Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice

Diagnostic dilemma of avoidant/restrictive food intake disorder after bariatric surgery: A case report and review of literature

BACKGROUND

Bariatric surgery is an effective treatment for severe obesity but is associated with an increased risk for development of eating disorders. Indeed, numerous maladaptive eating behaviors and eating disorders have been described following bariatric surgery. However, the differentiation of pathologic eating patterns from expected dietary changes following bariatric surgery can sometimes be difficult to discern.

CASE SUMMARY

A female in her early 40s presented for medical stabilization of severe protein calorie malnutrition after losing 52.3 kg over the last six months after Roux-en-Y gastric bypass, with subsequent development of cyclic nausea and vomiting. Fear of these aversive physical symptoms led to further restriction of nutritional intake and weight loss. The patient was diagnosed with avoidant/restrictive food intake disorder, which has not been previously reported after bariatric surgery.

CONCLUSION

Improvement in the diagnostic nomenclature for feeding and eating disorders is warranted for patients who have undergone bariatric surgery.

The effects of protein supplementation on body composition after bariatric surgery: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

We aimed to explore the effect of protein supplementation on anthropometric measures and body composition in patients after metabolic bariatric surgery (MBS).

METHODS

We performed a systematic search up to January 2024 including randomized controlled trials investigating the effects of protein or amino acid supplementation on the body composition of patients who underwent MBS. The overall effect was presented as the weighted mean difference (WMD) at a 95% CI.

RESULTS

Ten trials were included in this meta-analysis. Our results indicate that there was a statistically greater change in weight (WMD, -1.31 kg, 95% CI: -1.93 to -0.69, p < 0.001; Grading of Recommendations Assessment, Development, and Evaluation [GRADE] = moderate), muscle mass (WMD, 1.33 kg, 95% CI: 0.1 to 2.57, p = 0.035; GRADE = low), fat-free mass (WMD, 1.74 kg, 95% CI: 0.46 to 3.01, p = 0.01; GRADE = low), and fat mass (WMD, -3.91 kg, 95% CI: -4.10 to -0.59, p = 0.01; GRADE = low) in the protein group compared to the control group. However, protein supplementation did not significantly change BMI and lean body mass.

CONCLUSIONS

Based on moderate- to low-certainty evidence, our findings suggest that although protein supplementation may improve weight and some body composition metrics, it does not influence overall BMI and lean body mass. More research is needed to recommend protein supplementation after MBS.

Expert-based physical activity guidelines for metabolic and bariatric surgery patients: a systematic review of randomized controlled trials

Patients undergoing metabolic and bariatric surgery (MBS) can improve outcomes through a physically active lifestyle. Despite ongoing research, clinical recommendations for physical activity (PA) are not fully developed. For this review, 39 articles representing 24 randomized clinical trials satisfied inclusion criteria. The PA interventions utilized in these trials, the expertise of the multidisciplinary research team, and the general principles of strength and conditioning were considered in the creation of the following 12 PA recommendations: 1) Begin PA intervention pre-MBS; 2) Unless contraindicated, walk short distances the day of the surgery; 3) Progressively increase movement through activities of daily living during the first month postoperatively; 4) Avoid prolonged sitting and adopt lifestyle routines that decrease sedentary time; 5) Slowly progress to 150-300 minutes of accumulated moderate-intensity cardiovascular exercise/week; 6) In addition to walking, gradually increase structured PA through a variety of activities; 7) Delay water exercise until surgical wounds have healed, around 4 weeks postoperatively; 8) Begin full body resistance training (RT) 4-6 weeks post-MBS on 2 noncontinuous d/wk; 9) Delay high-intensity PA and abdominal exercises for 8-12 weeks; 10) Have periodic assessments of strength and cardiovascular fitness to evaluate progress; 11) Continue long-term monitoring with exercise professionals in the context of health; and 12) Consult with a registered dietitian to optimize nutrition alongside changes in PA.

Anemia rates after one-anastomosis gastric bypass versus sleeve gastrectomy: a retrospective cohort study

PURPOSE

To compare postoperative anemia rates after one-anastomosis gastric bypass (OAGB) with those after sleeve gastrectomy (SG) in a large nationwide, population-based cohort study.

METHODS

We sourced data from the Israeli Bariatric Surgery Registry. The study included a cohort of adults who underwent bariatric surgery (BS) between 2013 and 2017. Hemoglobin (Hb) was measured preoperatively and then 1 and 2 years post-BS. Anemia rates were compared between the patients who underwent OAGB and those who underwent SG, using multivariable analyses.

RESULTS

The study comprised 1,052 patients who underwent OAGB and 5,885 patients who underwent SG. Among them, 24.1% and 23.6% were men, respectively, and the preoperative mean body mass index values were 41.7 ± 5.0 and 42.1 ± 5.1 kg/m2, respectively. The 1-year and 2-year postoperative anemia rates were significantly higher after OAGB than after SG, when adjusted for age, pre-surgery BMI, sex and other covariates (1 year: 37.5% vs. 20.2%; adj-OR = 2.43; 95% CI 2.08-2.86; 2 years: 45.1% vs. 28.5%; adj-OR = 1.92; 95% CI 1.59-2.32).

CONCLUSIONS

Patients who underwent OAGB had significantly higher anemia rates 1 year and 2 years postoperatively than those who underwent SG. Consequently, vigilant surveillance and intervention strategies post-OAGB should be considered to mitigate the incidence of anemia and its associated complications.

New Approaches to the Treatment of Severe Obesity-Prehabilitation as the Key to Success

PURPOSE OF REVIEW

Bariatric surgery (BS) has emerged as a crucial and effective treatment for severe obesity (SO), providing significant and sustained weight loss and improving comorbidities. Optimizing perioperative careparticularly through structured prehabilitation is crucial for improving surgical outcomes and long-term weight management. This review examines the role of prehabilitation, nutrition, psychological support, physical activity, and pharmacologic treatment in improving the effectiveness of BS.

RECENT FINDINGS

Despite the benefits of prehabilitation, there are significant differences in the way it is implemented in different healthcare centers. Protocols vary widely in terms of duration, components and intensity, leading to inconsistencies in patient preparation and postoperative recovery. Many patients still do not receive multidisciplinary support from dietitians, psychologists or physiotherapists prior to surgery, which can affect long-term outcomes. Barriers to effective prehabilitation include a lack of standardized guidelines, insufficient healthcare resources and limited patient adherence due to lack of awareness, low motivation or logistical constraints. Despite its proven benefits, structured prehabilitation lasting at least 3-6 months is not available to all patients, as access remains unequal and suboptimal in many healthcare settings. Prehabilitation is an important but underutilized component of BS preparation. Standardizing protocols and ensuring multidisciplinary, patient-centered support are essential to maximizing surgical benefit. Overcoming barriers such as healthcare system limitations, patient motivation and knowledge gaps is critical to integrating prehabilitation into routine bariatric care. This review emphasizes the need for evidence-based, multimodal prehabilitation strategies to improve perioperative care and long-term outcomes for BS patients.

Recent advances in carotenoid absorption, distribution, and elimination

Carotenoids are a class of pigments with antioxidant properties synthesized by photosynthetic and heterotrophic organisms. Humans can store carotenoids in their intact form or cleave them enzymatically to apocarotenoids such as vitamin A, a hormone-like nutrient with crucial roles in gene expression and vision. Clinical and preclinical studies suggest that the consumption of diets rich in carotenoids attenuate cardiometabolic diseases, some types of cancer, neurodegenerative disorders, and inflammatory conditions. The bioactive properties of carotenoids depend, at least in part, on their accumulation in target tissues. However, the pathways that drive carotenoid absorption, delivery, and accumulation in tissues remain largely uncharacterized. This review provides a critical overview of the experimental models utilized to monitor carotenoid homeostasis in mammals. We also delve into recent findings concerning carotenoid intestinal uptake, bodily distribution, cellular uptake, and intracellular trafficking. Finally, we discuss the physiological relevance of a fecal carotenoid elimination pathway that operates independently of carotenoid enzymatic cleavage. Establishing the players governing carotenoid biodistribution and elimination is essential to maximize the bioactive properties of carotenoids in humans to prevent chronic diseases.

