One size does not fit all; practical, personal tailoring of the diet to NAFLD patients.

Different dietary regimens for weight loss have developed over the years. Since the most evidenced treatment for non-alcoholic fatty liver disease (NAFLD) is weight reduction, it is not surprising that more diets targeting obesity are also utilized for NAFLD treatment. However, beyond the desired weight loss effects, one should not ignore the dietary composition of each diet, which may not necessarily be healthy or safe over the long term for hepatic and extrahepatic outcomes, especially cardiometabolic outcomes. Some of these diets are rich in saturated fat and red meat, are very strict, and require close medical supervision. Some may also be very difficult to adhere to for long periods, thus reducing the patient's motivation. The evidence for a direct benefit to NAFLD by restrictive diets such as very-low-carb, ketogenic, very-low-calorie diets, and intermittent fasting is scarce, and the long-term safety has not been tested. Nowadays, the approach is that the diet should be tailored to the patient's cultural and personal preferences. There is strong evidence for the independent protective association of NAFLD with a diet based on healthy eating patterns of minimally-processed foods, low in sugar and saturated fat, high in polyphenols, and healthy types of fats. This leads to the conclusion that a Mediterranean diet should serve as a basis that can be restructured into other kinds of diets. This review will elaborate on the different diets and their role in NAFLD. It will provide a practical guide to tailor the diet to the patients without compromising its composition and safety.

Short-Term Changes in Mental, Physical, and Social Factors After Metabolic Bariatric Surgery in Adolescents: A Nationwide Prospective Cohort Study.

Background: Metabolic bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. However, changes in mental, physical, and social factors, as well as their association with the extent of excess weight loss (%EWL) after MBS, remain controversial. Methods: We followed 97 adolescents (64% females, aged 17 ± 0.9 years, BMI 46.1 ± 5.9 kg/m2) before and 9 months following MBS in a multi-center, prospective cohort study. Changes in mental, physical, and social factors were assessed by self-reported questionnaires, and associations with %EWL were evaluated after adjustment for potential confounders. Results: The body mass index (BMI) decreased by 30%, and all physical parameters significantly improved (p ≤ 0.001). Energy level increased by 24%, mood level by 14%, and mental health by 9.5% (p ≤ 0.002). Social parameters were also improved, with a significant decrease in social rejection (p = 0.02), and an increase in participation in after-school social activities (p = 0.008). Mental health improvement was associated with baseline social rejection (r = 0.514, p < 0.001). The improvement in all factors was not related to the extent of %EWL. Conclusion: Metabolic bariatric surgery MBS in adolescents led to a meaningful decrease in BMI and to an improvement in short-term physical, mental, and social factors that were not related to %EWL. Patients experiencing social rejection may improve their mental health following BS.

Weight Loss Outcomes and Lifestyle Patterns Following Sleeve Gastrectomy: an 8-Year Retrospective Study of 212 Patients.

PURPOSE: Sleeve gastrectomy (SG) is an effective treatment for extreme obesity; however, long-term weight loss outcomes remain largely understudied. We aimed to examine the long-term weight changes following SG and patient characteristics and lifestyle patterns related to weight loss outcomes. MATERIALS AND METHODS: Data from medical records of patients operated in a tertiary university medical center between 2008 and 2014 were reviewed, along with information derived from a telephone questionnaire. Information included the following: current medical status, medications, side effects, behavior, lifestyle habits, and weight changes. RESULTS: A total of 212 patients (69.3% females) were included, with a median follow-up duration of 8 years post-SG. Mean age and baseline body mass index (BMI) of participants were 39.7 ± 12.0 years and 42.2 ± 4.9 kg/m2, respectively. Mean BMI, percentage excess weight loss, and percentage total body weight loss were 33.1 ± 6.1, 55.5 ± 27.5%, and 21.7 ± 10.7%, respectively. Higher baseline BMI was found to be the strongest independent predictor for insufficient weight loss (OR = 0.90, P = 0.001, 95% CI 0.85, 0.96). Sweetened beverage intake, usage of psychiatric medications, higher initial BMI, and lower age were significant predictors for increased weight gain from nadir weight (P < 0.0001, P = 0.005, P = 0.035, and P < 0.0001, respectively). CONCLUSIONS: SG patients were found to maintain a notable long-term weight loss. Nevertheless, weight regain and insufficient weight loss were prevalent in the long-term post-operative period, and were related to certain lifestyle patterns. Clinical practice should emphasize the relationship between post-operative weight loss outcomes and specific behaviors. Efforts should be made to educate patients on the need for lifelong follow-up and support.

