Nutrient Deficiency 10 Years Following Roux-en-Y Gastric Bypass: Who's Responsible?

Phase Angle, Inflammation, and Sarcopenia in Late Postoperative Roux-En-Y Gastric Bypass

Sarcopenic obesity is characterized by a disproportion between the amount of muscle to fat. Contrary to most studies evaluating parameters related to sarcopenic obesity in the elderly, this study aims to evaluate the phase angle (PhA) and sarcopenia in young individuals pre- and post-Roux-en-Y gastric bypass. A total of 69 volunteers (46 women and 23 men; 38.5 ± 8.1 years) participated in this study. Body composition and PhA were assessed using BIA. Sarcopenia was assessed using a handgrip strength test (HGS) and gait speed (GS), and appendicular lean mass (ALM) was assessed using Dual Energy X-ray Absorptiometry (DXA). The PhA was significantly lower (p < 0.0007) and the resistance (R) significantly higher (p = 0.0026) in the postoperative group. HGS was negatively correlated with R (r = -0.63669; p < 0.0001), hs-CRP (r = -0.45436; p = 0.0197), and leptin (r = -0.46505; p = 0.0043). GS was negatively correlated with R (r = -0.36220; p = 0.0254), and ALM was negatively correlated with reactance (r = -0.49485; p = 0.0034) and R (r = -0.65797; p ≤ 0.0001). PhA and other components of BIA provide a good correlation with sarcopenia, especially regarding the reduction in muscle function, in an early form, in individuals in the pre- and postoperative period of gastric bypass.

Gut microbiota and vitamin status in persons with obesity: A key interplay

There are numerous factors involved in obesity progression and maintenance including systemic low-grade inflammation, adipose tissue dysfunction, or gut microbiota dysbiosis. Recently, a growing interest has arisen for vitamins' role in obesity and related disorders, both at the host and gut bacterial level. Indeed, vitamins are provided mostly by food, but some, from the B and K groups in particular, can be synthesized by the gut bacterial ecosystem and absorbed in the colon. Knowing that vitamin deficiency can alter many important cellular functions and lead to serious health issues, it is important to carefully monitor the vitamin status of patients with obesity and potentially already existing comorbidities as well as to examine the dysbiotic gut microbiota and thus potentially altered bacterial metabolism of vitamins. In this review, we examined both murine and human studies, to assess the prevalence of sub-optimal levels of several vitamins in obesity and metabolic alterations. This review also examines the relationship between vitamins and the gut microbiota in terms of vitamin production and the modulation of the gut bacterial ecosystem in conditions of vitamin shortage or supplementation. Furthermore, some strategies to improve vitamin status of patients with severe obesity are proposed within this review.

Nonadherence to Micronutrient Supplementation After Bariatric Surgery: Results from an Italian Internet-Based Survey

BACKGROUND AND AIM

Bariatric surgery (BS) is a pillar for the treatment of morbid obesity and its related comorbidities. However, it might be associated with long-term deficiencies and absorption issues. Adherence to micronutrient supplementation is a crucial aspect in the management of these patients.

AIM

The aim of the present survey was to evaluate the adherence to micronutrient supplementation in a cohort of Italian patients submitted to BS (BS patients) and to identify predictors of adherence using a self-administered, anonymous, internet-based instrument.

METHODS

Patients who underwent BS over the last decade in a single center were invited to participate to a self-administered, anonymous, internet-based survey consisting of a 23 items structured questionnaire evaluating: a. demographic information b. Bariatric procedures performed; c. Indication to BS; d. Lapse of time since last BS, e. Frequency of follow up visits post-surgery, f. Perception of well-being post BS; g. Adherence to micronutrient supplementation; h. Changes in their quality of life and self-esteem.

RESULTS

We received an automatic notification of delivery from 1100 out of 1600 BS patients and 290 (81.4% female, mean age 39.5 ± 10.1 years) completed the questionnaire. The main reported bariatric procedures were: Sleeve Gastrectomy (59%), Roux-en-Y Gastric Bypass (31%) and Adjustable Gastric Banding (7.2%). Only 33.1% of the sample acknowledged to have taken all recommended medication regularly. BS patients who underwent malabsorptive procedures and had their last follow up visit more than 5 years earlier, had a higher risk of being nonadherent to micronutrient supplementation. Conversely, BS patients in their forties seemed more likely to adhere to treatment recommendations. Losing more weight was the only independent risk factors for nonadherence to micronutrient supplementation, independently from patient's perception of wellbeing.