The Effect of Adding a Smartphone-Based Platform to the Metabolic Bariatric Surgery Nutritional Preparation Process: A Randomized Controlled Trial

BACKGROUND

Metabolic bariatric surgery (MBS) candidates undergo a comprehensive nutritional preparation process by a registered dietitian (RD). The effect of eHealth interventions on the MBS preparation process is unknown.

OBJECTIVES

To assess the impact of adding an application to the nutritional preparation process on pre-surgery nutritional knowledge, physical, and behavioral parameters among MBS candidates.

METHODS

An open-label randomized controlled trial among MBS candidates. All participants received 3-6 meetings with an RD and the intervention group also received access to an application containing information modules and a communication platform. Data was collected at baseline and end of preparation.

RESULTS

Forty participants were recruited, of them 67.5% women, with a mean age and body mass index of 34 ± 10.1 years and 43.5 ± 6.0 kg/m2, respectively. Nutritional knowledge, anthropometrics, functionality, adherence to most behavioral recommendations, and subjective state of health improved in both groups (P Time ≤ 0.044). Physical activity initiation (i.e., beginning of regular exercise engagement) was higher among the intervention group (40% at baseline and 68% at end of preparation vs 35% at baseline and 32% at end of preparation for interventions and controls, respectively, P Time × Group = 0.026). The application was rated as providing added value (8.2 on a scale of 1 (no added value) to 10 (meaningful added value)).

CONCLUSIONS

Nutrition preparation process with an RD improved MBS knowledge, adherence to behavioral recommendations, subjective state of health, and modestly enhanced weight and functionality outcomes among MBS candidates. Although rated as having an added value, incorporating an application had only a minimal impact on these outcomes.

The Korean Society for Metabolic and Bariatric Surgery (KSMBS) Position Statement on Female Candidates of Reproductive Age for Metabolic Bariatric Surgery

Obesity has emerged as a major global health issue. The ratio of male to female patients undergoing metabolic bariatric surgery (MBS) is 1:3.5. Although not as dramatic compared to the global trend, the rate of obesity in women of reproductive age in Korea has been steadily increasing over the past several decades. The impact of obesity on reproductive health and perinatal outcomes should be carefully considered when consulting female candidates of reproductive age for MBS. Obesity adversely affects reproductive health by causing menstrual irregularities, anovulation, subfertility, and increased miscarriage risk, as well as impairing the success of assisted reproductive technologies. Maternal obesity also heightens the risk of adverse perinatal outcomes, including childhood obesity and metabolic disorders. MBS has been shown to improve fertility outcomes and reduce obesity-related pregnancy complications, although concerns remain regarding potential risks such as small-for-gestational-age infants due to rapid weight loss and nutritional deficiencies. Despite these implications, current MBS guidelines rarely address the unique needs of reproductive-age women. In response, the Korean Society for Metabolic and Bariatric Surgery convened a task force to develop evidence-based recommendations tailored to this population. This position statement aims to guide the management of obesity in women of reproductive age to optimize reproductive and perinatal outcomes.

Beyond the decade: unveiling long-term weight and co-morbidity outcomes up to 10 years post laparoscopic sleeve gastrectomy

INTRODUCTION

Despite its effectiveness, long-term data on the safety and efficacy of laparoscopic sleeve gastrectomy (LSG) for morbid obesity are sparce.

METHODS

We collected data through phone interviews and hospital records for patients who had LSG, including those that then underwent revisional bariatric surgery, assessing their weight outcomes, associated health conditions, and complications.

RESULTS

2982 patients (72% female) were included in the study, with a maximum follow-up reached of 13 years. The mean pre-operative age and body mass index (BMI) were 34.7 ± 11.3 years and 45.5 ± 7.7 kg/m2, respectively. The prevalence of obesity classes were as follows: Class I, 3.1%; Class II, 19.2%; and Class III, 75.9%. BMI at nadir was 32.35 Kg/m2 equating to a mean nadir excess weight loss (EWL) of 67.03%. Weight outcomes at 13 years post-LSG showed a mean BMI of 31.83 kg/m2 and total weight loss (TWL) percentage of 31.43%. Weight loss outcomes varied according to pre-operative obesity class, with class I achieving the highest percentage EWL and class III observing the highest TWL at the end of one year. Weight regain occurred in 1.3% of the patient population, with class III experiencing the highest weight regain at 13 years. Significant reductions in comorbidities were observed, while complication rates were low, with 0.4% bleed, 0.5% leak, and 7.9% GERD.

CONCLUSION

LSG demonstrates sustained weight loss and resolution of comorbidities with low complication rates. The influence of initial obesity class on weight loss was found to be significant in the first 18 months post-LSG.

Bariatric nutrition and evaluation of the metabolic surgical patient: Update to the 2022 Obesity Medicine Association (OMA) bariatric surgery, gastrointestinal hormones, and the microbiome clinical practice statement (CPS)

Background

In 2022, the Obesity Medicine Association (OMA) published a Clinical Practice Statement (CPS) which provided an overview of bariatric surgery and related procedures, a discussion on gastrointestinal hormones and a review of the microbiome as it relates to patients with obesity. This update to the 2022 OMA CPS provides a focus on nutrition as it relates to the adult bariatric surgery patient, incorporating a detailed discussion on how to conduct a bariatric nutrition assessment and manage patients seeking metabolic and bariatric surgery (MBS) and postoperative nutrition care. In particular, the section on macronutrients, micronutrients, and bariatric surgery has been updated, highlighting practical approaches to nutrient deficiencies typically encountered in the bariatric surgery patient. Also included is a section on how to envision and develop an interdisciplinary team of medical providers with evidence-based nutrition knowledge and consistent information that improves the quality of nutrition care provided to MBS patients. This CPS adds to the series of OMA CPSs meant to provide guidance to clinicians in their care of patients with obesity.

Methods

The foundation of this paper is supported by scientific evidence in the medical literature and expert opinion derived from several bariatric nutrition resources, as well as from the 2022 OMA CPS focused on bariatric surgery.

Results

This OMA Clinical Practice Statement provides an overview of the current bariatric nutrition clinical guidelines and nutrition tools adapted for clinicians who may not have access to an MBS team or a registered dietitian knowledgeable about bariatric nutrition.

Conclusions

This evidence-based review of the literature includes an overview of current bariatric nutrition recommendations. It is intended to provide clinicians with more advanced knowledge and skills in nutrition assessment and management of the preoperative and post-surgical MBS patients. This CPS also addresses macronutrient and micronutrient deficiencies common in MBS patients, and treatment recommendations designed to help the clinician with clinical decision making.

Change in carbohydrate intake one year after Roux-en-Y gastric bypass: A prospective study

Background and objectives: To investigate the effect of carbohydrate intake before laparoscopic Roux-en-Y gastric bypass (LRYGB) on body weight, body composition and glycaemic status after surgery. Methods: In a tertiary centre cohort study, dietary habits, body composition and glycaemic status were evaluated before and 3, 6 and 12 months after LRYGB. Detailed dietary food records were processed by specialized dietitians on the basis of a standard protocol. The study population was subdivided according to relative carbohydrate intake before surgery. Results: Before surgery, 30 patients had a moderate relative carbohydrate intake (26%-45%, M-CHO), a mean body mass index (BMI) of 40.4 ± 3.9 kg/m² and a mean glycated haemoglobin A1c (A1C) of 6.5 ± 1.2% compared to 20 patients with a high relative carbohydrate intake (> 45%, H-CHO), mean BMI of 40.9 ± 3.7 kg/m² (non-significant, NS) and a mean A1C of 6.2% (NS). One year after surgery, body weight, body composition and glycaemic status were similar in the M-CHO (n = 25) and H-CHO groups (n = 16), despite less caloric intake in the H-CHO group (1317 ± 285 g vs. 1646 ± 345 g in M-CHO, p < 0.01). Their relative carbohydrate intake converged to 46% in both groups, but the H-CHO group reduced the absolute total carbohydrate consumption more than the M-CHO group (190 ± 50 g in M-CHO vs. 153 ± 39 g in H-CHO, p < 0.05), and this was especially pronounced for the mono- and disaccharides (86 ± 30 g in M-CHO vs. 65 ± 27 g in H-CHO, p < 0.05). Conclusion: A high relative carbohydrate intake before LRYGB, did not influence the change in body composition or diabetes status after surgery, despite a significantly lower total energy intake and less mono- and disaccharide consumption after surgery.

