No full-text available
To read the full-text of this research,
you can request a copy directly from the author.
Nutritional Considerations After Bariatric Surgery
Abstract
Malnutrition is a risk that is associated with all bariatric surgeries. Malnutrition is largely preventable after these surgeries if proper patient selection, thorough preoperative nutrition education, and postoperative nutritional follow-up take place along with patient compliance. Bariatric surgery is divided into 2 major categories: restrictive or malabsorptive (with or without the restrictive aspect). The more dramatic weight loss is generally associated with procedures that are malabsorptive in nature. There is an increased risk of specific nutritional deficiencies associated with these surgeries. With proper supplementation these deficiencies are largely avoidable. This article reviews the more common bariatric surgeries and the nutritional considerations associated specifically with each surgery. The article then summarizes the typical diet advancement schedule and reviews critical care nutrition in regards to total parenteral nutrition administration for the morbidly obese individual, following bariatric surgery.
... El seguimiento, nos ha permitido observar que un 54 % de los pacientes presentan déficit antes de someterse a la cirugía, y que tras la cirugía, sobre todo en DBP; la presentaban entorno al 9-38% de los pacientes.(3)En cuanto al tratamiento: la suplementación con un preparado polivitamínico (400 mcg/día) suele ser suficiente para prevenir su carencia, aunque hay autores como Elliot K. Et al .(46) que recomiendan dosis superiores (800-1.000 ...
... (3) Antes de iniciar tratamiento debemos asegurarnos de la existencia de un posible déficit de vitamina B12, y en caso de un déficit concomitante, tratar primero la carencia de vitamina B12, para evitar agravamiento de las manifestaciones neurológicas(14,23,39,45,47).Es crucial que en las mujeres con deseo genésico se comience una suplementación de 1mg/día durante 1 mes antes de la concepción y durante el primer trimestre, con la intención de evitar malformaciones en el tubo neural. 20(power),45(46) ...
Se trata de una revisión bibliográfica sobre los déficits nutricionales post cirugía bariátrica
... As revisional bariatric surgery increases, postoperative dumping syndrome is also likely to become more prevalent, given that it occurs in 40% of patients undergoing RYGB [18]. This syndrome, first described by Hertz in 1913 [19], is attributed to rapid gastric emptying or rapid exposure of the small intestine to high-calorie nutrients, causing an intense gastrointestinal, vasomotor and delayed hyperinsulinemic effect [18,20]. This often gives rise to a variety of unpleasant symptoms including nausea, bloating, flushing, palpitations, weakness, tremor, syncope, and severe diarrhea [21][22][23]. ...
... Though behavioral diet changes have already been documented after restrictive surgery, the topic of dumping has received surprisingly little attention in studies of revisional bariatric surgery. LAGB often leads to the consumption of high-caloric soft sweet foods, especially in liquid form, as they can easily pass through small openings in the GI tract [18][19][20]. These habits remain unchanged after conversion to revisional RYGB. ...
PurposeDumping is currently seen as a negative side effect of Roux-en-Y gastric bypass (RYGB). However, it may help patients to comply with their prescribed diet. In this study, we assess the role of dumping on weight loss in patients who have undergone conversion of failed restrictive surgery into RYGB. Methods
An analysis was performed of 100 consecutive patients who underwent revisional RYGB (rRYGB) between 2006 and 2011 due to inadequate weight loss or band intolerance after laparoscopic adjustable gastric banding (LAGB). The percentage of excess weight loss (%EWL) was used to evaluate weight reduction. The Sigstad clinical diagnostic index was used to detect dumping symptoms. ResultsFifty-five patients (59.1%) suffered from dumping. Overall, dumpers showed a greater %EWL than non-dumpers (83.8 ± 48.0 vs 66.9 ± 44.1%, respectively, p = 0.0725). When rRYGB was performed because of inadequate weight loss following LAGB, dumping played a crucial role in weight loss (88.0 ± 21.2 vs 68.9 ± 34.5%, p = 0.0137). This effect positively correlates to post-LAGB body mass index (BMI) with a statistically significant result at BMI > 35 kg/m2 (82.4 ± 15.7 vs 58.4 ± 32.4%, p = 0.00341). A regression analysis of the Sigstad dumping score and %EWL shows that dumping tends to increase the %EWL. Conclusions
This study provides new insights into the effect of dumping on weight loss in patients who underwent conversion of failed restrictive surgery into RYGB. Based on the findings in our patient group, we suggest that dumping helps patients achieve sustainable weight loss. Therefore, dumping can be regarded as a positive side effect rather than a complication.
... Along with these benefits, there are risks associated with bariatric surgery. Common among all the procedures are risks associated with anesthesia, bleeding, and trauma to internal organs (Byrne, 2001;Elliot, 2003). ...
... Moreover, a majority of patients maintain their weight loss up to 10 years following the procedure (Valezi et al., 2013). However, because the anatomy of the digestive system is altered, common surgical side-effects include nutritional deficiencies and problems with malabsorption with a number of vitamins and minerals, such as B12, magnesium, calcium, and iron (Byrne, 2001;Elliot, 2003;Koch & Finelli, 2010;Latifi et al., 2002;Ziegler, Sirveaux, Brunaud, Reibel, & Quilliot, 2009). Moreover, nutritional deficiencies in pregnant women following RYGB have been associated with low birth weight of infants that may be a result of nutritional growth restriction during pregnancy (Santulli et al., 2010). ...
Although a number of studies have asserted that psychosocial factors contribute to suboptimal weight loss outcomes following bariatric surgery; research has been inconsistent regarding the associations between preoperative psychiatric diagnoses and psychological testing results and suboptimal weight loss. Research implies that psychopathology and personality are best capture by a hierarchical framework. The current investigation examined the utility of using the hierarchical model of psychopathology to predict 5-year Body Mass Index (BMI) outcomes. A total of 446 consecutively, locally residing consented patients who underwent a Roux-en-Y Gastric Bypass (RYGB) at least 5-years ago were included in the study. A majority were women (74.2%) and of Caucasian descent (66.2%). Patients’ mean pre-surgical BMI was 49.14 kg/m2 [Standard Deviation (SD) = 9.50 kg/m2]. Psychiatric diagnoses were obtained from a pre-surgical, semi-structured clinical interview and all participants were administered the MMPI-2-RF at their pre-surgical evaluations. BMIs were collected at 4 post-operative time points across a 5-year trajectory. Age significantly predicted the nonlinear rate of BMI-reduction across time, such that older individuals evidenced a slower rate of change over time. Pre-surgical levels of Externalizing and Low Positive Activation/Emotionality predicted higher BMIs at the 5-year outcome. Pre-operative indicators of psychopathology are important in predicting post-operative outcomes, particularly when they are dimensional in nature and aligned with the hierarchical model of psychopathology. A closer follow-up with patients who evidence pre-surgical problems, both before and after surgery, may help improve outcomes.
... Although overt macronutrient malabsorption is rarely reported, possible adverse outcomes of RYGB include protein deficiency, bone loss, abnormal fluid distribution, and excessive lean tissue loss. [1][2][3][4] While body composition has been measured by many groups in the first year after surgery, 5-12 few data exist regarding the impact of RYGB on body composition between 5 and 10 years after surgery. As might be expected, fat mass (FM) 5,8,10-12 and percent body fat 5,6,10,11 have been observed to substantially decrease in the first year after RYGB; however, fat-free mass (FFM) also decreases after surgery, albeit to a lesser extent. ...
... Although overt macronutrient malabsorption is rarely reported, possible adverse outcomes of RYGB include protein deficiency, bone loss, abnormal fluid distribution, and excessive lean tissue loss. [1][2][3][4] While body composition has been measured by many groups in the first year after surgery, [5][6][7][8][9][10][11][12] few data exist regarding the impact of RYGB on body composition between 5 and 10 years after surgery. As might be expected, fat mass (FM) 5,8,[10][11][12] and percent body fat 5,6,10,11 have been observed to substantially decrease in the first year after RYGB; however, fat-free mass (FFM) also decreases after surgery, albeit to a lesser extent. ...
Background:
Although most individuals experience successful weight loss following Roux-en-Y gastric bypass (RYGB), weight regain is a concern, the composition of which is not well documented. Our aim was to evaluate changes in body composition and handgrip strength as a measure of functional status in participants from a previous 1-year post-RYGB longitudinal study who had undergone RYGB approximately 9 years prior.
Methods:
Five women from an original larger cohort were monitored pre-RYGB and 1.5 months, 6 months, 1 year, and 9 years post-RYGB. Body composition was assessed at all time points using dual energy x-ray absorptiometry and multiple dilution. Handgrip strength was measured using a digital isokinetic hand dynamometer (Takei Scientific Instruments, Ltd, Tokyo, Japan).
