Nutrition and metabolic support recommendations for the bariatric patient

The Impact of Cholecystectomy in Patients with Post-Bariatric Surgery Hypoglycemia

BACKGROUND

Metabolic surgery is the foremost treatment for obesity and its associated medical conditions. Nonetheless, post-bariatric hypoglycemia (PBH) emerges as a prevalent complication. PBH pathophysiology implicates heightened insulin and glucagon-like peptide 1 (GLP-1) levels, with bile acids (BA) contributing to GLP-1 release. A plausible association exists between cholecystectomy and PBH, which is attributed to alterations in BA metabolism and ensuing hormonal responses. The objective of this retrospective cohort study was to evaluate the impact of cholecystectomy on PBH pharmacological treatment, diagnostic timelines and metabolic parameters.

MATERIALS AND METHODS

Patients diagnosed with PBH after bariatric surgery were evaluated based on their history of cholecystectomy. Demographic, anthropometric and clinical data were collected. Mixed meal tolerance tests (MMTT) results were compiled to assess metabolic responses.

RESULTS

Of the 131 patients with PBH included in the study, 29 had prior cholecystectomy. The time to PBH diagnosis was similar across groups. Patients with prior cholecystectomy required higher doses of acarbose (p = 0.046), compared to those without prior cholecystectomy. Additionally, MMTT revealed higher insulin (t = 60 min: p = 0.010 and t = 90 min: p = 0.034) and c-peptide levels (t = 60 min: p = 0.008) and greater glycemic variability in patients with prior cholecystectomy (p = 0.049), highlighting the impact of cholecystectomy on glucose metabolism.

CONCLUSION

Our study offers novel insights into PBH pharmacotherapy, indicating that PBH patients with a history of cholecystectomy require elevated doses of acarbose for symptom control than PBH patients without such surgical history. Furthermore, our findings underscore the pivotal role of hyperinsulinism in PBH aetiology, emphasizing the significance of the BA-GLP-1-insulin axis.

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

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

Comparison of a pre-bariatric surgery very low-calorie ketogenic diet and the Mediterranean diet effects on weight loss, metabolic parameters, and liver size reduction

This study compared the effects on weight as well as on metabolic parameters and liver size of a very low-calorie ketogenic diet versus a Mediterranean diet in patients with morbid obesity preparing to undergo bariatric surgery. This prospective comparison study evaluated patients 18-65 years of age who enrolled for bariatric surgery. Study duration was limited to an immediate preoperative period of 15 days. The very low-calorie ketogenic diet incorporated 10-12 kcal/kg/day of energy and 1-1.2 g/kg of protein using Kalibra (Societa Dietetica Medica) (VLCKD-SDM). The Mediterranean diet (MD) included 15-20% protein, 45-50% carbohydrate, and 25-35% fat. Changes in body mass index (BMI), liver size, and anthropometric and metabolic measurements were assessed. Between January 2016 and March 2017, of 45 patients enrolled, 30 completed the study (VLCKD-SDM, n = 15; MD, n = 15). Respective median BMI loss after VLCKD-SDM was 2.7 kg/m² versus MD 1.4 kg/m² (p < 0.05); median fat percentage reduction was 3.2 units versus 1.7 units (p < 0.05). Median liver size decreased 5.5% in the VLCKD-SDM group versus 1.7% in the MD group (p < 0.05). Median total cholesterol, and LDL levels decreased in both groups (p < 0.05), with greater relative decreases in the VLCKD-SDM group. Short-term preoperative diet-based weight loss in patients with morbid obesity preparing for bariatric surgery was significantly greater following a very low-calorie ketogenic diet versus a Mediterranean diet. The very low-calorie diet also significantly improved anthropometric and metabolic parameters and reduced preoperative liver size above that of the MD.

Perioperative nutrition care and dietetic practices in the scope of bariatric surgery in Saudi Arabia using adapted protocols for evaluation

Objectives:

This study evaluates the availability of perioperative nutritional care protocols and the practices of bariatric registered dietitians in Saudi Arabia. The primary outcomes of the study were conducted using an adapted American survey “with permission.”

Methods:

A cross-sectional survey of a selected 32 dietitians providing bariatric services completed a self-administered online questionnaire from 12 hospitals in Jeddah, Saudi Arabia.

