Impact of Probiotics on Gastrointestinal Function and Metabolic Status After Roux-en-Y Gastric Bypass: A Double-Blind, Randomized Trial.

PURPOSE: Postoperative changes in gut microbiota may occur in patients undergoing Roux-en-Y gastric bypass surgery. In this study, we evaluate the impact of administering probiotic tablets on the gastrointestinal function and metabolic status of these patients. MATERIALS AND METHODS: This double-blinded randomized clinical trial was conducted from 2021 to 2022 on 135 Roux-en-Y surgery candidates. The intervention group underwent the surgical procedure and started receiving probiotic supplements (Familact Co.) 1 week after surgery; the control group received a placebo. The laboratory and anthropometric data were measured and analyzed before and 3 and 6 months after the intervention. GIQLI questionnaire was also used at the beginning and 6 months after the intervention to evaluate GI symptoms. RESULTS: We observed significantly reduced BMI in both groups after surgeries (P < 0.001). The levels of FBS and HbA1C were significantly lower in the probiotic group compared to the placebo in 3 months (P = 0.02 and P = 0.001, respectively) and 6 months (P < 0.001 for both) after the intervention. The levels of vitamin B12 increased significantly in the probiotic group (P < 0.001), and the values were substantially higher than the placebo group in 3 and 6 months (P < 0.001), respectively. Analysis of the GIQLI questionnaire before and 6 months after interventions also revealed significant improvement in the GIQLI score in both groups (P < 0.001 for probiotics and P = 0.03 for placebo). CONCLUSION: Probiotic supplement administration following RYGB improves patients' vitamin and metabolic profile, as well as GI function, although it cannot significantly affect weight loss.

The impact of obesity-associated glycine deficiency on the elimination of endogenous and exogenous metabolites via the glycine conjugation pathway.

Background: Glycine is an integral component of the human detoxification system as it reacts with potentially toxic exogenous and endogenously produced compounds and metabolites via the glycine conjugation pathway for urinary excretion. Because individuals with obesity have reduced glycine availability, this detoxification pathway may be compromised. However, it should be restored after bariatric surgery because of increased glycine production. Objective: To examine the impact of obesity-associated glycine deficiency on the glycine conjugation pathway. We hypothesize that the synthesis rates of acylglycines from endogenous and exogenous sources are significantly reduced in individuals with obesity but increase after bariatric surgery. Methods: We recruited 21 participants with class III obesity and 21 with healthy weight as controls. At baseline, [1,2-13C2] glycine was infused to study the glycine conjugation pathway by quantifying the synthesis rates of several acylglycines. The same measurements were repeated in participants with obesity six months after bariatric surgery. Data are presented as mean ± standard deviation, and p-value< 0.05 is considered statistically significant. Results: Baseline data of 20 participants with obesity were first compared to controls. Participants with obesity were significantly heavier than controls (mean BMI 40.5 ± 7.1 vs. 20.8 ± 2.1 kg/m2). They had significantly lower plasma glycine concentration (168 ± 30 vs. 209 ± 50 µmol/L) and slower absolute synthesis rates of acetylglycine, isobutyrylglycine, tigylglycine, isovalerylglycine, and hexanoylglycine. Pre- and post-surgery data were available for 16 participants with obesity. Post-surgery BMI decreased from 40.9 ± 7.3 to 31.6 ± 6.0 kg/m2. Plasma glycine concentration increased from 164 ± 26 to 212 ± 38 µmol/L) and was associated with significantly higher rates of excretion of acetylglycine, isobutyrylglycine, tigylglycine, isovalerylglycine, and hexanoylglycine. Benzoic acid (a xenobiotic dicarboxylic acid) is excreted as benzoylglycine; its synthesis rate was significantly slower in participants with obesity but increased after bariatric surgery. Conclusion: Obesity-associated glycine deficiency impairs the human body's ability to eliminate endogenous and exogenous metabolites/compounds via the glycine conjugation pathway. This impairment is ameliorated when glycine supply is restored after bariatric surgery. These findings imply that dietary glycine supplementation could treat obesity-associated metabolic complications due to the accumulation of intramitochondrial toxic metabolites. Clinical trial registration: https://clinicaltrials.gov/study/NCT04660513, identifier NCT04660513.

The Association between Lifestyle Factors and COVID-19: Findings from Qatar Biobank.