Results:
Mean time to final follow-up was 8.7 years. Lean soft tissue (LST) loss over the ~9-year period was on average 11.9 ± 5.6 kg. Compared with 1-year post-RYGB, 9-year LST was 4.4 ± 3.0 kg lower (P = .03). Fat-free mass decreased over the 9-year period by 12.6 ± 5.8 kg. Mean fat mass (FM) decreased from 75.4 ± 22.6 kg pre-RYGB to 35.5 ± 21.5 kg 1 year post-RYGB but then trended toward an increase of 8.6 ± 7.0 kg between 1 year and 9 years post-RYGB (P = .053). Loss of LST was correlated with loss of handgrip strength (r = 0.64, P = .0005).
Conclusion:
The continued loss of lean mass associated with decreased handgrip strength occurring with long-term trend toward FM regain post-RYGB is concerning. The loss of LST and functional strength carries particular implications for the aging bariatric population and should be investigated further.
... Based on the literature that advises 40 to 65 mg intake of iron in men and 100 mg in female patients after RYGB, the iron content in WLS Forte was increased to 70 mg, that is, 5 times RDA. 8,23,33,34 In the present study with a male to female ratio of 1 : 2.3, this was sufficient to maintain serum ferritin at baseline level, whereas, in patients on sMVS, ferritin steadily decreased over the year. The fact that the difference in ferritin levels at 12 months did not reach statistical significance is attributed to a lack of power in this study. ...
... 32 In contrast to these guidelines, reports in the literature advise postoperative vitamin D supplements varying between 320 IU and 2000 IU per day, 12,27,41,42 and a calcium intake of 1000 to 1500 mg daily. 27,34,42 Carlin et al 43 demonstrated that despite daily intake of 800 IU vitamin D, 44% of the population still remained insufficient for vitamin D. Goldner et al 41 conducted a prospective, randomized controlled trial comparing 3 different doses of vitamin D supplementation of 800 IU, 2000 IU and 5000 IU daily following RYGB. The postoperative increase of mean serum vitamin D level at 12 months was higher with higher doses (800-5000 IU) of vitamin D supplement. ...
Iron, vitamin B12, and folic acid deficiencies are among the most common deficiencies occurring after laparoscopic Roux-en-Y gastric bypass (LRYGB). The present study evaluates the effectiveness of a specially designed multivitamin supplement (WLS Forte, FitForMe, Rotterdam, the Netherlands) specifically developed for LRYGB patients.
A triple-blind, randomized, 12-month study was conducted comparing WLS forte with a standard multivitamin supplement (sMVS) containing approximately 100% of the recommended daily allowance (RDA) for iron, vitamin B12, and folic acid. WLS Forte contains vitamin B12 14000% RDA, iron 500% RDA, and folic acid 300% RDA.
In total, 148 patients (74 in each group) underwent a LRYGB procedure. Baseline characteristics were similar for both groups. Per protocol analysis demonstrated that sMVS treatment was associated with a decline in ferritin (−24.4 ± 70.1 μg/L) and vitamin B12 (−45.9 ± 150.3 pmol/L) over 12 months, whereas in WLS Forte patients, ferritin remained stable (+3.2 ± 93.2 μg/L) and vitamin B12 increased significantly (+55.1 ± 144.2 pmol/L). The number of patients developing ferritin or vitamin B12 deficiency was significantly lower with WLS Forte compared with sMVS (P < 0.05). Iron deficiency (ID) was reduced by 88% after WLS Forte compared with sMVS. Adverse events related to supplement use did not occur.
An optimized multivitamin supplement is safe and reduces the development of iron and vitamin B12 deficiencies after LRYGB.
... Current postoperative diet guidelines are based on both the food texture and nutrient needs of patients with the goals of providing adequate energy and nutrients while minimizing symptoms such as dumping syndrome and early satiety. 9,32,42,43 It is important for clinicians working with bariatric surgery patients, and especially registered dietitians (RDs), to help patients transition through these texture-based diet stages, because this progression is necessary during GI tract healing after bariatric surgery. ...
... Dating back to the 1980s and 1990s, micronutrient supplementation became important through reports of micronutrient deficiencies. [19][20][21][22][23][24][25][27][28][29][30][31]33,42,43,[46][47][48]53,54,60,[64][65][66][67] As a result of these reports, prophylactic micronutrient supplementation was recommended in the early 1990s and is now a standard requirement in the 2000s. ...
In Brief
This article reviews the history of the postoperative nutrition recommendations for today's common bariatric (weight loss) surgery procedures. Discussion of the evolution of postoperative nutrition guidelines supports the proposal for a standardized postoperative diet for patients who undergo a Roux-en-Y gastric bypass or a laparoscopic adjustable gastric band procedure.
... After surgery, patients need to receive periodic counseling from a registered dietitian to maximise the outcomes of the bariatric procedure and minimise the risk of regaining weight (Bettini et al., 2020). Detailed preprocedural nutritional education, appropriate patient selection, and postoperative nutritional monitoring, along with patient adherence to guidelines (Elliot, 2003), can prevent the risk of malnutrition, one that is associated with all BS. It remains the most effective solution (Panteliou, & Miras, 2017;Wilson, 2020), even though there are many options for losing weight, including most moderate diets with calorie restriction, cognitive-behavioural therapies, pharmacotherapy, and increased physical activity. ...
p dir="ltr"> Artificial intelligence (AI) is having a major impact in the field of bariatric surgery (BS) as it helps improve outcomes for patients with severe obesity. This advanced technology optimises clinical decision-making processes and helps reduce the risks associated with surgery. In the context of bariatrics, AI is used to identify suitable patients, and monitor postoperative recovery but also to predict complications that may occur. BS is an effective solution for treating severe obesity, a condition characterised by the excessive accumulation of body fat, which can lead to serious health problems. However, this surgical field faces challenges in terms of patient selection and follow-up. By implementing machine learning (ML) algorithms and advanced imaging technologies, AI offers advantages to surgeons in performing interventions with increased precision and efficiency. The integration of AI into BS brings significant benefits to both patients and healthcare professionals, thereby facilitating the development of a personalised and safe approach to obesity management. Through this review, we aim to explore the potential, benefits, and risks of using AI in the context of BS. </p
... İdrar miktarındaki azalma (oligüri, anüri) ile plazma üre ve nitrojen seviyelerindeki artış bir diğer belirtidir (Yılmaz ve Topal Kanama: Genellikle dikiş ya da anastomoz hattından kaynaklanan, ameliyat sonrası ilk 48 saat içinde ortaya çıkan kanamalarda hastada taşikardi, melena, hemoglobin ve hematokrit değerlerinde düşme gibi klinik belirtiler gelişmektedir. Kanama tanısı koyma kriteri, 500 kat fazla artış görülmektedir(Aygin ve Açıl, 2015; Barth ve diğ., 2006;Bozkurt, 2016).Emilim Bozuklukları:Bariatrik cerrahi sonrası hastaların yeni diyetlerine uyum sağlayabilmeleri için bireysel düzenlemeler yapılması önemlidir(Elliot, 2003). Beslenmeyetersizliği veya emilim bozukluğu nedeniyle protein, demir, B12 vitamini, kalsiyum, folat ve A, D, E, K vitaminlerinin düzeylerinde düşüşler olabilmekte ve emilim bozukluğuna bağlı olarak da kemik metabolizmasında meydana gelen değişimler sonucunda osteoporoz ve osteomalazi oluşabilmektedir (Yılmaz ve Topal Hançer, 2019). ...
The research was carried out with the aim of determining the opinions of individuals
who underwent bariatric surgery about their nutritional behavior. In the research conducted in qualitative design and phenomenological design, data were collected by in-depth interview method. The data collection process was concluded with a total of 13 participants, 10 female and 3 male. The data of the research were collected by the researcher with the "Personal Data Collection Form" and "In-depth Interview Form", which were created in line with the literature data. The analysis of the data was made using thematic analysis and content analysis method using the MAXQDA 2022 program. The findings obtained as a result of the research,
'motivation to undergo surgery', 'post-operative nutritional behavior', 'changes in post-operative nutritional behavior', 'difficulties', 'coping', 'expectations from life after surgery', 'changes in mood', ' life changes', 'reasons for weight gain', 'support product', 'diagnosed mental illness' were gathered under 11 main themes. Three categories were created in the theme of postoperative nutritional behavior and the participants; They mentioned that they were fed only with liquid for the first 2 months after the surgery, they switched to puree nutrition in the 2nd and 3rd months, and that they started to consume meat in the 8th and 9th months. Participants who experienced changes in their eating behavior after surgery; They stated various changes in physical activity patterns, water consumption rates, maintaining old habits, diets and food consumption. In addition to these, individuals who have some difficulties after surgery, in 16 codes; It was observed that they faced many difficulties such as intense stomach cramps, disgust, vomiting, self-vomiting, weakness, inability to eat, and loss of strength. In order to overcome all these difficulties, individuals are in the theme of coping; they experience positive emotions such as being determined, feeling strong, receiving support from close circles, seeing surgery as a second chance, and considering getting expert support; In addition to these, they also stated that they experienced negativities such as crying, having panic attacks, removing people from their lives and coping with chronic diseases. It has been observed that individuals who expect to get their lives on the road and to get rid of diseases after the surgery, actually realize that this situation has nothing to do with the surgery. In addition, individuals who experience changes in their emotional states; It was determined that they were happy, disappointed, regretted the operation, and thought of being a burden developed. Participants who experienced significant changes in their lives during the post-operative period; It was seen that they were more free in their choice of clothes, they experienced a significant increase in their self-confidence by being praised, they improved in family relations, they had ease in moving and they felt energetic, their sleep improved and they did not experience health problems. Participants; It was determined that they gained weight due to genetic predisposition, having an overweight childhood, eating irregularly, having an illness, psychological problems, life course, quitting sports, and deliberately gaining weight in order to have surgery. It was concluded that the participants who used supplements such as drugs and herbalife to lose weight did not benefit from them, and it was observed that the individuals with panic attacks and epilepsy diagnoses before the surgery continued to have these conditions after the surgery. In conclusion; It is recommended that awareness issues related to nutrition after bariatric surgery should be included in in-service training programs.
