Bariatric surgery patients in AUD treatment in Norway-an exploratory cross-sectional study

AIMS

Patients who have undergone some forms of bariatric surgery have increased risk of developing alcohol use disorder (AUD). In the present observational study, we compared patients with AUD who themselves reported to having undergone bariatric surgery with other patients in treatment for AUD.

MATERIALS

One-hundred-and-six consecutively enrolled patients in residential treatment for AUD were asked if they had undergone bariatric surgery. Sociodemographics, mental health-related, and alcohol use-related parameters were compared between those who had and those who had not undergone bariatric surgery.

RESULTS

Of the 106 patients with AUD, seven (6.6%; 95% confidence interval, 2.7%-13.1%) had undergone bariatric surgery. Six of seven patients had undergone such surgery were women (P < .001). The patients with AUD who had undergone bariatric surgery were similar to other patients with AUD on most other parameters, the exception being a larger number of alcohol units ingested to feel an effect of alcohol (adjusted odds ratio 7.1; 95% confidence interval 2.0-12.2; P = .007).

CONCLUSION

The high number of patients with AUD that reported having undergone bariatric surgery emphasizes the risks following such a procedure. The overrepresentation of women may reflect than more women undergo such procedures. The unexpected finding that patients with AUD having undergone bariatric surgery seemed to need more alcohol to feel intoxicated warrants further research.

Effects of Sleeve Gastrectomy and Roux-en-Y Gastric Bypass on Escitalopram Pharmacokinetics: A Cohort Study

BACKGROUND

Changes in the gastrointestinal physiology after bariatric surgery may affect the pharmacokinetics of medications. Data on the impact of different surgical techniques on the pharmacokinetics of commonly prescribed antidepressants such as escitalopram are limited.

METHODS

This case-only prospective study investigated escitalopram-treated patients who underwent bariatric surgery at hospitals in Central Norway. Escitalopram concentrations were assessed using serial blood samples obtained during a dose interval of 24 hours preoperatively and at 1, 6, and 12 months, postoperatively. The primary outcomes were changes in the area under the time-concentration curve (AUC 0-24 ) with secondary outcomes, including full pharmacokinetic profiling. We performed repeated-measures analysis of variance for the AUC 0-24 and secondary outcomes.

RESULTS

Escitalopram-treated obese patients who underwent sleeve gastrectomy (n = 5) and Roux-en-Y gastric bypass (n = 4) were included. Compared with preoperative baseline, dose-adjusted AUC 0-24 values were within ±20% at all time points, postoperatively in the sleeve gastrectomy and oux-en-Y gastric bypass groups, with the largest changes occurring 1 month postoperatively (+14.5 and +17.2%, respectively). No statistically significant changes in any pharmacokinetic variables over time were reported; however, there was a trend toward increased maximum concentrations after surgery ( P = 0.069).

CONCLUSIONS

Our findings suggest that bariatric surgery has no systematic effect on the pharmacokinetics of escitalopram. However, because of the substantial interindividual variation, therapeutic drug monitoring can be considered to guide postoperative dose adjustments.

The patient-practitioner interaction in post bariatric surgery consultations: an interpersonal process recall study

PURPOSE

The patient-practitioner relationship is fundamental to rehabilitation practice and patients' health and wellbeing. Dissonance between patients who have had bariatric surgery and health care practitioners about what supportive care and good outcomes are can undermine care. To address the mechanisms of this process, we conducted an Interpersonal Process Recall study.

MATERIALS AND METHODS

We interviewed patients (11), video recorded consultations (10), conducted video-assisted individual interviews with patients (10) and practitioners (11) and a dyadic data analysis.

RESULTS

We identified relational states and shifts in the clinical encounter 2-3 years post-surgery, described in themes: a) Playing by the Book - Making it Easier for Each Other, b) Down the Blind Alley - Giving up on Each Other, and c) Opposite Poles - Towards and Away from Each Other.

