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Nutritional Support for Bariatric Surgery Patients: The Skin beyond the Fat.
Toninello, P, Montanari, A, Bassetto, F, Vindigni, V, Paoli, A
Nutrients. 2021;(5)
Abstract
Body contouring surgery after the massive weight loss due to bariatric surgery deals with different kinds of complications. The aim of this review is to analyze the role that some nutrients may play in tissue healing after surgery, thus helping plastic surgeons to improve the aesthetic and health outcomes in massive weight loss patients under a multidisciplinary approach. As a matter of fact, preoperative nutritional deficiencies have been shown for vitamins and minerals in a large percentage of post-bariatric patients. Preoperative deficiencies mainly concern iron, zinc, selenium, and vitamins (both fat-soluble and water-soluble), but also total protein. During the postoperative period, these problems may increase because of the patients' very low intake of vitamins and minerals after bariatric surgery (below 50% of the recommended dietary allowance) and the patients' low compliance with the suggested multivitamin supplementation (approximately 60%). In the postoperative period, more attention should be given to nutritional aspects in regard to the length of absorptive area and the percentage of weight loss.
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The Effects of Bariatric Surgery on Vitamin B Status and Mental Health.
Al Mansoori, A, Shakoor, H, Ali, HI, Feehan, J, Al Dhaheri, AS, Cheikh Ismail, L, Bosevski, M, Apostolopoulos, V, Stojanovska, L
Nutrients. 2021;(4)
Abstract
Diet is a modifiable factor that ensures optimal growth, biochemical performance, improved mood and mental functioning. Lack of nutrients, notably vitamin B, has an impact on human health and wellbeing. The United Arab Emirates is facing a serious problem of micronutrient deficiencies because of the growing trend for bariatric surgery, including Roux-en-Y gastric bypass and sleeve gastrectomy. People undergoing bariatric surgery are at high risk of developing neurological, cognitive, and mental disabilities and cardiovascular disease due to deficiency in vitamin B. Vitamin B is involved in neurotransmitter synthesis, including γ-aminobutyric acid, serotonin, dopamine, and noradrenaline. Deficiency of vitamin B increases the risk of depression, anxiety, dementia and Alzheimer's disease. In addition, vitamin B deficiency can disrupt the methylation of homocysteine, leading to hyperhomocysteinemia. Elevated homocysteine levels are detrimental to human health. Vitamin B deficiency also suppresses immune function, increases the production of pro-inflammatory cytokines and upregulates NF-κB. Considering the important functions of vitamin B and the severe consequences associated with its deficiency following bariatric surgery, proper dietary intervention and administration of adequate supplements should be considered to prevent negative clinical outcomes.
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Bariatric Surgery and Liver Disease: General Considerations and Role of the Gut-Liver Axis.
Cerreto, M, Santopaolo, F, Gasbarrini, A, Pompili, M, Ponziani, FR
Nutrients. 2021;(8)
Abstract
Weight loss is a therapeutic solution for many metabolic disorders, such as obesity and its complications. Bariatric surgery aims to achieve lasting weight loss in all patients who have failed after multiple dietary attempts. Among its many benefits, it has been associated with the regression of non-alcoholic fatty liver disease (NAFLD), which is often associated with obesity, with evidence of substantial improvement in tissue inflammation and fibrosis. These benefits are mediated not only by weight loss, but also by favorable changes in systemic inflammation and in the composition of the gut microbiota. Changes in microbial metabolites such as short-chain fatty acids (SCFAs), capable of acting as endocrine mediators, and bile acids (BAs) as well as modifications of the gut-brain axis, are among the involved mechanisms. However, not all bariatric surgeries show beneficial effects on the liver; those leading to malabsorption can cause liver failure or a marked worsening of fibrosis and the development of cirrhosis. Nevertheless, there are still many unclear aspects, including the extent of the benefits and the magnitude of the risks of bariatric surgery in cirrhotic patients. In addition, the usefulness and the safety of these procedures in patients who are candidates to or who have undergone liver transplant need solid supporting evidence. This paper aims to review literature data on the use of bariatric surgery in the setting of chronic liver disease.
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Prediction of Suicide and Nonfatal Self-harm After Bariatric Surgery: A Risk Score Based on Sociodemographic Factors, Lifestyle Behavior, and Mental Health: A Nonrandomized Controlled Trial.
