months. Rates of vitamin D insufficiency and iron deficiency were lower at 24 months than at baseline. Micronutrient intake was consistent with recommendations in groups post-surgery, but most BPD-DS patients took vitamin A and vitamin D supplement doses above initial recommendations.

Conclusion

With appropriate medical and nutritional management, all surgeries led to similar rates of vitamin D, calcium, iron, vitamin A and vitamin B12 deficiencies at 24 months. However, initial vitamin A and vitamin D supplementation recommendations for BPD-DS patients should be revised upwards.

Baseline 25(OH)D level is a prognostic indicator for bariatric surgery readmission: a matched retrospective cohort study

Introduction

Managing postsurgical complications is crucial in optimizing the outcomes of bariatric surgery, for which preoperative nutritional assessment is essential. In this study, we aimed to evaluate and validate the efficacy of vitamin D levels as an immunonutritional biomarker for bariatric surgery prognosis.

Methods

This matched retrospective cohort study included adult patients who underwent bariatric surgery at a tertiary medical center in China between July 2021 and June 2022. Patients with insufficient and sufficient 25(OH)D (< 30 ng/mL) were matched in a 1:1 ratio. Follow-up records of readmission at 3 months, 6 months, and 1 year were obtained to identify prognostic indicators.

Results

A matched cohort of 452 patients with a mean age of 37.14 ± 9.25 years and involving 69.47% females was enrolled. Among them, 94.25 and 5.75% underwent sleeve gastrectomy and gastric bypass, respectively. Overall, 25 patients (5.54%) were readmitted during the 1-year follow-up. The prognostic nutritional index and controlling nutritional status scores calculated from inflammatory factors did not efficiently detect malnourishment. A low 25(OH)D level (3.58 [95% CI, 1.16-11.03]) and surgery season in summer or autumn (2.68 [95% CI, 1.05-6.83]) increased the risk of 1-year readmission in both the training and validation cohorts. The area under the receiver operating characteristic curve was 0.747 (95% CI, 0.640-0.855), with a positive clinical benefit in the decision curve analyses. The relationship between 25(OH)D and 6-month readmission was U-shaped.

Conclusion

Serum 25(OH)D levels have prognostic significance in bariatric surgery readmission. Hence, preferable 25(OH)D levels are recommended for patients undergoing bariatric surgery.

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.

Prevalence of Micronutrient Deficiencies in Preoperative Bariatric Patients in a New Zealand Tertiary Centre

PURPOSE

A potential complication of bariatric surgery is development of nutritional deficiencies. Study aims were to assess prevalence of micronutrient deficiencies in preoperative bariatric patients and to examine for ethnic differences.

METHODS

Retrospective analysis of 573 patients that underwent bariatric surgery at Counties Manukau District Health Board was carried out. Mean preoperative levels of albumin, calcium, phosphate, folate, vitamin B12, vitamin D, magnesium, haemoglobin, haematocrit, mean cell volume, mean cell haemoglobin, ferritin, iron, and transferrin were calculated. Chi square, fisher exact test, and multiple logistic regression was used to assess for differences in prevalence of micronutrient deficiencies across ethnicities.

RESULTS

The most common micronutrient deficiency was vitamin D (30.85%). There were statistically significant differences in vitamin D deficiency across ethnicities (p < 0.0001). Asians had the highest prevalence of vitamin D deficiency (60%), followed by Pacifica (44.57%), and Māori (31.68%). Asians were more likely to have vitamin D deficiency compared to NZ/Other Europeans (OR = 14.93, p < 0.001). Vitamin D deficiency was associated with higher BMI (OR = 1.05, p = 0.008). The second most common deficiency was iron (21.1%). Asians had the highest prevalence of iron deficiency (44%), followed by Māori (27.95%), and Pacifica (19.57%) (p = 0.0064). Compared to NZ/Other Europeans, Asians (OR = 4.26) and Māori (OR = 1.78) were more likely to be iron deficient (p = 0.004). Female gender was associated with iron deficiency (OR = 2.12, p = 0.007).

CONCLUSION

Vitamin D and iron are the most common micronutrient deficiencies among preoperative bariatric patients in this cohort and ethnic differences were seen. There may be a role for preoperative supplementation in these at-risk ethnic groups.

Society for Endocrinology guidelines for the diagnosis and management of post-bariatric hypoglycaemia

Post bariatric hypoglycaemia (PBH) is typically a post-prandial hypoglycaemia occurring about 2-4 hours after eating in people who have undergone bariatric surgery. PBH develops relatively late after surgery and often after discharge from post-surgical follow-up by bariatric teams, leading to variability in diagnosis and management in non-specialist centres.