Effect of Dietary Strategies on Respiratory Quotient and Its Association with Clinical Parameters and Organ Fat Loss: A Randomized Controlled Trial.

The relation between changes in respiratory quotient (RQ) following dietary interventions and clinical parameters and body fat pools remains unknown. In this randomized controlled trial, participants with moderate abdominal obesity or/and dyslipidemia (n = 159) were randomly assigned to a Mediterranean/low carbohydrate (MED/LC, n = 80) or a low fat (LF, n = 79) isocaloric weight loss diet and completed a metabolic assessment. Changes in RQ (measured by indirect calorimeter), adipose-tissue pools (MRI), and clinical measurements were assessed at baseline and after 6 months of intervention. An elevated RQ at baseline was significantly associated with increased visceral adipose tissue, hepatic fat, higher levels of insulin and homeostatic insulin resistance. After 6 months, body weight had decreased similarly between the diet groups (-6 ± 6 kg). However, the MED/LC diet, which greatly improved metabolic health, decreased RQ significantly more than the LF diet (-0.022 ± 0.007 vs. -0.002 ± 0.008, p = 0.005). Total cholesterol and diastolic blood pressure were independently associated with RQ changes (p = 0.045). RQ was positively associated with increased superficial subcutaneous-adipose-tissue but decreased renal sinus, pancreatic, and intramuscular fats after adjusting for confounders. Fasting RQ may reflect differences in metabolic characteristics between subjects affecting their potential individual response to the diet.

Nutritional Assessment and Preparation for Adult Bariatric Surgery Candidates: Clinical Practice.

Bariatric surgery (BS) has proven to be highly efficacious in the treatment of obesity and its comorbidities. However, careful patient selection is critical for its success. Thus, patients should undergo medical, behavioral, and nutritional assessment by a multidisciplinary team. From the nutritional point of view, BS candidates should undergo nutritional assessment, preparation, and education by a registered dietitian in the preoperative period. Currently, detailed specified and comprehensive information on these topics is lacking. The present narrative review aimed to summarize the available literature concerning both the preoperative nutritional assessment components and the preoperative nutritional preparation and education components of patients planning to undergo BS. Current literature indicates that proper management before BS should include a comprehensive nutritional assessment, in which it is advisable to perform a clinical interview to assess patients' medical background, weight management history, eating patterns and pathologies, oral health, physical activity habits, nutritional status, supplementation usage, BS knowledge, surgery expectations and anthropometric measurements. Nutritional preparation and educational strategies should include an individualized preoperative weight-loss nutrition program, improvement of glycemic control, micronutrients deficiencies correction, eating and lifestyle habits adaptation, physical activity initiation, and strengthening knowledge on obesity and BS. At this stage, more well-designed intervention and long-term cohort studies are needed in order to formulate uniform evidence-based nutritional guidelines for patients who plan to undergo BS, including populations at higher nutritional risk. Moreover, postoperative outcomes of presurgical nutritional intervention programs should be studied.

Knowledge, attitudes, and behaviors of women during pregnancy after bariatric surgery.

BACKGROUND: Women of childbearing age constitute a substantial proportion of the patients who undergo weight loss procedures. However, little is known regarding attitudes and behaviors of women during pregnancy after bariatric surgery (BS). OBJECTIVES: We explored women's experience and behavior during pregnancy after BS. SETTING: University hospital. METHODS: A cross-sectional survey study was performed among women who underwent sleeve gastrectomy and delivered at our center. RESULTS: Overall, 111 women completed the questionnaire (response rate 88.1%). The median surgery-to-conception interval was 34 (25-50) months. For 28 (25.2%) women, future pregnancy was a motivation for undergoing the weight loss procedure. Only 10 (9.0%) received contraceptive advice perioperatively. Oral contraception was the most commonly used method after surgery (n = 47, 42.3%). Pregnancy was reported as unintended by 37 (33.3%) women. Only 14 (12.6%) women stated receiving an explanation regarding the implications of BS on pregnancy outcomes. Rates of follow-up with maternal-fetal medicine specialists, bariatric surgeons, and dieticians during pregnancy were 36.0%, 9.0%, and 23.4%, respectively. Forty-four women (39.6%) felt follow-up throughout gestation was inadequate. Satisfaction from BS improved after pregnancy in 23 (20.7%) women, and 75 (67.6%) stated that they would recommend BS to a friend with obesity who plans to conceive in the future. CONCLUSIONS: Women reported insufficient knowledge regarding the expected outcomes of pregnancy after surgery, with low rates of medical and nutritional follow-up. Only a minority of respondents received contraceptive advice after surgery, and unintended pregnancies were common. These observations represent areas of improvement for following women of childbearing age who undergo weight loss procedures.