... Nowadays, bariatric surgery is one of the common methods for durable weight loss and improvement in these comorbidities. But achieving proper weight loss depends on several factors such as the quantity and quality of the patient's daily diet [25][26][27] While, a study that was conducted on Mediterranean subjects in 2013 regarding dietary intake and nutritional deficiencies following RYGB [23] indicated that 24 months after the surgery, the total calorie intake of the patients was 1,533 kcal/day, which is a little lower value compared to the results of the present study. The discrepancy in this regard could be due to the differences in the periods following bariatric surgeries. ...
Decreased food intake is an effective mechanism for gastric bypass surgery (GBS) for successful weight loss. This cross-sectional study aimed to assess dietary intake, micro-and macro-nutrients in the patients undergoing GBS and determine the possible associations with weight changes. We assessed anthropometric indices and food intake at 24 month-post gastric bypass surgery. Dietary data was evaluated using three-day food records. After the 24 months of surgery, among 35 patients (mean age: 43.5 ± 11.2 years; 82.85% females), with the mean body mass index (BMI) of 30.5 ± 4.5 kg/m2, 17 cases were < 50% of their excess weight. The average daily calorie intake was 1,733 ± 630 kcal, with 14.88% of calories from protein. Consumption amounts of protein (0.82 ± 0.27 g/kg of the current weight), as well as fiber, and some micro-nutrients (vitamin B9, E, K, B5, and D3) were lower than recommended amounts. Patients were classified into three groups based on their success in weight loss after surgery. Calorie intake was not significantly different between groups, but successful groups consumed considerably more protein and less carbohydrate than the unsuccessful group (p < 0.05). Based on our findings, the patients undergoing GBS had inadequate macro- and micro-nutrient intake after 24 months. However, protein intake can affect patients' success in achieving better weight loss. Long-term cohort and clinical studies need to be conducted to comprehend this process further.
... This may strengthen their efforts to avoid consuming food in response to emotions, which may wane over time 51 . Emotional eating typically involves a preference for highly palatable foods 52 , whereas after bariatric surgery avoidance of high-fat/high-sugar foods may occur as a learnt response to postprandial discomfort or dumping syndrome 53,54 . A conditioned avoidance might then override the desire to consume these foods. ...
Background:
The effect of bariatric surgery on 'emotional eating' (EE) in people with obesity is unclear. This systematic review and meta-analysis aimed to examine changes in self-reported emotional eating behaviour after bariatric surgery.
Methods:
Fifteen electronic databases were searched from inception to August 2019. Included studies encompassed patients undergoing primary bariatric surgery, quantitatively assessed EE, and reported EE scores before and after surgery in the same participants. Studies were excluded if they were not in English or available in full text. The systematic review and meta-analysis were conducted according to the PRISMA guidelines. Random-effects models were used for quantitative analysis. Study quality was assessed using the National Heart, Lung, and Blood Institute quality assessment tool for before-after (pre-post) studies with no control group.
Results:
Some 23 studies containing 6749 participants were included in the qualitative synthesis, with follow-up of from 2 weeks to 48 months. EE scores decreased to 12 months after surgery. Results were mixed beyond 12 months. Quantitative synthesis of 17 studies (2811 participants) found that EE scores decreased by a standardized mean difference of 1·09 (95 per cent c.i. 0·76 to 1·42) 4-18 months after surgery, indicating a large effect size.
Conclusion:
Bariatric surgery may mitigate the tendency to eat in response to emotions in the short to medium term.
... Herramienta. La encuesta fue desarrollada teniendo en cuenta una revisión extensa de la literatura científica y los aspectos más importantes del manejo nutricional, según los consensos europeo, norteamericano, español y argentino, sobre nutrición en cirugía bariátrica (8,(18)(19)(20)(21)(22)(23) . La encuesta fue validada según criterio de expertos. ...
La cirugía bariátrica se asocia a alteraciones metabólicas, desnutrición proteico-calórica y deficiencias nutricionales cuando no se hace un manejo y un seguimiento médico nutricional adecuado del paciente por parte de equipos interdisciplinarios. Hasta el año 2012 Colombia no contaba con una guía de manejo propia y se desconocía la práctica actual de los grupos de cirugía bariátrica. Por lo tanto, este estudio tuvo como objetivo conocer el seguimiento y manejo nutricional que realizan los médicos y nutricionistas involucrados en la cirugía bariátrica en el país.
... Hastanın yeni diyetine uyum sağlayabilmesi için kişisel düzenlemeler yapılması gerekmektedir. Ameliyat öncesi eğitim ve ameliyat sonrası takip bireyin uyumunu kolaylaştırmaktadır. 23 Beslenmenin yetersizliği ya da emilim bozukluğu nedeni ile protein, demir, vitamin B 12 , folat, kalsiyum ve yağda eriyen vitamin (A, D, E, K) düzeylerinde düşüş olabilmektedir. 5,24 Emilim bozukluğuna bağlı olarak kemik metabolizmasında da değişimler olabilmekte, bu değişimler sonucunda osteomalazi ve osteoporoz meydana gelebilmektedir. ...
... Postprandial discomfort often occurs after the consumption of high carbohydrates and fatty meals (91). It was originally thought that because the brain associates those food groups with sickness, a conditioned taste aversion to "sweet" and "fatty" food occurs. ...
Obesity is an escalating global chronic disease. Bariatric surgery is a very efficacious treatment for obesity and its comorbidities. Alterations to gastrointestinal anatomy during bariatric surgery result in neurological and physiological changes affecting hypothalamic signaling, gut hormones, bile acids, and gut microbiota, which coalesce to exert a profound influence on eating behavior. A thorough understanding of the mechanisms underlying eating behavior is essential in the management of patients after bariatric surgery. Studies investigating candidate mechanisms have expanded dramatically in the last decade. Herein we review the proposed mechanisms governing changes in eating behavior, food intake, and body weight after bariatric surgery. Additive or synergistic effects of both conditioned and unconditioned factors likely account for the complete picture of changes in eating behavior. Considered application of strategies designed to support the underlying principles governing changes in eating behavior holds promise as a means of optimizing responses to surgery and long-term outcomes.
... The main reported reason is the reduction of gastric acid and intrinsic factor as a consequence of the surgery [35]. Another possible reason for post-operative deficiency is the limited consumption of animal proteins due to poor tolerance [36]. This might also be supported by the current finding of hypoalbuminemia and low transferrin in a considerable number of patients post-LSG indicating low-protein intake. ...
Introduction:
Obesity is considered a public health problem and has led to advancements in bariatric surgery. Laparoscopic sleeve gastrectomy (LSG) had become the most performed procedure worldwide; however, its consequences on nutritional status in the short and long term are of concern.
Methods:
A retrospective analysis of medical records and bariatric database of patients who underwent LSG from October 2008-September 2015 at Al-Amiri Hospital, Kuwait, was performed. Data regarding nutritional status along with demographic data were collected over a 5-year follow-up period.
Results:
One thousand seven hundred ninety-three patients comprising of 74% females and 26% males were included. The greatest % total body weight loss (%TBWL) was at 18 months post-LSG (33%), corresponding to a % excess weight loss (%EWL) of 73.8%. With regard to nutritional status, vitamin B1 showed a significant drop at 3-5 years post-op in comparison to pre-op value, but stayed within the normal range throughout the study. Red blood cells count, hemoglobin, and hematocrit also showed a significant drop starting from 6 months post-op until the fifth year of follow-up. On the other hand, vitamins B6 and B12 showed a significant increase at 6 months post-op and decreased afterwards, but did not reach pre-op values. Vitamin D also showed a significant increase throughout the study period from deficient value at the pre-op time, but remained insufficient. Albumin, transferrin, folate, ferritin, iron, and vitamin B2 showed no significant changes at 5 years post-LSG compared to pre-op values.
Conclusion:
Little is known about the nutritional status and optimal nutritional care plan post-LSG, especially in the longer term. Nutritional deficiencies were prevalent prior and post-LSG. Some of the nutritional parameters improved and even reached the abnormal high level post-LSG. These observations highlight the importance of pre- and post-operative nutritional assessment and tailored supplementation to ensure optimal nutritional status.