AIM

to improve and standardise clinical practice in the diagnosis and management of PBH.

OBJECTIVES

(1) to undertake an up-to-date review of the current literature; (2) to formulate practical and evidence-based guidance with regards on the diagnosis and treatment of PBH; (3) to recommend future avenues for research in this condition.

METHOD

A scoping review was undertaken after an extensive literature search. A consensus on the guidance and confidence in the recommendations was reached by the steering group authors prior to review by key stakeholders.

OUTCOME

We make pragmatic recommendations for the practical diagnosis and management of PBH including criteria for diagnosis and recognition, as well as recommendations for research areas that should be explored.

Safety and Efficacy of LSG Versus LRYGB on Patients with Obesity: a Systematic Review and Meta-analysis from RCTs

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) and laparoscopic sleeve gastrectomy (LSG) are the two most frequently performed techniques in treating obesity and its related comorbidities. We aimed to compare the clinical efficacy and safety of LSG with LRYGB in terms of short- and mid-term outcomes of weight loss, obesity-related comorbidities, and post-operative complications via a meta-analysis of RCTs.

METHODS

Clinical comparative RCTs on LSG and LRYGB were searched through PubMed, MEDLINE, and Web of Science databases from inception to August 2022. Pooled outcomes from the selected studies were discussed by the random-effect meta-analysis method. Quality assessment and risk of bias for selected RCTs were implemented, and all the statistical analyses were performed.

RESULTS

Twenty studies, including 1270 patients, were enrolled. Meta-analysis results indicated the great superior efficacy of LRYGB to LSG in BMI loss at 6 (MD -1.35 kg/m2, 95% CI: -2.07 to -0.62, p = 0.0003), 12 months (MD -1.09 kg/m2, 95% CI: -1.86 to -0.33, p = 0.005), and 36 months (MD -1.47 kg/m2, 95% CI: -2.77 to -0.16, p = 0.03) as well as %EWL gaining at 36 months. Significantly higher remission rates of T2DM and dyslipidemia were achieved by LRYGB at 12 months. Besides, better improvements for T2DM-related and lipid biochemical parameters were found favoring LRYGB. However, LSG resulted in a lower post-operative complication rate and shorter operating time.

CONCLUSIONS

Present meta-analysis results suggested that LRYGB was superior to LSG concerning short- and mid-term weight loss, short-term T2DM remission efficacy, and related biochemical parameters. LSG is favored for obviously fewer complications and shorter operating time.

Associations between Zinc Deficiency, Taste Changes, and Salivary Flow Rates following Gastric Bypass and Sleeve Gastrectomy Surgeries

BACKGROUND

The prevalence of taste change (hypogeusia) and its association with zinc deficiency is unclear due to differences in methods of assessment. We investigate the prevalence of hypogeusia using mixed methods and link it with changes in zinc levels following mini gastric bypass (MGB) and sleeve gastrectomy (SG).

METHODS

This was a prospective observational study of MGB (N = 18) and SG (N = 25). Hypogeusia was evaluated by using a validated questionnaire and by taste strips procedure along with serum zinc levels and salivary flow rate measurements.

RESULTS

The mean age was 40.0 ± 9.7 years; 60.5% were female. By using a questionnaire, MGB patients experienced greater hypogeusia than SG at 3 months (72.0% vs 36.0%; (p=0.03)), but not at 6 months (56.0% vs 45.0%; (p=0.74)), respectively. Using taste strips, at 6 months, more MGB patients experienced hypogeusia compared with SG (44.0% vs 11.0%; p=0.03). Zinc level was reduced following MGB at 6 months (85.6 ± 16.9 μgm/dl vs 67.5 ± 9.2 μgm/dl; (P=0.004)) but was increased at 6 months following SG (76.9 ± 11.4 vs 84.9 ± 21.7 μgm/dl). Reduction in the rate of salivary flow was observed in 66.0% and 72.0% of MGB and SG patients, respectively, at 3 months and in 53.0% and 70.0% at 6 months.

CONCLUSION

Taste change is more prevalent following MGB compared with SG, especially at 6 months postoperation which parallel with changes in zinc levels. More than half of all patients who had undergone bariatric surgery (BS) had low to very low salivary flow rates during the follow-up. This study suggests an association between low zinc levels and reduced salivary flow with hypogeusia following BS.