Vitamin K-what is known regarding bariatric surgery patients: a systematic review.

Vitamin K, a fat-soluble vitamin, is involved in blood coagulation, bone mineralization, inhibition of vascular calcification, and regulation of numerous enzyme systems. Patients who undergo bariatric surgery (BS), especially procedures that involve a malabsorptive component, are prone to develop vitamin K deficiency (VKD). The causes of VKD include decreased absorptive surface areas, steatorrhea, bacterial overgrowth, marked reduction of carriers of vitamin K, decrease in vitamin K intake, and modifications of gut microbiota. Data on vitamin K status among BS patients are scarce and the strength of evidence supporting vitamin K supplementation is weak. Thus, this systematic review summarized the scientific literature on vitamin K and examined the status among patients before and after BS, as well as among pregnant women with a history of BS. A MEDLINE/Pubmed and Embase electronic search was performed. After a thorough screening of 204 titles, 19 articles were selected by 2 independent reviewers. Five studies on BS candidates (n = 750), 12 studies after BS (n = 1442), and 4 studies on pregnant woman after BS (n = 83, of them n = 7 from case reports) were included. Results of the current review suggest that patients who undergo major malabsorptive surgeries are at a higher risk of developing VKD and should be better monitored. At this point, it is still unclear whether supplementation of vitamin K is required, and what oral dose or vitamer type should be used to normalize serum levels after different types of bariatric procedures. It should be noted that the current protocols for VKD treatment are still experiential in these patients. It is also unknown at what intervals screening tests for vitamin K should be performed and what assay is most appropriate for screening purposes. Future studies are needed to answer these unresolved issues.

Maternal nutritional status and related pregnancy outcomes following bariatric surgery: A systematic review.

Up to 80% of patients who undergo bariatric surgery are women of childbearing age. Coupled with improved fertility in women with obesity after bariatric surgery, pregnancy postbariatric surgery has become increasingly more common. Although numerous studies have evaluated associations of bariatric surgery with pregnancy outcomes, the effect of maternal nutritional status on maternal and perinatal outcomes is not well established. We used Medline and Embase databases and a manual search of references for articles published until June 2018 to conduct a systematic review on nutritional status after bariatric surgery and its association with maternal and perinatal outcomes. Of the 306 initially identified articles, 27 met the study inclusion criteria, comprising 2056 women with pregnancies after bariatric surgery. Deficiencies were reported in maternal concentrations of vitamins A, B1, B6, B12, C, D, K, iron, calcium, selenium, and phosphorous. The only adverse events documented for these deficiencies encountered during pregnancy were anemia (vitamin B12, iron), night blindness (vitamin A), and urinary tract infections (vitamin A, D). This systematic review suggests that various micronutrient deficiencies are common among pregnant postbariatric surgery patients. Nevertheless, despite the concern that these deficiencies could adversely affect pregnancy outcomes (e.g., lower neonatal birth weight), evidence of such is lacking. Further prospective studies are warranted to confirm our findings and better delineate the optimal supplementation regimen during pregnancy after bariatric surgery.

The long-term effect of pregnancy on weight loss after sleeve gastrectomy.

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 (ß = .78, P < .0001), and inversely correlated with time lapsed from surgery (ß = -.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.

Predictors for Adherence to Multidisciplinary Follow-Up Care after Sleeve Gastrectomy.