Results:

All surveyed dietitians were females, mainly Saudi nationals (93.9%, n = 30), and accredited by the Saudi Commission for Health Specialties (93.8%, n = 30). Only 37.5% (n = 6) of the dietitians were specialized in bariatric surgery. Perioperative common practices of dietitians included a conduct of screening for nutrition risk before (44%, n = 14) and after surgery (62.5%, n = 20) and applied a nutrition management protocol that is mainly based on the application of nutrition care process (62.5%, n = 20). Dietitians (81%, n = 26) reported the importance of having standardized protocols for nutritional management of patients undoing bariatric surgery, where 69% (n = 22) confirmed the availability of pre-operative written protocols in hospitals and 75% (n = 24) confirmed the existence of post-operative protocols. Pre-operative practices included using approaches for weight loss before surgery, for example, very low and low-calorie diet. Dietitians (25%, n = 8) see two to ten patients per month. The sleeve gastrectomy procedure is the most often performed surgery.

Conclusion:

This is the first study to evaluate the perioperative nutrition care protocols and practices related to bariatric surgery in Saudi Arabia. Perioperative bariatric protocols are available, but some dietitians are not aware of their availability and contents. Researchers emphasize the importance of creating national protocols by the Saudi Credentials Body to standardize practices within the field.

Understanding the Experience of Osteoporosis Risk in Bariatric Surgical Patients

Despite what is known about risk factors, preventive treatment, and increased prevalence of fragility fractures in post-bariatric surgical patients, little is known about how patient perspectives of osteoporosis risk inform their commitment to bone health. The purpose of this study was to examine the lived experience of osteoporosis risk in people who have had bariatric surgery. Interpretive phenomenology was used to explore osteoporosis from the perspectives of patients who have had bariatric surgery. Eligibility criteria included female, age older than 18 years, and able to understand and speak English. This research provided an understanding of the risk of osteoporosis from the constructed realities and experiences of those who have had bariatric surgery. Participants in this study incorrectly felt they had little to no risk for osteoporosis after bariatric surgery. Patients need to be aware of an increased risk for osteoporosis leading to the potential for fragility fractures after bariatric surgery; nurses are well positioned to enhance osteoporosis prevention efforts in this population through pre- and postoperative education.

Assessment of Protein Intake in the First Three Months after Sleeve Gastrectomy in Patients with Severe Obesity

An adequate protein intake prevents the loss of fat-free mass during weight loss. Laparoscopic sleeve gastrectomy (SG) jeopardizes protein intake due to post-operative dietary restriction and intolerance to protein-rich foods. The purpose of this study is to evaluate protein intake in the first three months after SG. We evaluated, 1 month and 3 months after surgery, 47 consecutive patients treated with SG. Protein intake, both from foods and from protein supplementation, was assessed through a weekly dietary record. Patients consumed 30.0 ± 10.2 g of protein/day on average from foods in the first month, with a significant increase to 34.9 ± 4.8 g of protein/day in the third month (p = 0.003). The use of protein supplementation significantly increased total protein intake to 42.3 ± 15.9 g protein/day (p < 0.001) in the first month and to 39.6 ± 14.2 g of protein/day (p = 0.002) in the third one. Compliance with supplement consumption was 63.8% in the first month and only 21.3% in the third month. In conclusion, both one and three months after SG, protein intake from foods was not sufficient. The use of modular supplements seems to have a significant impact on protein intake, but nevertheless it remains lower than recommended.

A scoping review of the phenomenon of osteoporosis in post bariatric surgical patients

BACKGROUND

Risk factors, preventive treatment, and increased prevalence of fragility fractures in post-bariatric surgical patients have been researched, however, little is known about how patients' perspectives of osteoporosis risk determine their commitment to bone health.

PURPOSE

The purpose of this review was to provide an overview and appraisal of the research regarding osteoporosis in post bariatric surgical patients, as well as to identify gaps in the literature in this area.

METHODS

Data bases searched included OVID Medline, CINAHL, and EMBASE which included ahead of print articles that had not yet been indexed. Relevant key words were used independently and in combination: "osteoporosis," "morbid obesity," and "bariatric surgery."

RESULTS

A total of 24 quantitative studies and 15 qualitative studies were retrieved for this review; none of the qualitative studies examined both osteoporosis and bariatric surgery.

CONCLUSION

The current trend in bariatric surgical patients regarding osteoporosis is to examine the degree of bone loss based on significant influences including extent of weight loss, years since surgery, type of procedure performed, and subject selection. Patient perceptions about osteoporosis risk after bariatric surgery were rarely addressed.