Obesity: current state of the problem, multidisciplinary approach. (based on the consensus of the World Gastroenterological Organization “Obesity 2023” and the European guideline on obesity care in patients with gastrointestinal and liver diseases, 2022)

Obesity is the largest pandemic in the world, and its prevalence continues to increase. The purpose of the presented publication is to raise awareness of doctors about modern methods of diagnosing obesity and approaches to therapy, using an interdisciplinary team approach similar to that used in other chronic diseases, such as diabetes, heart disease and cancer. The article presents data from the World Gastroenterological Organization (2023) and the European Guidelines for the Treatment of Obesity in patients with diseases of the gastrointestinal tract and liver (2022). According to modern approaches, obesity should be considered as a chronic recurrent progressive disease, the treatment of which requires a comprehensive interdisciplinary approach involving psychologists and psychiatrists, nutritionists/nutritionists, therapists, endoscopists and surgeons, including lifestyle changes, a well-defined diet and exercise regimen, drug therapy, endoscopic or surgical methods of treatment. Conclusions. In order to stop the growing wave of obesity and its many complications and costs, doctors, insurance companies and health authorities should make systematic efforts to raise public awareness of both the adverse health risks associated with obesity and the potential reduction of risks through a comprehensive approach to therapy.

Bone health following paediatric and adolescent bariatric surgery: a systematic review and meta-analysis

Background

Childhood obesity is a pressing health crisis of epidemic proportions. Bariatric surgery (BS) is an effective weight loss solution however its role in the paediatric population is contentious owing to the paucity of weight specific and generalised health outcomes. This systematic review and meta-analysis aimed to assess the impact of paediatric BS on bone health.

Methods

This prospectively registered systematic review (PROSPERO ID: CRD42023432035) was performed in accordance with PRISMA guidelines. We searched MEDLINE (1946-1928 September 2023), EMBASE (1947-1928 September 2023) via the Ovid platform, and the Cochrane Review Library to identify scientific publications reporting bone outcome measures in patients under the age of 18 years who underwent BS. Meta-analysis was undertaken on post-operative weight and bone parameters in paediatric patients following BS. Outcomes were reported as weighted or standardized mean difference with 95 percent confidence intervals. Subgroup analysis by intervention, quality scoring and risk of bias were assessed.

Findings

Twelve studies with 681 patients across 5 countries (mean age 17 ± 0.57 years) were included. The quality of included studies was rated as high and there was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 0% to 99.1%). Patients underwent Roux-en-Y gastric bypass (RYGB, n = 216), sleeve gastrectomy (SG, n = 257), gastric band (n = 184) or intragastric balloon placement (n = 24). BS was associated with significant weight reduction, body mass index (BMI) -12.7 kg/m2 (95% CI -14.5 to -10.9, p < 0.001), with RYGB being most effective, BMI -16.58 kg/m2 (95% CI -19.6 to -13.6, p < 0.001). Patients who underwent SG or RYGB had significantly lower lumbar bone mineral density, -0.96 g/cm2 (95% CI -0.1 to -0.03, p < 0.001), Z score, -1.132 (95% CI -1.8 to -0.45, p < 0.001) and subtotal body bone mineral density, -0.7 g/cm2 (95% CI -1.2 to -0.2, p < 0.001) following surgery. This was accompanied with higher markers of bone resorption, C-terminal telopeptide of type 1 collagen 0.22 ng/ml (95% CI 0.12-0.32, p < 0.001) and osteocalcin, 10.83 ng/ml (95% CI 6.01-15.67, p < 0.001). There was a significant reduction in calcium levels following BS, -3.78 mg/dl (95% CI -6.1 to -1.5, p < 0.001) but no difference in 25-hydroxyvitamin D, phosphate, bone alkaline phosphatase, procollagen type 1 N propeptide or parathyroid hormone.

Interpretation

BS effectively reduces weight in paediatric patients, but RYGB and SG may have adverse effects on bone health in the medium term. It is crucial to monitor and support bone health through appropriate nutritional supplementation and judicious follow-up. Long-term data is needed to fully understand the clinical implications of these findings on bone outcomes.

Funding

Medical Research Council (MRC), United Kingdom.

The Effect of Diet Composition on the Post-operative Outcomes of Roux-en-Y Gastric Bypass in Mice

PURPOSE

Roux-en-Y gastric bypass (RYGB) leads to the improvement of many obesity-associated conditions. The degree to which post-operative macronutrient composition contributes to metabolic improvement after RYGB is understudied.

METHODS

A mouse model of RYGB was used to examine the effects of diet on the post-operative outcomes of RYGB. Obese mice underwent either Sham or RYGB surgery and were administered either chow or HFD and then monitored for an additional 8 weeks.