... It should be pointed out that measures were taken more than 2 wk after surgery, at which point the body weights of the RYGB rats had stabilized (albeit at an expectedly lower weight than Sham rats), and different results may have been obtained if the five food items were presented sooner after surgery during the dynamic phase of weight loss. It has been postulated that changes in the preference for certain foods and fluids after RYGB in rats or humans is due to altered taste sensibility; for example, sweet foods taste sweeter, even to the point of being cloying (e.g., 6,29), and are thus consumed in smaller amounts. Indeed, the detectability of sugar is heightened after RYGB in humans, but this does not seem to translate to a reduced hedonic value of sweet foods and fluids (3,4). ...
Roux-en-Y gastric bypass surgery (RYGB) decreases caloric intake in both human patients and rodent models. In long-term intake tests, rats decrease their preference for fat and/or sugar after RYGB, and patients may have similar changes in food selection. Here we evaluated the impact of RYGB on intake during a 'cafeteria'-style presentation of foods to assess if rats would lower the percentage of calories taken from fat and/or sugar after RYGB in a more complex dietary context. Male Sprague-Dawley rats that underwent either RYGB or sham surgery (SHAM) were presurgically and postsurgically given 8-days free access to four semi-solid foods representative of different fat and sugar levels along with standard chow and water. In comparison to SHAM rats, RYGB rats took proportionally fewer calories from fat and more calories from carbohydrates; the latter was not attributable to an increase in sugar intake. The proportion of calories taken from protein after RYGB also increased slightly. Importantly, these postsurgical macronutrient caloric intake changes in the RYGB rats were progressive, making it unlikely that the surgery had an immediate impact on the hedonic evaluation of the foods and strongly suggesting that learning is influencing the food choices. Indeed, despite these dietary shifts, RYGB, as well as SHAM, rats continued to select the majority of their calories from the high-fat / high-sugar option. Apparently after RYGB, rats can progressively regulate their intake and selection of complex foods to achieve a seemingly healthier macronutrient dietary composition.
... It has been shown that bariatric surgery leads to an increased risk for developing protein malnutrition [3,4]. Possible reasons might be the restricted food intake and the malabsorption of nutrients after surgery [5][6][7]. Postoperative occurrence of vomiting or different food intolerances may further enhance the risk [8,9]. As a consequence, reduction in blood protein levels and finally in muscle mass has to be expected [10]. ...
Objectives:
Bariatric patients are at risk of protein deficiency. The aim of this study was to determine possible benefits of postoperative protein supplementation weight reduction, body composition, and protein status.
Methods:
Twenty obese patients who underwent bariatric surgery were randomized either to the protein (PRO) group, which received a daily protein supplement over 6 months postoperatively, or to the control (CON) group, which received an isocaloric placebo in a double-blind fashion. Data on protein and energy intake, body weight, body composition, blood proteins, and grip force was collected preinterventionally and at 1, 3, and 6 months postoperatively.
Results:
In both groups body weight was significantly reduced to a similar extent (after 6 months: PRO group 25.4 ± 7.2%, CON group 20.9 ± 3.9%; intergroup comparison P > 0.05). Protein intake was steadily increased in the PRO group, but not in the CON group, and reached maximum at month 6 (25.4 ± 3.7% of energy intake versus 15.8 ± 4.4%; P < 0.001). In the PRO group, body fat mass loss was higher than that in the CON group (79% of absolute weight loss versus 73%; P = 0.02) while lean body mass loss was less pronounced (21% versus 27%, P = 0.05). Blood proteins and grip force did not differ at any time point between the two groups.
Conclusions:
The present study suggests that protein supplementation after bariatric surgery improves body composition by enhancing loss of body fat mass and reducing loss of lean body mass within the 6 months follow up.
... Όταν η ζάχαρη καταναλώνεται, περνά γρήγορα στο λεπτό έντερο, προκαλώντας ένα ωσμωτικό φορτίο, το οποίο οδηγεί σε μετατόπιση υγρών από το αίμα στο έντερο. 26,41,42 Η μείωση στον όγκο αίματος αυξάνει τον καρδιακό ρυθμό, με συνέπεια το άτομο να αισθάνεται ότι θέλει να ξαπλώσει (κάτι που θα βελτίωνε την καρδιακή παροχή). Η απάντηση ινσουλίνης προκαλεί τα συμπτώματα της υπογλυκαιμίας. ...
... The SG group showed higher mean percentage intake of dairy products from total energy and lower mean percentage intake of bread and cereals and protein foods versus the RYGB group, although not significantly (Fig. 4) [63,64]. In general, dry, sticky, gummy, or stringy foods (such as red meat, bread, and raw vegetables) represent the biggest problems and are poorly tolerated following bariatric surgery [65]. Fig. 4 Mean percentage of the food category intake from total energy for SG and RYGB. ...
Data on gastrointestinal (GI) and dietary changes following bariatric surgery are scarce in the Middle Eastern region. The objective of this work was to retrospectively compare dietary intake, food preferences, and GI symptoms in subjects with extreme obesity after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG).
Sixty subjects equally divided between RYGB and SG with a postoperative period of ≥6 months were recruited for a retrospective, non-randomized, and observational study. All subjects completed three questionnaires (GI symptoms, food preferences, and quantitative food frequency questionnaire (FFQ)) and three 24-h recalls.
At one year postoperatively, both surgical groups showed similar percentage of excess weight loss that exceeded 50 %. In addition, percentage of carbohydrate, protein, and sugar intake from total energy, frequency of daily consumption from the eight food categories and daily energy intake were comparable between surgical groups. RYGB subjects consumed significantly more fruits and juices from total energy (P < 0.05) whereas SG subjects tended to consume more sweets and desserts. Heartburn (P < 0.001), regurgitation (P < 0.01), nausea (P < 0.01), vomiting (P < 0.001), and constipation (P < 0.05) were significantly more frequent among SG subjects. Flatulence (P < 0.001) and diarrhea (P < 0.05), as well as dizziness (P < 0.001), and fast heartbeat (P < 0.05) after eating were significantly more frequent after RYGB.
There were no major differences in dietary intake and food preferences between RYGB and SG groups. There was a trend for sweet-eating in SG subjects with less dumping symptoms to suggest different mechanisms of action for each procedure, which might impact eating behavior.
... Poor eating behaviour, food intolerance, vomiting and micronutrient malabsorption can lead to iron, vitamin B 12 , vitamin D, calcium, folate and thiamine deficiencies (Aasheim 2009). In a US study of 1663 patients who underwent biliopancreatic diversion, 2 patients developed Wernicke-Korsakoff encephalo pathy 3-5 months after surgery (Elliot 2003), and a systematic review found 80 case reports of Wernicke's encephalopathy after gastric bypass surgery (Aasheim 2008). These studies highlight the importance of adherence to multivitamin regimes to maintain nutrient levels. ...
Obesity is common in patients with mental illness. Weight-loss surgery, known as bariatric surgery, is becoming a familiar intervention for treating people who are morbidly obese and for whom other weight-reduction methods have failed. This article offers guidance for mental health professionals on the assessment and management of patients with mental illness undergoing such treatment. Assessment is of the patient's suitability for surgery, taking into account their mental health diagnosis, expectations, knowledge and insight into the psychological impact of surgery, and abilit y to address and cope with lifestyle changes before and after surgery. The patient's capacity and ability to cooperate and engage with services are also assessed. Potential risks and complications of bariatric surgery and how the weight-loss procedures may affect patients'mental health and management of their medication are addressed.
... The protein food intolerance for patients in the postoperative of the bariatric surgery has been reported some studies, that can happen at short and long term 28 . Reach the daily requirements of protein help to inducing satiety, which stimulate weigh loss and improves body composition, helping at the maintenance of lean mass 29 . ...
Introduction: bariatric surgery is a treatment for morbid obesity that besides result in high weight loss promotes improvements in laboratory tests and in the pressure reduction. However the surgery can cause bad effects as deficiency some nutrients. This fact become more important evaluates the adequacy of dietary intake of these patients. The objective this study was evaluates the adequacy dietetic of patients after bariatric surgery.
Material and methods: we select forty women who underwent Roux-en-Y gastric and carried evaluation anthropometric and dietetic. The dietary evaluate was compared with the daily consumption requirement and food pyramid for these patients.
Results: forty women with 43.1 ± 9.96 years, obesity and very high risk for metabolic complications associate with obesity, and with acceptation of supplementation (95%) participated this study. The majority of women consumed group’s foods “high-calorie foods, fats and sweets are energy-dense foods” and showed high intake of foods groups “grains and cereals” and “high-fiber, low-calorie foods”. Dietary intake was low-calorie (1342.50 ± 474.06 Kcal), adequate in protein (22.10 ± 6.94%), carbohydrate (50.74 ± 10.96%), lipid (26.14 ± 7.17%), saturated fatty acids (8.69 ± 2.74%) and polyunsaturated fatty acids (8.93 ± 3.51%) and low-monounsaturated fatty acids (4.13 ± 1.78%) and fibers (17.02 ± 10.64 g).