CONCLUSIONS

The post-surgery consultations facilitated responsibility for health and self-care but did not invite dialogues about the psychosocial burdens of living with obesity and undergoing bariatric surgery. Patients and practitioners tried to avoid creating conflict, which in turn seemed to foster distance, rather than human connection. This limits the encounter's benefit to both parties, leaving them frustrated and less willing to either meet again or take any gains into their future lives.IMPLICATIONS FOR REHABILITATIONIllness evokes feelings of stress and uncertainty and is experienced very differently from the perspective of patients and health care practitioners (HCPs), who encounter each other in a field fraught with tension.Bodily changes and difficult emotions related to food and eating are to be expected when undergoing bariatric surgery, and to explicitly "notice, name and validate" emotions can promote the patient's capacity to sustain self-care, lifestyle change, weight loss and health gains.Making interpersonal connection and interaction between patient and HCP the centre of bariatric aftercare can enhance engagement in and outcomes of the post-surgery clinical encounter.

Effect of Delayed Centrifugation on the Levels of NMR-Measured Lipoproteins and Metabolites in Plasma and Serum Samples

Metabolic profiling is widely used for large-scale association studies, based on biobank material. The main obstacle to the translation of metabolomic findings into clinical application is the lack of standardization, making validation in independent cohorts challenging. One reason for this is sensitivity of metabolites to preanalytical conditions. We present a systematic investigation of the effect of delayed centrifugation on the levels of NMR-measured metabolites and lipoproteins in serum and plasma samples. Blood was collected from 20 anonymous donors, of which 10 were recruited from an obesity clinic. Samples were stored at room temperature until centrifugation after 30 min, 1, 2, 4, or 8 h, which is within a realistic time scenario in clinical practice. The effect of delaying centrifugation on plasma and serum metabolic concentrations, and on concentrations of lipoprotein subfractions, was investigated. Our results show that lipoproteins are only minimally affected by a delay in centrifugation while metabolite levels are more sensitive to a delay. Metabolites significantly increased or decreased in concentration depending on delay duration. Further, we describe differences in the stability of serum and plasma, showing that plasma is more stable for metabolites, while lipoprotein subfractions are equally stable for both types of matrices.

Establishing Serum Reference Ranges for Antihypertensive Drugs

BACKGROUND

Therapeutic drug monitoring (TDM) involves the measurement of serum drug concentrations to optimize pharmacotherapy. Traditionally, blood pressure measurements alone, and not TDM, have been used to evaluate the antihypertensive drug response. However, approximately 50% of hypertensive patients treated with lifestyle changes and antihypertensive drugs fail to achieve blood pressure control. Serum drug concentration measurements could be useful to select the optimal drugs in adjusted doses and to identify nonadherence. Implementation of TDM in clinical routine for antihypertensive drugs depends on established serum reference ranges.

METHODS

Commonly used antihypertensive drugs were identified based on prescription data. The authors performed a review of authoritative literature on reported serum drug concentrations and calculated expected concentrations from previously reported pharmacokinetic parameters with commonly prescribed daily doses. Finally, serum drug concentrations in samples from patients undergoing antihypertensive treatment were measured.

RESULTS

Serum reference ranges for 24 frequently used antihypertensive drugs were established based on results from 3 approaches.

CONCLUSIONS

Serum drug concentration measurements, interpreted in light of the established reference ranges, together with blood pressure measurements and other clinical data, may help identify nonadherent patients and tailor individual antihypertensive treatment when deviant drug responses appear in line with the concept of personalized medicine.

Characteristics of Patients Reporting Presumed Problematic Drinking Behavior After Gastric Bypass: Exploring Long-Term Data From the BAROBS Study

OBJECTIVE

To explore patients' long-term experiences with drinking alcohol after Roux-n-Y gastric bypass (RYGB) for conceptualizing what may indicate problematic drinking behavior after bariatric surgery.

STUDY DESIGN

Three-center, observational study.

PATIENTS

546 adult patients undergoing RYGB in the period 2003-2009 in Norway.

MAIN OUTCOME MEASURES

Self-reported data on drinking behavior and experiences related to alcohol collected 10-15 years after surgery.

