Diet approach before and after bariatric surgery

Nutritional Considerations During Major Weight Loss Therapy: Focus on Optimal Protein and a Low-Carbohydrate Dietary Pattern

PURPOSE OF REVIEW

Considering the high prevalence of obesity and related metabolic impairments in the population, the unique role nutrition has in weight loss, reversing metabolic disorders, and maintaining health cannot be overstated. Normal weight and well-being are compatible with varying dietary patterns, but for the last half century there has been a strong emphasis on low-fat, low-saturated fat, high-carbohydrate based approaches. Whereas low-fat dietary patterns can be effective for a subset of individuals, we now have a population where the vast majority of adults have excess adiposity and some degree of metabolic impairment. We are also entering a new era with greater access to bariatric surgery and approval of anti-obesity medications (glucagon-like peptide-1 analogues) that produce substantial weight loss for many people, but there are concerns about disproportionate loss of lean mass and nutritional deficiencies.

RECENT FINDINGS

No matter the approach used to achieve major weight loss, careful attention to nutritional considerations is necessary. Here, we examine the recent findings regarding the importance of adequate protein to maintain lean mass, the rationale and evidence supporting low-carbohydrate and ketogenic dietary patterns, and the potential benefits of including exercise training in the context of major weight loss. While losing and sustaining weight loss has proven challenging, we are optimistic that application of emerging nutrition science, particularly personalized well-formulated low-carbohydrate dietary patterns that contain adequate protein (1.2 to 2.0 g per kilogram reference weight) and achieve the beneficial metabolic state of euketonemia (circulating ketones 0.5 to 5 mM), is a promising path for many individuals with excess adiposity.

Weight Loss with an AI-Powered Digital Platform for Lifestyle Intervention

BACKGROUND

Lifestyle intervention remains the cornerstone of weight loss programs in addition to pharmacological or surgical therapies. Artificial intelligence (AI) and other digital technologies can offer individualized approaches to lifestyle intervention to enable people with obesity to reach successful weight loss.

METHODS

SureMediks, a digital lifestyle intervention platform using AI, was tested by 391 participants (58% women) with a broad range of BMI (20-78 kg/m2), with the aim of losing weight over 24 weeks in a multinational field trial. SureMediks consists of a mobile app, an Internet-connected scale, and a discipline of artificial intelligence called Expert system to provide individualized guidance and weight-loss management.

RESULTS

All participants lost body weight (average 14%, range 4-22%). Almost all (98.7%) participants lost at least 5% of body weight, 75% lost at least 10%, 43% at least 15%, and 9% at least 20%, suggesting that this AI-powered lifestyle intervention was also effective in reducing the burden of obesity co-morbidities. Weight loss was partially positively correlated with female sex, accountability circle size, and participation in challenges, while it was negatively correlated with sub-goal reassignment. The latter three variables are specific features of the SureMediks weight loss program.

CONCLUSION

An AI-assisted lifestyle intervention allowed people with different body sizes to lose 14% body weight on average, with 99% of them losing more than 5%, over 24 weeks. These results show that digital technologies and AI might provide a successful means to lose weight, before, during, and after pharmacological or surgical therapies.

Bioavailability of Orally Administered Drugs After Bariatric Surgery

PURPOSE OF REVIEW

Oral drug absorption after bariatric surgery is likely to be altered, but the impact of different bariatric surgery procedures on individual drugs is not uniform. The aim of this article is to describe factors influencing the bioavailability of orally administered drugs after bariatric surgery and to provide readers with practical recommendations for drug dosing. We also discuss the medications that may be harmful after bariatric surgery.

RECENT FINDINGS

The fundamental factors for enteral drug absorption are the production of gastric acid; the preserved length of the intestine, i.e., the size of the absorption surface and/or the preserved enterohepatic circulation; and the length of common loop where food and drugs are mixed with digestive enzymes and bile acids. Bypassing of metabolizing enzymes or efflux pumps and changes in intestinal motility can also play an important role. Significant changes of drug absorption early after the anatomic alteration may also be gradually ameliorated due to gradual intestinal adaptation. The most affected drugs are those with low or variable bioavailability and those undergoing enterohepatic circulation. Attention should also be paid to oral drug formulations, especially in the early postoperative period, when immediate-release and liquid formulations are preferred. The changes in oral bioavailability are especially clinically meaningful in patients treated with drugs possessing narrow therapeutic index (e.g., oral anticoagulants, levothyroxine, and anticonvulsants) or in acute conditions (e.g., anti-infectives); nevertheless, it may also influence the therapeutic value of chronic therapy (e.g., antidepressants. antihypertensives, antiplatelets, statins, PPIs, contraceptives, and analgesics); therapeutic effect of chronic therapy is further influenced by pharmacokinetic alterations resulting from weight loss. Therapeutic drug monitoring, periodical clinical evaluation, and adequate dose adjustments are necessary. Due to safety reasons, patients should avoid oral bisphosphonates, regular use of non-steroidal anti-inflammatory drugs, and, if possible, corticosteroids after bariatric surgery.

Adaptation of a standardized lifestyle intervention to maximize health outcomes in adolescent metabolic and bariatric surgery patients

BACKGROUND

Metabolic and bariatric surgery (MBS) is safe and efficacious in treating adolescents with severe obesity. Behavioral/lifestyle programs can support successful preparation for surgery and post-MBS weight loss, but no standardized lifestyle intervention exists for adolescents. Here we describe the process of developing and adapting the Diabetes Prevention Program Group Lifestyle Balance (DPP/GLB) curriculum to support adolescents pre- and post-MBS.

METHODS

We collected both qualitative and quantitative data from a diverse group of adolescents (N = 19, mean age 15.2 years, range 13-17, 76% female, 42% non-Hispanic Black, 41% Hispanic, 17% other). Additionally, we included data from 13 parents, all of whom were mothers. These participants were recruited from an adolescent MBS program at Children's Health System of Texas. In an online survey, we asked participants to rank their preferences and interests in DPP/GLB content topics. We complemented these results with in-depth interviews from a subset of 10 participants. This qualitative data triangulation informed the development of the TeenLYFT lifestyle intervention program, designed to support adolescents who were completing MBS and described here. This program was adapted from adolescent and parent DPP/GLB content preferences, incorporating the social cognitive model (SCM) and the socioecological model (SEM) constructs to better cater to the needs of adolescent MBS patients.

RESULTS

Adolescents' top 3 ranked areas of content were: (1) steps to adopt better eating habits and healthier foods; (2) healthy ways to cope with stress; and (3) steps to stay motivated and manage self-defeating thoughts. Nearly all adolescent participants preferred online delivery of content (versus in-person). Mothers chose similar topics with the addition of information on eating healthy outside the home. Key themes from the adolescent qualitative interviews included familial support, body image and self-confidence, and comorbidities as key motivating factors in moving forward with MBS.

CONCLUSIONS

The feedback provided by both adolescents and parents informed the development of TeenLYFT, an online support intervention for adolescent MBS candidates. The adapted program may reinforce healthy behaviors and by involving parents, help create a supportive environment, increasing the likelihood of sustained behavior change. Understanding adolescent/parent needs to support weight management may also help healthcare providers improve long-term health outcomes for this patient population.

Positive Program Evaluation and Health Maintenance among Post-Metabolic and Bariatric Surgery Patients Following a 6-Week Pilot Program

PURPOSE

Despite lifestyle changes and medication therapies, weight loss is difficult to maintain. Metabolic and bariatric surgery (MBS) is an effective route for significant weight reduction. However, post-operation there are limited opportunities to support weight loss maintenance. The following study aimed to pilot test a 6-week, 6-session nutrition and support program for post-MBS surgery patients.