CONCLUSION

After BS, several clinical and psychosocial factors might predict nonadherence to micronutrient supplementation.

Micronutrient status in bariatric surgery patients receiving postoperative supplementation per guidelines: Insights from a systematic review and meta-analysis of longitudinal studies

The micronutrient status and optimal monitoring schedule after bariatric surgery have not been sufficiently assessed. This systematic review and meta-analysis investigated the longitudinal changes in micronutrient status after bariatric surgery. PubMed, EMBASE, and Cochrane Library were searched for articles that measured preoperative and postoperative serum micronutrient levels in patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Among guideline-adherent studies, the longitudinal changes in micronutrient status were investigated using weighted mean difference (WMD) using a random-effects model. Among the 82 included studies, the guideline adherence rates for micronutrient supplementation after bariatric surgery did not exceed 20%. In patients supplemented per guidelines, vitamin A significantly decreased after RYGB by -7.54 (95% confidence interval [CI], -10.16 to -4.92) μg/dl at 12-23 months, vitamin E decreased after RYGB by -2.35 (95% CI, -3.65 to -1.05) μg/dl at ≥24 months, and ferritin by -54.93 (95% CI, -77.19 to -32.67] μg/L at ≥24 months after SG, compared with baseline, with moderate level of evidence. Significant decreases in micronutrient levels at certain follow-up intervals in studies with supplementation per guidelines need to be considered to establish a post-bariatric micronutrient monitoring schedule for timely detection and management of micronutrient deficiencies.

Early postoperative follow-up reduces risk of late severe nutritional complications after Roux-En-Y gastric bypass: a population based study

BACKGROUND

Severe nutritional complications can occur following Roux-en-Y gastric bypass (RYGB). Adherence to follow-up visits can reduce the risk of many bariatric surgery complications, but whether this applies to severe nutritional complications is unknown.

OBJECTIVES

Determine the association between adherence to follow-up visits after RYGB and risk of severe nutritional complications.

SETTING

Multicenter publicly-funded Ontario Bariatric Network.

METHODS

Retrospective cohort study of Ontario adults participating in the Ontario Bariatric Registry who underwent RYGB between January 1, 2009, and December 31, 2015. The primary outcome was a severe nutritional complication (hospital admission with malnutrition or nutrient deficiency) occurring 1 year or more after RYGB. The primary exposure was adherence to postoperative follow-up visits, occurring at 3, 6, and 12 months postoperatively, and categorized as perfect (3 visits), partial (1-2 visits), or none. Cox proportional hazards modeling quantified the association between adherence to follow-up visits and the primary outcome using hazard ratios (HR).

RESULTS

In total, 9105 adults (84% female, age 44.7 ± 10.3 yr) met study criteria. Mean preoperative body mass index (BMI) was 48.6 kg/m². First year follow-up attendance was: 51.7% perfect, 31.6% partial, and 16.7% none. Median time in the study was 3.4 years. Severe nutritional complications occurred in 1.1% of patients. Compared with perfect follow-up, patients with no follow-up (HR 3.09, 95% CI 1.74-5.50) and partial follow-up (HR 1.94, 95% CI 1.25-3.03) had an increased risk of severe nutritional complications.

CONCLUSION

Adherence to follow-up visits during the first year after RYGB is independently associated with reduction in the risk of subsequent severe nutritional complications.

Long-term results of laparoscopic Roux-en-Y gastric bypass for morbid obesity: 105 patients with minimum follow-up of 15 years

BACKGROUND

Laparoscopic Roux-en-Y gastric bypass (LRYGB) is the second most frequently performed bariatric procedure worldwide; however, long-term results are not frequently reported.

OBJECTIVES

To evaluate the outcomes of LRYGB on weight loss and co-morbidities in a single center 15 years after the operation.

SETTING

Tertiary-care referral hospital.