RESULTS

Out of the 959 patients undergoing RYGB in the period, 29 were diseased and 546 participated in this follow-up study (58.7%). Focusing on suspicious changes in drinking behavior, 8.8% reported drinking more, 11.5% consumed alcohol at least twice a week, and 10.6% consumed at a minimum of 6 units of alcohol at a frequency of at least once monthly. The nature of hangovers had changed for about a third of the patients, with 21.6% reporting these to feel weaker or absent. Repeated alcoholic blackouts were reported by 11.9%. A subgroup of the patients were categorized as displaying presumed problematic drinking behavior(PPDB). Among the PPDB-men there was a significant association to having had a fall last year (6 (100.0%) PPDB-patients vs. 30 (29.7%) non-PPDB, p<.001). Among the PPDB-women, there was a significant association to having had alcohol problems prior to surgery (7 (70.0%) PPDB-patients vs. 67 (17.7%) non-PPDB, p<.001). Less significant associations to PPDB reported for explorative purposes were lack of patient education (men) (16 (26.2%) PPDB-patients vs. 8 (61.5%) non-PPDB, p=.014); more than 3 months persistent musculoskeletal pain (women) (45 (15.3%) PPDB-patients vs. 29 (24.6%) non-PPDB, p=.026); subjective problems with memory (women) (58 (20.7%) PPDB-patients vs. 10 (9.1%) non-PPDB, p=.006); and, receiving professional help for mental problems last 12 months (women) (29 (22.7%) PPDB-patients vs. 45 (14.7%) non-PPDB, p=.043).

CONCLUSION

A subset of patients display drinking behaviors that may be consistent with postsurgical alcohol problems. Screening instruments like AUDIT may not be sufficiently specific to capture several risk behaviors occurring after bariatric surgery.

Effect of Sleeve Gastrectomy on Buprenorphine Pharmacokinetics: A Planned Case Observation

PURPOSE

Bariatric surgery may affect the absorption and metabolism of drugs by various mechanisms. We present a planned case observation of a patient treated with sublingual buprenorphine in an opioid maintenance treatment program, and the observed changes in buprenorphine pharmacokinetics following gastric sleeve surgery.

METHODS

Serial blood samples during a dose interval of 24 hours were obtained approximately 1 year preoperatively as well as 1 week, 1 month and 12 months postoperatively and key pharmacokinetic variables were calculated.

FINDINGS

The systemic exposure of buprenorphine (AUC) was relatively stable from the preoperative sampling to 1 week postoperatively (-6.3%), but declined markedly at 1 month (-43%) and 12 months (-42%) postoperatively. The maximum concentration of buprenorphine almost doubled at 1 week postoperatively before returning to baseline values 1 month and 12 months postoperatively.

IMPLICATIONS

This case observation indicates that after sleeve gastrectomy, the systemic exposure of sublingual buprenorphine can decrease. Clinicians should be aware of the possibility of loss of effect and emerging abstinence symptoms following sleeve gastrectomy. We recommend monitoring the patient closely for abstinence symptoms postoperatively and considering measuring serum concentrations of buprenorphine pre- and postoperatively.

Diagnoses related to abuse of alcohol and addictive substances after gastric bypass and sleeve gastrectomy: a nation-wide registry study from Norway

BACKGROUND

After Roux-en-Y gastric bypass (RYGB) patients are at higher risk of alcohol problems. In recent years, sleeve gastrectomy (SG) has become a common procedure, but the incidence rates (IRs) of alcohol abuse after SG are unexplored.

OBJECTIVES

To compare IRs of diagnoses indicating problems with alcohol or other substances between patients having undergone SG or RYGB with a minimum of 6-month follow-up.

SETTING

All government funded hospitals in Norway providing bariatric surgery.

METHODS

A retrospective population-based cohort study based on data from the Norwegian Patient Registry. The outcomes were ICD-10 of Diseases and Related Health Problems diagnoses relating to alcohol (F10) and other substances (F11-F19).