Introduction Long-Term Effects of Professional and Non-professional Support on a Healthy Lifestyle Following Bariatric Surgeries

BACKGROUND

Obesity, defined as a body mass index (BMI) of ≥ 30 kg/m2, is a global health crisis with severe physical and mental health implications. While bariatric surgery offers the most effective solution for severe obesity, long-term success depends on sustained behavioral changes and support (non-professional and professional). This study explores the role of support in promoting a healthy lifestyle after surgery.

METHODS

This study surveyed 211 individuals, aged 18-65, who had bariatric surgery more than 2 years ago, using random selection. Data were collected via phone interviews, ensuring anonymity. Questionnaires assessed healthy lifestyle (physical activity and nutrition) as well as professional and non-professional support participants received. Analysis methods encompassed χ2 tests, Pearson correlations, t-tests, and multiple regressions for predicting a healthy lifestyle.

RESULTS

Most participants underwent sleeve gastrectomy with varied BMIs (17-47), and only 19.4% had a healthy weight. Two-thirds engaged in physical activities, with generally healthy diets. While 78.7% received post-surgery support, most of this support was provided by surgeons. However, less than half had access to professional psychological support or participated in non-professional support, such as joining support groups. Regression models showed that support significantly predicted nutrition but not physical activity level. However, years from surgery were also an important predictor with the overall model predicting 2% (general nutrition-not appropriate) to 12% (bariatric nutrition) of healthy lifestyle variability.

CONCLUSIONS

Most participants sought surgical consultation early post-surgery, but long-term follow-up and engagement with professional services were low. Support from dietitians or psychologists was linked to improved nutritional outcomes, highlighting the importance of sustained professional guidance.

Impact of Dietary Behavioural Changes on Prognosis of Postoperative Oesophageal Squamous Cell Carcinoma Patients: A Retrospective Cohort Study

OBJECTIVE

In recent years, the incidence of oesophageal squamous cell carcinoma has been increasing, becoming a major focus of public attention. Despite surgery being the primary treatment method, the long-term prognosis after surgery is also of significant importance. Therefore, this study aims to investigate the impact of dietary behaviour changes on the long-term prognosis of patients with oesophageal squamous cell carcinoma after surgery.

METHODS

A retrospective cohort study was adopted, involving patients with oesophageal squamous cell carcinoma who underwent surgery at the Department of Thoracic Surgery, Affiliated Huaian No. 1 People's Hospital of Nanjing Medical University from January 1, 2018, to December 31, 2019. Data collected included characteristics of dietary behaviour, complications, postoperative quality of life scores and survival periods. Data were gathered through review of clinical pathological characteristics and patient survey questionnaires.

RESULTS

Patients with oesophageal squamous cell carcinoma who changed their dietary behaviours had a significant reduction in the risk of postoperative complications, higher quality of life scores (mean QoL score NDC: 9.8 vs. DC: 21.1; p < 0.001) and a slightly prolonged overall survival period (univariate hazard ratio: 0.58, 95% CI: 0.40-0.83, p = 0.003). Study findings also indicated age as a significant independent risk factor influencing patient prognosis.

CONCLUSION

To improve postoperative prognosis in patients with oesophageal squamous cell carcinoma, guidance and management of dietary behaviour should be emphasised. Appropriate changes in dietary behaviour are expected to reduce the risk of postoperative complications, improve the quality of life and extend the survival period of patients.

PATIENT OR PUBLIC CONTRIBUTION

The findings of this study have important implications for both patients and the public. By investigating the impact of dietary behaviour changes on the long-term prognosis of patients with oesophageal squamous cell carcinoma after surgery, this study provides valuable insights into potential strategies to improve patient outcomes. For patients, the study emphasises the importance of adopting healthy dietary behaviours after surgery. The results demonstrate that dietary behaviour changes can have a significant impact on the long-term prognosis of postoperative oesophageal squamous cell carcinoma patients. By following a healthy diet, patients may improve their overall quality of life, decrease complications and potentially increase their survival period.

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

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

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

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

Management of obesity

PURPOSE

This review summarizes the comprehensive management of obesity with a focus on the pharmacology, efficacy, and safety of anti-obesity medications.

SUMMARY

Obesity is a highly prevalent chronic disease with significant health risks, requiring a multifaceted approach to treatment. While most approved weight loss medications have modest effects, newer medications such as semaglutide and tirzepatide have shown greater than 15% reduction in baseline weight. Optimal selection of therapy requires taking into consideration patient factors, such as comorbidities and goals, and medication-related factors, including weight loss efficacy, contraindications, and improvements in cardiovascular risk. As the availability of anti-obesity medications increases, multidisciplinary care teams will play an important role in selecting optimal strategies for long-term health benefits in individuals with obesity.

CONCLUSION

The expanding array of anti-obesity medications provides valuable treatment options alongside lifestyle interventions and surgical approaches for managing obesity and reducing weight-related health risks. As this therapeutic area continues to grow, selecting optimal agents and educating patients on administration, monitoring, and potential adverse effects will be critical for improving overall outcomes.

The Presence of Food Addiction in Patients with Binge Eating Disorder Was Associated with Higher Weight, Poor Body Composition Outcomes, Lower Serum Level of Magnesium and Higher Ferritin 2 Years Post-LSG Surgery

BACKGROUND

This study examined the presence of food addiction (FA) in patients with binge eating disorder (BED) 2 years after laparoscopic sleeve gastrectomy (LSG) and explored its association with some minerals, ferritin, weight loss and, body composition outcomes.

MATERIALS AND METHODS

In this study, 120 patients with BED who had undergone LSG 2 years prior to participation were enrolled. BED was assessed using Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) criteria and presence of FA was assessed using the Yale Food Addiction Scale (YFAS). The collected data included general characteristic, food intake, physical activity, weight loss percentage, body composition measurements such as fat mass (FM) and fat-free mass (FFM), as well as serum level of magnesium, zinc, iron, and ferritin.

RESULTS

Fifty individuals with BED met the criteria for FA disorder (41.66%). BED patients who had FA had significantly higher weight (P = 0.01) compared to those without FA. Regarding body composition changes, the finding reveals that patients with BED + FA (vs. only-BED) had a significantly lower FM loss percentage (p = 0.04) and higher FFM loss percentage (p = 0.04). The BED patients with FA had significantly lower levels of magnesium (p = 0.02) and a higher level of ferritin (p = 0.04) compared to those without FA at second year after LSG.

CONCLUSION

The presence of FA in patients with BED was associated with higher weight, poor body composition outcomes, lower serum level of magnesium, and higher ferritin two years post-LSG surgery.

Innovative Approaches to Managing Postoperative Complications in Laparoscopic Sleeve Gastrectomy: A Scoping Review

Background: Laparoscopic sleeve gastrectomy (LSG) is an effective surgical intervention for obesity, but managing complications post LSG remains crucial. Given the global prevalence of obesity, innovative approaches are needed to improve patient outcomes. Objective: This scoping review aimed to comprehensively map the existing literature on innovative approaches for managing complications in adult patients undergoing LSG to treat morbid obesity. This management strategy may include surgical techniques, perioperative care, nutritional support, or other relevant strategies. Methods: A systematic search of PubMed and Scopus databases was conducted to identify relevant studies. The prespecified inclusion criteria were applied through a two-stage screening process. Studies involving adult patients who underwent LSG for morbid obesity (body mass index > 35) and those investigating interventions related to complications were included. The scoping review process adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. The results were summarized using a narrative approach. Results: This review included 31 studies with 4547 participants, showing diverse study designs, patient demographics, and surgical locations. Among them, 6 were case reports, 18 were randomized controlled trials, and 7 were retrospective studies. Complications of LSG include staple-line leaks, stenosis, hemorrhage, infection, gastric volvulus, and nutrient malabsorption. Innovative interventions, such as staple-line reinforcement, plication methods, and the Over-the-Scope Clip system, have been investigated for effective management. Conclusion: This scoping review provides valuable insights into innovative interventions for managing complications post LSG. This review highlights the need for further research to explore long-term outcomes, compare different interventions, and address the existing gaps in the literature.

