Dietary supplements and bariatric surgery

Breastfeeding in metabolic and bariatric patients: a comprehensive guide for surgeons, patients, and the multidisciplinary team

Since nearly 40% of metabolic and bariatric surgery (MBS) patients are individuals with the ability to bear children, many may seek to become pregnant or may be currently lactating when seeking surgery. While many patients plan to breastfeed, MBS patients are at high risk for premature cessation of breastfeeding. Limited literature exists on the impact of MBS on lactation and there are no established guidelines to help clinicians support and educate MBS patients about breastfeeding. Herein, we aim to fill that gap by providing a comprehensive guide for bariatric surgeons, obstetricians, women's health providers, lactation consultants, registered dietitians, bariatric nurse coordinators, and advanced practice providers to support breastfeeding in patients with a history of MBS or who are considering MBS. We review physician-patient discussion points on how MBS impacts lactation, the micronutrient and caloric needs for this unique population, and data to support successful breastfeeding in post-MBS patients who are lactating regarding practical, anesthetic, and imaging considerations.

Analysis of Changes in Protein Intake Following Laparoscopic Sleeve Gastrectomy and Its Influencing Factors

BACKGROUND

Little is known about factors associated with protein intake post-laparoscopic sleeve gastrectomy, especially in Chinese weight loss patients over 6 months. This project aimed to identify possible factors to improve protein intake and investigate protein supplement usage to reduce complications such as malnutrition.

METHODS

A prospective observational study was conducted on 120 eligible patients at a tertiary hospital. They completed study measures at baseline, 3 months post-surgery (T0), and 6 months post-surgery (T1). Univariate and multivariate Linear regressions were utilized to analyze factors related to protein intake.

RESULTS

At 6 months post-surgery, most patients did not meet the recommended protein intake of ≥ 60 g/day. Patients who intake protein < 60 g/day lost more weight at T0, but patients who intake protein ≥ 60 g/day lost more weight at T0 to T1. The three macronutrients for all patients were significant differences in dietary and protein supplement sources between T0 and T1. Multi-factor linear regression found that lower educational level, pre-operative hypertension, and the lower EBBS total score at 6 months were significant predictors of insufficient daily protein intake.

CONCLUSIONS

Findings shed new light on factors that may account for deficiency protein intake, which have implications for guiding effective interventions targeting this behavior.

Pharmacokinetics after bariatric surgery: adverse effects and drug safety issues in bariatric patients

INTRODUCTION

Medication management after bariatric surgery is a major and complex challenge. The altered gastrointestinal anatomy/physiology post-surgery may impact oral drug absorption/pharmacokinetics, with potential clinical implications. Along with multiple studies/cases of impaired post-surgery drug absorption/pharmacokinetics, leading to potential treatment failure, reports of increased drug exposure, leading to post-bariatric safety issues and adverse effects risk, are also available; yet, this second scenario of increased post-surgery drug levels, is less familiar in practice.

AREAS COVERED

In this article, we highlight and overview the literature reports of increased post-bariatric drug exposure and safety issues, and discuss the underlying relevant mechanisms. Finally, we provide clinical recommendations for managing this therapeutic challenge.

EXPERT OPINION

Around 25 drugs were found to exhibit post-bariatric enhanced pharmacokinetics and risk of adverse effects. Among them, toxicity with lithium treatment is well-established. Clear safety concerns were also raised for other drugs, including levothyroxine, atorvastatin, paracetamol and, importantly, immediate-release morphine. Cautious use, while closely monitoring clinical signs of toxicity, is advised for these drugs. Realizing the potentially altered post-bariatric pharmacokinetics of various drugs, and, in particular, the risk of increased exposure with related adverse effects, is essential for providing optimal pharmacological therapy and overall patient care to the growing bariatric population.

Psychological predictors of adherence to lifestyle changes after bariatric surgery: A systematic review

Objective

Adherence to lifestyle changes after bariatric surgery is associated with better health outcomes; however, research suggests that patients struggle to follow post-operative recommendations. This systematic review aimed to examine psychological factors associated with adherence after bariatric surgery.

Methods

PubMed, PsycInfo, and Embase were searched (from earliest searchable to August 2022) to identify studies that reported on clinically modifiable psychological factors related to adherence after bariatric surgery. Retrieved abstracts (n = 891) were screened and coded by two raters.