Coronavirus Disease 2019 (COVID-19) manifestations range from mild to severe life-threatening symptoms, including death. COVID-19 susceptibility has been associated with various factors, but studies in Qatar are limited. The objective of this study was to investigate the correlation between COVID-19 susceptibility and various sociodemographic and lifestyle factors, including age, gender, body mass index, smoking status, education level, dietary patterns, supplement usage, physical activity, a history of bariatric surgery, diabetes, and hypertension. We utilized logistic regression to analyze these associations, using the data of 10,000 adult participants, aged from 18 to 79, from Qatar Biobank. In total, 10.5% (n = 1045) of the participants had COVID-19. Compared to non-smokers, current and ex-smokers had lower odds of having COVID-19 (odds ratio [OR] = 0.55; 95% CI: 0.44-0.68 and OR = 0.70; 95% CI: 0.57-0.86, respectively). Vitamin D supplement use was associated with an 18% reduction in the likelihood of contracting COVID-19 (OR = 0.82; 95% CI: 0.69-0.97). Obesity (BMI ≥ 30 kg/m2), a history of bariatric surgery, and higher adherence to the modern dietary pattern-characterized by the consumption of foods high in saturated fat and refined carbohydrates-were positively associated with COVID-19. Our findings indicate that adopting a healthy lifestyle may be helpful in the prevention of COVID-19 infection.

Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study.

BACKGROUND: Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy. METHODS: In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n = 59 [gastric bypass surgery n = 26, sleeve gastrectomy n = 31, missing n = 2] and controls n = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17-20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5). RESULTS: The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p = 0.228) or development of gestational diabetes (n = 3 [5%] vs. n = 7 [5%], p = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p = 0.030). CONCLUSION: Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Moderate-intensity constant or high-intensity interval training? Metabolic effects on candidates to undergo bariatric surgery.

BACKGROUND & AIMS: Bariatric surgery is highly effective against obesity. Pre-surgical exercise programs are recommended to prepare the candidate physically and metabolically for surgery-related rapid weight loss. However, the ideal exercise prescription in this population is unknown. This study aimed to compare the metabolic effects of moderate-intensity constant (MICT) vs. a high-intensity interval training (HIIT) program in candidates to undergo bariatric surgery. METHODS AND RESULTS: Twenty-five candidates (22 women) to undergo sleeve gastrectomy aged from 18 to 60 years old were recruited. At baseline, we measured body composition, physical activity levels, grip strength, and aerobic capacity. Further, we assessed metabolic function through glycemia and insulinemia (both fasting and after oral glucose tolerance test (OGTT)), homeostatic model assessment for insulin resistance (HOMA-IR), lipid profile, glycated haemoglobin (HbA1c), transaminases, fibroblast growth factor 21 (FGF21), growth differentiation factor 15 (GDF15), apelin, and adiponectin. Afterward, participants were randomized into MICT (n = 14) or HIIT (n = 11). Both training programs consisted of 10 sessions (2-3 times/week, 30 min per session) distributed during 4 weeks before the surgery. After this, all outcomes were measured again at the end of the training programs and 1 month after the surgery (follow-up). A mixed effect with Tukey's post-hoc analysis was performed to compare values at baseline vs. post-training vs. postsurgical follow-up. Both training programs increased aerobic capacity after training (p < 0.05), but only after MICT these changes were kept at follow-up (p < 0.05). However, only MICT decreased fat mass and increased total muscle mass and physical activity levels (p < 0.05). Metabolically, MICT decreased insulinemia after OGTT (p < 0.05), whereas HIIT increased adiponectin after training and GDF15 at follow-up (both p < 0.05). CONCLUSIONS: Both MICT and HIIT conferred benefits in candidates to undergo bariatric surgery, however, several of those effects were program-specific, suggesting that exercise intensity should be considered when preparing these patients. Future studies should explore the potential benefits of prescribing MICT or HIIT in a customized fashion depending on a pretraining screening, along with possible summatory effects by combining these two exercise programs (MICT + HIIT). CLINICAL TRIAL REGISTRATION: International Traditional Medicine Clinical Trial Registry, N° ISRCTN42273422.

Impact of bariatric surgery on oral anticancer drugs: an analysis of real-world data.