Psychological and psychiatric standardized procedures for metabolic bariatric surgery: a clinical practice model for mental health providers

INTRODUCTION

Obesity is a multifactorial and chronic disease, constantly growing in prevalence. Metabolic and Bariatric Surgery (MBS) is among the most effective therapies for obesity, determining consistent long-term weight loss and maintenance. Increasing evidence suggests a relevant mental health contribution to obesity pathogenesis. European and International Guidelines for MBS emphasize the importance of a pre-surgical psychological/psychiatric assessment and a post-surgical follow-up to improve MBS outcomes. Yet, no standard psychological/psychiatric procedures currently exist.

METHODS

This paper overviews the psychological/psychiatric procedures which Italian mental health providers currently perform on MBS candidates to provide psychological support through every step of the MBS, from the assessment to the postsurgical follow-up, to evaluate eligibility, prevent mental health flare-ups and weight regain, as endorsed by the Board of the Italian Society of Surgery for Obesity and Metabolic Diseases (SICOB).

RESULTS

The psychological/psychiatric procedures should encompass two phases: pre-surgical assessment and post-surgical follow-up. Pre-surgical assessment should investigate every condition that might reduce the MBS effectiveness or contraindicate the surgical process. It must include a mental state evaluation, weight history, eating behavior, body image, psychosocial conditions, and motivation. The post-surgical follow-up should offer psychological support to patients in achieving weight loss and maintenance. It should also prevent the onset or recurrence of psychiatric disorders that may affect clinical outcomes.

DISCUSSION

This paper is the first to introduce a standardized protocol for psychological/psychiatric procedures for each phase of the surgical process, to allow MBS candidates to receive similar care despite geographical differences. It also serves as a potential clinical model for assessing mental eligibility or contraindications prior to MBS, and subsequently support the individual behavioral and lifestyle changes to achieve and maintain weight loss.

Observations of Ramadan fasting in the initial year after bariatric surgery

BACKGROUND

Ramadan is considered to be the holiest month of the Islamic religion. Hundreds of millions of Muslims practice the commitments of Ramadan, which include the abstinence from eating and drinking during daylight hours. Although there are exemptions to fasting for medical reasons, there is very limited guidance in terms of the safety of fasting in the postoperative period after bariatric surgery.

OBJECTIVES

To assess outcomes and impact of fasting on patients who underwent bariatric surgery within the year leading up to Ramadan 2023.

SETTING

Community hospital health system.

METHODS

Retrospective review of medical records and direct patient contact for 376 study participants.

RESULTS

Of the 376 participants who underwent bariatric surgery in the year before Ramadan, only 8 patients (2.1%) reported they did not intend to fast during Ramadan. Patients who ended up having to break fasting were closer to their surgery date, at 4.3 months from surgery, than patients who were able to fast for the entire month of Ramadan, who were 5.1 months out from surgery. There was no difference between the number of patients needing to break fasting on the basis of what type of bariatric surgery they had performed. The number of patients needing to go to the emergency department and receive intravenous fluids was small, at 11 patients (2.9%), and these patients were also closer to surgery than those not needing to go to the emergency department or receive intravenous fluids. Side effects experienced during Ramadan, including abdominal pain, nausea/vomiting, and hypoglycemia, were more common in patients that were closer to their surgery, notably within 4 months of their surgery date. Patients who lost weight during Ramadan were closer to their surgery date at 4.9 months from surgery compared with those who maintained or gained weight, who were 7.0 months out from surgery.

CONCLUSIONS

There are a limited number of studies examining the safety and patient outcomes in those who fast for religious purposes after bariatric surgery. In this study, 376 participants who were within 1 year of undergoing surgery were followed throughout the month of Ramadan. Patients closer to surgery were more likely to break fasting, present to the emergency department, and experience side effects. However, the overall rate of complications was low, suggesting that fasting in the setting of a religious tradition in the carefully chosen patient with counseling and supervision may be a safe option.

Protein supplementation preserves muscle mass in persons against sleeve gastrectomy

Introduction

Sleeve gastrectomy surgery can lead to deficiencies in both macro and micronutrients, with protein being particularly crucial due to its role in muscle mass, physiological, and metabolic functions. Inadequate protein intake due to physiological, psychological, or financial reasons may prevent achieving the recommended intake levels. The significance of this issue is often underappreciated.

Aim

This study evaluates the impact of protein supplementation on muscle mass in individuals undergoing sleeve gastrectomy and emphasizes the need for more comprehensive dietary training by expert dietitians.

Method

Data were collected from 60 participants (15 male, 45 female, aged 20-54) who visited the surgery clinic. Participants were divided into two groups: those receiving the recommended protein supplement (15 g/day) with post-bariatric surgery diet training (BSD + PS), and those receiving only the post-bariatric surgery diet (BSD). A pre-surgery questionnaire gathered health and general information. Daily energy and nutrient intakes were recorded using 24-h food consumption logs on the day before surgery and at 7 days, 1 month, and 3 months postoperatively. Anthropometric measurements, including muscle and fat mass, and International Physical Activity Questionnaire (IPAQ) data were also collected.

Findings

The characteristics of participants in both groups were similar, although there were more females in the BSD + PS group (86.7%) compared to the BSD group (63.3%). Despite an increase in energy and nutrient intake over time, levels remained below the recommended amounts in both groups. A significant difference was found in protein supplement consumption between the groups (p = 0.000). Repeated measures showed significant differences in body muscle mass percentage over time (F = 202.784; p = 0.000).

Conclusion

In individuals who underwent sleeve gastrectomy surgery, deficiencies in macro and micronutrient intake were observed below reference levels. For this reason, the first approach in the treatment of obesity should always be medical nutrition therapy accompanied by a dietician. When designing post-bariatric surgery nutrition programs, it should be taken into consideration that nutrition protocols and trainings should be followed more closely and given in more detail under the supervision of a specialist before supplements are considered.

Nutritional Management for Chronic Kidney Disease Undergoing Bariatric Surgery: A Case Report

Nutrition support is an essential aspect of treatment after bariatric surgery (BS). A high-protein diet with an intake of up to 1.5 g/kg of ideal body weight (IBW) per day is recommended to minimize loss of lean body mass after BS. However, protein intake recommendations may need to be adjusted for patients with compromised renal function, necessitating an individualized approach tailored to each patient's clinical status. This case report aimed to demonstrate nutritional evaluation, education, and counseling for a male patient with chronic kidney disease (CKD) who underwent BS one year after surgery. Following BS, the patient adhered to the standard Seoul National University Hospital BS diet protocol. Considering his postoperative renal function, protein requirement was set at 1.0 g/kg of IBW. A total of 10 individualized nutritional counseling sessions were conducted according to renal function and complications. One year after BS, he successfully lost weight with % excess weight loss of 93%, maintained CKD stage 3, reduced prescription of oral hypoglycemic agent, improved glycated hemoglobin levels, and improved eating habits significantly. Thus, individualized nutrition intervention is important for supporting patients with CKD to reach their goal weight after BS, improve nutritional status, and prevent post-operative complications.