Conclusions: nutritional habits of women showed inadequacy, these results reinforce the importance of nutritional accompanying in the late postoperative bariatric surgery.
... One patient received a diagnosis of malnutrition. This is a risk associated with all types of bariatric surgery and is largely avoidable through adequate patient selection, preoperative nutritional education, postoperative follow up and patient adherence to treatment 28 . ...
The aim of the present study was to describe the clinical- nutritional evolution of older women submitted to Roux-en-Y gastric bypass surgery. A concurrent, retrospective study was conducted involving a sample of 16 older women with morbid obesity submitted to Rouxen- Y gastric bypass surgery between 1997 and 2010. Weight, body mass index (BMI), percentage of weight loss (%WL) and percentage of excess weight loss (%EWL) were evaluated three, six and 12 months after surgery. Preoperative comorbidities, postoperative clinical-nutritional manifestations and peri-operative mortality were also investigated. Mean age was 62.02 ± 2.02 years. A progressive reduction was found in mean body weight (116.04 ± 22.99 to 80.96 ± 21.43 Kg) and BMI (47.13 ± 8.19 to 33.42 ± 9.31 Kg/m2), with a consequent %WL of 28.60 ± 8.59% and %EWL of 64.79 ± 3.99% throughout the one-year follow-up period (p < 0.05). All patients has diseases associated with obesity, the most frequent of which were arterial hypertension (n = 16), arthropathy (n = 11), dyslipidemia (n = 9) and diabetes (n = 7). The following clinical-nutritional symptoms were reported: alopecia (n = 9), nausea/vomiting (n = 7), constipation (n = 5) and food intolerance (n = 4). One patient was diagnosed with malnutrition one year after surgery. No deaths occurred within 30 days after surgery. At the one-year evaluation, surgical success was evidenced by the significant reductions in mean weight and BMI and the more than 50% loss of excess weight.
Copyright AULA MEDICA EDICIONES 2014. Published by AULA MEDICA. All rights reserved.
... The present study did not detect an association between the prevalence of these symptoms and red meat intolerance. Foods considered to be very dry, such as red meat, dryer chicken cuts, pork, and bread, can trigger vomiting [16]. In addition to food intolerances, fast/inefficient chewing and ingestion of large volumes or pieces of food can lead to a sensation of fullness or stuck food and to vomiting episodes, which would explain the occurrence of this symptom in patients tolerant to red meat. ...
Bariatric surgery provides significant weight reduction; however, it may result in food intolerance followed by gastrointestinal complications that may lead to nutritional deficiencies. This study evaluated the influence of red meat intolerance on the dietary pattern, biochemical indicators, and clinical symptoms after Roux-en-Y gastric bypass (RYGB).
This retrospective study evaluated patients 4 years after RYGB. The patients were divided into 2 groups: patients with and without red meat intolerance, and data for the following were collected: food intake, anthropometric data, biochemical data, and presence of nausea, vomiting, weakness, weak nails, and hair loss. The difference between groups in the times postoperative was determined by ANOVA.
Of the 72 patients included in the study, 63 were evaluated during the first postoperative year, 45 during the second, 56 during the third, and 41 during the fourth. Red meat intolerance was observed in 49.2%, 42.2%, 46.4%, and 39% of the patients after 1, 2, 3, and 4 years, respectively. After 1 year, the intolerant group showed lower calorie, carbohydrate, and iron intake. After 3 years, tolerant patients showed weight regain (2.9±5.3 kg), while the intolerant ones remained stable. There was no difference in the presence of clinical symptoms or biochemical indicators between groups.
Red meat intolerance is frequent after bariatric surgery and may alter energy, iron intake, and weight loss; however, it is not associated with the presence of clinical symptoms and biochemical profile.
Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.
... Foods with high osmolarity, such as those with high sugar content, cause osmotic overload in the small intestine(Fujioka, 2005;Mechanick et al., 2009). The symptoms include hypoglycemia, abdominal pain, nausea, diarrhea, rubor, and tachycardia(Elliot, 2003; Merchanick et al., 2009). Late dumping syndrome symptoms may be caused by reactive hypoglycemia, normally controlled through diet or treated prophylactically with half a cup of orange juice roughly one hour after a meal(Mechanick et al., 2009). ...
Obesity ultimately results from an unbalance between the intake and oxidation of the energy obtained from foods, and its treatments are based on correcting this unbalance by basicallyrestricting energy intake. Consequently, food intake is the center of attention when the subject is obesity, either as an etiological, protection, or even therapeutic factor. The inability of severely obese individuals to reduce or maintain their body weight using traditional methods makes them candidates to bariatric surgery, which is admittedly an effective method to reduce body weight significantly and obesity-associated morbidities. Bariatric surgery involves anatomic and physiological changes in the gastrointestinal tract that promote energy restriction, essential for weight loss, but also the restriction of many essential dietary nutrients. In addition to the anatomic aspects, bariatric surgery decreases appetite and increases postprandial satiety, possibly because of its effect on the secretion of hormones that regulate these systems (Kohli, Stefater e Inge, 2011). In addition to reducing body weight significantly, bariatric surgery also decreases some systemic inflammation markers (Chen et al., 2009; Miller et al., 2011), improves insulin sensitivity, promoting remission of type 2 diabetes (T2D), and lowers high blood pressure, among others. Although bariatric surgery is associated with better quality of life, nutritional deficiencies may occur after surgery because of the dramatically reduced food intake and/or micronutrient absorption. Unmonitored postoperative patients may develop severe malnutrition (Dodell et al., 2012). The literature has often reported deficiencies of vitamin B complex, iron, folic acid, vitamin D, and calcium (Saltzman e Karl, 2013). These deficiencies may cause neurological symptoms, osteopenia, and anemia. Hence, the nutritional approach of the bariatric patient, which began when the patient was in line for surgery and continued after surgery, is one of the most important themes of the interdisciplinary care of obese patients. The objective of this chapter is to review the theoretical bases for the nutritional approach of bariatric patients, the instruments for assessing food intake, and the nutritional recommendations, both preoperatively, when the patient is preparing for surgery, and postoperatively, during follow-up. The chapter also includes practical examples.
... En nuestra serie, el mayor número de pacientes con hipoproteinemia se dio a los 18 meses (n = 13, 12,8%), con valores de proteínas totales entre 5,7 y 6,4 g/dL, pero manteniendo cifras de albúmina normales, corrigiéndose de manera progresiva hasta normalizarse a los tres años de seguimiento, mientras que la hipoalbu- al tercer mes, hecho que concuerda con los valores referidos por Anthone 12 en una serie de 701 pacientes intervenidos con la misma técnica quirúrgica. Scopinaro 13 ha comprobado en un estudio de absorción intestinal con albúmina marcada, que la absorción proteica exógena es solo del 73%, pero se ha evidenciado, al igual que ha ocurrido con nuestros pacientes, que a medida que trascurre el tiempo tras la cirugía, el intestino se adapta y aumenta su capacidad absortiva, por lo que disminuye la malnutrición protéica 14 . La hipoalbuminemia y otros defectos nutricionales observados en pacientes con derivación gástrica pueden ser debidos más a la gran restricción gástrica que al componente malabsortivo. ...
Objective: To assess the course of blood parameters from patients with morbid obesity submitted to the duodenal crossing surgical technique. Methods: 110 patients were studied in whom post-surgical monitoring of ponderal and laboratory parameters (the ones most influenced by this type of surgery such as hematocrit, hemoglobin, glucose, total proteins, albumin, calcium, PTH, ALT, Quick's index, total bilirubin, cholesterol and triglycerides, iron, ferritin, folic acid, and vitamin B12) has been carried out. Postsurgical monitoring has been carried out at months 3, 6, 12, 18, 24, 36, 48, and 60. The shortest follow-up time has been one year. Results: Weight loss is higher than 50% of the weight in excess and is maintained throughout the study, comprising more than 75% of the patients. During the postsurgical follow-up, there is a clear iron deficiency concurrent with the presence of anemia, as well as an evident increase in PTH. Normalization of glycemia, cholesterol, and triglyceride levels reaches almost 100%. Conclusions: changes in blood parameters presented by patients with morbid obesity submitted to the duodenal crossing technique, indicators of nutritional complications, affect about 10% of the patients (with the exception of iron deficiency and PTH impairment), and most of them are easily corrected with pharmacological and nutritional supplements, the body getting adapted to these deficits, without any severe clinical-biological impairment and with a trend towards normalization.
... Vômito e diarréia podem exacerbar a desidratação. Como os pacientes não podem ingerir grande quantidade de líquidos, deve-se estimular a ingestão de pequenas quantidades com maior freqüência 15 . O paciente obeso deve ter a nutrição parenteral total (NPT) iniciada 3 a 5 dias após a cirurgia, se estiver impossibilitado de dieta oral. ...
Background and objectives:
Obesity is an epidemic disease reaching more than 300 million people all over the world. Its prevalence has increased during the past few years and according to some studies its mortality in the critically ill patient seems to be much higher, especially among patients who were submitted to surgery. This study has as objective to discuss some particularities of managing obese patients in the intensive care unit after bariatric surgery.