MATERIALS AND METHODS

A 6-week post-MBS pilot nutrition and support program was developed to test feasibility and acceptability. Participants completed a baseline survey that included demographics, weight changes, success post-surgery, and self-efficacy of leading a healthy lifestyle. Weight change, percent total weight loss, self-efficacy, and program evaluation measures were assessed.

RESULTS

Participants (n = 18) were recruited from a local MBS clinic, predominately female (88.9%), non-Hispanic white (94.4%), received sleeve gastrectomy surgery (100%), and were 2-3 years post-operation (44.4%). Eight of the 18 participants attended the in-person sessions, serving as the intervention group. Both weight loss over and behavioral variables remained stable for both groups across the 6 weeks with no significant differences from pre to post program (p > 0.05). For program evaluation, intervention participants "agreed" or "strongly agreed" with 10 of 11 program satisfaction measures.

CONCLUSION

Following the program, weight loss was maintained among both intervention and control groups. Intervention feedback indicated that the program's approach to provide nutrition education and support was successful and acceptable. Future enhancement of the intervention should include a broader multidisciplinary approach, longer intervention period, and intentional recruitment of participants with a weight regain.

Large area fractional laser treatment of mouse skin increases energy expenditure

Fractional laser (FL) treatment is a common dermatologic procedure that generates arrays of microscopic treatment zones separated by intact tissue, promoting fast wound healing. Using a mouse model, we introduced a large area fractional laser treatment (LAFLT) method to study metabolic effects. Using two laser modalities, ablative FL (AFL) and non-ablative FL (NAFL), and exposing different percentages of mice's total body surface area (TBSA), we followed changes in metabolic parameters in real time using metabolic cages. Additionally, body composition, markers of inflammation, neurohormonal signaling, and browning of adipocytes were investigated. LAFLT, especially in high TBSA groups, had specific metabolic effects such as significantly increased average daily energy expenditure, increased fat mass loss, systemic browning of adipocytes, and inflammatory states, without compromising other organs. The ability of LAFLT to stimulate metabolism in a controlled way could develop into a promising therapeutic treatment to induce positive metabolic changes that replace or augment systemic drugs.

Preparing Patients for Body Contouring Surgery and Postoperative Surveillance for Deep Venous Thrombosis

This article highlights the importance of the preoperative evaluation and considerations necessary in preparing patients for body contouring surgery after massive weight loss (MWL). The importance of evaluating such factors as body mass index stabilization, medical comorbidities, nutritional optimization, social factors, deep venous thrombosis prophylaxis, and postoperative surveillance is critically important. Patients undergoing body contouring surgery after MWL are at increased risk of thromboembolic events, and prophylactic measures should be taken to minimize this risk. Overall, a thorough preoperative evaluation is essential to ensure patient safety, optimize surgical outcomes, and address the unique challenges presented by the MWL patient population.

Weight reduction after bariatric surgery - Do results correlate with postoperative visit frequency?

Background

Consistent follow up after a bariatric surgery is considered vital to adequate and sustained weight reduction. This study examined the strength to which compliance with postsurgical appointments predicted an increase in total body weight loss percent (TBWL%) and change in body mass index (BMI) in a cohort of Illinois based surgical center patients.

Methods

Participants (n = 78) were patients with obesity who underwent bariatric surgery between 2019 and 2021. Patient preoperative weight and BMI, and postoperative weight and BMI at 3-month intervals for one year, and the number of visits were collected from chart review to calculate TBWL%, and change in BMI. Relationship between these factors and postoperative visit compliance were evaluated using linear regression to assess if it was a significant predictor of success.

Results

Follow up visit compliance had a weak positive association with increased TBWL% (Model R2 = 0.134, B = 0.011, p = 0.004) and a minimally stronger association with increased change in BMI (Model R2 = 0.229, B = 0.015, p = 0.0001).

Conclusions

Adherence with follow up visits was weakly related to improved weight reduction outcomes after bariatric surgery. Future investigations should consider how follow up visits can better influence a patient's success in sustaining achieved weight reduction.

Dumping Syndrome: Pragmatic Treatment Options and Experimental Approaches for Improving Clinical Outcomes

Dumping syndrome is a common complication after esophageal, gastric and bariatric surgery and has a significant negative impact on the quality of life of patients. This narrative review describes the clinical syndrome, pathophysiology, diagnosis and reports on standard and pragmatic therapeutical treatment options in order to improve the clinical outcome of patients with dumping syndrome. Dumping syndrome consists of early and late dumping symptoms and can be diagnosed using clinical parameters with the help of the Sigstad's score, questionnaires or by provocative testing. The prevalence of dumping syndrome varies depending on the employed definition of dumping syndrome. Overall, dumping syndrome is more frequent nowadays due to increasing numbers of upper gastrointestinal and bariatric surgeries being performed. First treatment step includes dietary adjustment and dietary supplements, which are often sufficient to manage symptoms for the majority of patients. Next step of therapy includes acarbose, which is effective for late dumping symptoms, but the use is limited due to side effects. Somatostatin analogues are indicated after these two steps have failed. Somatostatin analogues are very effective for controlling early and late dumping, also in the long term. Glucagon like peptide-1 receptor agonists, endoscopic and surgical (re)interventions are reported as treatment options for refractory dumping syndrome; however, their use is not recommended in clinical practice due to the limited evidence on and uncertainty of outcomes. These alternatives should be considered only as last resort options in patients with otherwise refractory and invalidating dumping syndrome.

Factors Involved in the Evolution of the Basal Metabolic Rate over 30 Months After Roux-en-Y Gastric Bypass

INTRODUCTION

After Roux-en-Y gastric bypass (RYGB), the basal metabolic rate (BMR) falls. However, it is important to know how BMR per kilogram of body weight (BMR/kg) varies in the postoperative period. The present study evaluated the changes in the BMR/kg and its correlates over 30 months after RYGB.

METHODS

Eighty adult patients of both genders who underwent RYGB agreed to participate in the study. The following evaluations were performed before surgery (n=48) and 6 (n=27), 12 (n=28), 24 (n=40), and 30 months (n=29) after surgery: anthropometry, body composition (bioelectrical impedance), metabolic analysis (indirect calorimetry), and diet (food recall). Statistical analysis was performed (p = 0.05).

RESULTS

Although BMR decreased after surgery, BMR/kg increased significantly as compared to baseline from 12 months onward, peaking at 24 months and not significantly dipping at 30 months, suggesting stabilization of BMR/kg 2 years after surgery (pre, 10.68 ± 2.33 kcal/kg; 12 months, 12.46 ± 2.85 kcal/kg; 24 months, 18.78 ± 4.81 kcal/kg; 30 months, 18.12 ± 3.69 kcal/kg; p <0.001). Regarding the variables that influenced the BMR/kg, at 12 months, they were %LBM and intake of calcium-source foods (34%); at 24 months, it was protein intake (16%); and at 30 months, it was the intake of calcium-source foods (26.7%).

CONCLUSION

RYGB is associated with a significant increase in BMR when it is adjusted to body weight from 12 to 24 months postoperatively. Among the factors involved in the increase in BMR/kg are body composition and intake of protein-rich foods.