Bariatric Surgery and Metabolic Status

Background and Objectives: Obesity is associated with numerous co-morbidities, including dyslipidemia, insulin resistance and diabetes mellitus. Bariatric surgery is the mainstay of treatment for obesity as the only method with confirmed long-term effects in weight reduction and the remission of comorbidities. Postoperative recommendations leading to changes in dietary habits and changes in digestion and absorption in the gastrointestinal tract after bariatric surgery may additionally influence the levels of laboratory parameters that reflect the metabolic and nutritional status. The purpose of the study was to analyze the possible influence of changes in dietary habits after bariatric surgery on those laboratory results that reflect the metabolic and nutritional status. Materials and Methods: This was a retrospective study of 88 patients with a history of bariatric surgery. Data were gathered from before the surgery and at 6 months after the surgery and included diet structure and selected laboratory parameters reflecting the metabolic and nutritional status, i.e., levels of fasting glucose, glycated hemoglobin, cholesterol, low- and high-density lipoproteins, triglycerides, alanine and aspartate aminotransferases, proteins, ferrum, ferritin, vitamin B12, folic acid, vitamin D and calcium, the red blood cell count and the hematocrit. Results: Postoperative festive glucose levels were reduced by 14% and were more significant in patients after Roux-en-Y gastric bypass. There was an increase of 22% in concentrations of high-density lipoproteins. Triglyceride concentrations were reduced by 32%. Aminotransferase levels decreased by 43% for alanine aminotransferase and by 14% for aspartate aminotransferase. Among the changes in dietary habits, post-bariatric patients had a reduced consumption of red meat and an increased consumption of fish, milk and dairy products and wholegrain products. Vitamin D and ferrum levels were higher after the surgery, whereas vitamin B12 and folic acid levels remained unchanged. Conclusions: Improved dietary habits of patients after bariatric surgery may lead to changes in laboratory parameters that reflect the ameliorated metabolic and nutritional status of patients after bariatric surgery.

Responsiveness and Reliability of a Sipping Device to Measure Motivation in Normal-Weight Individuals and Bariatric Surgery Patients

There is an urgent need to measure the motivation to taste a sweet fluid in order to determine the influence of sweet tastes on the potential choices and consumption of beverages in patients with obesity. Current methods utilize either survey instruments or arbitrary operant tasks. The sipometer enables the participant to utilize an actual ingestive behavioral response to measure motivation during access to beverages on either ad libitum (AL) or progressive time ratio (PR) schedules. We determined the sipometer's responsiveness and reliability as a test of change in motivation for sweet tastes after bariatric surgery. Participants (58 patients and 28 controls, BMI: 18.5-24.9 kg/m2) sham-consumed an aspartame-sweetened (S) and non-sweetened (N) beverage under AL and PR schedules at a pre-surgery/baseline and a 3-month and 24-month visit (patients only). Cumulative pressure (CumPres), a measure of effort, was the sum of the pressures exerted during sipping under each condition. Baseline CumPres for PRS was higher than ALS and ALN in patients (p < 0.03) and higher than PRN in controls (p = 0.009). At 3 months, CumPres did not differ amongst conditions in patients, but CumPres for PRS was higher than all other conditions in controls (p < 0.0005). There were no baseline group differences; however, patients' CumPres for PRS was lower than controls' at 3 months (p = 0.002). Patients' CumPres for PRS decreased non-significantly between the baseline and 3 months but increased at 24 months compared to 3 months (p = 0.025) and was no different from baseline. Controls' CumPres for PRS increased at 3 months (p = 0.0359), but CumPres for all conditions was correlated between visits (p's < 0.038). The sipometer is a reliable and sensitive measure of motivation to consume sweet beverages and may reflect changes in post-operative energy intake.

Dietary intake by patients taking GLP-1 and dual GIP/GLP-1 receptor agonists: A narrative review and discussion of research needs

Background

Obesity and type 2 diabetes mellitus (T2DM) are increasingly common in the United States and worldwide. Because both conditions are associated with serious health consequences, weight reduction is recommended by professional medical and nutrition societies to improve outcomes. Due to the striking efficacy of glucagon-like peptide receptor agonists (GLP-1RAs) and dual mechanism glucose-dependent insulinotropic polypeptide/glucagon-like peptide receptor agonists (GIP/GLP-1RAs) for weight reduction and glycemic control, there is increased utilization for patients with obesity and/or T2DM. Yet, the impact of these medications on dietary intake is less understood.

Methods

This narrative literature review summarizes clinical studies quantifying and characterizing dietary intake in people with obesity and/or T2DM using GLP-1 or GIP/GLP-1 RAs.

Results

Though data from these studies reveal that total caloric intake was reduced by 16-39 %, few studies evaluated the actual composition of the diet.

Conclusions

Further research is needed to understand the unique nutritional needs of adults on GLP-1 or dual GIP/GLP-1RAs and to support the development of nutritional guidelines for these individuals.

Unilateral peroneal neuropathy in a patient following laparoscopic sleeve gastrectomy

Peroneal neuropathy, characterized by the occurrence of a foot drop, can develop due to a variety of factors, such as tumors, trauma, or metabolic conditions, making it one of the most prevalent peripheral neuropathies of the lower limbs. This condition is becoming more identifiable among patients who have undergone substantial weight reduction through bariatric surgery. The condition may present with symptoms like pain, sporadic paresthesia, and functional restrictions, primarily linked to foot drop. This case study explores an episode of acute foot drop in a patient who underwent a sleeve gastrectomy, leading to substantial weight loss.The patient, a middle-aged woman with a history of obesity, underwent sleeve gastrectomy and achieved normal body mass index (BMI) within a year. Eleven months post-surgery, she experienced a right-sided foot drop following a minor knee injury. Detailed history taking revealed noncompliance with vitamin supplementation, recurrent vomiting episodes, and a recent diagnosis of pancreatic insufficiency. Peripheral neuropathy, particularly peroneal nerve involvement, was confirmed through nerve conduction studies and radiological imaging. The mechanism of injury was attributed to rapid weight loss, potential nutrient deficiencies, and possible traction to the nerve.This case underscores the importance of early identification, comprehensive nutritional assessment, and timely intervention in managing neurological complications of post-bariatric surgery. Increased awareness among healthcare providers, particularly musculoskeletal specialists, is crucial as the prevalence of bariatric surgery continues to grow, ensuring optimal care for patients in this vulnerable population.

Reduction in Serum Carotenoid Levels Following One Anastomosis Gastric Bypass

Given the health benefits of carotenoids, it is crucial to evaluate their levels in patients undergoing malabsorptive procedures like one anastomosis gastric bypass (OAGB). This study aimed to assess serum carotenoid levels before and 6 months following OAGB. Prospectively collected data from patients who underwent primary OAGB were analyzed. Data included anthropometrics, dietary intake assessments, and biochemical tests. Serum samples were analyzed for lipid profile and serum carotenoids, including lutein, zeaxanthin, α-carotene, β-carotene, phytofluene, ζ-carotene, and lycopene. Data from 27 patients (median age 47.0 years and 55.6% female) were available before and 6 months post-OAGB. The median pre-surgical BMI was 39.5 kg/m2, and the median excess weight loss at 6 months post-surgery was 63.9%. Significant decreases in all carotenoid levels were observed over time (p < 0.001 for all). A median relative decline of 65.1% in absolute total carotenoid levels and 12.7% in total cholesterol levels were found. No associations were observed between changes in clinical outcomes and carotenoid levels during the study period. This study reveals significant decreases in carotenoid levels within the first 6 months following OAGB. Nutritional intervention studies are needed to explore how incorporating carotenoid-rich foods affects post-surgery carotenoid levels and clinical outcomes.

The Role of Dietary Intake in the Weight Loss Outcomes of Roux-en-Y Gastric Bypass and Sleeve Gastrectomy: A Systematic Review and Meta-analysis

The relationship between postoperative dietary intake and weight loss after bariatric surgery remains unclear. We performed a systematic review and meta-analysis of studies published between January 2000 and May 2023, reporting weight loss outcomes, and dietary intake before and after Roux-en-Y gastric bypass and sleeve gastrectomy. A total of 42 studies were included. There was no detectable difference in dietary intake between the two procedures. Roux-en-Y gastric bypass induced an average decrease in energy intake of 886 kcal/day at 12-month post-surgery; however, there was no correlation between daily energy intake and weight loss. These findings show a substantial reduction of energy intake in the first year after bariatric surgery but do not support a link between lower energy intake and greater weight loss.