Konttinen, H, Sjöholm, K, Jacobson, P, Svensson, PA, Carlsson, LMS, Peltonen, M
Annals of surgery. 2021;(2):339-345
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Abstract
OBJECTIVE To identify preoperative sociodemographic and health-related factors that predict higher risk of nonfatal self-harm and suicide after bariatric surgery. BACKGROUND Evidence is emerging that bariatric surgery is related to an increased risk of suicide and self-harm, but knowledge on whether certain preoperative characteristics further enhance the excess risk is scarce. METHODS The nonrandomized, prospective, controlled Swedish Obese Subjects study was linked to 2 Nationwide Swedish registers. The bariatric surgery group (N = 2007, per-protocol) underwent gastric bypass, banding or vertical banded gastroplasty, and matched controls (N = 2040) received usual care. Participants were recruited from 1987 to 2001, and information on the outcome (a death by suicide or nonfatal self-harm event) was retrieved until the end of 2016. Subhazard ratios (sub-HR) were calculated using competing risk regression analysis. RESULTS The risk for self-harm/suicide was almost twice as high in surgical patients compared to control patients both before and after adjusting for various baseline factors [adjusted sub-HR = 1.98, 95% confidence interval (CI) = 1.34-2.93]. Male sex, previous healthcare visits for self-harm or mental disorders, psychiatric drug use, and sleep difficulties predicted higher risk of self-harm/suicide in the multivariate models conducted in the surgery group. Interaction tests further indicated that the excess risk for self-harm/suicide related to bariatric surgery was stronger in men (sub-HR = 3.31, 95% CI = 1.73-6.31) than in women (sub-HR = 1.54, 95% CI = 1.02-2.32) (P = 0.007 for adjusted interaction). A simple-to-use score was developed to identify those at highest risk of these events in the surgery group. CONCLUSIONS Our findings suggest that male sex, psychiatric disorder history, and sleep difficulties are important predictors for nonfatal self-harm and suicide in postbariatric patients. High-risk patients who undergo surgery might require regular postoperative psychosocial monitoring to reduce the risk for future self-harm behaviors.
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Approach to the Patient: Management of the Post-Bariatric Surgery Patient With Weight Regain.
Istfan, NW, Lipartia, M, Anderson, WA, Hess, DT, Apovian, CM
The Journal of clinical endocrinology and metabolism. 2021;(1):251-263
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Abstract
CONTEXT Weight regain (WR) after bariatric surgery is emerging as a common clinical problem due to the increase in the number of procedures performed. Early interventions are necessary to curtail the potential recurrence of comorbid conditions. However, it is often difficult to recognize WR early enough to introduce mitigating measures because there are no current guidelines for timely diagnosis and assessment of the severity of this condition. OBJECTIVE We present a practical approach for the early recognition of WR, based on 11-year follow-up data from our multiethnic bariatric surgery patient population. METHODS We classify WR according to the rate of increase in weight relative to nadir weight, normalized per 30-day interval. We also review pertinent literature about the etiologic factors contributing to WR after bariatric surgery. RESULTS According to our algorithm, mild, moderate, and rapid WR are defined as weight increases of 0.2% to <0.5%, 0.5% to 1.0%, and more than 1.0% of nadir weight per 30 days, respectively. Treatment options, including dietary counseling, use of antiobesity medication, and consideration of surgical revision, are described. A case is presented to illustrate the utility of timely identification of WR and the importance of collaboration between bariatric surgeons, obesity medicine specialists, and dietitians. CONCLUSION Our approach emphasizes the importance of regular long-term follow-up for all bariatric surgery patients.
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Plasma GDF15 levels are similar between subjects after bariatric surgery and matched controls and are unaffected by meals.
