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Pregnancy after bariatric surgery: Effects of personalized nutrition counseling on pregnancy outcomes.
Araki, S, Shani Levi, C, Abutbul Vered, S, Solt, I, Rozen, GS
Clinical nutrition (Edinburgh, Scotland). 2022;(2):288-297
Abstract
BACKGROUND & AIMS Nutritional challenges following bariatric surgery can be intensified during pregnancy and may have crucial effects on the fetus, including lower birth weight. To the best of our knowledge, the effect of nutritional counseling during post-bariatric pregnancy to improve maternal diet quality and eating habits on neonatal outcome has not been evaluated. The aim of this research was to examine the effects of personal nutritional counseling during post-bariatric pregnancy on nutritional intake and neonatal outcomes. METHODS We performed a non-randomized, intervention-control clinical trial. Women (n = 61) were divided into three groups; two prospective, and one retrospective: 1. An Intervention Bariatric Prospective group 2. A Control Prospective group without surgery, and 3. A Control Bariatric Retrospective group. Patient enrollment was performed from April 2016 to March 2018. The intervention program included biweekly visits with a pregnancy nutrition certified bariatric dietitian. Data collection was performed four times during pregnancy, and included demographic and eating habits questionnaires, 24 h dietary recall, and information about delivery outcomes. In the retrospective group delivery outcomes and Food Frequency Questionnaire was collected once, after delivery. RESULTS There were no differences between groups at baseline except for a higher pre-pregnancy BMI in the post-bariatric groups. In the prospective groups, dietary protein, energy, and iron were found to be consumed in higher amounts in the Control-Prospective group than in the Intervention Bariatric-Prospective group (p < 0.05), without the addition of supplements. On the other hand, iron and calcium calculated from diet with supplements, were found to be significantly higher in the Intervention Bariatric Prospective group than in the Control Prospective group. In addition, consumption of saturated fats, oil, and salty snacks was lower in both prospective groups compared to the retrospective group (p < 0.05), suggesting better food quality habits for the bariatric group with nutritional counseling. Mean birth weight was significantly lower in the Control Bariatric Retrospective group than in the Control-Prospective group (3074 ± 368 g vs. 3396 ± 502 g, respectively. p = 0.023). In the Intervention Bariatric Prospective group, mean birth weight was 3168 ± 412 g, and no significant difference was observed from the Control Prospective group. Birth percentiles were also significantly lower in the Control Bariatric Retrospective group compared to the Control Prospective group (27th vs. 42nd, respectively. p < 0.05). In the Intervention Bariatric Prospective group, mean birth percentile was 35th, and no significant difference was observed from the Control Prospective group. As for the weight change of the woman during pregnancy, the highest variability was noted among the Control Bariatric Retrospective group with cases of weight loss up to 37 kg, due to conception close to the bariatric operation. Nevertheless, this variable was controlled, and showed no significant impact on birth weight results. CONCLUSIONS Our results suggest that personalized nutritional counseling care during post bariatric pregnancy improved nutrient intake of mothers and may contribute to higher birth weight of offspring. Further research is needed to examine the effects of prenatal nutrition care intervention, in addition to repeating this trial with a larger sample size, to allow for clearer findings. CLINICAL TRIAL REGISTRATION IRB number: 0310-15-RMB. IDENTIFICATION NIH NUMBER NCT02697981 URL: https://www.nih.gov.
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PREVENT: A Randomized, Placebo-controlled Crossover Trial of Avexitide for Treatment of Postbariatric Hypoglycemia.