Diabetic Markers, Five Years after Bariatric Surgery

Background: Bariatric surgery delivers substantial weight loss for obese patients with comorbidities like diabetes mellitus. We aimed to investigate the impacts of bariatric surgery on diabetic markers after 5 years of follow-up. Methods: This is a retrospective study on patients with diabetes and a history of bariatric surgery between 2016-2017. The diabetic markers before and 5 years following surgery, including a lipid profile, glucose level, and the required antidiabetic medications, were evaluated. Results: 34 consecutive patients were included, 30 (88.2%) women, with a mean age of 52.71±8.53 years. The majority (65%) of surgeries were Roux-en-Y gastric bypass (RYGB), and the remaining were one anastomosis gastric bypass (OAGB) and sleeve gastrectomy (SG). The serum levels of diabetic markers reduced during follow-up (P=0.001), except for high-density lipoprotein levels and serum total cholesterol, which increased (P=0.011, P=0.838). Low-density lipoprotein levels reduced, but it was insignificant (P=0.194). Surgery types had affected the changes of diabetic markers (P>0.05). Demand for oral medication was reduced significantly, but insulin injection reduction was not significant (P=0.006 and P=0.099, respectively). Conclusion: Our study showed favorable bariatric surgery results on patients with diabetes in long-term follow-up. However, dyslipidemia is still a concern.

Bariatric Artery Embolization for Obese Patients. An Up-to-Date Review

Overweight and obesity are one of public health's major problems in the world. Conservative treatment with exercise, diet and pharmacotherapy is often ineffective, especially in the long term. Bariatric surgery is the gold standard method for a sustained long-term weight loss. Recently the endovascular technique of bariatric artery embolization (BAE) has been studied as an obesity and overweight treatment, with promising results. The goal of this article is to analyze the rationale behind BAE and to provide an up-to-date analysis of its strengths and limitation in comparison with bariatric surgery as a treatment for obesity.

Identifying Ferroptosis-Related Genes Associated with Weight Loss Outcomes and Regulation of Adipocyte Microenvironment

SCOPE

The study is about the influence of ferroptosis-related genes combined with the immune microenvironment exerted on weight control outcomes and systematic analysis.

METHODS AND RESULTS

Subcutaneous adipose tissue (sWAT) samples from 11 subjects with good outcome and 10 subjects with poor outcome in weight management are obtained from the Gene Expression Omnibus database. The results are validated in vivo in animal models with different weight loss outcomes. The CIBERSORT algorithm is used to evaluate the differences in immune cell infiltration in each sample. Patients with poor outcome have higher levels of ferroptosis in the adipose tissue. Remarkable differences in cytokine production, nuclear factor kappa-B(NF-κB) transcription factor activity, leukocyte migration involved in the inflammatory response, and other biological processes are also observed compared to that in the well-controlled group. Aldo-keto reductase family 1-member C1(AKR1C1), nuclear receptor coactivator 4(NCOA4), and glutamate-cysteine ligase catalytic subunit(GCLC) are identified as core predictive markers and their expression patterns are confirmed in animal models.

CONCLUSIONS

Ferroptosis and its mediated inflammation play an important role in long-term weight control, and analyses of the role of ferroptosis-related genes(FRGs) in weight control may provide new potential therapeutic targets for long-term weight control. Anti-inflammatory diets that mitigate inflammatory responses and affect ferroptosis may be considered in the future to improve weight control.

WEIGHT REGAIN AND THE METABOLIC PROFILE OF WOMEN IN THE POSTOPERATIVE PERIOD OF BARIATRIC SURGERY: A MULTIVARIATE ANALYSIS

BACKGROUND

Weight regain in the postoperative period after bariatric surgery is directly related to the relapse of preoperative comorbidities and a negative impact on the patients' biochemical profile.

AIMS

To assess the metabolic impact of weight regain on preoperative comorbidities and on patients' biochemical profiles, in order to show the impact of the complications on the metabolic outcomes of bariatric surgery.

METHODS

A retrospective study was carried out with 75 women in the late postoperative period of bariatric surgery who presented pathological weight regain (≥20% of the maximum weight loss). Data of interest consisted of glycemic, lipid, and inflammatory profile measurements at three different moments of evaluation: preoperative period, at the weight nadir (minimum weight), and after weight regain. A multivariate analysis was performed.

RESULTS

The mean age was 46.39±12.09 years. Preoperative body mass index was 40.10±4.11 kg/m2. There was an overall increase of 3.36 points in the mean body mass index between the nadir and after regain: from 26.30±3.9 kg/m2 to 29.66±4.66 kg/m2. The mean time to reach the nadir was 18±7.6 months, with an average percentage of excess weight loss of 91.08±11.8%. The median time for pathological weight regain was 48 months, and the mean regain amongst the sample was 8.85±5.65 kg. There was a significant correlation between pathological weight regain and levels of insulin (r=0.351; p<0.011), C-peptide (r=0.303; p<0.011), C-reactive protein (r=0.402; p<0.001), and vitamin D (r=-0.435; p<0.001), the last two being the most influenced by the percentage of weight regained.

CONCLUSIONS

The pathological weight regain in the postoperative period of bariatric surgery results in losses in the patients' metabolic and inflammatory profiles. However, the biochemical benefits are sustained up to the preoperative levels of the parameters analyzed.

Nutrition, Physical Activity, and Prescription of Supplements in Pre- and Post-bariatric Surgery Patients: An Updated Comprehensive Practical Guideline

Only in the USA, 315 billion dollars are spent annually on the medical cost of obesity in adult patients. Till now, bariatric surgery is the most effective method for treating obesity and can play an essential role in reducing the direct and indirect costs of obesity treatment. Nonetheless, there are few comprehensive guidelines which include nutrition, physical activity, and supplements, before and after surgery. The purpose of the present narrative review is to provide an updated and comprehensive practical guideline to help multidisciplinary teams. The core keywords include nutrition, diet, physical activity, exercise, supplements, macronutrients, micronutrients, weight reduction, bariatric surgery, Roux-en-Y Gastric Bypass, Sleeve Gastrostomy, Laparoscopic Adjustable Gastric Banding, and Biliopancreatic diversion with duodenal switch which were searched in databases including PubMed/Medline, Cochrane, and some other sources such as Google Scholar. We answered questions in five important areas: (a) nutritional strategies before bariatric surgery, (b) nutrition after bariatric surgery, (c) physical activity before and after bariatric surgery, (d) weight regain after bariatric surgery, and (e) micronutrient assessments and recommendations before and after bariatric surgery. Some new items were added in this updated guideline including "weight regain" and "pregnancy after bariatric surgery." Other fields were updated based on new evidence and guidelines.

Psychometric Analysis of the Rapid Eating Assessment for Participants-Short Form to Evaluate Dietary Quality in a Pre-Surgical Bariatric Population

Dietary quality and eating behaviors are essential to evaluating bariatric surgery candidates. The Rapid Eating Assessment for Participants-Short Form (REAP-S) is a previously validated measure of dietary quality suited for use in primary care. This study aimed to evaluate the psychometric properties of the REAP-S in a pre-surgical bariatric population. This study included data from one academic medical center from August 2020 to August 2022. Variables included socio-demographics, the REAP-S, mental health, and assessments of appetitive traits. Statistical methods included Cronbach's alpha, confirmatory factor analysis (CFA), and multivariable analyses. A total of 587 adult patients were included in this analysis. The mean score for the REAP-S was 28.32 (SD: 4.02), indicative of relatively moderate dietary quality. The internal consistency of the REAP-S was moderate, with a Cronbach's alpha of 0.65. The three-factor CFA model resulted in a comparative fit index of 0.91. Race (p = 0.01), body mass index (p = 0.01), food fussiness (p < 0.0001), food responsiveness (p = 0.005), and socially desirable responses (p = 0.003) were significantly associated with the total REAP-S score. Although the REAP-S's original purpose was to assess dietary quality within a primary care population, it shows promise for application within a bariatric surgery-seeking population.