PURPOSE: The number of patients with bariatric surgery who receive oral anticancer drugs is rising. Bariatric surgery may affect the absorption of oral anticancer drugs. Strikingly, no specific drug dosing recommendations are available. We aim to provide practical recommendations on the application of oral anticancer drugs in patients who underwent bariatric surgery. METHODS: Patients with any kind of bariatric surgery were extracted retrospectively in a comprehensive cancer center. In addition, a flowchart was proposed to assess the risk of inadequate exposure to oral anticancer drugs in patients who underwent bariatric surgery. Subsequently, the flowchart was evaluated retrospectively using routine Therapeutic drug monitoring (TDM) samples. RESULTS: In our analysis, 571 cancer patients (0.4% of 140.000 treated or referred patients) had previous bariatric surgery. Of these patients, 78 unique patients received 152 oral anticancer drugs equaling an overall number of 30 unique drugs. The 30 different prescribed oral anticancer drugs were categorized as low risk (13%), medium risk (67%), and high risk (20%) of underdosing. TDM plasma samples of 25 patients (82 samples) were available, of which 21 samples post-bariatric surgery (25%) were below the target value. CONCLUSIONS: The proposed flowchart can support optimizing the treatment with orally administered anticancer drugs in patients who underwent bariatric surgery. We recommend performing TDM in drugs that belong to BCS classes II, III, or IV. If more risk factors are present in BCS classes II or IV, a priori switches to other drugs may be advised. In specific cases, higher dosages can be provided from the start (e.g., tamoxifen).

Prevalence of Micronutrient Deficiencies in Preoperative Bariatric Patients in a New Zealand Tertiary Centre.

PURPOSE: A potential complication of bariatric surgery is development of nutritional deficiencies. Study aims were to assess prevalence of micronutrient deficiencies in preoperative bariatric patients and to examine for ethnic differences. METHODS: Retrospective analysis of 573 patients that underwent bariatric surgery at Counties Manukau District Health Board was carried out. Mean preoperative levels of albumin, calcium, phosphate, folate, vitamin B12, vitamin D, magnesium, haemoglobin, haematocrit, mean cell volume, mean cell haemoglobin, ferritin, iron, and transferrin were calculated. Chi square, fisher exact test, and multiple logistic regression was used to assess for differences in prevalence of micronutrient deficiencies across ethnicities. RESULTS: The most common micronutrient deficiency was vitamin D (30.85%). There were statistically significant differences in vitamin D deficiency across ethnicities (p < 0.0001). Asians had the highest prevalence of vitamin D deficiency (60%), followed by Pacifica (44.57%), and Maori (31.68%). Asians were more likely to have vitamin D deficiency compared to NZ/Other Europeans (OR = 14.93, p < 0.001). Vitamin D deficiency was associated with higher BMI (OR = 1.05, p = 0.008). The second most common deficiency was iron (21.1%). Asians had the highest prevalence of iron deficiency (44%), followed by Maori (27.95%), and Pacifica (19.57%) (p = 0.0064). Compared to NZ/Other Europeans, Asians (OR = 4.26) and Maori (OR = 1.78) were more likely to be iron deficient (p = 0.004). Female gender was associated with iron deficiency (OR = 2.12, p = 0.007). CONCLUSION: Vitamin D and iron are the most common micronutrient deficiencies among preoperative bariatric patients in this cohort and ethnic differences were seen. There may be a role for preoperative supplementation in these at-risk ethnic groups.

Is Sigstad's score really capable of detecting post-surgical late dumping syndrome?

BACKGROUND: This clinical trial explores the Sigstad score for late dumping syndrome in postoperative patients who have undergone sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). The aims of this study are to investigate the correlations with late dumping syndrome, to evaluate the reliability and validity of the Sigstad score and to discuss a modified scoring system. METHODS: The study was conducted at the Obesity Center of the Westküstenklinikum Heide and included 271 patients. Data collection involved conducting interviews, diet diaries and measuring blood glucose levels. Non-parametric tests, logistic regression and McDonald's Omega were the selected statistical approaches. RESULTS: Body Mass Index (BMI) decreased over time (-9.67 kg/m2 at 4 months, -15.58 kg/m2 at 12 months). Preoperatively, the Sigstad score exhibited the highest value, and no occurrences of late dumping syndrome were observed. No significant differences were found in BMI concerning late dumping syndrome or Sigstad score among postoperative patients. Postoperative patients experienced an increase in gastrointestinal symptoms. The reliability test showed a McDonald's omega value of 0.509. The analysis conducted through binary logistic regression indicated dizziness as a significant predictor of late dumping syndrome; however, this finding did not hold up after performing Bonferroni correction. CONCLUSION: The Sigstad score is not a reliable or valid method for detecting late dumping syndrome after surgery for obesity and metabolic disorders. It is necessary to have alternatives that use objective measures and assess the quality of life, and that these alternatives be validated in large patient cohorts.