Euglycemic Diabetic Ketoacidosis With Sodium-Glucose Cotransporter-2 Inhibitor Use Post-Bariatric Surgery: A Brief Review of the Literature

Sodium-glucose cotransporter-2 (SGLT-2) inhibitors are antihyperglycemic drugs that are currently being recommended as second-line therapy for patients with diabetes mellitus. SGLT-2 Inhibitors function by inhibiting renal cotransporters, which reduces the reabsorption of glucose in the kidney, ultimately decreasing the concentration of glucose in the body. They have gained popularity in recent years due to their protective effects on the heart and kidneys - both organ systems that diabetes mellitus has shown to have a deleterious effect on. However, despite their growing fame, they have been found to increase the risk of euglycemic diabetic ketoacidosis (DKA). Euglycemic DKA is particularly dangerous as there is a chance that it can be missed by clinicians due to glucose levels generally being less than 200 mg/dL. There is an increasing body of literature detailing cases of euglycemic DKA after bariatric surgery. We present a brief review of the literature regarding this important side effect of SGLT-2 inhibitors seen in patients after bariatric surgery.

Insights from the Impact of Meal Composition on Glucose Profile Towards Post-bariatric Hypoglycemia Management

BACKGROUND/AIM

The need to improve post-bariatric hypoglycemia (PBH) diagnosis and clinical management is well recognized. Our aim was to evaluate the influence of meal nutritional composition on interstitial fluid glucose (IFG) profiles and symptom profile after Roux-en-Y gastric bypass (RYGB).

METHODS

Seventeen subjects previously submitted to RYGB were allocated into two groups of symptomatic (n = 9) or control individuals (n = 8), according to spontaneous report of symptoms suggestive of hypoglycemia. Subjects were provided with a food and symptom diary (FSD) to record dietary intake and symptoms experienced, while using a flash glucose monitoring (FGM) system for 14 days.

RESULTS

Postprandial symptom reports occurred in 70.5% of subjects (88.9% vs 50.0%, p = 0.0790, symptomatic vs control), although symptoms with concurrent IFG < 54 mg/dL and within 54 to 69 mg/dL were only observed in 31.9% and 4.8% of the events in the symptomatic vs control group, respectively (p = 0.0110). Daily glucose profiles, total energy, and macronutrients intake were not significantly different between the groups. However, nutritional composition of meals preceding reported symptoms had lower protein (3.2 g ± 1.0 g vs 7.7 g ± 0.5 g, p = 0.0286) or higher sugar (11.6 g ± 2.4 g vs 4.3 g ± 0.9 g, p = 0.0333) content.

CONCLUSIONS

Postprandial symptoms are often in patients after RYGB. Concurrent hypoglycemia only occurs in up to a third of the symptomatic episodes being more frequent in patients that spontaneously reported complaints. Hypoglycemia is more likely to be triggered by meals with a low protein or high sugar content. These findings highlight the putative role of meal composition in eliciting PBH and reinforce the need to refine nutritional intervention.

The Skeletal Consequences of Bariatric Surgery

PURPOSE OF REVIEW

This review outlines the recent findings regarding the impact of bariatric surgery on bone. It explores potential mechanisms for skeletal changes following bariatric surgery and strategies for management.

RECENT FINDINGS

Bone loss following bariatric surgery is multifactorial. Probable mechanisms include skeletal unloading, abnormalities in calciotropic hormones, and changes in gut hormones. Skeletal changes that occur after bariatric surgery are specific to procedure type and persist for several years post-operatively. Studies suggest that while bone loss begins early, fracture risk may be increased later in the post-operative course, particularly after Roux-en-Y gastric bypass (RYGB). Further research is needed to assess the extent to which skeletal changes following bariatric surgery result in fragility. Current management should be geared toward prevention of bone loss, correction of nutritional deficiencies, and incorporation of weight bearing exercise. Pharmacologic treatment should be considered for high-risk patients.

A Spanish Society joint SECO and SEEDO approach to the Post-operative management of the patients undergoing surgery for obesity

PURPOSE

Bariatric surgery is the method of choice for the management or treatment of obesity. Bariatric surgery brings about several physiological changes in the body and is associated with set of complications. The aim of this study is to provide guidelines on post bariatric surgery management based on consensus by the Spanish society for Obesity Surgery (Sociedad Española de Cirugía de la Obesidad) (SECO) and the Spanish Society for the Study of Obesity (Sociedad Española para el Estudio de la Obesidad) (SEEDO).

METHOD

The boards proposed seven experts from each society. The experts provided the evidence and a grade of recommendation on the selected topics based on systematic reviews/meta-analysis. A list of clinical practical recommendations levels of evidence and grades of these recommendations was derived from the consensus statements from the members of these societies.

RESULTS

Seventeen topics related to post-operative management were reviewed after bariatric surgery. The experts came with 47 recommendations and statements. The mean number of persons voting at each statement was 54 (range 36-76).

CONCLUSION

In this consensus, we have designed a set of guidelines to be followed while managing patients after bariatric surgery. Expertise and knowledge of the clinicians are required to convey suitable considerations to the post-bariatric patients. There should also be extensive follow-up plans for the bariatric surgery patients.