METHODS

From February 2000 to December 2003, 105 patients (86 women; mean age 39.9 ± 17.4; mean body mass index [BMI] 47.2 ± 6.4 kg/m²; 78 with BMI < 50 kg/m² and 27 with BMI ≥ 50 kg/m²) underwent LRYGB. Retrospective analyses of a prospectively maintained database were carried out to evaluate weight loss; resolution of co-morbidities, including type 2 diabetes mellitus (T2D), hypertension (HTN), and dyslipidemia; complications; and nutritional status.

RESULTS

The follow-up rate at 15 years was 87.6%. Mean excess weight loss was 58.6 ± 27%, with 74.1% of patients achieving a total weight loss ≥ 20%. According to the Biron et al. criteria, an inadequate outcome was found in 11/21 (52.4%) of patients with an initial BMI ≥ 50 kg/m² versus 21/64 (32.8%) of patients with a preoperative BMI < 50 kg/m² (P = .001). Both groups experienced gradual weight regain (WR); specifically, 34.1% of patients regained more than 15% of their lowest postoperative weight. The rates of reoperations due to early and late surgical complications were 3.8% and 9.5%, respectively. T2D was resolved in 50% of patients, HTN in 61.1%, and dyslipidemia in 58.3%. Iron deficiency anemia (53%) was the most common postoperative nutritional finding.

CONCLUSION

LRYGB provides satisfactory weight loss and resolution of co-morbidities up to 15 years. WR was a common finding. A significant proportion of patients with a preoperative BMI ≥ 50 kg/m² did not achieve a favorable weight loss outcome. Indications to perform LRYGB in this group of patients should be definitively reconsidered.

Personalized Nutrition for Management of Micronutrient Deficiency-Literature Review in Non-bariatric Populations and Possible Utility in Bariatric Cohort

Background

Bariatric surgery can effectively treat morbid obesity; however, micronutrient deficiencies are common despite recommendations for high-dose supplements. Genetic predisposition to deficiencies underscores necessary identification of high-risk candidates. Personalized nutrition (PN) can be a tool to manage these deficiencies.

Methods

Medline, PubMed, and Google Scholar were searched. Articles involving genetic testing, micronutrient metabolism, and bariatric surgery were included.

Results

Studies show associations between genetic variants and micronutrient metabolism. Research demonstrates genetic testing to be a predictor for outcomes among obesity and bariatric surgery populations. There is limited research in bariatric surgery and micronutrient genetic variants.

Conclusion

Genotype-based PN is becoming feasible to provide an effective treatment of micronutrient deficiencies associated with bariatric surgery. The role of genomic technology in micronutrient recommendations needs further investigation.

Challenging the Surgical Axiom: Albumin Level Does Not Reliably Predict Development of Wound Complications in Patients Undergoing Body Contouring

INTRODUCTION

Hypoalbuminemia has traditionally been associated with a poor nutritional status and subsequent high incidence of postoperative wound complications in surgical patients. Recent evidence, however, suggests that traditional nutritional markers are inadequate in predicting postoperative morbidity.

OBJECTIVE

To test the hypothesis that preoperative albumin levels are not associated with adverse outcomes in patients undergoing body contouring.

METHODS

All patients undergoing body contouring from 2015 to 2017 were identified using the American College of Surgeons National Surgical Quality Improvement Program database. Demographics, comorbidities, and wound classification were extracted from the database. The independent predictors of developing wound complications were identified. Logistic regressions were used to identify the impact of albumin on outcomes.

RESULTS

During the study period, 4496 patients were identified. Wound complications developed in 202 patients (4.5%). Increasing body mass index, history of diabetes mellitus, American Society of Anesthesiologists classification, history of prior open wound, and tobacco use were independently associated with the development of postoperative complications. Albumin levels were not associated with the development of wound complications. Similarly, albumin levels were not associated with the need for a repeated operation, with readmission, or with the total hospital length of stay.

CONCLUSION

Albumin values were not associated with wound complications or need for reoperation in patients undergoing body contouring. Further research is warranted.