Nutritional Deficiencies Before and After Bariatric Surgery in Low- and High-Income Countries: Prevention and Treatment.

Nutritional deficiencies represent a prevalent concern among individuals with obesity, stemming from suboptimal dietary habits, chronic inflammation, and preoperative weight reduction efforts. Bariatric surgical interventions, employing either restrictive, malabsorptive or a combination of the two methods, further compound these deficiencies. Commonly observed nutritional deficits following bariatric surgeries include vitamin B12, vitamin D, thiamine, folate, iron, and protein deficiencies. These deficiencies are further complicated by disparities in healthcare resources and income that distinguish low, medium, and high-income countries. The escalating rates of obesity in low- and medium-income countries are primarily attributed to the increasing availability of cheap, nutritionally depleted, and processed foods, coupled with limited access to healthcare. The provision of bariatric surgical interventions in such regions is hindered by the lack of appropriately trained medical personnel and adequate infrastructure. Additionally, the crucial facets of postoperative care, including diligent follow-up, precise weight loss monitoring, and the administration of appropriate nutritional supplements, often remain lacking. This narrative review provides a comprehensive examination of the prevention and treatment of nutritional deficiencies before and after bariatric surgery in the context of varying healthcare resources and income levels. Bariatric procedures and their global prevalence are discussed, and the prevalence, symptoms, and management strategies of specific nutritional deficiencies are explained. This review also outlines practical strategies for providing more equitable care in low- and medium-income countries.

Evaluation study of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy in the treatment of Chinese obese patients based on efficacy and nutrition.

To evaluate the efficacy and nutrition of single-anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) in Chinese obese patients in the first postoperative year. Clinical data of 66 obese patients who underwent SADI-S surgery at China-Japan Union Hospital of Jilin University from November 2018 to May 2022 were retrospectively collected. The weight, body mass index (BMI), percentage of excess weight loss (%EWL), and percentage of total weight loss (%TWL) were recorded at 3, 6, and 12 months after surgery. Moreover, metabolic disease remission and nutrient deficiencies were assessed at 1 year postoperatively. Overall, 66 patients (38 males and 28 females) were recruited, with a mean age of 35 (18-61) years and an average preoperative BMI of 42.94 kg/m2. Before surgery, 38 patients had type 2 diabetes mellitus (T2DM), 46 patients had hyperuricemia (HUA), 45 patients had hypertension (HTN), 35 patients had hyperlipidemia, 12 patients had hypercholesterolemia, 12 patients had hyper-low-density lipoproteinemia, and 14 patients had gastroesophageal reflux disease symptoms (GERD). All patients had undergone a DaVinci robotic or laparoscopic SADI-S surgery, and none converted to laparotomy or died. Four patients developed postoperative complications and were cured and discharged after conservative treatment or surgical treatment. At 3, 6 and 12 months, the average %EWL was 62.07 ± 26.56, 85.93 ± 27.92, and 106.65 ± 29.65%, %TWL was 22.67 ± 4.94, 32.10 ± 5.18, and 40.56 ± 7.89%, respectively. Fasting blood glucose (FBG), glycated hemoglobin (HbA1c), uric acid (UA), triglycerides (TG), blood pressure (BP), and other indexes were significantly lower after one year post-surgery compared with the preoperative period (P < 0.05). The remission rates of T2DM, HUA, HTN, hypertriglyceridemia, hypercholesterolemia, and hyper-low-density lipoproteinemia 1 year after surgery were 100, 65.2, 62.2, 94.3, 100, and100%, respectively. One year after surgery, the remission rate of GERD was 71.4% (10/14), the rate of new occurrence of GERD was 12.1% (8/66), and the overall incidence rate was 18.2% (12/66). Except for vitamin B12(vit B12), the other nutrient indexes were significantly decreased after 1 year of surgery relative to levels before surgery (P < 0.05). The deficiency rates for vitamin A (vit A), vitamin E (vit E), zinc ion (Zn), and folic acid (FA) were higher (45.5, 25.8, 24.2, and 16.7%, respectively); however, there were no related clinical symptoms. SADI-S had significant effects on weight loss and metabolic disease remission. The main nutrient deficiencies after SADI-S were vit A, vit E, Zn, and FA deficiencies. The long-term efficacy and safety of SADI-S warrant further follow-up.