Craig, CM, Lawler, HM, Lee, CJE, Tan, M, Davis, DB, Tong, J, Glodowski, M, Rogowitz, E, Karaman, R, McLaughlin, TL, et al
The Journal of clinical endocrinology and metabolism. 2021;(8):e3235-e3248
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Abstract
CONTEXT Postbariatric hypoglycemia (PBH), characterized by enteroinsular axis overstimulation and hyperinsulinemic hypoglycemia, is a complication of bariatric surgery for which there is no approved therapy. OBJECTIVE To evaluate efficacy and safety of avexitide [exendin (9-39)], a glucagon-like peptide-1 antagonist, for treatment of PBH. METHODS A multicenter, Phase 2, randomized, placebo-controlled crossover study (PREVENT). Eighteen female patients with PBH were given placebo for 14 days followed by avexitide 30 mg twice daily and 60 mg once daily, each for 14 days in random order. The main outcome measures were glucose nadir and insulin peak during mixed-meal tolerance testing (MMTT) and hypoglycemic events captured by self-monitoring of blood glucose (SMBG), electronic diary, and blinded continuous glucose monitoring (CGM). RESULTS Compared with placebo, avexitide 30 mg twice daily and 60 mg once daily raised the glucose nadir by 21% (P = .001) and 26% (P = .0002) and lowered the insulin peak by 23% (P = .029) and 21% (P = .042), corresponding to 50% and 75% fewer participants requiring rescue during MMTT, respectively. Significant reductions in rates of Levels 1 to 3 hypoglycemia were observed, defined, respectively, as SMBG <70 mg/dL, SMBG <54 mg/dL, and a severe event characterized by altered mental and/or physical function requiring assistance. CGM demonstrated reductions in hypoglycemia without induction of clinically relevant hyperglycemia. Avexitide was well tolerated, with no increase in adverse events. CONCLUSION Avexitide administered for 28 days was well tolerated and resulted in robust and consistent improvements across multiple clinical and metabolic parameters, reinforcing the targeted therapeutic approach and demonstrating durability of effect. Avexitide may represent a first promising treatment for patients with severe PBH.
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Fracture risk after three bariatric surgery procedures in Swedish obese subjects: up to 26 years follow-up of a controlled intervention study.
Ahlin, S, Peltonen, M, Sjöholm, K, Anveden, Å, Jacobson, P, Andersson-Assarsson, JC, Taube, M, Larsson, I, Lohmander, LS, Näslund, I, et al
Journal of internal medicine. 2020;(5):546-557
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BACKGROUND Previous studies have reported an increased fracture risk after bariatric surgery. OBJECTIVE To investigate the association between different bariatric surgery procedures and fracture risk. METHODS Incidence rates and hazard ratios for fracture events were analysed in the Swedish Obese Subjects study; an ongoing, nonrandomized, prospective, controlled intervention study. Hazard ratios were adjusted for risk factors for osteoporosis and year of inclusion. Information on fracture events were captured from the Swedish National Patient Register. The current analysis includes 2007 patients treated with bariatric surgery (13.3% gastric bypass, 18.7% gastric banding, and 68.0% vertical banded gastroplasty) and 2040 control patients with obesity matched on group level based on 18 variables. Median follow-up was between 15.1 and 17.9 years for the different treatment groups. RESULTS During follow-up, the highest incidence rate for first-time fracture was observed in the gastric bypass group (22.9 per 1000 person-years). The corresponding incidence rates were 10.4, 10.7 and 9.3 per 1000 person-years for the vertical banded gastroplasty, gastric banding and control groups, respectively. The risk of fracture was increased in the gastric bypass group compared with the control group (adjusted hazard ratio [adjHR] 2.58; 95% confidence interval [CI] 2.02-3.31; P < 0.001), the gastric banding group (adjHR 1.99; 95%CI 1.41-2.82; P < 0.001), and the vertical banded gastroplasty group (adjHR 2.15; 95% CI 1.66-2.79; P < 0.001). CONCLUSIONS The risk of fracture is increased after gastric bypass surgery. Our findings highlight the need for long-term follow-up of bone health for patients undergoing this treatment.
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An Application May Help Improve Protein Consumption after Bariatric Surgery.
Estrade, A, Montastier, E, Turnin, MC, Buisson, JC, du Rieu, MC, Tuyeras, G, Hernandez, G, Bérard, E, Ritz, P
Obesity surgery. 2019;(6):1982-1983
Abstract
This brief communication suggests that in patients who had bariatric surgery and in whom protein intake is lower than 60 g/d, the use of an application is likely to improve protein intake.
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Outcomes of bariatric surgery in patients with depression disorders.