Contents:
The rate of obese patient in the ICU ranges from 9% to 26% and the increase in the number of bariatric surgeries has raised the number of obese patients in the ICU. It is important to know the physiopathology of obesity and to treat its particularities during the postoperative care. Such as pulmonary restriction, that causes an increase in pulmonary complications, coronary artery disease and thromboembolic events.
Conclusions:
The number of patients that undergo to bariatric surgery has increased; therefore, the number of obese patients in the ICU has also risen. Different physiological events and complications in obese patients are challenges to clinical practice. The knowledge of obese physiopathology helps in the managing routine procedures and complications after bariatric surgery.
... As is true for nonobese patients, if absence of oral intake is anticipated for 5 days or more, total parenteral nutrition or fine-bore nasojejunal feeding is recommended. These individuals are at risk for the refeeding syndrome, and serum levels of potassium, magnesium, and phosphorous should be checked daily for the first 3 days and promptly replaced if low [54]. ...
Obesity is defined as the accumulation of excess body fat to the extent that it may have an adverse effect on health. Generally, the body mass index (BMI) is utilized to characterize further the degree of obesity, and it is calculated based on height and weight in kg/m2. According to the definition established by the World Health Organization, individuals are classed as overweight if their BMI is ≥25, whereas obese individuals are those with a BMI ≥30. Based on the degree, obesity is further categorized into class I (BMI 30–34.9), class II (BMI 35–39.9), and class III (BMI ≥40). There is a linear correlation between incidence of chronic diseases and increased BMI.
Obesity is now recognized as a worldwide epidemic, and its incidence is increasing exponentially. According to the World Health Organization's projections from 2005, approximately 1.7 billion people are considered overweight, and at least 400 million adults are obese.1 In the United States alone, nearly 33% of the population (97 million) are obese, and approximately 10 million people are morbidly obese (class III).1,2
Although obesity has a multifactorial etiology, the most relevant causes can be grouped into environmental, genetics, and behavioral factors. In general, increased calorie consumption and decreased physical activity play a key role.
Contrary to common beliefs, the obese individual is not well nourished. The routine screening of obese patients prior to bariatric surgery has highlighted the multiple nutritional deficiencies of this patient population. The causes of this phenomenon are not entirely understood. It seems likely, though, that the excess caloric intake does not mean the overconsumption of fresh fruit, vegetables, and unprocessed foods, but rather the lack of consumption of these types of foods, exposing obese individuals to several micronutrient deficiencies.3
Therapeutic options for weight loss include dietary and behavioral modifications, increased physical activity, pharmacologic therapy, and, lastly, surgical intervention. Commonly, caloric restriction with behavioral modifications and physical activity lead to an average weight loss of only 5–10%.4 The addition of pharmacologic intervention can improve the results to 15%. Unfortunately, none of these interventions leads to long-lasting results, and weight regain seems to be the norm.5
Surgery, on the other hand, has been proven to provide consistent and durable weight loss, as stated by the National Institute of Health Consensus Development Conference Panel.6 In addition, weight loss surgery is associated with resolution or improvement, to different degrees, of the comorbid conditions associated with obesity.7 Although highly effective in terms of weight loss and resolution of comorbidities, the different bariatric surgery procedures can contribute to nutritional derangements postoperatively. Certainly, the procedures that affect the physiologic absorption of nutrients have a higher tendency to determine deficiencies, but also the procedures that solely reduce the quantity of intake can affect individuals' long-term nutritional status. It is a prime responsibility of the bariatric surgery team to assess, educate, and follow the obese patient in order to avoid dangerous nutritional abnormalities.
The incidence of obesity is rising throughout the world. The likelihood of a morbidly obese patient being admitted to an intensive therapy unit (ITU) either electively or as an emergency is increasing (Pieracci et al., Crit Care Med 34(6):1796–1804, 2006). In the UK around 25% of the population are obese and just over 3% of men are classed as morbidly obese. The prevalence in women is slightly lower at around 1.6% (Public Health England Obesity Knowledge and Intelligence Team 2013). In a meta-analysis of obese patients admitted to ITU, 25% of the pooled population was obese (Akinnusi et al., Crit Care Med 36(1):151–158, 2008). The care of this population on ITU brings with it challenges and uncertainties as the use of conventional treatments in ITU cannot necessarily be extrapolated to very overweight patients. The mortality and morbidity of ITU admission of bariatric patients is not necessarily increased in comparison to the non-obese population. However, a raised body mass index (BMI) is associated with an increased risk of ITU admission. Overall there is a scarcity of evidence from large, randomized trials to support the care of this patient group and as a result many questions remain unanswered.
Bariatric and metabolic surgeries have advanced in terms of knowledge acquired and technology produced, resulting in increased safety of the procedures, additional benefits to the patients, and a substantial decrease in patient morbidity. Postoperative complications may arise or even worsen, however, such as those related to nutritional deficiencies, due to hormonal changes and physiological functioning consequent to the surgeries. The most common complications are anemia, thiamine deficiency, vitamin B12 deficiency, dumping syndrome and/or hypoglycemia, hair loss, bone disease, lean tissue loss and sarcopenia, weight regain, and excessive weight loss. These well-known complications are detectable, preventable, and treatable. Professionals in the area of healthcare should be alerted about the signs and symptoms of these complications in order to diagnose and treat patients quickly.
Bariatric surgeries induce structural changes that can alter the absorption of drugs in patients already at risk of polypharmacy. This scoping review aimed to explore pharmacokinetic changes of orally administered drugs in patients post-bariatric surgery, and assess the quality and level of bias. Electronic databases were searched for articles relating to bariatric surgery and pharmacokinetics published between 1998 and 2019. Pre-post studies reporting on pharmacokinetic parameters were included, and the Newcastle-Ottawa Scale was used to assess risk-of-bias. A total of 21 studies were included in this review, and changes in absorption were reported in all included studies across 29 drugs. In 11 studies, this change was reported as statistically significant (p<.05), while six reported a nonsignificant change. More drugs exhibited a shorter Tmax and higher Cmax after surgery than otherwise, however changes in AUC were variable. Four studies were assessed as having fair quality while the remainder of the included studies were of good quality and low risk-of-bias. Bariatric surgery alters the absorption of drugs and several mechanisms are implicated to be responsible. Short and long-term monitoring is recommended in patients post-surgery for clinical changes in response to medications. Future research with a higher number of participants and greater control of variables, such as concurrent medications, malabsorptive disorders, and body composition should be considered.
Bariatric surgery is an effective weight loss procedure in morbidly obese people. A short term pre-operative energy restrictive diet or ‘liver shrinkage diet’ is widely accepted practice to reduce the fatty liver mass and to improve the liver flexibility [1]. This occurs by reduction of glycogen and lipid stores and reduction of visceral adipose tissue depots. This enables easy access to the upper stomach and oesophagus during liver retraction [1–4]. Preoperative weight loss has been shown to improve control of co-morbidities, decrease operative times and improve percentage of excess weight loss in the short term [5]. In addition some studies have also demonstrated a decrease in postoperative complications [6, 7].
Roux-en-Y gastric bypass (RNYGB), the most commonly performed bariatric (weight loss) operation in the USA, involves two surgical alterations: restriction of gastric volume and diversion of ingested nutrients away from the proximal small intestine. The strength of the RNYGB lies in the hybridization of restriction and bypass into one procedure. The reduction of food intake mediated by restriction is accompanied by dynamic changes in nutrient transport along the gastrointestinal tract. Thus, resultant changes in hormonal profiles constitute one of the first and most important roles of RNYGB. Although the physiological changes contributing to loss of body weight and improvements in obesity-related comorbidities are incompletely understood, the complexities of neurohormonal changes and precise mechanisms resulting in durable weight loss and reduction in associated comorbidities continue to be elucidated. Even though we continue to learn and progress in understanding the intricate interplay between the alimentary tract and neurohormonal axis, the benefits of gastric bypass are clear and well-documented with long-term follow-up results of surgery demonstrating obesity-related mortality and morbidity significantly reduced.
Morbide obesitas is een sterk groeiend gezondheidsprobleem, waarvoor behandeling noodzakelijk is vanwege het hoge risico op allerlei ziekten, zoals diabetes mellitus en hart- en vaatziekten. Conservatieve behandeling, zoals een dieet, leidt in de meeste gevallen niet tot het gewenste resultaat en heeft vaak alleen effect voor korte duur. De chirurgische behandeling, hetzij door een beperking van de voedselinneming, hetzij door een ingreep die de energieopname beperkt, geeft op dit moment de meeste kans op een succesvol resultaat. Voorwaarde voor succes zijn een goede patiëntenselectie (multidisciplinair team), een op de patiënt afgestemde operatie en een optimale (pre- en) postoperatieve begeleiding. Hierbij is een belangrijke rol voor de diëtist weggelegd. Adequate dieetadviezen en het tijdig herkennen van problemen zijn daarbij cruciaal. Basiskennis van de gebruikte operatieve technieken komt daarbij zeer van pas.