RESULTS

After RYGB, reductions to body weight, fat mass, and lean mass were similar regardless of diet. RYGB and HFD were independently detrimental to bone mineral density and plasma vitamin D levels. Independent of surgery, HFD accelerated hematopoietic stem and progenitor cell proliferation and differentiation and exhibited greater myeloid lineage commitment. Independent of diet, systemic iron deficiency was present after RYGB. In both Sham and RYGB groups, HFD increased energy expenditure. RYGB increased fecal energy loss, and HFD after RYGB increased fecal lipid content. RYGB lowered fasting glucose and liver glycogen levels but HFD had an opposing effect. Indices of insulin sensitivity improved independent of diet. HFD impaired improvements to dyslipidemia, NAFLD, and fibrosis.

CONCLUSION

Post-operative diet plays a significant role in determining the degree to which RYGB reverses obesity-induced metabolic abnormalities such as hyperglycemia, dyslipidemia, and NAFLD. Diet composition may be targeted in order to assist in the treatment of post-RYGB bone mineral density loss and vitamin D deficiency as well as to reverse myeloid lineage commitment. HFD after RYGB continues to pose a significant multidimensional health risk.

Dynamic Changes in Adiponectin and Resistin Drive Remission of Cardiometabolic Risk Biomarkers in Individuals with Obesity Following Bariatric Surgery

The remission of obesity-related diseases following bariatric surgery appears to result from the reorganization of metabolic and hormonal pathways involving adipokines. This study aimed to investigate the relationship between changes in body adiposity and serum adipokine levels, as well as the association between variations in adiponectin or resistin levels and cardiometabolic risk blood biomarkers before and after Roux-en-Y gastric bypass. A longitudinal and prospective study was conducted with bariatric surgery patients. Anthropometric, body composition and blood biochemical parameters were measured before and at 2 and 6 months post-surgery. The data were analyzed using ANOVA, Pearson or Spearman correlation, and simple linear regression with a significance level of p < 0.05. Among 36 mostly female patients aged 30 to 39 years, significant reductions in body weight (-26.8%), fat mass (-50%), waist circumference (-18%) and waist-to-height ratio (-22%) were observed post-surgery. Serum adiponectin levels increased (+107%), while resistin (-12.2%), TNF-α (-35%), and PAI-1 (-11.1%) decreased. Glucose, insulin, CRP, cholesterol, LDL-c, triglycerides, and vitamin D also decreased. Waist circumference variation showed a positive correlation with PAI-1 and TNF-α and a negative correlation with adiponectin. The total fat mass showed a positive correlation with PAI-1. Adiponectin variation correlated negatively with glucose, resistin, and CRP but positively with HDL-c. Resistin showed a positive correlation with insulin and CRP. In conclusion, 6 months post-bariatric surgery, reducing abdominal adiposity had a more significant impact on serum adipokine levels than total fat mass. Adiponectin increase and resistin decrease acted as endocrine mediators driving the remission of cardiometabolic risk biomarkers in individuals with obesity following Roux-en-Y gastric bypass.

Using the 5-Item Medication Adherence Report Scale (MARS-5) to Screen for Non-adherence to Vitamin and Mineral Supplementation After Bariatric Surgery

INTRODUCTION

Poor adherence to recommended vitamin and mineral supplementation after bariatric surgery is common and challenging for healthcare professionals to identify. There are several questionnaires for self-reporting of adherence to chronic medication, but none has so far been evaluated for assessment of adherence to vitamin and mineral supplementation after bariatric surgery. The aim of this study was to assess the accuracy of the 5-item Medication Adherence Report Scale (MARS-5) in measuring adherence to vitamin and mineral supplementation post bariatric surgery (gastric bypass or sleeve gastrectomy).

METHOD

The psychometric properties of MARS-5 for vitamin and mineral supplementation were validated in two cohorts: one at 1 year post bariatric surgery (n = 120) and the other at 2 years post-surgery (n = 211). MARS-5 was compared to pharmacy refill data for vitamin B12 and combined calcium/vitamin D as reference.

RESULTS

Correlation analyses demonstrated that the MARS-5 had acceptable validity compared to objectively measured adherence rates from pharmacy refill data (calculated as continuous, multiple-interval measures of medication availability/gaps-coefficient ranged from 0.49 to 0.54). Internal reliability (Cronbach's α) was high: 0.81 and 0.95, respectively. There was a clear ceiling effect where one out of three had a maximum score on MARS-5.

CONCLUSION

MARS-5 demonstrated acceptable psychometric properties for assessment of adherence to vitamin and mineral supplementation post bariatric surgery.