Ramadan Fasting in Individuals with Metabolic Dysfunction-Associated Steatotic Liver Disease, Liver Transplant, and Bariatric Surgery: A Narrative Review

Metabolic dysfunction-associated steatotic liver disease is a growing worldwide pandemic. A limited number of studies have investigated the potential effect of Ramadan fasting on metabolic dysfunction-associated steatotic liver disease (MASLD). There is no single medication for the treatment of MASLD. There is a growing interest in dietary intervention as potential treatment for metabolic diseases including MASLD. The aim of this study was to discuss the epidemiology, pathogenesis, and risk factors of MASLD and the potential effects of Ramadan fasting on MASLD, liver transplant, and bariatric surgery. We searched PubMed and SCOPUS databases using different search terms. The literature search was based on research studies published in English from the year 2000 to the 2024. Thirty-two studies were included in this review. Ramadan fasting reduced body weight and improved lipid profile, anthropometric indices, fasting plasma glucose, plasma insulin, and inflammatory cytokines. Ramadan fasting improved risk factors of nonalcoholic fatty liver disease and might improve MASLD through weight reduction. However, further studies are needed to assess the safety and effectiveness of Ramadan fasting in liver transplant recipients and bariatric surgery.

Approach to Obesity Treatment in Primary Care: A Review

Importance

More than 40% of US adults have obesity, which increases the risks for multiple chronic diseases and premature mortality. Historically, nonsurgical interventions often have not led to sufficient weight loss and maintenance to improve health, but highly effective antiobesity medications (AOMs) have recently become available, and additional effective therapeutics are under development. Given that most medical care for adults with obesity is delivered in primary care settings, guidance for integrating weight-management approaches is needed.

Observations

Lifestyle interventions can lead to a mean weight loss of 2% to 9% of initial weight at 1 year and increase the likelihood of weight loss of 5% or more, but weight regain over time is common even with continued treatment. Adjunctive treatments, including AOMs and surgical approaches, can lead to larger, more sustained weight loss and improvements in numerous obesity-associated medical conditions. Highly effective AOMs, including nutrient-stimulated hormone-based therapies, induce mean weight loss of 15% or more. Barriers to intervention, including access to care, have a disproportionate influence on populations most affected by obesity and its consequences.

Conclusions and Relevance

Primary care clinicians play a vital role in the assessment, management, and support of patients with obesity. With careful clinical assessment and shared decision-making, a flexible treatment plan can be developed that reflects evidence of treatment efficacy, patient preference, and feasibility of implementation. Adjunctive therapies to lifestyle interventions, including more effective pharmacotherapeutics for obesity, offer hope to patients and the potential for considerable improvements in health and quality of life.

Effect of laparoscopic sleeve gastrectomy versus laparoscopic Roux-en-Y gastric bypass on body composition

BACKGROUND

There is limited data with respect to body composition changes for laparoscopic sleeve gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (RYGB). The objective of this study was to analyse changes in body composition between these two procedures during the first year after bariatric surgery.

METHODS

A prospective study was performed in patients undergoing bariatric surgery at two tertiary hospitals between 2017 and 2023. Body composition was assessed with dual-energy x-ray absorptiometry immediately before surgery, and at 1-, 6-, 12-, 18- and 24-months post-operatively, with a subgroup analysis performed for patients who undertook a scan at 18- and 24-months. Total weight loss (TWL), body mass index (BMI), fat mass (FM), lean body mass (LBM) and bone mineral content (BMC) parameters were compared between SG and RYGB.

RESULTS

Forty-five patients were included in this series (SG n = 30, RYGB n = 15). There was a significant reduction in mean %TWL of 26.94 ± 8.86% and mean BMI of 11.12 ± 3.70 kg/m2 over 12-months. LBM accounted for 17.8% of TWL over 12-months, SG and RYGB did not differ in terms of loss of FM or LBM. For both procedures, the loss of LBM appeared to plateau at 6-months post-operatively. The only statistically significant finding between the two procedures was that RYGB resulted in an additional 0.06 kg loss compared with SG.

CONCLUSION

SG and RYGB have been shown to have comparable weight loss and body composition changes in the short-to-medium term following surgery. LBM reduction was most significant in the early post-operative period across the entire cohort.

Completeness of intervention reporting of nutrition-focused weight management interventions adjunct to metabolic and bariatric surgery: effect of the TIDieR checklist

Nutrition-focused interventions are essential to optimize the bariatric care process and improve health and weight outcomes over time. Clear and detailed reporting of these interventions in research reports is crucial for understanding and applying the findings effectively in clinical practice and research replication. Given the importance of reporting transparency in research, this study aimed to use the Template for Intervention Description and Replication (TIDieR) checklist to evaluate the completeness of intervention reporting in nutritional weight management interventions adjunct to metabolic and bariatric surgery (MBS). The secondary aim was to examine the factors associated with better reporting. A literature search in PubMed, PsychINFO, EMBASE, Scopus, and the Cochrane Controlled Register of Trials was conducted to include randomized controlled trials (RCT), quasi-RCTs and parallel group trials. A total of 22 trials were included in the final analysis. Among the TIDieR 12 items, 6.6 ± 1.9 items were fully reported by all studies. None of the studies completely reported all intervention descriptors. The main areas where reporting required improvement were providing adequate details of the materials and procedures of the interventions, intervention personalization, and intervention modifications during the study. The quality of intervention reporting remained the same after vs. before the release of the TIDieR guidelines. Receiving funds from industrial organizations (p = 0.02) and having the study recorded within a registry platform (p = 0.08) were associated with better intervention reporting. Nutritional weight management interventions in MBS care are still below the desirable standards for reporting. The present study highlights the need to improve adequate reporting of such interventions, which would allow for greater replicability, evaluation through evidence synthesis studies, and transferability into clinical practice.

Evaluating the Impact of a Virtual Health Coaching Lifestyle Program on Weight Loss after Sleeve Gastrectomy: A Prospective Study

Bariatric surgery (BS) is a leading treatment for obesity; however, adverse side effects (e.g., pain and infection) can deter patients or affect weight maintenance. This study investigates how a post-operative virtual health coaching lifestyle program, monitoring virtual weekly goal progress made by patients, affects weight loss after BS, specifically sleeve gastrectomy. Patients recruited for this 6-month study were classified with a BMI > 30 kg/m2 90 days post-operatively. Patients were prescribed lifestyle support delivered by certified health and wellness coaches (InHealth Lifestyle Therapeutics™). Demographic variables (e.g., age, weight, height, and gender) were obtained and compared according to initial, 3-, 6-month, and current weight through repeated measures ANOVA and post hoc comparison. Thirty-eight adult participants were included, with a mean age of 52 years ± 12.9 and with a majority (n = 35; 97%) of them being female. There were significant differences in weight reported across all five time points (p < 0.05), with the greatest weight difference seen between the initial (250.3 ± 45.5 lbs.) and final time points (226.7± 40.4 lbs.). This study suggests post-operative virtual health coaching can enhance weight loss outcomes after sleeve gastrectomy. Further research is needed to assess the long-term effects and cost-effectiveness of such a form of coaching for bariatric surgery patients.

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

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

Early Exercise Through Telerehabilitation After Bariatric Surgery: Is It Feasible?

PURPOSE

The feasibility of early telerehabilitation after bariatric surgery is unknown. The objective of this study was to assess the feasibility and perception of engaging in the online exercise protocol in patients during the first month after bariatric surgery.

MATERIAL AND METHODS

A total of 67 patients, enrolled in a telerehabilitation program following bariatric surgery, completed a survey assessing their perception of the intensity, discomfort, and safety during exercise sessions.

RESULTS

Forty percent of participants began exercising between 5 and 10 days after surgery. Seventy-one percent of patients did not experience discomfort during the first month of exercise, and those who reported discomfort mainly mentioned dizziness and abdominal pain. No significant differences were found in the presence of discomfort among different types of surgeries performed. There was a significant difference in the presence of discomfort between patients who started exercising before and after 15 days of surgery, with less discomfort reported in the group that started after 15 days. Ninety-eight percent of patients felt safe during online exercise sessions. Most participants perceived the intensity of the sessions as moderate. The most frequently mentioned benefits of exercise were increased energy, mood, and feeling more active.

CONCLUSION

Telerehabilitation conducted during the first month after bariatric surgery was feasible and well tolerated by patients, providing a safe alternative for those patients who face difficulties with in-person interventions.

Translation and cross cultural adaptation of the questionnaire "Quality of Alimentation" for brazilian portuguese

PURPOSE

We aimed to provide translation and cultural adaptation of the questionnaire "Quality of Alimentation" from English to Brazilian Portuguese.