The obesity epidemic among adults in the USA is well established. National data reveals significant growth of clinically severe obesity over the past several decades. Given the complexity of obesity as a disease, a multidisciplinary team approach to evaluation and treatment to include dietary, behavioral, medical, and surgical components is considered mandatory, as is the long-term postoperative follow-up and evaluation of the patient to ensure safety and provide ongoing support. There are several standard and well-studied metabolic surgery procedures currently performed in the USA. These include the adjustable gastric band, Roux-en-Y gastric bypass, sleeve gastrectomy, and duodenal switch. There are also several novel procedures that are early in their development in other countries. Future research will determine which will become standard techniques in years to come.
Obesity is a major global health problem, and its multisystem effects are inextricably linked with elevated cardiovascular risk and adverse outcomes. The cardiovascular benefits of reversing obesity in adults are well-established. Compared with other weight-loss strategies, programmes that incorporate bariatric surgery for weight loss are beneficial for sustained BMI reduction. A marked improvement in cardiovascular risk factors, including hypertension, dyslipidaemia, inflammation, and type 2 diabetes mellitus, has been observed after bariatric surgery. This broad improvement in cardiovascular risk profile has led to substantial reductions in the risk of myocardial infarction, stroke, and death. As with all procedures, the benefits of bariatric surgery must be weighed against its potential risks. Modern bariatric surgery has an excellent safety profile, but important limitations remain, including the potential for surgical complications and nutritional deficiencies, and the lifelong requirement for nutritional supplementation. Surgery should be considered in patients with severe obesity, especially those with cardiovascular comorbidities. In this Review, we summarize the current management options for patients with obesity, and discuss the effects of bariatric surgery on cardiovascular risk factors and outcomes.
Dietary intervention for obese patients with cardiovascular disease (CVD) presents a challenge because of the many different diets available to promote weight loss and to improve blood lipid levels. Weight-loss diets can be classified as low-calorie diet (LCD), defined as providing 800 to 1500 cal/day, or very low calorie diet (VLCD), defined as providing 800 cal or less per day. It is beyond the scope of this chapter to cover every weight-loss and/or lipid-lowering diet. This chapter will review the following LCDs: the National Cholesterol Education Project (NCEP) diet, the Dietary Approaches to Stop Hypertension (DASH) diet, glycemic index (GI), plant-based diets, and the post–gastric bypass diet; VLCDs will also be reviewed.
The incidence of obesity is rising throughout the world. The likelihood of a morbidly obese patient being admitted to an intensive therapy unit (ITU) either electively or as an emergency is increasing (Pieracci et al., Crit Care Med 34(6):1796–1804, 2006). In the UK around 25 % of the population are obese and just over 3 % of men are classed as morbidly obese. The prevalence in women is slightly lower at around 1.6 % (Public Health England Obesity Knowledge and Intelligence Team 2013). In a meta-analysis of obese patients admitted to ITU, 25 % of the pooled population was obese (Akinnusi et al., Crit Care Med 36(1):151–158, 2008). The care of this population on ITU brings with it challenges and uncertainties as the use of conventional treatments in ITU cannot necessarily be extrapolated to very overweight patients. The mortality and morbidity of ITU admission of bariatric patients is not necessarily increased in comparison to the non-obese population. However, a raised body mass index (BMI) is associated with an increased risk of ITU admission. Overall there is a scarcity of evidence from large, randomized trials to support the care of this patient group and as a result many questions remain unanswered.
As a field of surgery, bariatric procedures have never been safer or more effective for achieving meaningful and sustainable weight loss. However, all of the currently performed operations result in dramatic changes in gastrointestinal anatomy, physiology, and/or dietary habits. Unfortunately, a good surgical result does not ensure a successful outcome. Even after excellent weight loss, patients must still be carefully followed long term to guard against the development of nutritional or gastrointestinal complications (Table 1).
Gastric bypass surgery requires ongoing patient effort and commitment to attaining and maintaining the appro priate body weight and a healthy lifestyle. Surgery helps limit the food intake, whereas patients should attempt to improve their eating habits and dietary practice. This requirement should be made clear to prospective patients and continually emphasized during pre-and postopera tive counseling. For maintaining the desired weight, patients need to learn how to make the right food selec tions and comply with all nutrient supplementations. The Roux-en-Y gastric bypass procedure involves bypassing a large part of the stomach and the duodenum, and a vari able length of the proximal jejunum. Consequently, patients are at risk for developing various deficiencies, in particular protein, iron, vitamin B12, folate, calcium, and other macro-and micronutrients. With proper supple mentation these deficiencies are largely avoidable.
As the prevalence of obesity continues to increase worldwide, bariatric surgery is increasingly being utilized for the severely obese. The most commonly performed surgery is Roux-en-Y gastric bypass, which usually results in significant and sustained weight loss. However, increasingly, problems are being recognized after such procedures. One such problem is the development of alcohol use disorders, which may at least partially result from changes in the pharmacokinetics of alcohol after surgery. Eating problems can also develop, including binge eating or loss of control eating and, rarely, full-blown eating disorders. Other addictive disorders can occur as well, but have been much less studied. Clinicians need to be alert to the development of such problems and to institute proper evaluation and treatment if they occur.
Patients who chose to have Roux-en-Y gastric bypass (RYGB) surgery need to be able to make long-term lifestyle changes and commit to lifelong vitamin and mineral supplementation. Because the amount of food that can be eaten is limited and nutrients are not fully absorbed, patients are at risk for developing a variety of macro- and micronutrient deficiencies. Nutrition guidelines should be explained at the onset of surgery consideration and reiterated at every phase of the process. This chapter will outline postoperative nutrition and supplementation requirements as well as review possible nutrient deficiencies, symptoms, and treatment for deficiencies should they occur. In addition, this chapter will address postoperative nutrition evaluation and follow-up protocols. It is important to provide continuous monitoring and adequate support to patients after surgery to ensure that they understand and are following program guidelines in order to achieve maximal weight loss and acquire skills to maintain a healthy weight.
Obesity continues to plague our society in epidemic proportions. Surgery for morbid obesity is considered by many as the most effective therapy for this complex disorder. Today, multiple surgical procedures for the treatment of obesity are available. As with most procedures, there are benefits and risks associated with open and laparoscopic gastric bypass surgery, as well as with laparoscopic adjustable gastric banding and partial biliopancreatic bypass with a duodenal switch. The risks and complications associated with bariatric surgery may be serious and in some cases life threatening. However, surgery for obesity has shown remarkable results in helping patients to achieve significant long-term weight control. In addition, it is associated with improvement and often resolution of co-morbid conditions, including type 2 diabetes mellitus, systemic hypertension, obesity hypoventilation, sleep apnea, venous stasis disease, pseudotumor cerebri, polycystic ovary syndrome, complications of pregnancy and delivery, gastroesophageal reflux disease, stress urinary incontinence, degenerative joint disease, and non-alcoholic steatohepatitis.
Weight loss after gastric bypass surgery is induced by severe restriction of stomach capacity causing reduction in overall food intake and malabsorption of nutrients by bypassing the proximal intestine. Although relatively infrequent, protein malnutrition after gastric bypass has been reported in the literature. Definitive data are lacking on the optimal amount of dietary protein to minimize risk of protein malnutrition and to support optimal body composition changes during the rapid weight loss after surgery. This review explores the prevalence of protein malnutrition in gastric bypass patients and investigates if there is an optimal protein intake that could maximize preservation of lean body mass during rapid weight loss. The impact of diet composition on body composition changes during rapid weight loss are explored through a selected review of the literature on very low calorie diets.
1. Background La chirurgia Bariatrica è una possibile strategia di intervento per soggetti attentamente se-lezionati con obesità morbigena (BMI>40 o con BMI>35 e patologie concomitanti) quando i metodi meno invasivi si sono rivelati inefficaci 1,2,3,19,21,23,25. L'approccio chirurgico, oltre a determinare una sostanziale perdita di peso, permette anche di ottenere tempi più lunghi di mantenimento del peso perduto, e si è rivelato in grado di ridurre i fattori di rischio e le patologie associate con l'obesità 1,4,5,22. Il team multidisciplinare è fondamentale per far fronte alla cura pre e post operatoria del paziente obeso 6,7,8,20,21,23. L'ottenimento di risultati ottimali richiede una attenta selezione dei pazienti ed un team multidisciplinare con sufficiente esperienza nelle dimensioni medica, chirurgica, dietistica e sociale 6,9,10,21,23. Il dietista risulta essere la figura più qualificata per la valutazione nutrizionale che include l'inquadramento pre-operatorio, l'educazione postoperatoria, il counseling e il follow-up 6,12,21,23. 2. Posizione E' posizione dell'ANDID che il dietista impegnato nella gestione nutrizionale del paziente obeso trattato con terapia chirurgia: 1) ponga al centro del proprio intervento il paziente e le sue esigenze, 2) collabori attivamente con i membri del team dell'obesità (chirurgo, medico, psicologo, infermiere, ecc.) per attuare il suo ruolo specifico, 3) possegga una for-mazione specifica e un aggiornamento continuo nell'ambito dell'obesità e dei disturbi del comportamento alimentare e, 4) valuti costantemente l'efficacia della sua prestazione. 2.1 Centralità del paziente Applicando i principi della Medicina basata sull'Evidenza 13,14,23, il dietista impiega il pro-prio giudizio professionale per adattare la miglior evidenza fornita dalla ricerca alla situa-zione clinica e personale del singolo paziente. Nel suo lavoro, il dietista applica le indica-zioni fornite dalle linee guida nazionali e internazionali 15,16,17,21.