Martinussen, C, Svane, MS, Bojsen-Møller, KN, Jensen, CZ, Kristiansen, VB, Bookout, AL, Jørgensen, SB, Holst, JJ, Wewer Albrechtsen, NJ, Madsbad, S, et al
American journal of physiology. Endocrinology and metabolism. 2021;(4):E443-E452
Abstract
Growth differentiating factor 15 (GDF15) is expressed in the intestine and is one of the most recently identified satiety peptides. The mechanisms controlling its secretion are unclear. The present study investigated whether plasma GDF15 concentrations are meal-related and if potential responses depend on macronutrient type or are affected by previous bariatric surgery. The study included 1) volunteers ingesting rapidly vs. slowly digested carbohydrates (sucrose vs. isomaltose; n = 10), 2) volunteers who had undergone Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) surgery and unoperated matched controls ingesting a liquid mixed meal (n = 9-10 in each group), and 3) individuals with previous RYGB compared with unoperated controls ingesting isocaloric glucose, fat, or protein (n = 6 in each group). Plasma was collected after an overnight fast and up to 6 h after ingestion (≥12 time points). In cohort 1, fasting GDF15 concentrations were ∼480 pg/mL. Concentrations after sucrose or isomaltose intake did not differ from baseline (P = 0.26 to P > 0.99) and total area under the curves (tAUCs were similar between groups (P = 0.77). In cohort 2, fasting GDF15 concentrations were as follows (pg/mL): RYGB = 540 ± 41.4, SG = 477 ± 36.4, and controls = 590 ± 41.8, with no between-group differences (P = 0.73). Concentrations did not increase at any postprandial time point (over all time factor: P = 0.10) and tAUCs were similar between groups (P = 0.73). In cohort 3, fasting plasma GDF15 was similar among the groups (P > 0.99) and neither glucose, fat, nor protein intake consistently increased the concentrations. In conclusion, we find that plasma GDF15 was not stimulated by meal intake and that fasting concentrations did not differ between RYGB-, SG-, and body mass index (BMI)-matched controls when investigated during the weight stable phase after RYGB and SG.NEW & NOTEWORTHY Our combined data show that GDF15 does not increase in response to a liquid meal. Moreover, we show for the first time that ingestion of sucrose, isomaltose, glucose, fat, or protein also does not increase plasma GDF15 concentrations, questioning the role of GDF15 in regulation of food source preference. Finally, we find that neither fasting nor postprandial plasma GDF15 concentrations are increased in individuals with previous bariatric surgery compared with unoperated body mass index (BMI)-matched controls.
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Endovascular Bariatric Surgery as Novel Minimally Invasive Technique for Weight Management in the Morbidly Obese: Review of the Literature.
Sangiorgi, GM, Cereda, A, Porchetta, N, Benedetto, D, Matteucci, A, Bonanni, M, Chiricolo, G, De Lorenzo, A
Nutrients. 2021;(8)
Abstract
Nowadays, obesity represents one of the most unresolved global pandemics, posing a critical health issue in developed countries. According to the World Health Organization, its prevalence has tripled since 1975, reaching a prevalence of 13% of the world population in 2016. Indeed, as obesity increases worldwide, novel strategies to fight this condition are of the utmost importance to reduce obese-related morbidity and overall mortality related to its complications. Early experimental and initial clinical data have suggested that endovascular bariatric surgery (EBS) may be a promising technique to reduce weight and hormonal imbalance in the obese population. Compared to open bariatric surgery and minimally invasive surgery (MIS), EBS is much less invasive, well tolerated, with a shorter recovery time, and is probably cost-saving. However, there are still several technical aspects to investigate before EBS can be routinely offered to all obese patients. Further prospective studies and eventually a randomized trial comparing open bariatric surgery vs. EBS are needed, powered for clinically relevant outcomes, and with adequate follow-up. Yet, EBS may already appear as an appealing alternative treatment for weight management and cardiovascular prevention in morbidly obese patients at high surgical risk.
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Don't seek, don't find: The diagnostic challenge of Wernicke's encephalopathy.
Kohnke, S, Meek, CL
Annals of clinical biochemistry. 2021;(1):38-46
Abstract
Wernicke's encephalopathy is caused by thiamine deficiency and has a range of presenting features, including gait disturbance, altered cognitive state, nystagmus and other eye movement disorders. In the past, Wernicke's encephalopathy was described almost exclusively in the alcohol-dependent population. However, in current times, Wernicke's encephalopathy is also well recognized in many other patient groups, including patients following bariatric surgery, gastrointestinal surgery, cancer and pancreatitis. Early recognition of Wernicke's encephalopathy is vital, as prompt treatment can restore cognitive or ocular function and can prevent permanent disability. Unfortunately, Wernicke's encephalopathy is often undiagnosed - presumably because it is relatively uncommon and has a variable clinical presentation. Clinical biochemists have a unique role in advising clinicians about potential nutritional or metabolic causes of unexplained neurological symptoms and to prompt consideration of thiamine deficiency as a potential cause in high-risk patient groups. The aim of this review is to summarize the clinical features, diagnosis and treatment of Wernicke's encephalopathy and to highlight some non-traditional causes, such as after bariatric surgery.