Management of Diabetes in Patients Undergoing Bariatric Surgery

PURPOSE OF REVIEW

The number of bariatric surgeries for patients with type 1 or type 2 diabetes continues to grow. Clinicians are challenged to choose therapies that reach glycemic targets without inducing adverse effects in post-bariatric patients without published guidelines. This review evaluates data supporting the best strategies for diabetes management in patients undergoing bariatric surgery.

RECENT FINDINGS

Though few clinical trials have evaluated the safety and effectiveness of different glucose-lowering therapies following bariatric surgery, remission of diabetes or reduced medications is an established benefit of bariatric surgery. Adverse events including diabetic ketoacidosis in post-bariatric patients on sodium-glucose co-transporter 2 (SGLT2) inhibitors or inadequate insulin have been reported in patient's with both type 1 and type 2 diabetes. Metformin, glucagon-like peptide-1 (GLP-1) agonists, dipeptidyl peptidase-4 (DPP-4) inhibitors, SGLT2 inhibitors, insulin, and sulfonylureas have been used successfully in the perioperative period for other surgeries and guidelines recommend adjusting the doses of these medications especially in the perioperative period. Clinicians should favor weight-neutral or weight-loss promoting therapies in post-bariatric surgery patients such as medical nutrition therapy, metformin, GLP-1 agonists, SGLT2 inhibitors, and DPP-4 inhibitors.

Vitamin K-what is known regarding bariatric surgery patients: a systematic review

Vitamin K, a fat-soluble vitamin, is involved in blood coagulation, bone mineralization, inhibition of vascular calcification, and regulation of numerous enzyme systems. Patients who undergo bariatric surgery (BS), especially procedures that involve a malabsorptive component, are prone to develop vitamin K deficiency (VKD). The causes of VKD include decreased absorptive surface areas, steatorrhea, bacterial overgrowth, marked reduction of carriers of vitamin K, decrease in vitamin K intake, and modifications of gut microbiota. Data on vitamin K status among BS patients are scarce and the strength of evidence supporting vitamin K supplementation is weak. Thus, this systematic review summarized the scientific literature on vitamin K and examined the status among patients before and after BS, as well as among pregnant women with a history of BS. A MEDLINE/Pubmed and Embase electronic search was performed. After a thorough screening of 204 titles, 19 articles were selected by 2 independent reviewers. Five studies on BS candidates (n = 750), 12 studies after BS (n = 1442), and 4 studies on pregnant woman after BS (n = 83, of them n = 7 from case reports) were included. Results of the current review suggest that patients who undergo major malabsorptive surgeries are at a higher risk of developing VKD and should be better monitored. At this point, it is still unclear whether supplementation of vitamin K is required, and what oral dose or vitamer type should be used to normalize serum levels after different types of bariatric procedures. It should be noted that the current protocols for VKD treatment are still experiential in these patients. It is also unknown at what intervals screening tests for vitamin K should be performed and what assay is most appropriate for screening purposes. Future studies are needed to answer these unresolved issues.

Nutritional Management for Chronic Kidney Disease Patients who Undergo Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) may be effective for chronic kidney disease (CKD) patients by reducing microalbuminuria and proteinuria, and by facilitating their meeting inclusion criteria for kidney transplantation. However, nutritional management for this population is complex and specific guidelines are scarce. A literature search was performed to create dietetic practice for these patients based on the most recent evidence. For the purposes of nutritional recommendations, we divided the patients into 2 subgroups: 1) patients with CKD and dialysis, and 2) patients after kidney transplantation. Before surgery, nutritional care includes nutritional status evaluation and adjusting doses of supplements to treat deficiencies and daily nutrient intake according to the dietary restrictions derived from kidney disease, including quantities of fluids, protein, phosphorus, potassium, and vitamins. After BS, these patients are at major risk for lean body mass loss, malnutrition and dehydration because of fluid restriction and diuretics. Postoperative nutritional recommendations should be carefully tailored according to CKD nutritional limitations and include specific considerations regarding protein, fluids, and supplementation, in particular calcium, vitamin A, and vitamin D. Nutritional management of CKD and kidney transplant patients undergoing BS is challenging and future studies are required to establish uniform high-level evidence-based guidelines.

Willing to go the extra mile: Prospective evaluation of an intensified non-surgical treatment for patients with morbid obesity

BACKGROUND & AIMS

Bariatric surgery has been well established and considered the treatment of choice in morbid obesity. However, some patients refuse surgery because long-term effects have not been fully elucidated, quality of life might change and lifelong supplementation with vitamins and trace elements may be required. Our aim was to exhaust non-surgical treatment modalities and to evaluate such an intensified treatment alternative.