RESULTS

The registry provided data on 10,208 patients who underwent either RYGB or SG during the years 2008 to 2014 with a total postoperative observation time of 33,352 person-years. This corresponds to 8196 patients with RYGB (27,846 person-yr, average 3.4 yr) and 2012 patients with SG (5506 person-yr; average 2.7 yr). The IR for the diagnoses related to alcohol problems after RYGB was 6.36 (95% confidence interval: 5.45-7.36) per 1000 person-years and 4.54 (2.94-6.70) after SG. When controlling for age and sex, adjusted hazard ratio was .75 (.49-1.14) for SG compared with RYGB. When combining both bariatric procedures, women <26 years were more likely to have alcohol-related diagnoses (3.2%, 2.1-4.4) than women of 26 to 40 years (1.6%, 1.1-2.1) or women >40 (1.3%, .9-1.7). The IR after RYGB for the diagnoses related to problems with substances other than alcohol was 3.48 (95% confidence interval: 2.82-4.25) compared with 3.27 (1.94-5.17) per 1000 person-years after SG. Controlling for age and sex, the hazard ratio was .99 (.60-1.64) for SG compared with RYGB.

CONCLUSIONS

In our study, procedure-specific differences were not found in the risks (RYGB versus SG) for postoperative diagnoses related to problems with alcohol and other substances within the available observation time. A longer observation period seems required to explore these findings further.

Suboptimal Weight Loss and Weight Regain after Gastric Bypass Surgery-Postoperative Status of Energy Intake, Eating Behavior, Physical Activity, and Psychometrics

BACKGROUND

Suboptimal weight loss (SWL) and weight regain (WR) after gastric bypass surgery (GB) remains poorly understood.

OBJECTIVES

This study aims to compare GB patients experiencing SWL or significant WR (SigWR) with successful controls, regarding postoperative food intake, eating behavior, physical activity (PA), and psychometrics.

METHODS

Forty-nine patients with >1 year post-surgery were classified as either experiencing SWL (excess body weight loss, EWL, <50%, n = 22) or SigWR (total weight regain ≥15%, n = 38), with respective control groups. Energy intake (EI) was measured with a Food Frequency Questionnaire, eating behavior using the Dutch Eating Behavior Questionnaire and the Three-Factor Eating Questionnaire, and PA using both SenseWear Armbands and the International Physical Activity Questionnaire. Eating disorders, depression, and quality of life (QoL) were measured using the Eating Disorder Examination Questionnaire, Beck Depression Inventory II, and Impact of Weight on Quality of Life, respectively.

RESULTS

EI, macronutrient distribution, and meal frequency were similar among groups. However, disinhibited eating behavior score was higher, while most subcategories from IWQOL were significantly lower in both SWL and SigWR groups compared with their respective controls. PA was significantly lower in the SWL and SigWR groups compared with the respective controls. There were no differences between groups regarding depression.

CONCLUSIONS

Lower PA levels, disordered eating behavior and lower QoL are associated with unsuccessful weigh loss outcome after GB surgery. Longitudinal studies are needed to clarify the potential causal relationship between the previously described variables and SWL/SigWR after GB.

Bariatric surgery versus lifestyle interventions for severe obesity: 5-year changes in body weight, risk factors and comorbidities

Changes in body weight (BW), risk factors and comorbidities 5 years after Roux-en-Y gastric bypass (RYGB) or different lifestyle interventions are compared. A total of 209 (75% women) severe obese adults were non-randomly allocated to: (A) RYGB (n = 58), (B) weight loss (WL) camp (n = 30), (C) residential intermittent programme (n = 64) or (D) hospital outpatient programme (n = 57). Body weight, risk factors and comorbidities were assessed at baseline, 1 and 5 years. A total of 89 and 54% completed the 1- and 5-year follow-up. The RYGB group experienced more WL at 5 years (-23.9%, 95% CI [-27.7, -20.0]) compared with lifestyle groups: (B) (-9.2%, 95% CI [-16.9, -1.5]), (C) (-4.1%, 95% CI [-8.0, -0.1]) and (D) (-4.1 kg, 95% CI [-10.0, 1.8]) (all P < 0.001). No differences were observed between lifestyle groups, although groups B and C had significant WL after 5 years (all P < 0.05). Plasma glucose and high-density lipoprotein cholesterol were improved in the RYGB group at 5 years compared with lifestyle groups (all P < 0.05). More patients in the RYGB group experienced remission of hypertension (P < 0.05). RYGB was associated with a lower BW, improved blood parameters and hypertension remission compared with lifestyle interventions at 5 years. However, significant WL was also achieved with lifestyle interventions.