Hypothalamic control of body fat mass by food intake: The key to understanding why obesity should be treated as a disease.

BACKGROUND: Hypothalamic centres have been recognized to play a central role in body weight regulation for nearly 70 years. AIMS: In this review, we will explore the current undersanding of the role the hypothalamus plays in controlling food intake behaviours. MATERIALS AND METHODS: Review of relevant literature from PubMed searches and review article citations. RESULTS: Beginning with autopsy studies showing destructive hypothalamic lesions in patients manifesting hyperphagia and rapid weight gain, followed by animal lesioning studies pinpointing adjacent hypothalamic sites as the 'satiety' centre and the 'feeding' centre of the brain, the neurocircuitry that governs our body weight is now understood to consist of a complex, interconnected network, including the hypothalamus and extending to cortical sites, reward centres and brainstem. Neurons in these sites receive afferent signals from the gastrointestinal tract and adipose tissue indicating food availability, calorie content, as well as body fat mass. DISCUSSION: Integration of these complex signals leads to modulation of the two prime effector systems that defend a body fat mass set point: food intake and energy expenditure. CONCLUSION: Understanding the hypothalamic control of food intake forms the foundation for understanding and managing obesity as a chronic disease.

Bone health following paediatric and adolescent bariatric surgery: a systematic review and meta-analysis.

Background: Childhood obesity is a pressing health crisis of epidemic proportions. Bariatric surgery (BS) is an effective weight loss solution however its role in the paediatric population is contentious owing to the paucity of weight specific and generalised health outcomes. This systematic review and meta-analysis aimed to assess the impact of paediatric BS on bone health. Methods: This prospectively registered systematic review (PROSPERO ID: CRD42023432035) was performed in accordance with PRISMA guidelines. We searched MEDLINE (1946-1928 September 2023), EMBASE (1947-1928 September 2023) via the Ovid platform, and the Cochrane Review Library to identify scientific publications reporting bone outcome measures in patients under the age of 18 years who underwent BS. Meta-analysis was undertaken on post-operative weight and bone parameters in paediatric patients following BS. Outcomes were reported as weighted or standardized mean difference with 95 percent confidence intervals. Subgroup analysis by intervention, quality scoring and risk of bias were assessed. Findings: Twelve studies with 681 patients across 5 countries (mean age 17 ± 0.57 years) were included. The quality of included studies was rated as high and there was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 0% to 99.1%). Patients underwent Roux-en-Y gastric bypass (RYGB, n = 216), sleeve gastrectomy (SG, n = 257), gastric band (n = 184) or intragastric balloon placement (n = 24). BS was associated with significant weight reduction, body mass index (BMI) -12.7 kg/m2 (95% CI -14.5 to -10.9, p < 0.001), with RYGB being most effective, BMI -16.58 kg/m2 (95% CI -19.6 to -13.6, p < 0.001). Patients who underwent SG or RYGB had significantly lower lumbar bone mineral density, -0.96 g/cm2 (95% CI -0.1 to -0.03, p < 0.001), Z score, -1.132 (95% CI -1.8 to -0.45, p < 0.001) and subtotal body bone mineral density, -0.7 g/cm2 (95% CI -1.2 to -0.2, p < 0.001) following surgery. This was accompanied with higher markers of bone resorption, C-terminal telopeptide of type 1 collagen 0.22 ng/ml (95% CI 0.12-0.32, p < 0.001) and osteocalcin, 10.83 ng/ml (95% CI 6.01-15.67, p < 0.001). There was a significant reduction in calcium levels following BS, -3.78 mg/dl (95% CI -6.1 to -1.5, p < 0.001) but no difference in 25-hydroxyvitamin D, phosphate, bone alkaline phosphatase, procollagen type 1 N propeptide or parathyroid hormone. Interpretation: BS effectively reduces weight in paediatric patients, but RYGB and SG may have adverse effects on bone health in the medium term. It is crucial to monitor and support bone health through appropriate nutritional supplementation and judicious follow-up. Long-term data is needed to fully understand the clinical implications of these findings on bone outcomes. Funding: Medical Research Council (MRC), United Kingdom.

Collaborative Prescribing Practice in Managing Patients Post-Bariatric Surgery in a Tertiary Centre in Singapore.