Very Low-Calorie Ketogenic Diet (VLCKD) as Pre-Operative First-Line Dietary Therapy in Patients with Obesity Who Are Candidates for Bariatric Surgery

Bariatric surgery is currently the most effective method for achieving long-term weight loss and reducing the risk of comorbidities and mortality in individuals with severe obesity. The pre-operative diet is an important factor in determining patients' suitability for surgery, as well as their post-operative outcomes and success in achieving weight loss. Therefore, the nutritional management of bariatric patients requires specialized expertise. Very low-calorie diets and intragastric balloon placement have already been studied and shown to be effective in promoting pre-operative weight loss. In addition, the very low-calorie ketogenic diet has a well-established role in the treatment of obesity and type 2 diabetes mellitus, but its potential role as a pre-operative dietary treatment prior to bariatric surgery has received less attention. Thus, this article will provide a brief overview of the current evidence on the very low-calorie ketogenic diet as a pre-operative dietary treatment in patients with obesity who are candidates for bariatric surgery.

The incidence of cardiac arrhythmias during exercise stress testing: a focus on patients with severe obesity undergoing sleeve gastrectomy

INTRODUCTION

Obesity is associated with a higher risk of cardiac arrhythmias. Sleeve gastrectomy (SG) is a common bariatric surgery with beneficial effects on weight loss and comorbidities. The study aimed to investigate the prevalence of arrhythmias during maximal exercise testing in patients with moderate-severe obesity and to evaluate the impact of SG on these arrhythmic events.

METHODS

All patients with moderate or severe obesity who were considered suitable candidates for SG between June 2015 and September 2020 were recruited. Each patient underwent three incremental, maximal, ECG-monitored cardiopulmonary exercise test 1 month before and 6 and 12 months after SG; the frequency and complexity of ventricular premature beats (VPBs) and atrial premature beats (APBs) have been evaluated during rest, exercise and recovery phases.

RESULTS

Fifty patients with severe obesity (BMI 46.39 ± 7.89 kg/m²) were included in the study. After SG, patients presented a decreased BMI (34.15 ± 6.25 kg/m² at 6 months post-SG and 31.87 ± 5.99 kg/m² at 12 months post-SG). At 6 months post-SG, an increase in VPBs, mainly during the recovery phase, was observed. At 12 months post-SG, a reduction in VPBs compared with the 6 months evaluation was showed.

CONCLUSION

Although in the early post-surgical phase the risk of exercise-induced arrhythmias may be higher, SG does not seem to increase the occurrence of arrhythmias in the long-term. No life-threating arrhythmias were found during post-SG evaluations.

[State of the art on the pathophysiology, diagnosis and treatment of non-alcoholic steatohepatitis (NASH)]

NAFLD or non-alcoholic fatty liver disease is one of the complications of obesity and diabetes, the prevalence of which is increasing. The causes of the pathology and its development towards its severe form, NASH or non-alcoholic steatohepatitis, are multiple and still poorly understood. Many different pharmacological classes are being tested in clinical trials to treat NASH, but no pharmaceutical treatment is currently on the market. Moreover, the diagnosis of certainty is only possible by liver biopsy and histological analysis, an invasive procedure with high risk for the patient. It is therefore necessary to better understand the natural history of the disease in order to identify therapeutic targets, but also to identify markers for the diagnosis and monitoring of the disease using a blood sample, which will allow an improvement in patient management.

SICOB-endorsed national Delphi consensus on obesity treatment optimization: focus on diagnosis, pre-operative management, and weight regain/insufficient weight loss approach

PURPOSE

Overweight and obesity affects 60% of adults causing more than 1.2 million deaths across world every year. Fight against involved different specialist figures and multiple are the approved weapons. Aim of the present survey endorsed by the Italian Society of Bariatric Surgery (SICOB) is to reach a national consensus on obesity treatment optimization through a Delphi process.

METHODS

Eleven key opinion leaders (KOLs) identified 22 statements with a major need of clarification and debate. The explored pathways were: (1) Management of patient candidate to bariatric/metabolic surgery (BMS); (2) Management of patient not eligible for BMS; (3) Management of patient with short-term (2 years) weight regain (WR) or insufficient weight loss (IWL); (4) Management of the patient with medium-term (5 years) WR; and (5) Association between drugs and BMS as WR prevention. The questionnaire was distributed to 65 national experts via an online platform with anonymized results.

RESULTS

54 out of 65 invited panelists (83%) respond. Positive consensus was reached for 18/22 statements (82%); while, negative consensus (s20.4; s21.5) and no consensus (s11.5, s17) were reached for 2 statements, respectively (9%).

CONCLUSION

The Delphi results underline the importance of first-line interdisciplinary management, with large pre-treatment examination, and establish a common opinion on how to properly manage post-operative IWL/WR.

LEVEL OF EVIDENCE V

Report of expert committees.

Clinical Evidence of Low-Carbohydrate Diets against Obesity and Diabetes Mellitus

The popularity of low-carbohydrate diets (LCDs) in the last few decades has motivated several research studies on their role in a variety of metabolic and non-morbid conditions. The available data of the results of these studies are put under the research perspective of the present literature review of clinical studies in search of the effects of LCDs on Obesity and Diabetes Mellitus. The electronic literature search was performed in the databases PubMed, Cochrane, and Embase. The literature search found seven studies that met the review's inclusion and exclusion criteria out of a total of 2637 studies. The included studies involved randomized controlled trials of at least 12 weeks' duration, in subjects with BMI ≥ 25 kg/m², with dietary interventions. The results of the study on the effects of LCDs on obesity showed their effectiveness in reducing Body Mass Index and total body fat mass. In addition, LCDs appear to cause drops in blood pressure, low-density lipoprotein (LDL), and triglycerides, and seem to improve high-density lipoprotein (HDL) values. Regarding the effectiveness of LCDs in Diabetes Mellitus, their effect on reducing insulin resistance and fasting blood glucose and HbA1c values are supported. In conclusion, the results suggest the critical role of LCDs to improve the health of people affected by obesity or diabetes.

Clinical pathways in the management of the obese: Pre- and postoperative aspects

INTRODUCTION

Bariatric surgery (BS) leads to substantial weight loss accompanied by reversal of several obesity-related co-morbidities and reduced mortality. However, surgery is associated with risks and its nearly irreversible characteristic requires a clearly established pre- and postoperative clinical pathway. In France, this pathway relies on recommendations made by the High Authority of Health (Haute Autorité de santé (HAS)) in 2009; an update is awaited in 2023.

PREOPERATIVE ASPECTS

BS should be proposed only after failure of well-conducted medical treatment and is intended for patients whose body mass index (BMI) is ≥40kg/m² or for those with BMI ≥35kg/m² who also have co-morbidities amenable to improvement, and in whom there are no contra-indications, particularly, those related to general anesthesia or psychological factors. The success and safety of surgical management requires preparation of the patient with regard to dietetic and nutritional counseling, and physical activity. The possibility of complications must be recognized and communicated, including, in view of the large variability of outcomes between individuals, the risk of failure and regain of weight.

POSTOPERATIVE ASPECTS

Prior to the operation, patients should be informed of and accept the program of postoperative clinical and laboratory follow-up, as well as the need for lifelong supplementation in micronutrients and the financial implications including what patients may have to pay out of their own pocket.