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Tissue and circulating microRNAs as biomarkers of response to obesity treatment strategies.
Catanzaro, G, Filardi, T, Sabato, C, Vacca, A, Migliaccio, S, Morano, S, Ferretti, E
Journal of endocrinological investigation. 2021;(6):1159-1174
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Abstract
BACKGROUND Obesity, characterized by an increased amount of adipose tissue, is a metabolic chronic alteration which has reached pandemic proportion. Lifestyle changes are the first line therapy for obesity and a large variety of dietary approaches have demonstrated efficacy in promoting weight loss and improving obesity-related metabolic alterations. Besides diet and physical activity, bariatric surgery might be an effective therapeutic strategy for morbid obese patients. Response to weight-loss interventions is characterised by high inter-individual variability, which might involve epigenetic factors. microRNAs have critical roles in metabolic processes and their dysregulated expression has been reported in obesity. AIM: The aim of this review is to provide a comprehensive overview of current studies evaluating changes in microRNA expression in obese patients undergoing lifestyle interventions or bariatric surgery. RESULTS A considerable number of studies have reported a differential expression of circulating microRNAs before and after various dietary and bariatric surgery approaches, identifying several candidate biomarkers of response to weight loss. Significant changes in microRNA expression have been observed at a tissue level as well, with entirely different patterns between visceral and subcutaneous adipose tissue. Interestingly, relevant differences in microRNA expression have emerged between responders and non-responders to dietary or surgical interventions. A wide variety of dysregulated microRNA target pathways have also been identified, helping to understand the pathophysiological mechanisms underlying obesity and obesity-related metabolic diseases. CONCLUSIONS Although further research is needed to draw firm conclusions, there is increasing evidence about microRNAs as potential biomarkers for weight loss and response to intervention strategies in obesity.
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Beta Cell Function as a Baseline Predictor of Weight Loss After Bariatric Surgery.
Borges-Canha, M, Neves, JS, Mendonça, F, Silva, MM, Costa, C, M Cabral, P, Guerreiro, V, Lourenço, R, Meira, P, Salazar, D, et al
Frontiers in endocrinology. 2021;:714173
Abstract
BACKGROUND Obesity is a multifactorial disease, which is strongly associated to other metabolic disorders. Bariatric surgery is the most effective treatment of morbid obesity. The role of beta cell function in weight loss after bariatric surgery is uncertain. AIM: To evaluate the association between beta cell function and percentage of total body weight loss (TBWL%) 1, 2, 3, and 4 years after bariatric surgery in patients with morbid obesity. METHODS Retrospective longitudinal study in patients with morbid obesity followed in our center between January 2010 and July 2018. Patients were excluded if they had diabetes at baseline or missing data on the needed parameters. We evaluated baseline Homeostatic Model Assessment of IR, Homeostatic Model Assessment of β-cell function (HOMA-beta), Quantitative Insulin Sensitivity Check Index, and Matsuda and DeFronzo index, and TBWL% at years 1 to 4. Linear regression models were used to evaluate the association of indexes of insulin resistance with TBWL% (unadjusted and adjusted for age, sex, BMI, and type of surgery). RESULTS There were 1,561 patients included in this analysis. HOMA-beta was negatively associated with TBWL% at second, third, and fourth years post-surgery (β = -1.04 [-1.82 to -0.26], p<0.01; β = -1.16 [-2.13 to -0.19], p=0.02; β = -1.29 [-2.64 to 0.06], p=0.061, respectively). This was not observed in the first year post-surgery nor for the other indexes. Glycemia at baseline was positively associated to EWL% at second and third years post-surgery. CONCLUSION β-cell function at baseline seems to be associated to long-term weight loss, explicitly after the first year post bariatric surgery. This might be a helpful predictor of weight loss in clinical practice.