Background: A collaborative prescribing (CP) practice model, established by the endocrinologists, pharmacists, and advanced practice nurses, aims to provide for the postoperative monitoring and medical and nutritional management of stable patients after bariatric surgery. Method: Under the CP agreement, endocrinologists refer patients who have undergone bariatric surgery with stable medical conditions to CP practitioners, comprising senior pharmacists and advanced practice nurses. CP practitioners review the patient's weight loss progress, blood test results and vitals, the sufficiency of micronutrient repletion, adherence to supplements and medications, and chronic disease control. CP practitioners can prescribe and adjust the medications and supplements, in accordance with a clinical evaluation and standard guidance. Patients who require immediate attention due to complications or red flags are referred to the primary endocrinologist for further management. Results: From 5 May 2020 to 30 September 2023, CP practitioners provided 672 consultations. At least 68% and 80% of patients achieved appropriate weight loss post-surgery during the acute and maintenance phases, respectively. Less than 10% of the patients presented with anaemia and iron deficiency, and vitamin B12, folate and vitamin D deficiency. More than 80% of patients achieved a HbA1c of less than 7%. Conclusions: The CP practice framework provides a sustainable and viable model to facilitate optimal outcomes after bariatric surgery.

Using the 5-Item Medication Adherence Report Scale (MARS-5) to Screen for Non-adherence to Vitamin and Mineral Supplementation After Bariatric Surgery.

INTRODUCTION: Poor adherence to recommended vitamin and mineral supplementation after bariatric surgery is common and challenging for healthcare professionals to identify. There are several questionnaires for self-reporting of adherence to chronic medication, but none has so far been evaluated for assessment of adherence to vitamin and mineral supplementation after bariatric surgery. The aim of this study was to assess the accuracy of the 5-item Medication Adherence Report Scale (MARS-5) in measuring adherence to vitamin and mineral supplementation post bariatric surgery (gastric bypass or sleeve gastrectomy). METHOD: The psychometric properties of MARS-5 for vitamin and mineral supplementation were validated in two cohorts: one at 1 year post bariatric surgery (n = 120) and the other at 2 years post-surgery (n = 211). MARS-5 was compared to pharmacy refill data for vitamin B12 and combined calcium/vitamin D as reference. RESULTS: Correlation analyses demonstrated that the MARS-5 had acceptable validity compared to objectively measured adherence rates from pharmacy refill data (calculated as continuous, multiple-interval measures of medication availability/gaps-coefficient ranged from 0.49 to 0.54). Internal reliability (Cronbach's α) was high: 0.81 and 0.95, respectively. There was a clear ceiling effect where one out of three had a maximum score on MARS-5. CONCLUSION: MARS-5 demonstrated acceptable psychometric properties for assessment of adherence to vitamin and mineral supplementation post bariatric surgery.

Prospective evaluation of transoral outlet reduction (TORe) after Roux-en-Y gastric bypass (RYGB) failure.

BACKGROUND AND AIMS: Weight regain after RYGB is multifactorial including dilatation of the gastro-jejunal anastomosis. Transoral outlet reduction (TORe) procedure is a minimally invasive alternative to surgical anastomotic revision. METHODS: We conducted a prospective, multicenter, simple blind, randomized study in patients with weight regain following RYGB, comparing the efficacy of conventional nutritional and behavioral management associated with a TORe procedure (TORe group) with conventional management alone and a Sham procedure (Sham group). The main objective of this study was to evaluate the percentage of excess weight loss (%EWL) at 12 months after endoscopy. RESULTS: From January 2015 to January 2019, 73 subjects were randomized in four French Bariatric centers. The final analysis involved 50 subjects, 25 in each group, 44 women, 6 men, with an average BMI of 40.6 kg/m2. At 12 months, the average %EWL was significantly higher in the TORe group than in the Sham group (13.5 ± 14.1 vs. - 0.77 ± 17.1; p = 0.002). Cohen's d was 0.91, indicating a large effect size of the procedure on the %EWL. There was no significant difference between groups concerning the improvement of obesity-related comorbidities (diabetes and dyslipidemia) and quality of life at 12 months. We report frequent adverse events in the TORe group (20% had adverse events related to the procedure). Three adverse events were serious, including two perforations of the gastro-jejunal anastomosis after TORe group that led to the premature termination of the study. CONCLUSIONS: After RYGBP failure linked to the dilatation of the gastro-jejunal anastomosis, TORe procedure with nutritional management results in significantly higher %EWL at 12 months compared to patients with nutritional management alone. As surgery, this minimally invasive endoscopic procedure can be associated with severe adverse events.