CONCLUSION

Surgical management of obesity cannot replace the multidisciplinary medical management of severe obesity. The results obtained by BS are sustainable only if the patient adheres to the proposed modalities. New drugs such a GLP-1 analogues have opened encouraging perspectives as possible alternatives to BS in certain indications.

Severity of post-Roux-en-Y gastric bypass dumping syndrome and weight loss outcomes: is there any correlation?

PURPOSE

The present research was conducted to evaluate the effect of the severity of dumping syndrome (DS) on weight loss outcomes after Roux-en-Y gastric bypass (RYGB) in patients with class III obesity.

METHODS

The present retrospective cohort study used the dumping symptom rating scale (DSRS) to evaluate the severity of DS and its correlation with weight loss outcomes in 207 patients 1 year after their RYGB. The patients were assigned to group A with mild-to-moderate DS or group B with severe DS.

RESULTS

The mean age of the patients was 42.18 ± 10.46 years and their mean preoperative BMI 42.74 ± 5.59 kg/m2. The total weight loss percentage (%TWL) in group B was insignificantly higher than that in group A, but besides that was not significantly different in the two groups.

CONCLUSION

The present findings suggested insignificant relationships between the presence and severity of DS after RYGB and adequate postoperative weight loss.

Diet Management of Patients with Chronic Kidney Disease in Bariatric Surgery

Morbid obesity is considered a civilization disease of the 21st century. Not only does obesity increase mortality, but it is also the most important cause of the shortening life expectancy in the modern world. Obesity is associated with many metabolic abnormalities: dyslipidemia, hyperglycemia, cardiovascular diseases, and others. An increasing number of patients diagnosed with chronic kidney disease (CKD) are obese. Numerous additional disorders associated with impaired kidney function make it difficult to conduct slimming therapy and may also be associated with a greater number of complications than in people with normal kidney function. Currently available treatments for obesity include lifestyle modification, pharmacotherapy, and bariatric surgery (BS). There are no precise recommendations on how to reduce excess body weight in patients with CKD treated conservatively, undergoing chronic dialysis, or after kidney transplantation. The aim of this study was to analyze studies on the bariatric treatment of obesity in this group of people, as well as to compare the recommendations typical for bariatrics and CKD.

Prehabilitation of overweight and obese patients with dysglycemia awaiting bariatric surgery: Predicting the success of obesity treatment

Bariatric surgery offers the best health results in overweight and obese patients but is not a risk and/or complication-free treatment. In cases with additional hyperglycemia, the burden of surgery can be even higher and alter both short-term and long-term outcomes. Although bariatric surgery offers glycemic improvements and in the case of early onset diabetes disease remission, weight loss results are lower than for obese patients without diabetes. Different multimodal programs, usually including interventions related to patients’ performance, nutritional and psychological status as well as currently available pharmacotherapy before the surgery itself might considerably improve the immediate and late postoperative course. However, there are still no clear guidelines addressing the prehabilitation of obese patients with dysglycemia undergoing bariatric surgery and therefore no unique protocols to improve patients’ health. In this minireview, we summarize the current knowledge on prehabilitation before bariatric surgery procedures in patients with obesity and dysglycemia.

Ketogenic Diet for Preoperative Weight Reduction in Bariatric Surgery: A Narrative Review

Bariatric surgery (BS) is the most effective treatment in reducing weight and the burden of comorbidities in patients with severe obesity. Despite the overall low mortality rate, intra- and post-operative complications remains quite common. Weight loss before BS reduces surgical risk, but studies are inconclusive regarding which is the best approach to apply. In this review, we summarize the current evidence on the effect of a ketogenic diet (KD) before BS. All studies agree that KD leads to considerable weight loss and important improvements in terms of surgical risk, but populations, interventions and outcomes are very heterogeneous. KD appears to be a safe and effective approach to induce weight loss before BS. However, randomized controlled trials with better-defined dietary protocols and homogeneous outcomes are necessary in order to draw firm conclusions.

Do Lifestyle Interventions before Gastric Bypass Prevent Weight Regain after Surgery? A Five-Year Longitudinal Study

It is unclear whether weight loss (WL) achieved by means of lifestyle interventions (LSIs) before bariatric surgery (BS) can improve long-term WL outcomes after surgery. We aimed to assess the impact of a structured LSI on WL% after gastric bypass (GBP). Two groups of patients were selected from a large cohort of participants with obesity who underwent GBP surgery at Santa Maria Nuova Hospital (Reggio Emilia, Italy). The groups were categorized as those who have or have not received LSI prior to GBP. The LSI group included 91 participants (cases) compared to 123 participants (controls) in the non-LSI group. WL% was measured at follow-up times of 1, 3, 6, 12, 24, 36, 48, and 60 months. The LSI group achieved a clinically significant WL% (−7.5%) before BS, and at the time of surgery, the two groups had similar body weights and demographic statuses. At all points, until the 24-month follow-up, the two groups displayed similar WLs%. With regard to the longer follow-ups, the LSI group maintained weight loss until the last timepoint (60 months), whereas the non-LSI group experienced weight regain at 36, 48, and 60 months. In a real-world context, a structured behavioral LSI prior to GBP seems to prevent longer-term weight regain.

Effectiveness and Tolerability of a Two-Week Hypocaloric Protein-Rich Diet Prior to Obesity Surgery with Two Different Diet Interventions: a Prospective Randomized Trial

Purpose

Preoperative very low-calorie diets (VLCDs) have been shown to reduce liver volume and improve bariatric surgery safety. Here, we compare two VLCD that differ in macronutrient composition.

Material/Methods

Ninety patients awaiting obesity surgery were included in a prospective, open-label, randomized mono-centre trial comparing the effects of 2-week preoperative VLCDs: BCM Diät™ (diet 1) versus Optifast™ (diet 2).

Results

Data from 33 patients in diet 1 and 36 in diet 2 could be analysed. There was no significant difference between the two diet intervention arms on outcome parameters. Overall, both VLCD strategies led to a mean weight reduction of 5.24 [4.72–5.76] kg (p < 0.001), mean excess weight loss was 8.2 [7.4–9.1] % (p < 0.001). BMI reduction was 1.81 [1.63–1.99] kg/m² (p < 0.001). Over all patients, the liver volume was reduced by 397 [329–466] ml (p < 0.001), which corresponds to 14.6 [12.4; 16.8] %. Liver fat content was significantly reduced by 18.35 [8.98–27.71] %. Reduction of body weight correlates with liver volume loss.

In addition, hip/waist circumferences, body fat and fat-free mass decreased significantly. We found an increase of ALAT/ASAT and a significant decrease of triglycerides, LDL-cholesterol and HbA1c. Parameters of inflammatory were significantly reduced upon VLCD.

Conclusion

Independently of the macronutrient composition, VLCD leads to a significant decrease of body weight, reduction of liver volume and improved parameters of inflammation, glucose and lipid metabolism. Preoperative diets are widely used in conditioning; however, VLCD should be considered as option for patients with obesity undergoing other abdominal surgeries.