METHODS

A total of 206 patients (mean age = 46 years; BMI = 49 kg/m²) enrolled since 2013 into a non-surgical multimodality obesity treatment program covered by major health insurances were prospectively evaluated over a three year period. The 12-month treatment course comprised 57 h cognitive-behavioral therapy, 53.5 h physical exercise training, and 43.5 h nutritional therapy offered in small groups. Weight loss was induced by a formula-based, very low-calorie diet for 12 weeks in combination with a gastric balloon. The primary outcome was relative weight loss (RWL). Secondary outcome measures were waist-to-hip ratio, blood pressure, antihypertensive drug treatment, anti-diabetic medication, HbA1c, and quality of life.

RESULTS

166 Patients (81%) completed treatment. Mean (±SD) weight loss after 12 months for women and men were 28.8 kg (±14.7) and 33.7 kg (±19.5), respectively, among completers. RWL was 21.9% (±10.0) and excess weight loss (EWL) was 46.9% (±22.2), whereas intention-to-treat analysis revealed a RWL of 20.0% (±10.4) and an EWL of 42.9% (±22.9). Weight loss was accompanied by improved quality of life, lowered HbA1c values, and a significantly reduced need of antihypertensive and diabetes medications over the study period. Three year follow-up data from the first 78 patients (76% follow-up rate) revealed a RWL of 13% (±13.1) and an EWL of 27.2% (±28.8). The majority of patients (51%) maintained a RWL of 10% or more, and 44% had an EWL > 30%.

CONCLUSIONS

In patients with morbid obesity, an intensified non-surgical multimodality treatment program may achieve significant and sustained weight loss accompanied by improvement of disease markers as well as quality of life for at least three years.

Feeding the gut after revisional bariatric surgery: The fate of 126 enteral access tubes

BACKGROUND

Revisional bariatric surgery (RBS) is associated with higher complication rates compared with primary bariatric surgery. Feeding tubes (FTs), including gastrostomy and jejunostomy tubes placed during RBS, may serve as a safety net to provide nutrition when oral intake is contraindicated or limited; however, FTs in this setting have not been well investigated.

OBJECTIVES

This study aims to determine complications, use, and duration of FTs placed during RBS.

SETTING

A high-volume academic medical center in the United States.

METHODS

Included patients underwent RBS between January 2008 and December 2016 with FTs placed at the time of RBS.

RESULTS

There were 126 patients identified (84.9% female, 76.2% Caucasian, mean age 53.4-±10.9 yr). Patients had previously undergone Roux-en-Y gastric bypass (34.1%), vertical banded gastroplasty (27.8%), and adjustable gastric band (14.3%). Indications for RBS included correction of complication of prior bariatric surgeries (50%), weight regain/failure to lose weight (32.3%), or both (17.3%). Most FTs were placed in the excluded stomach (89.7%), and median tube size was 18 F. FTs were used for feeding in 68.2% of patients, with feeding initiated in a median of 2 days. Leakage around the tube (32.5%) and pain (26.8%) were common complaints. Significant tube-related complications included infection (9.1%), dislodgement (5.9%), reintervention (5.8%), and reoperation (2.8%); 16.7% experienced at least 1 significant complication. FTs were removed at a median of 36 days.

CONCLUSION

FTs may aid in prevention of perioperative dehydration and malnutrition after RBS, but should not be considered a benign intervention. FT use should be balanced against institutional outcomes and care goals.

Bone Health After Bariatric Surgery

Bariatric surgery results in long-term weight loss and improvement or resolution in obesity-related comorbidities. However, mounting evidence indicates that it adversely affects bone health. This review summarizes clinical research findings about the impact of bariatric surgery on skeletal outcomes. The literature is the largest and strongest for the Roux-en-Y gastric bypass (RYGB) procedure, as RYGB was the most commonly performed bariatric procedure worldwide until it was very recently overtaken by the sleeve gastrectomy (SG). Because SG is a newer procedure, its skeletal effects have not yet been well defined. Epidemiologic studies have now demonstrated an increased risk of fracture after RYGB and biliopancreatic diversion with duodenal switch, both of which include a malabsorptive component. As these epidemiologic data have emerged, patient-oriented studies have elucidated the bone tissue-level changes that may account for the heightened skeletal fragility. Bariatric surgery induces early and dramatic increases in biochemical markers of bone turnover. A notable feature of recent patient-oriented clinical studies is the application of advanced skeletal imaging modalities; studies address the limitations of dual-energy X-ray absorptiometry (DXA) by using quantitative computed tomography (QCT)-based modalities to examine volumetric bone mineral density and compartment-specific density and microstructure. RYGB results in pronounced declines in bone mass at the axial skeleton demonstrated by DXA and QCT, as well as at the appendicular skeleton demonstrated by high-resolution peripheral quantitative computed tomography (HR-pQCT). RYGB has detrimental effects on trabecular and cortical microarchitecture and estimated bone strength. Skeletal changes after RYGB appear early and continue even after weight loss plateaus and weight stabilizes. The skeletal effects of bariatric surgery are presumably multifactorial, and mechanisms may involve nutritional factors, mechanical unloading, hormonal factors, and changes in body composition and bone marrow fat. Clinical guidelines address bone health and may mitigate the negative skeletal effects of surgery, although more research is needed to direct and support such guidelines. © 2018 The Authors. JBMR Plus is published by Wiley Periodicals, Inc. on behalf of American Society for Bone and Mineral Research.