Susmallian, S, Nikiforova, I, Azoulai, S, Barnea, R
PloS one. 2019;(8):e0221576
Abstract
OBJECTIVE To determine the impact of sleeve gastrectomy in patients suffering from depression compared with those who are not in a depressive state. INTRODUCTION Obesity is considered a global epidemic. Often patients with obesity suffer from depressive state. Depressive disorders may be both a cause and a consequence of obesity. MATERIAL AND METHODS The study includes 300 consecutives patients that underwent laparoscopic sleeve gastrectomy. Out of the 300 patients, 253 (84.33%) of them completed the follow up for three years. RESULTS Out of the 300-patients, with the average age of 41.65±11.05 years old, the ratio of males to females was 1:2. The average baseline BMI was 42.02 kg/m2. A total of 105 (35.33%) of the patients suffer from depression, which was more common in male (43%) than in female (31.5%), with statistically significant difference (p = .05). Comparing the weight loss after surgery in both groups, the mean weight loss in the depression-group was 12.0 ΔBMI and in the non-depression group was 13.03 ΔBMI, (p< .001). After three years, 94 (88.68%) patients of the depression group responded as they were optimistic and satisfied with the results of the operation, with positive changes in their lives, 8 (7.55%) did not experience change and 4 (3.77%) expressed to have worsened their depressive state. CONCLUSION Laparoscopic sleeve gastrectomy is successful and leads to weight loss even in subjects who are affected by depression syndrome.
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Effect of laparoscopic Roux-en-Y gastric bypass versus laparoscopic sleeve gastrectomy on fasting gastrointestinal and pancreatic peptide hormones: A prospective nonrandomized trial.
Yang, J, Gao, Z, Williams, DB, Wang, C, Lee, S, Zhou, X, Qiu, P
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;(10):1521-1529
Abstract
BACKGROUND Changes in gastrointestinal and pancreatic hormones may play a role in promoting long-term weight reduction and improved glucose metabolism after sleeve gastrectomy and Roux-en-Y gastric bypass. However, few studies have examined the metabolic and endocrine effects of these procedures in Mainland China. OBJECTIVES To compare the effects of laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) on gastrointestinal and pancreatic peptide hormones. SETTING University hospital, China. METHODS A nonrandomized prospective study was conducted in Chinese obese patients undergoing LSG or LRYGB. Of 20 patients in this study, 10 underwent LSG, and 10 underwent LRYGB. Fasting plasma levels of insulin, glucagon, ghrelin, gastric inhibitory peptide, peptide YY, glucagon-like peptide (GLP)-1, and GLP-2 were measured preoperatively and at 1, 3, 6, and 12 months after surgery. This trial was registered at www.clinicaltrials.gov (NCT02963662). RESULTS During the first year after both operations, mean body mass index and fasting insulin levels steadily decreased at all intervals. Fasting plasma glucose levels significantly decreased at 1 month after surgery, then remained stable in both groups. Glucagon levels significantly decreased at 1, 3, and 6 months after surgery in both groups, but returned to baseline at 12 months. Fasting GLP-1 and peptide YY significantly increased in both groups, but more so after LRYGB. However, GLP-2 did not change in either group. Ghrelin levels significantly decreased after LSG, but not after LRYGB. Gastric inhibitory peptide levels decreased after LRYGB but not after LSG. CONCLUSIONS LSG and LRYGB resulted in significant and distinct changes in multiple gastrointestinal and pancreatic peptide hormones that are important regulators of obesity and metabolic health.
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The long-term effect of pregnancy on weight loss after sleeve gastrectomy.