METHODS

The transcultural translation process consisted of the following steps: translation of the original English version to Portuguese by two bilingual translators native in the targeted language; Reverse translation by two translators native in the original language; Review of reverse translation; Review of the Portuguese version from the questionnaire by a local committee of experts in bariatric surgery; Pre-trial to evaluate of clarity, comprehension, and overall acceptability by the target population.

RESULTS

In its final Portuguese version, the questionnaire "Quality of alimentation" was found to be of clear comprehension and easy applicability.

CONCLUSION

The questionnaire's translation and cultural adaptation for Brazilian Portuguese represents an important step towards improving food tolerance evaluation following bariatric surgery. Further studies are however necessary for validation of its psychometric properties in Brazil.

Association between Self-Perception of Chewing, Chewing Behavior, and the Presence of Gastrointestinal Symptoms in Candidates for Bariatric Surgery

Given the changes in the digestive tract post-bariatric surgery, adapting to a new pattern of eating behavior becomes crucial, with special attention to the specifics of chewing mechanics. This study aimed to investigate the association between self-perception of chewing, chewing behavior, and the presence of gastrointestinal symptoms in preoperative patients undergoing bariatric surgery. Sixty adult candidates for bariatric surgery at a public hospital in Belém (Brazil) were analyzed. Participants predominantly exhibited unilateral chewing patterns (91.6%), a fast chewing rhythm (73.3%), a large food bolus (80%), liquid intake during meals (36.7%), and 41.7% reported that chewing could cause some issue. Significant associations were found between the perception of causing problems and chewing scarcity (p = 0.006), diarrhea (p = 0.004), absence of slow chewing (p = 0.048), and frequent cutting of food with front teeth (p = 0.034). These findings reveal a relationship between the perception of chewing problems and chewing scarcity, presence of diarrhea, and fast chewing.

Nutritional aspects of prehabilitation in adults with cirrhosis awaiting liver transplant

Malnutrition, sarcopenia (low muscle mass), and physical frailty have gained increasing recognition in candidates for liver transplant (LT) as these conditions can impact postoperative functional capacity. Multidimensional prehabilitation programs have been proposed as a safe intervention in adults awaiting LT but the nutritional pillar of prehabilitation has been understudied. This review summarizes the nutritional recommendations for prehabilitation for individuals with cirrhosis awaiting LT. Three major aspects of nutritional prehabilitation are discussed: (1) Assess: Evaluate nutritional status and assess for malnutrition, sarcopenia, and frailty to guide the nutritional prehabilitation intervention intensity, increasing across universal, targeted, and specialist levels; (2) Intervene: Prescribe a nutritional prehabilitation intervention to meet established nutrition guidelines in cirrhosis with a targeted focus on improving nutritional status and muscle health; (3) Reassess: Follow-up based on the required intensity of nutritional care with as needed intervention adjustment. Topics covered in the review include nutritional care levels for prehabilitation, energy prescriptions across body mass index strata, detailed considerations around protein intake (amount, distribution, and quality), carbohydrate and fat intake, other nutritional considerations, and the potential role of dietary supplements and nutraceuticals. Future research is warranted to more accurately evaluate energy needs, evaluate emerging dietary supplementation strategies, and establish the role of nutraceuticals alongside food-based interventions. While the general principles of nutritional prehabilitation are ready for immediate application, future large-scale randomized controlled trials in this space will help to quantify the benefit that can be gained by transitioning the LT approach from passive "transplant waitlist time" to active "transplant preparation time."

Management of Patients With Kidney Disease Undergoing Bariatric Surgery: A Multidisciplinary Approach

Bariatric surgery is increasingly recognized as a safe and effective treatment for obesity in patients with chronic kidney disease (CKD), including stages 4, 5, and 5D (on dialysis). Among the available surgical methods, sleeve gastrectomy (SG) is the most commonly performed weight loss procedure and is mainly done to facilitate kidney transplantation (KT). However, many KT candidates treated with SG remain on the transplant waiting list for months to years, with some never receiving a transplant. Therefore, appropriate candidates for SG must be selected, and post-SG management should address the unique needs of this population, with a focus on sustaining the metabolic benefits of surgery while minimizing potential side effects related to rapid weight loss which may inadvertently lead to muscle and bone catabolism. Multidisciplinary post-SG care in this population may lead to overall better health on the transplant waiting list, resulting in a higher percentage of post-SG patients ultimately receiving KT. To tailor the effective treatment for these patients, clinicians should acknowledge that patients with CKD stage 4-5D have different nutritional needs and are metabolically and psychosocially distinct from the general bariatric surgery population. Sarcopenia is highly prevalent and may be exacerbated by muscle catabolism following SG if not adequately addressed. Blood pressure, glucose, and bone metabolism are all affected by the CKD stage 4-5D, and therefore require distinct diagnostic and management approaches. Long-standing chronic disease, associated comorbidities, and low adherence to medical therapies require ongoing comprehensive psychosocial assessment and support. This paper aims to review and consolidate the existing literature concerning the intersection of CKD stage 4-5D and the consequences of SG. We also suggest future clinical outcome studies examining novel treatment approaches for this medically complex population.

Changes in nutrient composition and diet quality in the first 6 months following bariatric surgery: An observational cohort study

BACKGROUND

Bariatric surgery (BS) may result in inadequate nutrient intake and poor diet quality, which can lead to nutritional complications. The present study aimed to evaluate changes in macro- and micronutrient composition and diet quality in the first 6 months following BS.

METHODS

One hundred seven participants undergoing BS (Roux-en-Y gastric bypass: n = 87, sleeve gastrectomy: n = 20) completed 3-day food records before and 6 months after surgery. Changes in energy, macronutrient (carbohydrates, protein, fat, dietary fibre) and micronutrient intake (folate, vitamin B12, vitamin D, calcium, iron) were evaluated. Diet quality was assessed by adherence to the Dutch food-based dietary guidelines.

RESULTS

After BS, we observed a significant decrease in intake of energy and all macro- and micronutrients (p < 0.01 for all), except for calcium (-39.0 ± 404.6 mg; p = 0.32). Overall, nutrient composition slightly changed with an increase in the relative intake of protein (+1.1 ± 4.3 energy percentage [en%]; p = 0.01) and mono- and disaccharides (+4.2 ± 6.4 en%; p < 0.001) post-surgery. Consumption (median [Q1, Q3]) of vegetables (-50 [-120, 6] g day-1 ), wholegrain products (-38 [-81, -8] g day-1 ), liquid fats (-5 [-13, 2] g day-1 ), red meat (-3 [-30, 4] g day-1 ), processed meat (-32 [-55, 13] g day-1 ), sodium (-0.7 [-1.1, -0.2] g day-1 ) and unhealthy food choices (-2.4 [-5.0, 0.6] serves week-1 ) significantly decreased after BS (p < 0.01 for all).

CONCLUSIONS

Our results demonstrate both favourable and unfavourable changes in macro- and micronutrient composition and diet quality in the first 6 months following BS. Insight into these changes can improve dietary counselling in this population. Future research into underlying causes, consequences and long-term changes in dietary intake is needed.

Nutritional Considerations for Patients With Renal Failure Undergoing Sleeve Gastrectomy

Obesity is highly prevalent in patients with renal disease, as it contributes to or accelerates the progression of kidney disease and is frequently a barrier to kidney transplantation. Patients with renal disease have unique dietary needs due to various metabolic disturbances resulting from altered processing and clearance of nutrients. They also frequently present with physical disability, resulting in difficulty achieving adequate weight loss through lifestyle modifications. Therefore, kidney transplant candidates may benefit from bariatric surgery, particularly sleeve gastrectomy (SG), as the safest, most effective, and long-lasting weight loss option to improve comorbidities and access to transplantation. However, concerns regarding nutritional risks prevent broader dissemination of SG in this population. No specific guidelines tailored to the nutritional needs of patients with renal disease undergoing SG have been developed. Moreover, appropriate monitoring strategies and interventions for muscle loss and functional status preservation, a major concern in this at-risk population, are unknown. We aimed to summarize the available literature on the nutritional requirements of patients with renal disease seeking SG as a bridge to transplantation. We also provide insight and guidance into the nutritional management pre and post-SG.