Graphical abstract

New Insights of OLFM2 and OLFM4 in Gut-Liver Axis and Their Potential Involvement in Nonalcoholic Fatty Liver Disease

Olfactomedins (OLFMs) are a family of glycoproteins that play a relevant role in embryonic development and in some pathological processes. Although OLFM2 is involved in the regulation of the energy metabolism and OLFM4 is an important player in inflammation, innate immunity and cancer, the role of OLFMs in NAFLD-related intestinal dysbiosis remains unknown. In this study, we analysed the hepatic mRNA expression of OLFM2 and the jejunal expression of OLFM4 in a well-established cohort of women with morbid obesity (MO), classified according to their hepatic histology into normal liver (n = 27), simple steatosis (n = 26) and nonalcoholic steatohepatitis (NASH, n = 16). Our results showed that OLFM2 hepatic mRNA was higher in NASH, in advanced degrees of steatosis and in the presence of lobular inflammation. Additionally, we obtained positive correlations between hepatic OLFM2 and glucose, cholesterol, trimethylamine N-oxide and deoxycholic acid levels and hepatic fatty acid synthase, and negative associations with weight and jejunal Toll-like receptors (TLR4) and TLR5 expression. Regarding jejunal OLFM4, we observed positive correlations with circulating interleukin (IL)-8, IL-10, IL-17 and jejunal TLR9. In conclusion, OLFM2 in the liver seems to play a relevant role in NAFLD progression, while OLFM4 in the jejunum could be involved in gut dysbiosis-related inflammatory events.

Association of Postoperative Dieting, Exercise, Dietitian, and Surgeon Follow up With Bariatric Surgery Outcomes

Although postoperative diet modification, exercise, and regular dietitian and surgeon follow-up are often recommended after bariatric surgery (BS), their impact on weight loss is unclear. A Retrospective chart review was conducted for patients who received sleeve gastrectomy or Roux-en-Y gastric bypass (RYGB) between August 2000 and November 2017 with telephone follow-up. Multivariable logistic regression models were used for analyses. There were 514 patients included in our study. Most were female (76.3%), mean age was 46.9 years (Standard Deviation [SD] = 11.8), and mean weight loss was 11.6 (SD = 6.5) BMI points at a mean follow-up of 7 years (SD = 4.3). Current surgeon follow-up OR = 2.08 (P < .01) was positively associated with postoperative weight loss, while current dietitian follow-up=OR .41 (P < .01) was negatively associated. Current weight loss supplement use OR = .45 (P = .03) was associated with reduced willingness to undergo surgery again. Increasing preoperative BMI OR = 1.06 (P = .04) and increasing age OR = 1.04 (P = .02) were associated with improved quality of life (QoL) due to BS. Lack of surgeon follow-up and regular dietician consultation was associated with suboptimal weight loss after BS. Older age was positively associated with improved QoL, while current weight loss supplement use was associated with lower likelihood of undergoing surgery again, both independent of weight loss.

The relationship between preoperative weight loss and intra and post-bariatric surgery complications: an appraisal of the current preoperative nutritional strategies

Preoperative weight loss before a bariatric surgery reduces long-term complications, but there is no solid evidence for short-term or perioperative complications. This review highlights recent evidence on dietary protocols and the possible correlation between weight loss and surgical complications. Updated evidence was searched in PubMedDirect with the terms "preoperative very low-calorie diet or very-low-calorie ketogenic diet or low-fat diet or intermittent fasting or Mediterranean diet and bariatric surgery or bariatric surgery complications." The main characteristics of each diet, achievements related to weight loss, liver reduction, peri and postoperative outcomes, surgical complications, tolerance, and adherence to the diet are presented from the selected studies. There are few reports about the Mediterranean diet as a strategy to reach these goals. The VLCKD has been associated with better body weight reduction and lesser postoperative complications risk. However, the results in animal models are still controversial. When comparing VLCD with an LCD, there is no apparent superiority between one against the other one. However, LCD has shown better tolerance and adherence than VLCD. There is still a need for more controlled studies to define the best preoperative dietary treatment for weight loss before bariatric surgery since there are controversial positions regarding this issue.

Advice of General Practitioner, of Surgeon, of Endocrinologist, and Self-determination: the Italian Road to Bariatric Surgery

PURPOSE

Bariatric surgery (BS) is considered the most efficient treatment for severe obesity. International guidelines recommend multidisciplinary approach to BS (general practitioners, endocrinologists, surgeons, psychologists, or psychiatrists), and access to BS should be the final part of a protocol of treatment of obesity. However, there are indications that general practitioners (GPs) are not fully aware of the possible benefits of BS, that specialty physicians are reluctant to refer their patients to surgeons, and that patients with obesity choose self-management of their own obesity, including internet-based choices. There are no data on the pathways chosen by physicians and patients to undergo BS in the real world in Italy.

METHODS

An exploratory exam was performed for 6 months in three pilot regions (Lombardy, Lazio, Campania) in twenty-three tertiary centers for the treatment of morbid obesity, to describe the real pathways to BS in Italy.

RESULTS

Charts of 2686 patients (788 men and 1895 women, 75.5% in the age range 30-59 years) were evaluated by physicians and surgeons of the participating centers. A chronic condition of obesity was evident for the majority of patients, as indicated by duration of obesity, by presence of several associated medical problems, and by frequency of previous dietary attempts to weight loss. The vast majority (75.8%) patients were self-presenting or referred by bariatric surgeons, 24.2% patients referred by GPs and other specialists. Self-presenting patients were younger, more educated, more professional, and more mobile than patients referred by other physicians. Patients above the age of 40 years or with a duration of obesity greater than 10 years had a higher prevalence of all associated medical problems.

CONCLUSIONS

The majority of patients referred to a tertiary center for the treatment of morbid obesity have a valid indication for BS. Most patients self-refer to the centers, with a minority referred by a GP or by specialists. Self-presenting patients are younger, more educated, more professional, and more mobile than patients referred by other physicians. Older patients and with a longer duration of obesity are probably representative of the conservative approach to BS, often regarded as the last resort in an endless story.

Impact of SARS-CoV-2 Lockdown on the Preoperative Care Program of Patients Scheduled for Bariatric Surgery

Objectives: To evaluate the effect of the SARS-CoV-2 lockdown on dietary habits, body weight, left hepatic lobe volume, use of micronutrient supplements, micronutrient status, frequency of physical activity, and evolution of comorbidities in patients undergoing preoperative care for BS. Materials and Methods: We prospectively evaluated the dietary habits (including use of micronutrient supplements and frequency of physical activity) of 36 patients who were candidates for BS from March to May 2020; 7-day food dietary records, body weight, left hepatic lobe volume by ultrasound, micronutrient status, and evolution of comorbidities were assessed. Results: All patients completed the study. Of the participants, 44.4% (16/36), 47.2% (17/36), and 27.8% (10/36) followed the preoperative indications for vegetables, fruits, and legumes, respectively, whereas over 50% did not. Furthermore, 30.6% (11/36) and 55.6% (20/36) of participants followed the prescribed recommendations for carbohydrates/sweets products and alcohol, respectively. A total of 61.1% (22/36) of participants experienced new foods and new culinary preparations. In addition, at the time of the study, we found that only 11.1% (4/36) were engaged in prescribed physical activity and only 36.1% (13/36) were taking prescribed micronutrient supplements. Compared to the initial weight, we observed an increased body weight and body mass index (+4.9%, p = 0.115; +1.89%, p = 0.0692, respectively), and no improvement in left hepatic lobe volume, micronutrient status, or comorbidities was recorded for any patient in the anamnesis. Conclusions: Lockdown determined by the SARS-CoV-2 pandemic has negatively affected the preoperative program of BS candidates, resulting in a postponement to the resumption of bariatric surgical activity.

A Hub and Spoke Learning Program in Bariatric Surgery in a Small Region of Italy

Background

Metabolic and bariatric surgery (BS) are considered life-changing and life-saving treatments for obese patients. The Italian Society of Obesity Surgery (SICOB) requires at least 25 operations per year to achieve the standard of care in the field. Despite the increasing need to treat obese patients, some small southern regions of Italy, such as Molise, do not have enough experience in bariatric procedures to be allowed to perform them. Therefore, our aim was to run a Hub and Spoke Program with a referral center in BS to treat obese patients and provide a proper learning curve in BS in Molise.