Bioavailability of Methadone After Sleeve Gastrectomy: A Planned Case Observation

OBJECTIVE

Morbidly obese patients on opioid-replacement therapy may be at risk for treatment refusal with regard to bariatric surgery. However, patients on opioid replacement may have the personal skills to facilitate the lifestyle changes required for successful outcomes after bariatric surgery. This planned case observation assessed the effects of sleeve gastrectomy on the pharmacokinetic properties of methadone.

METHODS

A white woman in her 40s on methadone maintenance therapy and with morbid obesity was referred for bariatric surgery. Serial blood samples for methadone concentration measurements were obtained before and at 5 days and 1, 7, and 11 months after surgery.

FINDINGS

Serum methadone concentrations increased from before to 5 days after surgery and continued to increase for 7 months thereafter. The predose measurement at 11 months postoperatively suggests a further increase compared with the previous predose measurements.

IMPLICATIONS

Clinicians should beware the potential for altered effects of methadone after bariatric surgery. We recommend that serum concentrations be routinely measured pre- and postoperatively, and that the dose be adjusted according to these measurements and regular clinical assessments.

The Impact of Feet Callosities, Arm Posture, and Usage of Electrolyte Wipes on Body Composition by Bioelectrical Impedance Analysis in Morbidly Obese Adults

OBJECTIVE

This study evaluated the impact of feet callosities, arm posture, and use of electrolyte wipes on body composition measurements by bioelectrical impedance analysis (BIA) in morbidly obese adults.

METHODS

36 morbidly obese patients (13 males, aged 28-70 years, BMI 41.6 ± 4.3 kg/m2) with moderate/severe feet callosities participated in this study. Body composition (percent body fat (%BF)) was measured while fasting using multi-frequency BIA (InBody 720®), before and after removal of callosities, with and without InBody® electrolyte wipes and custom-built auxiliary pads (to assess arm posture impact). Results from BIA were compared to air displacement plethysmography (ADP, BodPod®).

RESULTS

Median %BF was significantly higher with auxiliary pads than without (50.1 (interquartile range 8.2) vs. 49.3 (interquartile range 9.1); p < 0.001), while no differences were found with callosity removal (49.3 (interquartile range 9.1) vs. 50.0 (interquartile range 7.9); NS) or use of wipes (49.6 (interquartile range 8.5) vs. 49.3 (interquartile range 9.1); NS). No differences in %BF were found between BIA and ADP (49.1 (IQR: 8.9) vs. 49.3 (IQR: 9.1); NS).

CONCLUSION

Arm posture has a significant impact on %BF assessed by BIA, contrary to the presence of feet callosities and use of electrolyte wipes. Arm posture standardization during BIA for body composition assessment is, therefore, recommended.

Bariatric surgery or lifestyle intervention? An exploratory study of severely obese patients' motivation for two different treatments

BACKGROUND

In the complex field of treating severe obesity, motivation is receiving increased attention. This explorative study aims to highlight what influences the preferences of severely obese patients deciding for either gastric bypass surgery or lifestyle treatment.

METHODS

Patients awaiting laparoscopic gastric bypass were presented with an 18-week inpatient lifestyle programme alternative to gastric bypass. Questionnaires provided qualitative data (reasons for choosing one treatment over another) and quantitative data (mental health assessment using the Hospital Anxiety and Depression Scale). The material was analysed according to a sequential exploratory design involving thematic analysis of patients' arguments, validation using HADS, and statistical computations (hypothesis testing) with one-way ANOVA followed by Dunnett's post hoc test.