Distinctive patterns of sulfide- and butyrate-metabolizing bacteria after bariatric surgery: potential implications for colorectal cancer risk

Despite improved cardiometabolic outcomes following bariatric surgery, its long-term impact on colorectal cancer (CRC) risk remains uncertain. In parallel, the influence of bariatric surgery on the host microbiome and relationships with disease outcomes is beginning to be appreciated. Therefore, we investigated the impact of Roux-en-Y gastric bypass (RYGB) and vertical sleeve gastrectomy (VSG) on the patterns of sulfide-reducing and butyrate-producing bacteria, which are hypothesized to modulate CRC risk after bariatric surgery. In this single-center, cross-sectional study, we included 15 pre-surgery subjects with severe obesity and patients who are at a median (range) of 25.6 (9.9-46.5) months after RYGB (n = 16) or VSG (n = 10). The DNA abundance of fecal bacteria and enzymes involved in butyrate and sulfide metabolism were identified using metagenomic sequencing. Differences between pre-surgery and post-RYGB or post-VSG cohorts were quantified using the linear discriminant analysis (LDA) effect size (LEfSe) method. Our sample was predominantly female (87%) with a median (range) age of 46 (23-71) years. Post-RYGB and post-VSG patients had a higher DNA abundance of fecal sulfide-reducing bacteria than pre-surgery controls (LDA = 1.3-4.4, p < .05). The most significant enrichments were for fecal E. coli, Acidaminococcus and A. finegoldii after RYGB, and for A. finegoldii, S. vestibularis, V. parvula after VSG. As for butyrate-producing bacteria, R. faecis was more abundant, whereas B. dentium and A. hardus were lower post-RYGB vs. pre-surgery. B. dentium was also lower in post-VSG vs. pre-surgery. Consistent with these findings, our analysis showed a greater enrichment of sulfide-reducing enzymes after bariatric surgery, especially RYGB, vs. pre-surgery. The DNA abundance of butyrate-producing enzymes was lower post-RYGB. In conclusion, the two most used bariatric surgeries, RYGB and VSG, are associated with microbiome patterns that are potentially implicated in CRC risk. Future studies are needed to validate and understand the impact of these microbiome changes on CRC risk after bariatric surgery.

Change in Mineral Status After Bariatric Surgery: a Meta-analysis

BACKGROUND

The risk of protein and vitamin deficiencies after bariatric surgery has been well studied, but the change in mineral status has not gotten enough attention. This study aimed to perform a meta-analysis regarding the change in mineral levels after bariatric surgery and the prevalence of postoperative mineral deficiency, with subgroup analyses of different surgical procedures, study regions, and follow-up time.

METHODS

CENTRAL, PubMed, and EMBASE were searched for related articles. Meta-analysis, subgroup analysis, and sensitivity analysis were performed if necessary.

RESULTS

A total of 107 articles with 47,432 patients were included. The most severe mineral deficiency after bariatric surgery was iron (20.1%), followed by zinc (18.3%), copper (14.4%), chlorine (12.2%), phosphorus (7.5%), and calcium (7.4%). Serum concentrations of potassium, sodium, selenium, manganese, and molybdenum showed no significant change before and after surgery. Subgroup analyses revealed that SG had fewer deficiencies in serum iron, calcium, zinc, magnesium, phosphorus, copper, and selenium than RYGB. OAGB showed a higher incidence of serum iron and zinc deficiencies than RYGB. Studies conducted in different regions also found various mineral statuses after surgery. Studies with follow-up ≥ 5 years had a lower prevalence of zinc, copper, and selenium deficiencies than follow-up < 5 years.

CONCLUSION

A high deficiency rate of serum iron, zinc, copper, chlorine, phosphorus, and calcium was seen after bariatric surgery. The difference in surgical procedures, study regions, and follow-up time may affect postoperative mineral status; more targeted mineral supplement programs are needed considering these influencing factors.

Association between disordered eating and clinical outcomes following a surgical or endoscopic bariatric procedure: A real-world exploratory study

Problem

Disordered eating, such as binge, graze, and emotional eating, has been strongly linked to weight gain. Improved understanding of disordered eating by adults who elect bariatric weight loss procedures in a real-world setting is required.

Purpose

To determine the association between the number and type of disordered eating patterns (DEPs), as described by healthcare professionals during routine care without standardized assessment, with clinical outcomes in adults who elected a bariatric weight loss procedure.

Method

An observational cohort study recruited laparoscopic sleeve gastrectomy (LSG) and endoscopic sleeve gastroplasty (ESG) patients. DEPs documented in the medical record during routine care were observed and tested for association with events (symptoms, side-effects, or adverse events), micronutrient deficiencies, weight loss, and attrition. Data were observed up to 12-month post-procedure.

Results

215 LSG and 32 ESG patients were recruited. The mean number of DEPs was 6.4 (SD: 2.1) and 6.4 (SD: 2.1) in the LSG and ESG cohorts, respectively. Night eating was associated with a higher number of events (p < 0.008) in the LSG cohort, and non-hungry eating was associated with a higher number of events in the ESG cohort (p < 0.001). ESG patients who had a surgical or medical event by 6-months post-procedure had mean 1.78 (95%CI: 0.67, 2.89) more DEPs (p = 0.004). DEPs were not associated with weight loss, micronutrient deficiencies, nor attrition.

Conclusion

The treating healthcare team believed the LSG and ESG patients experienced a wide variety and high frequency of DEPs requiring multidisciplinary support. Non-hungry eating and night eating were associated with poorer outcomes following an LSG or ESG.

Trial registration

The study was prospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12622000332729).

Estimates of Resting Energy Expenditure and Total Energy Expenditure Using Predictive Equations for Individuals After Bariatric Surgery: a Systematic Review with Meta-analysis

PURPOSE

Patients after metabolic bariatric surgery (MBS) require attention to maintain energy balance and avoid weight regain. Predictive equations for resting energy expenditure (REE) and total energy expenditure (TEE) are needed since gold standard methods like calorimetry and doubly labeled water are rarely available in routine clinical practice. This study aimed to determine which predictive equation for REE and TEE has the lowest bias in subjects after MBS.

METHODS

MEDLINE, Embase, Web of Science, and CENTRAL searches were performed. Meta-analyses were performed with the data calculated by the predictive equations and measured by the gold standard methods for those equations that had at least two studies with these data. The DerSimonian and Laird random-effects model and the I2 statistic were used to quantify heterogeneity in the quantitative analyses. The risk of bias was assessed using the Joanna Briggs Institute critical appraisal checklist.

RESULTS

Seven studies were included. The present study found that the Mifflin St. Jeor (1990) equation had the lowest bias (mean difference =  - 39.71 kcal [95%CI =  - 128.97; 49.55]) for calculating REE in post-BS individuals. The Harris-Benedict (1919) equation also yielded satisfactory results (mean difference =  - 54.60 kcal [95%CI =  - 87.92; - 21.28]).

CONCLUSION

The predictive equation of Mifflin St. Jeor (1990) was the one that showed the lowest bias for calculating the REE of patients following MBS.

Development and complications of nutritional deficiencies after bariatric surgery

The clinical effectiveness of bariatric surgery has encouraged the use of bariatric procedures for the treatment of morbid obesity and its comorbidities, with sleeve gastrectomy and Roux-en-Y gastric bypass being the most common procedures. Notwithstanding its success, bariatric procedures are recognised to predispose the development of nutritional deficiencies. A framework is proposed that provides clarity regarding the immediate role of diet, the gastrointestinal tract and the medical state of the patient in the development of nutritional deficiencies after bariatric surgery, while highlighting different enabling resources that may contribute. Untreated, these nutritional deficiencies can progress in the short term into haematological, muscular and neurological complications and in the long term into skeletal complications. In this review, we explore the development of nutritional deficiencies after bariatric surgery through a newly developed conceptual framework. An in-depth understanding will enable the optimisation of the post-operative follow-up, including detecting clinical signs of complications, screening for laboratory abnormalities and treating nutritional deficiencies.