The effects of bariatric surgery on psychological aspects of eating behaviour and food intake in humans

Bariatric surgery has emerged as an increasingly popular weight loss intervention, with larger and more endurable weight loss compared to pharmacological and behavioural interventions. The degree of weight loss patients experience varies, between individuals, surgeries and over time. An explanation as to why differing weight loss trajectories exist post-surgery could be due to the complex interplay of individual differences in relation to eating behaviours and appetite. Thus the aim of this narrative review is to explore literature between 2008 and 2018, to assess the impact of impact of bariatric surgery on food selection and nutrient status, on eating behaviour traits and on disturbed and disordered eating behaviour, to determine their impact of weight loss success and weight loss trajectories. Immediately post-surgery, up until 1-2 years post-surgery, there is a reliance upon the surgery's alteration of the gastrointestinal tract to control food intake and subsequently lose weight. Energy intake is reduced, dietary adherence is higher, supplement intake is higher, appetite ratings are lower, there is a reduction in psychopathology, and an increase in wellbeing. After this point, patients become more susceptible to weight regain, as this is the point where passive observation of the weight reducing action of surgery, moves into more cognitive effort, on the part of the individual, to control energy intake. There are various factors which influence an individual's ability to successfully regulate their energy intake post-surgery, such as their level of Disinhibition, Restraint, Hunger, Emotional Eating, Uncontrolled Eating, psychopathology and wellbeing. The need for continued psychological and nutritional support post-surgery is necessary to reduce weight regain susceptibility.

Socioeconomically Distressed Communities Associated With Long-term Mortality After Bariatric Surgery

BACKGROUND

Surgical outcomes are affected by socioeconomic status, yet these factors are poorly accounted for in clinical databases. We sought to determine if the Distressed Communities Index (DCI), a composite ranking by zip code that quantifies socioeconomic risk, was associated with long-term survival after bariatric surgery.

METHODS

All patients undergoing Roux-en-Y gastric bypass (1985-2004) at a single institution were paired with DCI. Scores range from 0 (no distress) to 100 (severe distress) and account for unemployment, education, poverty, median income, housing vacancies, job growth, and business establishment growth. Distressed communities, defined as DCI ≥75, were compared with all other patients. Regression modeling was used to evaluate the effect of DCI on 10-year bariatric outcomes, whereas Cox Proportional Hazards and Kaplan-Meier analysis examined long-term survival.

RESULTS

Gastric bypass patients (n = 681) come from more distressed communities compared with the general public (DCI 60.5 ± 23.8 versus 50 ± 10; P < 0.0001). A total of 221 (32.3%) patients came from distressed communities (DCI ≥75). These patients had similar preoperative characteristics, including BMI (51.5 versus 51.7 kg/m²; P = 0.63). Socioeconomic status did not affect 10-year bariatric outcomes, including percent reduction in excess body mass index (57% versus 58%; P = 0.93). However, patients from distressed communities had decreased risk-adjusted long-term survival (hazard ratio, 1.38; P = 0.043).

CONCLUSIONS

Patients with low socioeconomic status, as determined by the DCI, have equivalent outcomes after bariatric surgery despite worse long-term survival. Future quality improvement efforts should focus on these persistent disparities in health care.

Metabolic surgery and iron homeostasis

Iron deficiency and anaemia after metabolic surgery, potentially modifiable nutritional complications, are becoming an increasing cause for concern as prevalence increases with time and there is limited evidence supporting the effectiveness of the current guidelines for prophylactic oral iron supplementation and treatment for deficiency. Abnormalities in iron nutrition predisposing to deficiency are common in severely obese patients, and the low-grade systemic inflammation, also common to these patients, reduces the effectiveness of oral iron supplementation. The surgical procedures result in alterations of foregut anatomy and physiology, which limit iron absorptive capacity and daily food intake. These alterations and the limited effects of oral iron supplementation explain the high prevalence of postoperative iron deficiency and anaemia. This review outlines current mechanisms concerning the pathogenesis of disordered iron nutrition in patients with severe obesity, current gaps in knowledge, and opportunities for quality improvement.

Pre-operative Bariatric Clinic Attendance Is a Predictor of Post-operative Clinic Attendance and Weight Loss Outcomes

AIM

Our primary aim was to determine whether non-attendance at pre-operative clinics were associated with non-attendance at post-operative clinics and its influence on weight loss. We also sought to examine the relationship between gender, ethnicity and post-operative clinic attendance with respect to weight loss post-bariatric surgery.

METHODS

A retrospective audit was performed for patients undertaking the bariatric surgery program at the Auckland City Hospital between 2013 and 2016.