Rottenstreich, A, Shufanieh, J, Kleinstern, G, Goldenshluger, A, Elchalal, U, Elazary, R
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2018;(10):1594-1599
Abstract
BACKGROUND Pregnancy outcomes after bariatric surgery have been addressed extensively; however, the impact of pregnancy on long-term outcomes after bariatric surgery has only been sparsely studied. OBJECTIVES We explored the effects of pregnancy on weight loss outcomes after laparoscopic sleeve gastrectomy (LSG). SETTING University hospital. METHODS A cross-sectional case-control study. Eighty women who became pregnant after LSG were matched by preoperative body mass index, age, and follow-up duration to 80 post-LSG patients who did not conceive after surgery (control group). RESULTS The median follow-up duration was 5.2 years for the study group and 5.3 years for the control group (P = .73). For the study group, the median time from surgery to conception was 508 (interquartile range 372-954) days and the median gestational weight gain was 9 (6-12) kg. Comparing the study with the control group, median percentage total weight loss was similar, 31% versus 30% (P = .77); as was percentage excess weight loss (EWL%) 72% versus 71% (P = .77). For the study group, a multivariable analysis showed EWL% at the end of follow-up to be directly correlated with the lowest EWL% achieved before pregnancy (β = .78, P < .0001), and inversely correlated with time lapsed from surgery (β = -.26, P < .0001); yet EWL% was not found to be associated with surgery-to-conception time interval, gestational weight gain, breastfeeding, co-morbidities, smoking, occupational status, physical activity, and dietary habits. CONCLUSIONS Pregnancy after LSG does not affect long-term weight results. Coupled with the positive reports of improved pregnancy outcomes after bariatric surgery, these data should reassure women who wish to conceive after surgery.
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Intravenous iron sucrose versus oral iron administration for the postoperative treatment of post-bariatric abdominoplasty anaemia: an open-label, randomised, superiority trial in Brazil.
Montano-Pedroso, JC, Bueno Garcia, E, Alcântara Rodrigues de Moraes, M, Francescato Veiga, D, Masako Ferreira, L
The Lancet. Haematology. 2018;(7):e310-e320
Abstract
BACKGROUND Anaemia and iron deficiency are common after post-bariatric abdominoplasty, which can involve removal of large areas of skin with associated blood loss. Because the oral absorbability of iron is reduced after bariatric surgery (through reduced intake, reduction of gastric acid secretion for conjugation of iron, and separation of the iron-absorptive areas of the duodenum and jejunum), it has been hypothesised that postoperative intravenous iron supplementation might be used to treat anaemia and iron deficiency in patients submitted to post-bariatric plastic surgeries. We aimed to assess whether intravenous iron administered postoperatively in post-bariatric abdominoplasty could result in increased blood haemoglobin concentrations compared with oral iron supplementation. METHODS In this open-label, randomised, superiority trial, we recruited women aged 18-55 years undergoing post-bariatric abdominoplasty at two public tertiary referral hospitals in São Paulo, Brazil. Eligible women had been treated for previous obesity with bariatric surgery using the vertical banded gastroplasty technique with Roux-en-Y gastric bypass by laparotomy; had grade III contour deformity via the Pittsburgh rating scale; and had a post-bariatric body-mass index (BMI) lower than 32 kg/m2, with stabilised weight loss for at least 6 months. Women were randomly assigned (1:1) to receive postoperative iron supplementation with two intravenous infusions of 200 mg of iron sucrose (intravenous group) or 100 mg of iron polymaltose complex orally twice a day for 8 weeks (oral group). The primary outcome in both groups was blood haemoglobin concentration at postoperative day 56 after abdominoplasty, with a minimum clinically relevant difference of 1·5 g/dL. Analyses were performed on an intention-to-treat basis. This trial is registered with ClinicalTrials.gov, number NCT01857011, and the Brazilian Clinical Trials Registry, number RBR-2JGRKQ. The trial is completed. FINDINGS From April 7, 2014, to June 27, 2016, 102 post-bariatric patients were assessed for eligibility. 56 patients were eligible and were randomly assigned, with 28 allocated to each group. Mean baseline haemoglobin concentration was slightly higher in the oral group than in the intravenous group (12·71 g/dL [SD 1·06] vs 12·24 g/L [1·09]), and by post-operative day 56 was 12·54 g/dL (SD 1·18) and 12·80 g/dL (0·81), respectively (mean difference of 0·26 g/dL, 95% CI -0·28 to 0·80; p=0·009 in favour of the intravenous group). The minimum clinically relevant difference in concentrations was not reached. No adverse events were recorded in the intravenous group, whereas in the oral group, constipation was recorded in five (18%) patients, diarrhoea in three (11%), and nausea in one (4%) patient. INTERPRETATION Postoperative intravenous administration of iron increased haemoglobin concentrations at 56 days post-operatively and reduced iron deficiency, without adverse events. Although superiority of intravenous iron was not shown, intravenous administration might be useful in post-bariatric patients, especially in those who have body-contouring treatment involving a second surgery within a short period of time. Larger trials, and trials using higher intravenous doses of iron, are needed to further assess the potential efficacy and safety of intravenous iron administration after post-bariatric plastic surgery. FUNDING The São Paulo Research Foundation (FAPESP).