Caring for the Orthopaedic Patient With a History of Bariatric Surgery

Bariatric surgery is performed on the gastrointestinal tract as a solution to obesity, and prevalence of these surgical procedures continues to rise. Bariatric surgery creates restrictive and/or malabsorptive properties, causing nutritional deficits from the physiological changes in absorption and a hypoacidic environment. Although surgery induces sustained weight loss, decreases mortality, and provides resolution or improvement to comorbidities of obesity, it can also come with complications. Common long-term complications of bariatric surgery include malnutrition, anemia, impaired wound healing, and impaired bone health. It is essential that nurses and the healthcare team caring for orthopaedic individuals with a history of bariatric surgery be aware of the special needs of these individuals, especially in the promotion of bone health. Using a multidisciplinary approach for the advancement of the orthopaedic patient's health will help promote quality patient care.

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.

Relationships of serum 25-hydroxyvitamin D, ionized calcium and parathyroid hormone after obesity surgery

OBJECTIVE

The high prevalence of secondary hyperparathyroidism (SHPT) after obesity surgery is a concern for long-term bone health. Limited knowledge exists about optimal vitamin D and suppression of parathyroid hormone (PTH) after these procedures. The aim of this study was to investigate the prevalence of SHPT and its relation to vitamin D status.

DESIGN

A cross-sectional study at Oslo University Hospital, Norway.

PATIENTS

A total of 502 consecutive patients, age 22-64 years, attending 2-year follow-up after Roux-en-Y gastric bypass.

MEASUREMENTS

A serum intact PTH >7.0 pmol/L in the absence of elevated serum ionized calcium (iCa) was considered as SHPT. Vitamin D status was defined by serum concentrations of 25-hydroxyvitamin D (S-25(OH)D).

RESULTS

Altogether, 171 patients (34%) had SHPT. The prevalence of SHPT varied across the range of S-25(OH)D (P < 0.001), being highest (71%) with S-25(OH)D < 25 nmol/L. Compared with S-25(OH)D < 50 nmol/L, the prevalence of SHPT was lower with S-25(OH)D ≥ 50 nmol/L (29.0%; RR = 0.64 (95%-CI:0.50-0.81)) and S-25(OH)D ≥ 75 nmol/L (27.7%; RR = 0.61 (95%-CI:0.44-0.84)). S-25(OH)D ≥ 100 nmol/L was associated with the lowest PTH and the lowest prevalence of SHPT (16.0%; RR = 0.35 (95%-CI:0.14-0.88) compared with S-25(OH)D < 50 nmol/L) and the most normal calcium distribution. These associations were most pronounced with iCa in the lower range. A synergistic association was found for S-25(OH)D and iCa on SHPT.

CONCLUSIONS

Vitamin D deficient patients had the highest prevalence of SHPT 2 years after gastric bypass. PTH and the prevalence of SHPT were notably lower with S-25(OH)D ≥ 100 nmol/L, compared with lower target levels.

Nutritional Status Prior to Laparoscopic Sleeve Gastrectomy Surgery

BACKGROUND

Two main causes for nutrient deficiencies following bariatric surgery (BS) are pre-operative deficiencies and favoring foods with high-energy density and poor micronutrient content. The aims of this study were to evaluate nutritional status and gender differences and the prevalence of nutritional deficiencies among candidates for laparoscopic sleeve gastrectomy (LSG) surgery.

METHODS

A cross-sectional analysis of pre-surgery data collected as part of a randomized clinical trial on 100 morbidly obese patients with non-alcoholic fatty liver disease (NAFLD) admitted to LSG surgery at Assuta Medical Center between February 2014 and January 2015. Anthropometrics, food intake, and fasting blood tests were evaluated during the baseline visit.