Tackling the dual burden of malnutrition in pregnancy - pregnancy after weight loss surgery.

The dual burden of malnutrition is characterised by the coexistence of undernutrition alongside overweight/obesity and diet-related noncommunicable diseases. It is a paradox which disproportionately affects women and is applicable to those who become pregnant after weight loss surgery. Obesity before and during pregnancy is associated with increased risk of adverse perinatal outcomes in both mother and child. Overall lifestyle interventions targeting weight loss in the preconception period have not proven effective, with people, and women in particular, increasingly seeking weight loss surgery. In women with severe obesity, surgery may normalise hormonal abnormalities and improve fertility. In those who become pregnant after surgery, evidence suggests a better overall obstetric outcome compared to those with severe obesity managed conservatively; however, there is heightened risk of maternal nutritional deficiencies and infants born small for gestational age. Specifically, pregnancy soon after surgery, in the catabolic phase when rapid weight loss is occurring, has the potential for poor outcomes. Lifelong micronutrient supplementation is required, and there is considerable risk of malnutrition if nutritional aftercare guidelines are not adhered to. It is therefore recommended that pregnancy is delayed until a stable weight is achieved and is supported by individualised advice from a multidisciplinary team. Further research is required to better understand how weight loss surgery affects the chances of having a healthy pregnancy and to ultimately improve nutritional management and patient care. In this review, we aim to summarise the evidence and guidance around nutrition during pregnancy after weight loss surgery.

Characteristics of Vitamin A Deficiency Retinopathy at a Tertiary Referral Center in the United States.

PURPOSE: To explore the risk factors and fundus imaging features of vitamin A deficiency retinopathy (VADR) in an academic tertiary referral center in Atlanta, GA, United States, and to propose guidance regarding diagnostic workup and management of affected patients. DESIGN: Single-center retrospective case series. SUBJECTS: Nine patients seen between 2015 and 2021 at the Emory Eye Center diagnosed with VADR. METHODS: Retrospective chart review. MAIN OUTCOME MEASURES: Baseline serum retinol level, Snellen visual acuity, multimodal fundus imaging findings, and electroretinography findings. RESULTS: Nine patients, 4 (44.4%) female, with a median (range) age of 68 (50-75) years were identified. The most common underlying etiologies for vitamin A deficiency included history of gastrointestinal surgery (55.6%), liver disease (44.4%), and nutritional depletion due to low-quality diet (44.4%). Only 1 (11.1%) patient had a history of bariatric surgery. Four (44.4%) patients were on some form of vitamin A supplementation before the diagnosis of VADR. Median (range) serum retinol level was 0.06 (< 0.06-0.19) mg/L. All patients had macular subretinal hyperreflective deposits resembling subretinal drusenoid deposits, although in some cases, these were scant and sparsely distributed. Six eyes of 3 patients with longstanding deficiency had defects in the external limiting membrane (ELM). Three of these eyes additionally had macular areas of complete retinal pigment epithelium and outer retinal atrophy (cRORA). Full-field electroretinography demonstrated severe rod dysfunction and mild to moderate cone system dysfunction. Many findings of VADR were reversible with vitamin A repletion. However, all eyes with ELM defects or cRORA had persistence or continued growth of these lesions. CONCLUSION: Vitamin A deficiency retinopathy is uncommon in the developed world. However, given that early intervention can lead to dramatic visual improvement and avoid potentially permanent retinal damage, retina specialists should be familiar with its clinical presentation. The presence of nyctalopia and subretinal hyperreflective deposits in a patient with a history of gastrointestinal surgery, liver disease, and/or poor diet can be suggestive of this diagnosis, even in the presence of ongoing vitamin A supplementation. Vitamin A supplementation can vary in route and dosage and can be tailored to the individual with serial testing of serum retinol. FINANCIAL DISCLOSURE(S): The authors have no proprietary or commercial interest in any materials discussed in this article.

Nephrogenic Calciphylaxis Arising after Bariatric Surgery: A Case Series.