INTRODUCTION: A considerable proportion of patients who undergo bariatric surgeries (BS) do not attend routine postoperative follow-up despite recommendations for such. Data are sparse regarding the various aspects of patient adherence to consultations following sleeve gastrectomy (SG). OBJECTIVES: To examine predictors of adherence to SG follow-up, reasons for attrition from follow-up, and the relationship between adherence to follow-up and weight loss results. METHODS: A retrospective cohort study was performed with a mean follow-up of 3 years. Data were collected from electronic medical records and telephone questionnaires. Adherence was defined both as a numerical variable (ranking 0-9 according to the number of pre-scheduled postoperative visits) and as a dichotomous variable (adherent and non-adherent groups). RESULTS: Of 178 patients, 46.63% were defined as "adherent," according to the dichotomous definition. Compared to the "non-adherent group," patients in the "adherent group" more regularly used vitamin D after the surgery, had fewer rehospitalizations, and reported a lower intake of sweetened beverages. The main reasons for attrition were work-related and difficulties in mobility. Adherence to postoperative follow-up was not found to be correlated to weight loss. Older age (OR = 1.04; p = 0.026) and postoperative side effects (OR = 2.33; p = 0.035) were found to be positive predictors for adherence, whereas rehospitalizations (OR = 0.08; p = 0.028) and ethnical minority status were negative predictors (OR = 0.42; p = 0.019). CONCLUSION: Adherence to postoperative follow-up was found to be associated with positive lifestyle behaviors; however, no correlation was found to mid-term weight loss outcomes.

Bone Health following Bariatric Surgery: Implications for Management Strategies to Attenuate Bone Loss.

Bariatric surgery (BS) is an effective treatment for morbid obesity and its associated comorbidities. Following such a procedure, however, patients are at risk of developing metabolic bone disease owing to the combination of rapid weight loss, severely restricted dietary intake, and reduced intestinal nutrient absorption. Patients undergoing malabsorptive procedures are at a higher risk of postoperative bone health deterioration than those undergoing restrictive procedures; however, studies have demonstrated negative skeletal consequences of restrictive procedures as well. The clinical practice guidelines of some international associations have previously addressed preoperative evaluation and postoperative clinical care in order to maintain bone health in BS patients. Nevertheless, some issues regarding bone health in BS patients remain unclear owing to the lack of relevant randomized clinical trials, including doses of nutritional supplements pre- and post-BS. This review summarizes the current data regarding the skeletal consequences of BS and its mechanisms, with an emphasis on the preventive strategies and nutritional care that may be warranted in order to attenuate bone deterioration following BS.

Postoperative Outcomes, Weight Loss Predictors, and Late Gastrointestinal Symptoms Following Laparoscopic Sleeve Gastrectomy.

OBJECTIVE: To evaluate the outcomes, weight loss predictors, and gastrointestinal symptoms of patients after laparoscopic sleeve gastrectomy (LSG). METHODS: The postoperative medical status of the patients was obtained retrospectively using a questionnaire and was compared to existing medical data before the surgery. RESULTS: We included 201 candidates, 178 patients completed mean of 3 years of follow-up. Mean excess body weight loss (%EWL) was 65.14% ± 15.74 at 6 months, 78.53% ± 20.28 at 12 months, and 74.32% ± 23.92 at 3 years after LSG. Older age (P = 0.018), higher baseline BMI (P = 0.003), and higher number of medications (P < 0.001) were negative predictors for EWL%. Total weekly hours of physical activity was found to be a positive predictor for EWL% (P = 0.008). Remission rates of co-morbidities were 83.5% for dyslipidemia (P < 0.001), 65.8% for hypertension (P < 0.001), 62.1% for type 2 diabetes mellitus (T2DM) (P < 0.001), and 60.7% for gastroesophageal reflux (GERD) (P < 0.001). Late gastrointestinal symptoms were as follows: emesis in 25.9%, constipation in 24.7%, diarrhea in 4.5%, food intolerance in 22.5% and alopecia in 42.7% of the patients. CONCLUSION: Our study shows LSG as a potential tool in achieving almost 75% of EWL% with significant remission of co-morbidities, along with various late gastrointestinal symptoms.

Nutritional deficiencies four years after laparoscopic sleeve gastrectomy-are supplements required for a lifetime?