Results

A total of 32 studies met the inclusion criteria and were included in the narrative synthesis. Appointment attendance and dietary recommendations were the most frequently studied post-operative instructions. Higher self-efficacy was consistently predictive of better post-operative adherence to diet and physical activity, while pre-operative depressive symptoms were commonly associated with poorer adherence to appointments, diet, and physical activity. Findings were less inconsistent for anxiety and other psychiatric conditions.

Conclusions

This systematic review identified that psychological factors such as mood disorders and patients' beliefs/attitudes are associated with adherence to lifestyle changes after bariatric surgery. These factors can be addressed with psychological interventions; therefore, they are important to consider in patient care after bariatric surgery. Future research should further examine psychological predictors of adherence with the aim of informing interventions to support recommended lifestyle changes.

Bridging the Gap: Pregnancy-And Lactation-Associated Osteoporosis

Early diagnosis of pregnancy- and lactation-associated osteoporosis (PLO) is mandatory for a good outcome. Standard care is not a matter of conventional guidelines, rather it requires an individualized strategy while true overall incidence and pathogeny remain open issues. This is a narrative review based on full-length English articles, published between January 2021 and March 2023 and accessed via PubMed (no traumatic fractures or secondary osteoporosis are included). Our case-sample-based analysis included 836 females with PLO (the largest cohort based on published cases so far) through 12 studies and 24 single case reports. Except for one survey, these involved retrospective cohorts of small size (6-10 females/study) to medium size (23-47 women/study), and large cohorts with >50 subjects per study (a maximum of 379). Age of diagnosis: from 24 to 40 years for case reports (most subjects being over 30 and primigravida), while original studies indicated an average age between 31 and 34.18 years. Type of fractures underlined a most frequent vertebral phenotype (a mean of 2 to 5.8 vertebral fractures per patient) versus a most severe non-vertebral phenotype (hip and femoral neck fractures mostly requiring surgery). Potential contributors varied: smoking (1/3-1/2 of subjects), family history of osteoporosis (1/3), heparin and glucocorticoid use in pregnancy, low body mass index (majority of cases), hypovitaminosis D; and (with a low level of statistical significance) anti-psychotic medication, gestational diabetes, lupus, thrombophilia, anemia, in vitro fertilization (1/3 in one study), twin pregnancy, tocolysis with MgSO4, and postpartum thyroiditis. Most remarkably, up to 50% of PLO patients harbor mutations of LRP5, WNT1, and COL1A1/A2 (more damaged form with potential benefits from osteoanabolic drugs); gene testing might become the new norm in PLO. The low index of clinical suspicion should be supported by performing magnetic resonance imaging (gold standard in pregnancy) with DXA (in lactation). Low bone mineral density is expected (Z-score varying from -2.2 SD to -4 SD, unless normal which does not exclude PLO). Bone turnover markers might be useful in individuals with normal DXA, in pregnancy when DXA cannot be performed, and in following the response to anti-osteoporosis drugs. Alternatively, microarchitecture damage might be reflected by DXA-trabecular bone score and high-resolution peripheral quantitative computed tomography. Specific medical interventions are currently focused on teriparatide (TPT) use (3 studies; n = 99 females treated with TPT and an additional subgroup of 18 patients from the gene-analysis-based study, thus a total of 117 females) which seems to be the therapy of choice as reflected by these new data: 6-24 months, 20 µg/day, no sequential therapy needed; case selection based on high fracture risk is necessary). The first case using romosozumab was reported in 2022. PAO/LAO remains a challenging condition which is a battle for the wellbeing of two individuals, on one hand, considering maternal-fetal outcomes and taking care of the offspring, but it is a battle for a multidisciplinary team, on the other hand, since a standardized approach is lacking.

L-Arginine-Functionalized Carbon Dots with Enhanced Red Emission and Upregulated Intracellular L-Arginine Intake for Obesity Inhibition

Obesity is a major global health problem that significantly increases the risk of many other diseases. Herein, a facile method of suppressing lipogenesis and obesity using L-arginine-functionalized carbon dots (L-Arg@CDots) is reported. The prepared CDots with a negative surface charge form stronger bonds than D-arginine and lysine with L-Arg in water. The L-Arg@CDots in the aqueous solution offer a high photoluminescence quantum yield of 23.6% in the red wavelength region. The proposed L-Arg functionalization strategy not only protects the red emission of the CDots from quenching by water molecules but also enhances the intracellular uptake of L-Arg to reduce lipogenesis. Injection of L-Arg@CDots can reduce the body weight increase in ob/ob mice by suppressing their food intake and shrinking the white adipose tissue cells, thereby significantly inhibiting obesity.