Background:
Preoperative bariatric patients can follow very low calorie diets (VLCD), reducing surgical risks. However, possible advantages of a liquid diet over one of normal consistency are controversial. This study investigated the effect of a liquid VLCD compared with one of normal consistency considering visceral fat (VF) loss and metabolic profile in preoperative clinically severe obese patients.
Methods:
This was a randomized, open-labeled, controlled clinical trial. Patients were divided into 2 groups: liquid diet and normal diet. Data were collected at baseline and 7 and 14 days after intervention. Information gathered was analyzed for loss of weight and VF, biochemical data, anthropometric data, and energy intake.
Results:
Fifty-seven patients consumed the liquid diet and 47 consumed the normal consistency diet. The liquid diet group lost significantly more weight (P<.0290) and VF (P<.0410) than the normal diet group. An inverse correlation occurred between VF loss and surgical time among the liquid diet group (r2=-.1302, P=.001). Additionally, there was a positive correlation between the percentage of excess weight loss and ketonuria (P=.0070). No between-group difference occurred regarding calorie intake.
Conclusion:
Patients that consumed a liquid diet presented a positive effect on reducing VF and greater weight loss than the normal diet group. Both VLCDs presented benefits offering a protective effect during the preoperative stage.
Calcium is important for bone health. It has been customary to focus on dietary calcium intake, but of central importance for the body needs in the individual patient is the actual calcium absorption. This absorption consists of an active vitamin D-mediated component and a passive diffusional component. A number of different methods are available for the evaluation of calcium absorption. At present the calcium absorption tests using calcium isotopes (radioactive or stable) appear to be the most reproducible way of determining calcium absorption. The major nutrient sources for calcium are milk and milk products, whereas some of the green vegetables have a low bioavailability of calcium. When deciding whether an increased calcium intake is advisable, the following questions must be answered. What is the calcium absorptive status of the patient? How should the calcium supplement be dispensed? What calcium salt should be used? When should calcium supplements be taken? What is the compliance of the patient? When should the treatment be evaluated? The calcium supplement might be taken as milk (or milk products) or, in patients with lactose intolerance, as calcium supplements. Quite a number of calcium supplements are available on the market, and many of them are marketed without proper knowledge of the bioavailability of the actual preparation. For the benefit of our patients it is now reasonable to demand such investigations before marketing calcium supplements.
Dietary intake was recorded on 7-d food registers by 18 patients for 2 y after horizontal gastroplasty (GP) for morbid obesity. The aim was to evaluate diet compliance and nutritional safety. In accordance with prescriptions, frequency of meals increased and amounts of food decreased. Contrary to intentions, qualitative improvements were minor and transient resulting in a lasting fractional increase of patients with inadequate intakes of a wide range of nutrients. Protein malnutrition could not be detected from measurements of serum-albumin, plasma-prealbumin, or plasma retinol-binding globulin. Calcium was not included in the vitamin-mineral supplement and serum-Ca decreased. Despite thorough instruction, close follow-up, and gastrosurgery, there were no major qualitative dietary improvements. The study showed that bad compliance with an intended qualitative improvement of diet adds to the risks of being on a severely energy-restricted GP diet and increases the necessity for broad long-term supplements.
Preoperatively, the energy intake was high, the protein intake was sufficient, whereas the relative contribution of fat was greater than and of carbohydrate less than the recommended values. After gastroplasty a dramatic fall occurred in the intake of energy and all nutrients, and a relative reduction in the contribution of fat at 3 months and of carbohydrate at 12 months was observed. Preoperatively, the intake of vitamins D, B6, folacin, biotin, magnesium, iron, zinc, manganese, copper, and fluoride was deficient. Twelve months after operation the intake of these components and of vitamin E and iodine was less than half of the values recommended.
Nutritional status after 238 gastric operations designed to reduce caloric intake and body weight to within 30% of ideal was assessed by measuring body composition using the multiple isotope dilution technique. Body cell mass (BCM) and body fat were quantitated before and at 24 months after operation. Malnutrition was defined as a total exchangeable sodium (Nae) to total exchangeable potassium (Ke) ratio greater than 1.22. Data were collected on 96 patients. All had lost a mean of 26% of preoperative weight by 24 months. Significant malnutrition occurred in 47 patients whose Nae/Ke ratio ranged from 1.23 to 2.17 (1.45 +/- 0.03). There was a 34% reduction in body fat. The malnourished patients lost 10% more BCM by 24 months than did the normally nourished group. Malnutrition resolved as the stoma enlarged in 19 patients, and dietary counselling helped eight patients. Eighteen patients required reoperation to establish a larger orifice, and endoscopic dilatation was successful in two patients. Administration of a liquid diet via the gastrostomy was required for prolonged periods in some malnourished patients. Seventeen patients who had lost weight rapidly over a short time had low vitamin B12, thiamine, and serum and RBC folate levels. One patient had a markedly decreased serum thiamine level with neuropathy. Symptoms of weakness, easy fatigability, and lassitude were found in the malnourished patients. Low thiamine and serum folate levels were also seen in patients ingesting a liquid diet of 750 kcal with a standard multivitamin supplement. Malnutrition was not seen in these patients. In the 49 patients who remained well nourished, BCM decreased by 19%, but the Nae/Ke remained normal. Weight loss was well tolerated, and no patients required reoperation or supplemental liquid diet to increase caloric or protein intake. The degree of malnutrition in patients after gastric operations is as great as following intestinal bypass but is not associated with liver failure. Malnutrition with vitamin deficiency is a great potential hazard in patients who undergo intake-limiting operations, especially if the goal of the operation is to restore near-normal weight. Current operations are successfully designed to maintain a small orifice size, so that the risks of malnutrition are likely to increase in the future.
Vertical banded gastroplasty combines the best that has been learned about gastric reduction operations with another feature: a window through both walls of the stomach just above the crow's foot and next to the outlet along the lesser curvature. This window allows the application of staples up to the His' angle to create a small pouch (less than 50 mL). In addition, the outlet can be banded with a polypropylene mesh collar that is sutured to itself but not to the stomach. This banding provides an outlet diameter that remains constant. In experience with 42 patients during a one-year period, there were fewer complications and greater weight loss than have been obtained with any other operation for obesity, to my knowledge.
In 1990 Scopinaro's technique of biliopancreatic diversion with distal gastrectomy (DG) and gastroileostomy was modified. A sleeve gastrectomy with duodenal switch (DS) was used instead of the distal gastrectomy; and the length of the common channel was made 100 cm instead of 50 cm. A questionnaire and a prescription for blood work were sent to 252 patients who underwent DG a mean 8.3 years ago (range 6-13 years) and 465 patients who underwent DS 4.1 years ago (range 1.7-6.0 years). The questionnaire response rate was 93%, and laboratory work was completed for 65% of both groups. The mean weight loss after DG was 37 +/- 21 kg and after DS 46 +/- 20 kg. There were fewer side effects after DS: The number of daily stools was lower (p < 0.0002), as was the prevalence of diarrhea (p < 0.01), vomiting (p < 0.001), and bone pain (p < 0.001). Greater benefits related to several aspects of life were reported after DS than DG (p < 0.0001). The mean serum levels of ferritin, calcium, and vitamin A were higher (p < 0.001), and parathyroid hormone was lower. The yearly revision rate for excessive malabsorption was 1.7% per year after DG and 0.1% per year after DS. The two procedures were equally efficient for treating co-morbid conditions such as diabetes, hypertension, and hypercholesterolemia. Biliopancreatic diversion with sleeve gastrectomy/duodenal switch and a 100-cm common limb was shown to produce greater weight loss with fewer side effects.
Surgery is now considered to be the most effective treatment for reducing weight and maintaining weight loss in patients with clinically severe obesity. Although the jejuno-ileal bypass has been abandoned, the vertical banded gastroplasty (VBG) and Roux-en-Y gastric bypass (RYGB) operations are now commonly performed. A third operation, the bilio-pancreatic diversion (BPD), is performed less frequently. The RYGB and BPD procedures cause predictable selective micronutrient deficiencies that can be avoided by early supplementation. Surgical complications from all of these procedures may result in more severe forms of malnutrition. This article is intended to familiarize the nutrition support specialist with the anatomic and physiologic changes produced by these procedures, the resulting nutritional deficiencies and recommended supplementation, and the manifestations of severe malnutrition caused by complications. A case of severe malnutrition after RYGB surgery is reported for illustration.