RESULTS

One-hundred patients completed the pre-operative measurements (60 % female) with a mean age of 41.9 ± 9.8 years and a mean BMI of 42.3 ± 4.7 kg/m(2). Pre-operatively, deficiencies for iron, ferritin, folic acid, vitamin B1, vitamin B12, vitamin D, and hemoglobin were 6, 1, 1, 6, 0, 22, and 6 %, respectively. Pre-surgery, mean energy, protein, fat, and carbohydrate intake were 2710.7 ± 1275.7 kcal/day, 114.2 ± 48.5, 110.6 ± 54.5, and 321.6 ± 176.1 gr/day, respectively. The intakes for iron, calcium, folic acid, vitamin B12, and vitamin B1 were below the Dietary Reference Intake (DRI) recommendations for 46, 48, 58, 14, and 34 % of the study population, respectively.

CONCLUSION

We found a low prevalence of nutritional deficiencies pre-operatively except for vitamin D. Most micronutrient intake did not reach the DRI recommendations, despite high-caloric and macronutrient intake indicating a poor dietary quality.

Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice

Bariatric surgery is currently the most effective treatment for morbid obesity and its associated metabolic complications. To ensure long-term postoperative success, patients must be prepared to adopt comprehensive lifestyle changes. This review summarizes the current evidence and expert opinions with regard to nutritional care in the perioperative and long-term postoperative periods. A literature search was performed with the use of different lines of searches for narrative reviews. Nutritional recommendations are divided into 3 main sections: 1) presurgery nutritional evaluation and presurgery diet and supplementation; 2) postsurgery diet progression, eating-related behaviors, and nutritional therapy for common gastrointestinal symptoms; and 3) recommendations for lifelong supplementation and advice for nutritional follow-up. We recognize the need for uniform, evidence-based nutritional guidelines for bariatric patients and summarize recommendations with the aim of optimizing long-term success and preventing complications.

The Surgical Management of Obesity

In the United States, more than one-third of the population is obese. Currently, bariatric surgery is the best known treatment for obesity, and multiple meta-analyses have shown bariatric surgery to be more effective for treating obesity than diet and exercise or pharmacologic treatment. The modern era of bariatric surgery began in 2005, which is defined by a drastic increase in the use of laparoscopy. Bariatric surgery has the potential to improve obesity-related comorbidities, such as type 2 diabetes, cardiovascular disease, and sleep apnea. The effect of bariatric surgery on weight loss and comorbidities varies by the type of procedure.

Recent advances in metabolic and bariatric surgery

Obesity and its associated medical conditions continue to increase and add significant burden to patients, as well as health-care systems, worldwide. Bariatric surgery is the most effective treatment for severe obesity and its comorbidities, and resolution of diabetes is weight loss-independent in the case of some operations. Although these weight-independent effects are frequently described clinically, the mechanisms behind them are not well understood and remain an intense area of focus in the growing field of metabolic and bariatric surgery. Perceptions of the mechanisms responsible for the beneficial metabolic effects of metabolic/bariatric operations have shifted from being mostly restrictive and malabsorption over the last 10 to 15 years to being more neuro-hormonal in origin. In this review, we describe recent basic and clinical findings of the major clinical procedures (adjustable gastric banding, vertical sleeve gastrectomy, Roux-en-Y gastric bypass, and biliopancreatic diversion) as well as other experimental procedures (ileal interposition and bile diversion) that recapitulate many of the metabolic effects of these complex operations in a simpler fashion. As the role of bile acids and the gut microbiome on metabolism is becoming increasingly well described, their potential roles in these improvements following metabolic surgery are becoming better appreciated. Bile acid and gut microbiome changes, in light of recent developments, are discussed in the context of these surgical procedures, as well as their implications for future study.

Guidelines on vitamin D replacement in bariatric surgery: Identification and systematic appraisal

INTRODUCTION

Bariatric surgery is the most effective therapeutic option to reduce weight in morbidly obese individuals, but it results in a number of mineral and vitamin deficiencies. Clinical Practice Guidelines (CPGs) attempt to balance those benefits and harms to provide guidance to physicians and patients.

OBJECTIVES

We compare and evaluate the quality of the evidence and of the development process of current CPGs that provide recommendations on vitamin D replacement in patients undergoing bariatric surgery, using a validated tool.

METHODS

We searched 4 databases, with no time restriction, to identify relevant and current CPGs. Two reviewers assessed eligibility and abstracted data, in duplicate. They evaluated the quality of CPGs development process using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) tool that consists of 6 domains. A content expert verified those assessments.