RESULTS

One hundred and eighty-four patients completed our program, with a mean age of 46.1 years. Mean weight at commencement was 133.3 kg, with a BMI of 47.4. At 2 years follow-up (n = 143), excess weight loss was 70.8% following RYGB and 68.0% following LSG (p = 0.5743). More patients attended all pre-operative than post-operative clinics (67.4% vs 37.5% p = < 0.001). One pre-operative clinic non-attendance was associated with less weight loss at 2 years and it increases the risk of missing at least 50% of post-operative clinics with a risk ratio of 2.73, p = 0.005. Non-attendance of at least 50% of post-operative clinics was also associated with less weight loss at 2 years (33.4 kg vs 44.3 kg, p = 0.040). Although Maori and Pacific Islanders more frequently missed > 50% of post-operative clinics, weight loss was similar between European, Maori and Pacific Islander populations (2-year weight loss 44.2 kg vs 40.74 kg vs 44.1 kg, respectively, p = 0.8192).

CONCLUSION

Pre-operative clinic non-attendance helps predict post-operative clinic non-attendance. Missing any pre-operative clinics and at least 50% of scheduled post-operative clinics is associated with poorer weight loss outcomes.

Long-term micronutrient surveillance after gastric bypass surgery in an integrated healthcare system

BACKGROUND

The number of patients undergoing bariatric surgery in the United States is growing. While gastric bypass surgery is an important tool in the management of obesity, it requires lifelong metabolic monitoring and medical management. Data describing compliance with recommended laboratory follow-up are limited, particularly in long-term and primary care settings.

OBJECTIVES

To evaluate postoperative follow-up laboratory testing for patients after laparoscopic Roux-en-Y gastric bypass (LRYGB).

SETTING

Academic-affiliated community hospital.

METHODS

A review of patients who underwent LRYGB from 2001 to 2016 was performed. The location of patients' follow-up care and compliance with recommended laboratory testing were determined from patient records. Compliance was analyzed at 1-year intervals.

RESULTS

One thousand four hundred ninety patients underwent LRYGB. Five years after their surgical date, patients were more likely to follow-up with primary care than bariatric surgery clinic (369 versus 159 patients). At 5 years postoperative, 82%, 85%, and 68% of patients that followed-up with primary care did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively. Patients that followed-up in bariatric clinic were slightly more likely to have recommended labs completed. At 5 years postprocedure, 81%, 55%, and 48% did not have a vitamin D, parathyroid hormone, or vitamin B12 test, respectively.

CONCLUSION

Most patients do not have the recommended laboratory testing completed, regardless of where their follow-up care occurred. This study identified a gap in long-term postoperative care for patients who have undergone gastric bypass surgery. Further studies will be necessary to develop interventions aimed at improving adherence to recommended monitoring after LRYGB.

Long-term nutritional follow-up post bariatric surgery

PURPOSE OF REVIEW

Bariatric surgery is an effective treatment for classes II and III obesity and its associated diseases. However, many important long-term outcomes of bariatric surgery are still poorly understood, such as neurological and psychological complications, bone health, and so on. This review summarizes the current evidence and expert opinions on nutritional care in the long-term postoperative period.

RECENT FINDINGS

In the first section, we will provide an update of the main long-term complications: risk of anaemia, risk of bone fracture, neurological and psychological complications, and risk of developing Barrett's oesophagus after sleeve gastrectomy. We will also examine the current strategies used to increase weight loss or reduce weight regain. As adherence to long-term follow-up has been shown to decrease over time, the second section aims to identify all measures that improve follow-up rates, to get the maximum benefit from bariatric surgery, while minimizing long-term adverse effects and complications.

SUMMARY

There is still a significant level of uncertainty regarding the best clinical practices for maintaining the health benefits provided by bariatric surgery. The role of family physician in postsurgery care needs to be clearly defined. More effort is needed to improve psychological care, behaviour management, and therapeutic patient education after bariatric surgery. A more patient-centred approach should probably be considered.

BARIATRIC DIET GUIDE: PLATE MODEL TEMPLATE FOR BARIATRIC SURGERY PATIENTS

BACKGROUND

The Bariatric Plate Model (BPM) may be an adequate form of nutritional guideline after obesity surgery.