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The Effects on Obesity Related Peptides of Laparoscopic Gastric Band Applications in Morbidly Obese Patients.
Arica, PC, Aydin, S, Zengin, U, Kocael, A, Orhan, A, Zengin, K, Gelisgen, R, Taskin, M, Uzun, H
Journal of investigative surgery : the official journal of the Academy of Surgical Research. 2018;(2):89-95
Abstract
BACKGROUND The aim of this study was to examine the relationship between weight loss and resistin, apelin, chemerin, and visfatin after laparoscopic adjustable gastric banding (LAGB). METHODS The study group consisted of 19 patients who were operated on for morbid obesity (BMI: 48.7 ± 6.6 kg/m2), and 22 healthy, normal-weight (BMI: 22.9 ± 2.5 kg/m2) subjects formed the control group. We obtained blood samples from the study subjects at three different times: before undergoing surgery and at one month and 6 months after surgery. Blood was obtained once from the control group. RESULTS Significant weight loss was achieved at one and 6 months after surgery. Plasma levels of apelin, resistin, chemerin, and visfatin were higher in morbidly obese patients compared with the control group. Obesity-related peptides decreased one month and 6 months after surgery. CONCLUSIONS Elevated plasma resistin, apelin, chemerin, and visfatin levels in morbidly obese patients are gradually reduced after weight loss. According to these findings, LAGB surgery is found to be an important and efficient means for morbidly obese patients both to lose weight and to develop a better metabolic risk profile in a short time period.
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Long-term nutritional impact of sleeve gastrectomy.
Caron, M, Hould, FS, Lescelleur, O, Marceau, S, Lebel, S, Julien, F, Simard, S, Biertho, L
Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2017;(10):1664-1673
Abstract
BACKGROUND Sleeve gastrectomy (SG) has become a predominant bariatric procedure throughout the world. However, the long-term nutritional impact of this procedure is unknown. OBJECTIVES To describe the nutritional deficiencies before and after SG and to analyze the influence of baseline weight on nutritional status. SETTING University-affiliated tertiary care center. METHODS All patients who underwent SG as a standalone procedure between 2008 and 2012 were included in this study. Patients were given multivitamin supplementation. Data were obtained from our prospectively maintained electronic database and are reported as mean ± standard deviation and percentage. Bivariate analyses were conducted to evaluate the influence of selected variables on outcomes. RESULTS The mean age of the 537 patients was 48.0 ± 11.3 years, with an initial body mass index of 48.1 ± 8.7 kg/m2. Excess weight loss and total weight loss were 56.2% and 28.0% at 1 year and 43.0% and 21.1% at 5 years, respectively (P<.0001). Percentage of follow-up was 74% at 5 years (n = 79). The mean follow-up time was 34.3 ± 17.2 months. Hypoalbuminemia was present in 1.1% preoperatively and 4.2% at 5 years (P = .0043), low ferritin levels in 8.6% and 37.8% (P<.0001), low vitamin B12 in 30.3% and 16.4% (P<.0001), low vitamin D 63.2% and 24.3% (P<.0001), and hyperparathyroidism in 23.4% and 20.8% (P<.0001). There was no significant difference in the prevalence of anemia over time (P = 0.4301). The prevalence of vitamin A insufficiency peaked from 7.9% preoperatively to 28.7% at 3 months (P<.0001) and returned to baseline thereafter. Baseline weight was negatively correlated with vitamin B12 and vitamin D. CONCLUSION Nutritional deficiencies are common in patients with morbid obesity before and after surgery. Preoperative supplementation and long-term nutritional follow-up are required to prevent nutritional deficiencies.