RESULTS

We identified 3 eligible CPGs: (1) the Endocrine Society (ES) guidelines (2010); (2) the American Association of Clinical Endocrinologists (AACE), The Obesity Society (TOS), and the American Society for Metabolic & Bariatric Surgery (ASMBS) guidelines (update 2013); and (3) the Interdisciplinary European (IE) guidelines on Metabolic and Bariatric Surgery (latest update 2014). The ES and the AACE/TOS/ASMBS guidelines recommended high doses of vitamin D, varying from 3000IU daily to 50,000IU 1-3 times weekly. Vitamin D doses were not mentioned in the IE guidelines. The recommendations were based on a low quality of evidence, if any, or limited to a single high quality trial, for some outcomes. In terms of quality, only the IE guidelines described their search methodology but none of the CPGs provided details on evidence selection and appraisal. None of the three CPGs rigorously assessed the preferences of the target population, resource implications, and the applicability of these guidelines. According to the AGREE II tool, we rated the ES guidelines as average in quality, and the other two as low in quality.

CONCLUSION

Current CPGs recommendations on vitamin D supplementation in bariatric surgery differ between societies. They do not fulfill criteria for optimal guideline development, in part possibly due to limited resources, and are based on expert opinion. Thus, the pressing need for high quality randomized trials to inform CPGs, to be developed based on recommended standards.

The Impact of Protein Nutritional Supplementation for Massive Weight Loss Patients Undergoing Abdominoplasty

BACKGROUND

As more patients undergo bariatric surgery to assist with weight loss, the demand for post-bariatric body contouring surgery, to address both functional and aesthetic concerns, is increasing. However, high wound healing complication rates remain a significant problem for these patients. One theory is that chronic malnourishment and hypoproteinemia may contribute significantly to these wound healing complications.

OBJECTIVE

The purpose of this study was to determine the effect of pretreatment protein nutritional supplementation on wound healing in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. Our hypothesis was that protein supplementation would decrease wound healing complications.

METHODS

A retrospective review was performed of 23 post-bariatric surgery patients undergoing abdominoplasty who received pretreatment protein nutritional supplementation. This group was compared with a historical control group of 23 post-bariatric surgery patients who underwent abdominoplasty in the period immediately before the implementation of the protein supplementation protocol. Patient demographics and procedural characteristics were similar for the two groups.

RESULTS

Forty-six patients were identified who had undergone abdominoplasty, half of whom were prescribed the protein supplementation protocol. Overall wound healing complication rates were significantly lower in the protein-supplemented group (0.0% vs. 21.8%, p = 0.04). There was no significant difference between the protein supplementation and historical control groups in regards to total complication rate.

CONCLUSIONS

Pretreatment protein supplementation is a simple intervention that can significantly decrease wound healing complications in post-bariatric surgery massive weight loss patients undergoing abdominoplasty. LEVEL OF EVIDENCE 4: Therapeutic.

Nutrition and metabolic support for critically ill patients

PURPOSE OF REVIEW

Acute critical illness increases the risk of malnutrition, are more obese, and have multiple comorbidities and frequent pre-existing nutritional deficits. There is a vast amount of research and literature being written on nutritional practices in the critically ill. We review and discuss herein the important nutrition literature over the past 12 months.

RECENT FINDINGS

Sarcopenia, defined as loss of skeletal mass and strength, is associated with increased mortality and morbidity, particularly in elderly patients with trauma. Ultrasound is emerging as a noninvasive and promising method of measuring muscularity. Measuring gastric residuals and postpyloric feeding may not decrease rates of pneumonia in critically ill patients. Trophic and full feeding lead to similar long-term functional and cognitive outcomes in patients with acute respiratory distress syndrome.

SUMMARY

Nutrition and metabolic support of critically ill patients is a complex and diverse topic. Nutritional measurements, requirements, and modes and routes of delivery are currently being studied to determine the best way to treat these complicated patients. We present just a few of the current controversial topics in this fascinating arena.

Interventions to improve long-term weight loss in patients following bariatric surgery: challenges and solutions

Bariatric surgery aims to provide long-term weight loss and improvement in weight-related comorbidities. Unfortunately, some patients do not achieve predicted weight loss targets and many regain a portion of their lost weight within 2-10 years postsurgery. A review of the literature found that behavioral, dietary, psychological, physical, and medical considerations can all play a role in suboptimal long-term weight loss. Recommendations to optimize long-term weight loss include ensuring that the patient understands how the procedure works, preoperative and postoperative education sessions, tailored nutritional supplements, restraint with liquid kilojoules, pureed foods, grazing and eating out of the home, an average of 60 minutes of physical activity per day, and lifelong annual medical, psychological, and dietary assessments.