AIM

Create a food guide, based on the Plate Model for nutritional education of bariatric patients.

METHOD

The Plate Model2 was revised from a model initially suggested for dyslipidemic and hypertensive patients to a new objective: adaptation to bariatric patient who needs effective long-term nutritional education.

RESULTS

The adaptation of the Plate Model considered protein needs with high biological value, as it is the priority in the BPM, followed by vitamins and minerals and lastly the carbohydrates, especially the whole ones.

CONCLUSION

The BPM is a tool that can be effectively used in nutritional education of bariatric patients.

Bariatric surgery increases risk of bone fracture

INTRODUCTION

The purpose of this study was to determine the long-term incidence of bone fracture after bariatric surgery, identify specific risk factors for fracture, and compare these data to baseline risk in a comorbidity-matched morbidly obese population. We hypothesize that, despite prior studies with conflicting results, bariatric surgery increases a patient's long-term risk of fracture.

METHODS

All patients who underwent bariatric surgery at a single institution 1985-2015 were reviewed. Univariate analysis of patient demographic data including comorbidities, insurance payer status, procedure type, and BMI was performed. Multivariate logistic regression was used to identify independent predictors of fracture in this population. Finally, we identified a propensity-matched control group of morbidly obese patients from our institutional Clinical Data Repository in the same timeframe who did not undergo bariatric surgery to determine expected rate of fracture without bariatric surgery.

RESULTS

A total of 3439 patients underwent bariatric surgery, with 220 (6.4%) patients experiencing a bone fracture at mean follow-up of 7.6 years. On multivariate logistic regression, independent predictors of increased fracture included tobacco use and Roux-en-Y gastric bypass while private insurance and race were protective (table). Additionally, 1:1 matching on all comorbidity and demographic factors identified 3880 patients (1940 surgical patients) with equal propensity to undergo bariatric surgery. Between the propensity-matched cohorts, patients who had a history of bariatric surgery were more than twice as likely to experience a fracture as those who did not (6.4 vs. 2.7%, p < 0.0001).

CONCLUSIONS

This study of bariatric surgery patients at our institution identified several independent predictors of postoperative fracture. Additionally, these long-term data demonstrate patients who had bariatric surgery are at a significantly increased risk of bone fracture compared to a propensity-matched control group. Future efforts need to focus on nutrient screening and risk modification to reduce the impact of this long-term complication.

Patient Reported Outcomes 10 years After Roux-en-Y Gastric Bypass

BACKGROUND

Following weight-loss surgery, patients who failed to achieve or sustain weight loss have nevertheless reported high satisfaction with their long-term bariatric experience. Understanding this phenomenon better will likely improve patients' experiences.

OBJECTIVE

The purpose of this study was to explore patients' long-term experiences following bariatric surgery.

SETTING

A 604-bed academic health system in the USA.

METHODS

Participants rated satisfaction and shared spontaneous comments regarding their gastric bypass experience. A phenomenological mode of inquiry explored participants' experiences. Transcribed phrases were categorized and themes identified.

RESULTS

In a 2004 surgical cohort, with 55% (155/281) participation, 99% of participants rated bariatric experience satisfaction (mean score 8.4) and 74% (115/155) shared comments regarding experiences. Responses were categorized as positive (63% 72/115), neutral (25% 29/115), or negative (12% 14/115). Satisfaction, Appreciation, and Gratefulness emerged as themes from positive comments, with 8% (6/72) explicitly acknowledging amount of weight loss achieved. Twenty-five percent (18/72) spontaneously mentioned undergoing surgery again or recommending the procedure to others. Neutral comments contained the themes of Reflection, Acknowledgment, and Wistfulness. Themes of Dissatisfaction, Disappointment, and Regret emerged from negative comments. Forty-three percent (6/14) of negative comments remarked on regaining weight or not reaching goal weight. Twenty-one percent (3/14) of negative comments explicitly stated regret at having undergone surgery.

CONCLUSIONS

Participants readily shared comments regarding their gastric bypass experience. Exploring themes provided insight into patients' satisfaction with bariatric surgery even when weight-loss goals were not met and conversely substantial dissatisfaction even when weight loss occurred. This study underscores the importance of understanding the patients' long-term experience following bariatric surgery.