Methods

In 2020, the “A. Cardarelli Hospital” in Campobasso, Molise, started a formal “Learning Model of Hub and Spoke Collaboration” with the Hub center “Ospedale Del Mare”, Naples. A multidisciplinary approach was achieved. Patients were supervised and operated under the supervision and tutoring of the referral center. We retrospectively reviewed our prospectively collected database from February 2020 to August 2021 in order to analyze the safety and effectiveness of our learning program.

Results

In total, 13 (3 men and 10 women) patients underwent BS with the mean age of 47.08 years and a presurgery BMI of 41.79. Seven (53.84%) patients were the American Society of Anesthesiologist (ASA) II, and 6 (46.16%) patients were ASA III. Twelve (92.31%) procedures were laparoscopic sleeve gastrectomies, 1 (7.69%) patient underwent endoscopic BioEnterics Intragastric Balloon (BIB) placement. One (8.33%) sleeve gastrectomy was associated to gastric band removal. Mean surgical time was 110.14 ± 23.54 min. The mean length of stay was 4.07 ± 2.40 days. No Clavien-Dindo ≥ III and mortality were reported. The follow-up program showed a mean decrease of 11.82 in terms of body mass index (BMI) value. The last 5 procedures were performed by the whole equips from “A. Cardarelli” under external tutoring without any impact on complication rate.

Conclusion

The setup of a proper Hub and Spoke Program may allow to perform BS to provide the standard of care. This approach may reduce health costs and related patient migration.

Nutritional status prior to bariatric surgery for severe obesity: a review

Obesity pandemic represents a threat to public health of paramount importance. Bariatric surgery represents the most effective and long-lasting treatment for severe obesity so far. The nutritional status of obese patients seeking bariatric surgery is impaired prior to surgery because of prevalent nutritional deficiencies. In addition, excess micronutrient levels may also occur, although this finding is not common. The onset of nutritional anomalies encountered in bariatric surgery candidates might stem from the following: obesity itself, poor quality food choices, preoperative weight loss or insufficient/excessive preoperative oral supplementation with vitamins and minerals. Nutritional management should begin preoperatively and should include a comprehensive assessment in order to identify those patients with clinical or subclinical deficiencies and hypervitaminoses. This paper provides background information on the nutritional status of bariatric surgery candidates, as well as on the prevalence and clinical significance of the most common micronutrient deficiencies and excess levels reported preoperatively among these patients.

Factors Associated with Nutritional Deficiency Biomarkers in Candidates for Bariatric Surgery: A Cross-Sectional Study in a Peruvian High-Resolution Clinic

Previous studies have described multiple nutritional deficiencies after bariatric surgery (BS). However, few studies have evaluated these deficiencies prior to BS, specifically in Latin America. This study aimed to determine the factors associated with nutritional deficiency biomarkers in candidates for BS in Peru. We included adults of both sexes, aged 18 to 59 years, admitted to a Peruvian clinic with a body mass index (BMI) ≥30 kg/m2; they were candidates for BS from 2017 to 2020. We considered the serum levels of hemoglobin and albumin (in tertiles) as the nutritional deficiency biomarkers. In order to assess the associated factors, we calculated crude (cPR) and adjusted prevalence ratios (aPR) with their respective 95% confidence intervals (95%CI). We analyzed 255 patients: 63.1% were males, with a mean age of 37.1 ± 10.3 years and mean hemoglobin and albumin values of 14.0 ± 1.5 g/dL and 4.6 ± 0.4 g/dL, respectively. We found that males (aPR = 1.86; 95%CI: 1.26–2.73; p = 0.002), participants between 30 and 49 (aPR = 2.02; 95%CI: 1.24–3.28; p = 0.004) or 50 years or more (aPR = 2.42; 95%CI: 1.35–4.35; p = 0.003), participants with a BMI ≥40 kg/m2 (aPR = 1.68; 95%CI: 1.09–2.60; p = 0.018), participants with impaired high-density lipoprotein levels (aPR = 1.43; 95%CI: 1.01–2.05; p = 0.049) and individuals in the high tertile of C-reactive protein (aPR = 6.94; 95%CI: 3.37–14.32; p < 0.003) had a higher probability of being in the lower tertile of albumin. In addition, we found that the male sex (aPR = 6.94; 95%CI: 3.37–14.32; p < 0.001) and elevated cholesterol levels (aPR = 0.71; 95%CI: 0.52–0.97; p = 0.034) were associated with the lowest hemoglobin tertile. In our setting, nutritional deficiency biomarkers were associated with sociodemographic, anthropometric and laboratory markers. The pre-bariatric surgery correction of nutritional deficiencies is essential, and can prevent major complications after surgery.

Low-Calorie Ketogenic Diet with Continuous Positive Airway Pressure to Alleviate Severe Obstructive Sleep Apnea Syndrome in Patients with Obesity Scheduled for Bariatric/Metabolic Surgery: a Pilot, Prospective, Randomized Multicenter Comparative Study

Obstructive sleep apnea syndrome (OSAS) and obesity are frequently associated with hypertension (HTN), dyslipidemia (DLP), and insulin resistance (IR). In patients with obesity and OSAS scheduled for bariatric surgery (BS), guidelines recommend at least 4 weeks of preoperative continuous positive airway pressure (CPAP). Low-calorie ketogenic diets (LCKDs) promote pre-BS weight loss (WL) and improve HTN, DLP, and IR. However, it is unclear whether pre-BS LCKD with CPAP improves OSAS more than CPAP alone. We assessed the clinical advantage of pre-BS CPAP and LCKD in patients with obesity and OSAS. Seventy patients with obesity and OSAS were randomly assigned to CPAP or CPAP+LCKD groups for 4 weeks. The effect of each intervention on the apnea–hypopnea index (AHI) was the primary endpoint. WL, C-reactive protein (CRP) levels, HTN, DLP, and IR were secondary endpoints. AHI scores improved significantly in both groups (CPAP, p=0.0231; CPAP+LCKD, p=0.0272). However, combining CPAP and LCKD registered no advantage on the AHI score (p=0.863). Furthermore, body weight, CRP levels, and systolic/diastolic blood pressure were significantly reduced in the CPAP+LCKD group after 4 weeks (p=0.0052, p=0.0161, p=0.0008, and p=0.0007 vs baseline, respectively), and CPAP+LCKD had a greater impact on CRP levels than CPAP alone (p=0.0329). The CPAP+LCKD group also registered a significant reduction in serum cholesterol, LDL, and triglyceride levels (p=0.0183, p=0.0198, and p<0.001, respectively). Combined with CPAP, LCKD-induced WL seems to not have a significant incremental effect on AHI, HTN, DLP, and IR but lower CRP levels demonstrated a positive impact on chronic inflammatory status.

Evaluation of Stomatognathic System Parameters After Bariatric Surgery

PURPOSE

The present study aimed to evaluate electromyographic activity, bite strength, and masticatory muscle thickness in women without obesity and with severe obesity elected for bariatric surgery. Also, patients with obesity underwent bariatric surgery and were re-evaluated 3 and 6 months after surgery to analyze the influence of bariatric surgery outcomes on the stomatognathic system, a functional anatomical system comprising teeth, jaw, and associated soft tissues.