Nephrogenic calciphylaxis is associated with multiple risk factors including long-term dialysis dependence, hyperphosphatemia, hypercalcemia, parathyroid hormone derangements, vitamin K deficiency, obesity, diabetes mellitus, warfarin use, and female sex. Bariatric surgery is known to cause altered absorption, leading to mineral and hormonal abnormalities in addition to nutritional deficiency. Prior case reports on calciphylaxis development following bariatric surgery have been published, though are limited in number. We report a case series of five bariatric patients from a single institution who developed nephrogenic calciphylaxis between 2012 and 2018. These patients had a history of bariatric surgery, and at the time of calciphylaxis diagnosis, demonstrated laboratory abnormalities associated with surgery including hypercalcemia (n = 3), hyperparathyroidism (n = 2), hypoalbuminemia (n = 5), and vitamin D deficiency (n = 5), in addition to other medication exposures such as vitamin D supplementation (n = 2), calcium supplementation (n = 4), warfarin (n = 2), and intravenous iron (n = 1). Despite the multifactorial etiology of calciphylaxis and the many risk factors present in the subjects of this case series, we submit that bariatric surgery represents an additional potential risk factor for calciphylaxis directly stemming from the adverse impact of malabsorption and overuse of therapeutic supplementation. We draw attention to this phenomenon to encourage early consideration of calciphylaxis in the differential for painful skin lesions arising after bariatric surgery as swift intervention is essential for these high-risk patients.

The Effect of Yoga on Early Clinical Outcomes and Pulmonary Functions in Patients Scheduled for Bariatric Surgery: a Randomized Controlled Study.

PURPOSE: The present research was undertaken to investigate the effect of yoga on pulmonary function and early clinical outcomes in patients scheduled for bariatric surgery. MATERIALS AND METHODS: This research with a randomized control group was performed on patients scheduled for bariatric surgery between October 2021 and June 2022 in the General Surgery Clinic of a University Hospital in Eastern Turkey. The sample consists of 100 randomized patients who received yoga breathing exercises and routine care. Pulmonary function test (PFT), posteroanterior chest X-rays (CXR), 6-min walk test, and oxygen saturation (SpO2) were applied as a pretest. The researcher practiced yoga for 40 min every day of the week. Post-test measurements were performed at the end of the yoga practice. Control group patients underwent the tests at the same intervals without any modifications to the standard clinical protocol. RESULTS: The difference between the control and experimental groups was significant in terms of post-test PFT measurements (p < 0.001). In the CXR of the patients, a statistically significant improvement was determined in 61.5% of the patients with yoga breathing practice (p < 0.001). Also, there was a significant increase in the 6-min walk test and SpO2 values in the experimental group (p < 0.05). CONCLUSION: Yoga practice positively affected the pulmonary function values of the patients.

Effect of Primary Versus Revisional One Anastomosis Gastric Bypass (OAGB) on Fatty Acid Profile.

INTRODUCTION: One anastomosis gastric bypass (OAGB) is one option of a revisional procedure for failed sleeve gastrectomy. Moreover, it can be used as a primary bariatric procedure, and is an effective surgery resulting in significant weight loss and the resolution or improvement of obesity-associated medical problems, accompanied by low perioperative complications. However, as with any therapy, OAGB has its limitations, including micronutrient deficiency or malnutrition. In our study, we compared the fatty acid (FA) profile in serum of patients after both primary OAGB (pOAGB) and revisional OAGB (rOAGB) to identify potential postsurgical FA alterations. METHODS: This is a retrospective study on patients with obesity who underwent OAGB procedures (pOAGB n=68; rOAGB n=17), conducted from 2016 to 2018. In blood, we analyzed a series of biochemical parameters, and in the serum, the FA profile was determined using gas chromatography-mass spectrometry. RESULTS: The percentage of excess BMI loss (% EBMIL) after pOAGB was 73.5 ± 2.47% in comparison to 45.9 ± 4.15% in the rOAGB group (p<0.001). In contrast to the lack of effect of rOAGB on most polyunsaturated FAs, in the pOAGB group, there was a decrease in eicosapentaenoic acid, and eicosatetraenoic and docosahexaenoic acid levels (p<0.001). We also found a decrease in very long-chain FAs (VLCFAs) and an increase in branched-chain FAs (BCFAs) after both types of OAGB procedure. CONCLUSIONS: Both OAGB procedures improved the profile of most FAs, leading to a decrease in VLCFAs, which are considered harmful, and an improvement in BCFAs, which are considered to be beneficial. There is a need to further investigate the possibility of n-3 polyunsaturated FA supplementation after pOAGB, due to the large decrease in these FAs after pOAGB.