BACKGROUND: Data regarding long-term nutritional deficiencies following laparoscopic sleeve gastrectomy (LSG) are scarce. OBJECTIVES: To assess the prevalence of nutritional deficiencies and supplement consumption 4 years post-LSG. SETTING: Hebrew University, Israel. METHODS: Data were collected prospectively from preoperative and 1 and 4 years postoperative including anthropometric parameters, biochemical tests, and supplement intake. RESULTS: Data were available for 192, 77, and 27 patients at presurgery and 1 and 4 years post-LSG, respectively. Prevalence of nutritional deficiencies at baseline and 1 and 4 years postsurgery, respectively, were specifically for iron (44%, 41.2%, 28.6%), anemia (11.5%, 20%, 18.5%), folate (46%, 14.3%, 12.5%), vitamin B12 (7.7%, 13.6%, 15.4%), vitamin D (96.2%, 89%, 86%), and elevated parathyroid hormone (PTH) (52%, 15.4%, 60%). Vitamin D levels remained low throughout the whole period. PTH levels were 37.5 pg/mL at 1 year postsurgery and increased to 77.3 pg/mL at 4 years postsurgery (P = .009). Females had higher prevalence of elevated PTH and a tendency for higher rates of anemia, compared with males 4 years postsurgery (80% versus 20%, P = .025; and 28% versus 0%, P = .08, respectively). Of the patients, 92.6% reported taking a multivitamin and 74.1% vitamin D supplements during the first postoperative year, while after 4 years only 37% and 11.1% were still taking these supplements, respectively. CONCLUSION: A high rate of nutritional deficiencies is common at 4 years post-LSG along with low adherence to the nutritional supplementation regimen. Long-term nutritional follow-up and supplementation maintenance are crucial for LSG patients. Future studies are needed to clarify the clinical impact of such deficiencies.

Nutritional Recommendations for Adult Bariatric Surgery Patients: Clinical Practice.

Bariatric surgery is currently the most effective treatment for morbid obesity and its associated metabolic complications. To ensure long-term postoperative success, patients must be prepared to adopt comprehensive lifestyle changes. This review summarizes the current evidence and expert opinions with regard to nutritional care in the perioperative and long-term postoperative periods. A literature search was performed with the use of different lines of searches for narrative reviews. Nutritional recommendations are divided into 3 main sections: 1) presurgery nutritional evaluation and presurgery diet and supplementation; 2) postsurgery diet progression, eating-related behaviors, and nutritional therapy for common gastrointestinal symptoms; and 3) recommendations for lifelong supplementation and advice for nutritional follow-up. We recognize the need for uniform, evidence-based nutritional guidelines for bariatric patients and summarize recommendations with the aim of optimizing long-term success and preventing complications.

Gastrointestinal phytobezoar following bariatric surgery: Systematic review.

Bezoars are collections of undigested foreign material that accumulate in the gastrointestinal tract. The most common are phytobezoars, which are formed from plant fibers, especially those related to the ingestion of persimmon. Patients who undergo abdominal surgery, including bariatric surgery for obesity, and particularly gastrectomy, are prone to bezoar formation due to reduced gastric motility, loss of pyloric function, and hypoacidity. Bezoars can form months to years postoperatively. Our objective was to review the published literature regarding phytobezoar formation after bariatric surgery. We investigated the entire scientific literature on phytobezoars as a complication after bariatric surgery using PubMed and Embase searches of all reports published to date. We used the following keywords: "phytobezoars" or "bezoars" and "bariatric surgery" or "laparoscopic adjustable gastric band" or "laparoscopic sleeve gastrectomy" or "Roux-en-Y gastric bypass" or "single anastomosis gastric bypass" or "biliopancreatic diversion." Seventeen eligible articles were included in the study. We provide an overview of the incidence, classification, and manifestations of bezoar formation as a rare, late morbidity of bariatric surgery. Treatment options include chemical enzyme therapy, endoscopic dissolution and removal, or surgery. Nutritional counseling regarding bezoar formation and prevention of recurrence after bariatric surgery should emphasize changing eating habits, including sufficient drinking and chewing and avoiding the overindulgence of foods with high-fiber content, especially citrus pith and persimmons. Clinicians should be aware of this potential rare complication. Additional studies are needed to examine the eating habits and food choices of bariatric patients with bezoar complications and to elucidate more clearly the risk factors for this pathologic condition.