MATERIAL AND METHODS

Thirty-seven women were enrolled in the study. Twenty-one women with class II and III obesity according to the body mass index (BMI) and eligible for bariatric surgery composed the obesity pre-surgery group (Ob). Sixteen women with a normal weight according to BMI composed the non-obesity group (NOb). Afterward, the patients from the Ob group were followed up for 3 and 6 months after undergoing Roux-en-Y gastric bypass. Anthropometry, body composition, and parameters of the stomatognathic system were evaluated.

RESULTS

The stomatognathic system of the Ob group had less muscle activity and bite strength, but the thickness of masseter and temporal muscles was larger than the NOb group. We also observed a significant change in the muscular activity and bit strength of the stomatognathic system post-bariatric surgery.

CONCLUSION

Evaluating the stomatognathic system indicated that women with clinically severe obesity have less masticatory efficiency than non-obese. Also, we found a positive influence of bariatric surgery in masticatory activity after 3 and 6 months. Thus, monitoring the parameters of the stomatognathic system could be important in the indication and outcomes of bariatric surgery.

Nutritional Management in Bariatric Surgery Patients

The obesity epidemic, mainly due to lifestyle changes in recent decades, leads to serious comorbidities that reduce life expectancy. This situation is affecting the health policies of many nations around the world. Traditional measures such as diet, physical activity, and drugs are often not enough to achieve weight loss goals and to maintain the results over time. Bariatric surgery (BS) includes various techniques, which favor rapid and sustained weight loss. BS is a useful and, in most cases, the best treatment in severe and complicated obesity. In addition, it has a greater benefit/risk ratio than non-surgical traditional therapies. BS can allow the obese patient to lose weight quickly compared with traditional lifestyle changes, and with a greater probability of maintaining the results. Moreover, BS promotes improvements in metabolic parameters, even diabetes remission, and in the quality of life. These changes can lead to an increase of life expectancy by over 6 years on average. The nutrition of people before and after BS must be the subject of indications from a trained staff, and patients must be followed in the subsequent years to reduce the risk of malnutrition and the associated problems. In particular, it is still debated whether it is necessary to lose weight prior to surgery, a procedure that can facilitate the surgeon's work reducing the surgical risk, but at the same time, lengthens preparation times increasing the risks associated with concomitant pathologies. Furthermore, preventing nutritional deficiencies prior to the intervention can improve the results and reduce short- and long-term mortality.

Religious Fasting of Muslim Patients After Metabolic and Bariatric Surgery: a Modified Delphi Consensus

BACKGROUND

Fasting during Ramadan is one of the five pillars of the Muslim faith. Despite the positive effects of fasting on health, there are no guidelines or clear recommendations regarding fasting after metabolic/bariatric surgery (MBS). The current study reports the result of a modified Delphi consensus among expert metabolic/bariatric surgeons with experience in managing patients who fast after MBS.

METHODS

A committee of 61 well-known metabolic and bariatric surgeons from 24 countries was created to participate in the Delphi consensus. The committee voted on 45 statements regarding recommendations and controversies around fasting after MBS. An agreement/disagreement ≥ of 70.0% was regarded as consensus.

RESULTS

The experts reached a consensus on 40 out of 45 statements after two rounds of voting. One hundred percent of the experts believed that fasting needs special nutritional support in patients who underwent MBS. The decision regarding fasting must be coordinated among the surgeon, the nutritionist and the patient. At any time after MBS, 96.7% advised stopping fasting in the presence of persistent symptoms of intolerance. Seventy percent of the experts recommended delaying fasting after MBS for 6 to 12 months after combined and malabsorptive procedures according to the patient's situation and surgeon's experience, and 90.1% felt that proton pump inhibitors should be continued in patients who start fasting less than 6 months after MBS. There was consensus that fasting may help in weight loss, improvement/remission of non-alcoholic fatty liver disease, dyslipidemia, hypertension and type 2 diabetes mellitus among 88.5%, 90.2%, 88.5%, 85.2% and 85.2% of experts, respectively.

CONCLUSION

Experts voted and reached a consensus on 40 statements covering various aspects of fasting after MBS.

Unklare Lymphadenopathie mit Panzytopenie bei einer Patientin mit rezidivierenden Hypoglykämien

Eine Patientin wurde aufgrund rezidivierender postprandialer Hypoglykämien nach Roux-en-Y-Magenbypass mit Diazoxid behandelt, nachdem eine Ernährungsumstellung keine Symptomlinderung erzielt hatte. Nach Eindosierung von Diazoxid mit guter Akutverträglichkeit wurde die Patientin entlassen. Eine Woche nach Therapieeinleitung kam es zu einer Lymphadenopathie und Panzytopenie. Es fanden sich keine Hinweise auf das Vorliegen eines Infekts. Nach Absetzen von Diazoxid sistierten die Beschwerden. Unser Fallbericht weist auf seltene unerwünschte hämatologische Arzneimittelwirkungen unter Diazoxid hin.

Effects of Low-Carbohydrate versus Mediterranean Diets on Weight Loss, Glucose Metabolism, Insulin Kinetics and β-Cell Function in Morbidly Obese Individuals

Low-calorie Mediterranean-style or low-carbohydrate dietary regimens are widely used nutritional strategies against obesity and associated metabolic diseases, including type 2 diabetes. The aim of this study was to compare the effectiveness of a balanced Mediterranean diet with a low-carbohydrate diet on weight loss and glucose homeostasis in morbidly obese individuals at high risk to develop diabetes. Insulin secretion, insulin clearance, and different β-cell function components were estimated by modeling plasma glucose, insulin and C-peptide profiles during 75-g oral glucose tolerance tests (OGTTs) performed at baseline and after 4 weeks of each dietary intervention. The average weight loss was 5%, being 58% greater in the low-carbohydrate-group than Mediterranean-group. Fasting plasma glucose and glucose tolerance were not affected by the diets. The two dietary regimens proved similarly effective in improving insulin resistance and fasting hyperinsulinemia, while enhancing endogenous insulin clearance and β-cell glucose sensitivity. In summary, we demonstrated that a low-carbohydrate diet is a successful short-term approach for weight loss in morbidly obese patients and a feasible alternative to the Mediterranean diet for its glucometabolic benefits, including improvements in insulin resistance, insulin clearance and β-cell function. Further studies are needed to compare the long-term efficacy and safety of the two diets.

Mono and dual agonists of the amylin, calcitonin, and CGRP receptors and their potential in metabolic diseases

BACKGROUND

Therapies for metabolic diseases are numerous, yet improving insulin sensitivity beyond that induced by weight loss remains challenging. Therefore, search continues for novel treatment candidates that can stimulate insulin sensitivity and increase weight loss efficacy in combination with current treatment options. Calcitonin gene-related peptide (CGRP) and amylin belong to the same peptide family and have been explored as treatments for metabolic diseases. However, their full potential remains controversial.

SCOPE OF REVIEW

In this article, we introduce this rather complex peptide family and its corresponding receptors. We discuss the physiology of the peptides with a focus on metabolism and insulin sensitivity. We also thoroughly review the pharmacological potential of amylin, calcitonin, CGRP, and peptide derivatives as treatments for metabolic diseases, emphasizing their ability to increase insulin sensitivity based on preclinical and clinical studies.

MAJOR CONCLUSIONS

Amylin receptor agonists and dual amylin and calcitonin receptor agonists are relevant treatment candidates, especially because they increase insulin sensitivity while also assisting weight loss, and their unique mode of action complements incretin-based therapies. However, CGRP and its derivatives seem to have only modest if any metabolic effects and are no longer of interest as therapies for metabolic diseases.