RESULTS

159 participants (mean BMI 47.2 kg/m(2)) returned questionnaires of which 32% wanted the lifestyle treatment alternative to surgery. Reasons for choosing the two treatments varied widely as did also the corresponding data on mental health. Two subgroups stood out with particularly high mental symptom scores, namely patients choosing surgery due to reluctance to engage in social interaction in lifestyle treatment, and patients preferring lifestyle treatment due to the fear of dying during general anaesthesia. These two subgroups showed significantly higher symptom scores than other subgroups within their therapy-of-choice group. The number of comorbid diseases was also found to impact upon motivation.

CONCLUSIONS

Patients carry different incentives for choosing the same type of treatment. On a subgroup level, psychopathological symptoms seem to follow motivational patterns. Analysing motivation and mental health may provide measures for identifying subgroups with various prospects for therapy outcome.

Bariatric surgery versus lifestyle interventions for morbid obesity--changes in body weight, risk factors and comorbidities at 1 year

BACKGROUND

Few studies have looked at non-surgical alternatives for morbid obese patients. This study aims to compare 1-year weight loss and changes in risk factors and comorbidities after bariatric surgery and three conservative treatments.

METHODS

Patients with morbid obesity (BMI > 40 or BMI > 35 kg/m(2) plus comorbidities) on waiting list for bariatric surgery, were non-randomly allocated to (A) bariatric surgery or to one of three conservative treatments; (B) residential intermittent program; (C) commercial weight loss camp and (D) hospital outpatient program. Body weight, risk factors and comorbidities were assessed at baseline and 1 year.

RESULTS

Of 206 participants, 179 completed the study. All treatments resulted in significant weight loss, but bariatric surgery (40 ± 14 kg, 31 ± 9%) led to the largest weight loss (P < 0.0001). There were no differences in weight loss between B and C (22 ± 13 kg, 15 ± 8% vs. 18 ± 12 kg, 13 ± 8%), but these resulted in larger weight loss compared with D (7 ± 10 kg, 5 ± 8%). There were no differences in changes in total or LDL cholesterol, triacylglycerols or glucose between groups; however, the increase in HDL cholesterol was significantly larger in groups A and C. There were no differences in comorbidities resolution between groups A and B, C and D combined (except hypertension, which was better in group A).

CONCLUSION

In conclusion, although bariatric surgery leads to a greater weight loss at 1 year compared with conservative treatment, in patients with morbid obesity, clinical significant weight loss and similar improvements in risk factors and comorbidities resolution can also be achieved with lifestyle interventions.

Prevalence of all relevant eating disorders in patients waiting for bariatric surgery: a comparison between patients with and without eating disorders

OBJECTIVE

To study the prevalence of all relevant eating disorders in 157 obese patients waiting for bariatric surgery. Another aim was to explore for possible differences between gender, and those with and without ED. The dependent variables were: socio-demographic characteristics, BMI, obesity onset, and obesity-related somatic diseases.

METHODS

ED was assessed using the self-report questionnaire, "Eating Disorders in Obesity" (EDO). The patients answered a questionnaire that targeted socio-demographic and health information.

RESULTS

Subgroups were based on the patients responses to items on the EDO: 1 patient (0.6%) with Bulimia Nervosa (BN), 6 (3.8%) with Eating Disorder Not Otherwise Specified (EDNOS), 21 (13.4%) with Binge Eating Disorder (BED), and 23 (14.6%) with Binge Eating (BE). The patients in the EDNOS group were those who lacked one criterion of the BN diagnosis. The patients in the BE group lacked one criterion of the BED diagnosis. Twenty-eight (17.8%) fulfilled the DSM-IV-TR criteria for ED. When patients with BE were added, 51 patients (32.5%) were identified with ED or sub-threshold ED. In the explorative part of the study, no gender differences in socio-demographic variables, BMI, obesity onset, and obesity-related somatic diseases emerged. With the exception of age, no differences were found in these variables between those with and without ED.

CONCLUSION

Employing all relevant eating disorders and binge eating symptoms (BE) for this population identified patients with pathological eating behaviors, which are not detected in previous studies measuring only BED and BE.