Alcohol Drinks Induce Acute Lowering in Circulating l-Arginine in Obese and Type 2 Diabetic Subjects.

Since low serum l-arginine (Arg) and high asymmetric dimethylarginine (ADMA) can predict microvascular complications in type 2 diabetes mellitus (T2DM), we tested whether Arg and ADMA are affected by diet and physical activity in overweight/obese and T2DM subjects. We tested the effects on serum Arg and ADMA of single loads of dextrose, protein, fat, or alcohol (∼300 calories each); one episode of physical exercise; and 12 weeks of standard lifestyle modification (dietary and physical activity counseling). Alcohol drink was followed by ∼30% lowering in Arg. Arg and ADMA increased after a protein load but remained stable after glucose or fat load or 30 min of treadmill walk. Following 12 weeks of lifestyle modification, ADMA declined only in subjects achieving weight loss >5%. In conclusion, alcohol is a previously unrecognized acute suppressor of serum Arg. Lifestyle modification lowers ADMA in subjects who achieve weight loss >5%. Clinical Trial Registration Number: NCT04406402.

Approach to Obesity in the Older Population.

Until recently, weight loss in older obese people was feared because of ensuing muscle loss and frailty. Facing overall increasing longevity, high rates of obesity in older individuals (age ≥ 65 years) and a growing recognition of the health and functional cost of the number of obesity years, abetted by evidence that intentional weight loss in older obese people is safe, this approach is gradually, but not unanimously, being replaced by more active principles. Lifestyle interventions that include reduced but sufficient energy intake, age-adequate protein and micronutrient intake, coupled with aerobic and resistance exercise tailored to personal limitations, can induce weight loss with improvement in frailty indices. Sustained weight loss at this age can prevent or ameliorate diabetes. More active steps are controversial. The use of weight loss medications, particularly glucagon-like peptide-1 analogs (liraglutide as the first example), provides an additional treatment tier. Its safety and cardiovascular health benefits have been convincingly shown in older obese patients with type 2 diabetes mellitus. In our opinion, this option should not be denied to obese individuals with prediabetes or other obesity-related comorbidities based on age. Finally, many reports now provide evidence that bariatric surgery can be safely performed in older people as the last treatment tier. Risk-benefit issues should be considered with extreme care and disclosed to candidates. The selection process requires good presurgical functional status, individualized consideration of the sequels of obesity, and reliance on centers that are highly experienced in the surgical procedure as well as short-term and long-term subsequent comprehensive care and support.

Vitamin E status among bariatric surgery patients: a systematic review.

Vitamin E, a fat-soluble vitamin with antioxidant properties, is thought to modulate enzymes involved in signal transduction, affect gene expression, and have immunomodulatory capabilities. Severe vitamin E deficiency is associated with neuronal disorders, impaired immune response, hemolytic anemia, and oxidative-based disorders. Patients who undergo bariatric surgery (BS), especially malabsorptive procedures, are at greater risk of developing fat-soluble vitamin deficiencies. Current data on vitamin E statuses among BS patients are limited. Therefore, this systematic review has summarized the scientific literature on vitamin E and examined its status among patients following different types of BS. Searches of the MEDLINE and Embase databases were performed, followed by hand-searching of reference lists from all relevant papers. Of the 671 initially identified articles, 24 met the inclusion criteria: 1 study on adjustable gastric banding patients (n = 21), 4 studies on sleeve gastrectomy patients (n = 173), 12 studies on Roux-en-Y gastric bypass patients (n = 689) and 12 studies on biliopancreatic diversion with or without duodenal switch (n = 799) or single anastomosis duodeno-ileal bypass with sleeve gastrectomy patients (n = 163). Results suggest that patients who undergo malabsorptive procedures are at higher risk of developing vitamin E deficiency, although clinical manifestations of vitamin E deficits following BS are rarely documented. The optimal dose of vitamin E supplementation required for prevention of deficiency or for treatment following BS has yet to be established. Future observational and intervention studies are needed to bridge the gaps in existing knowledge.

Health and Nutritional Status of Vegetarian Candidates for Bariatric Surgery and Practical Recommendations.

INTRODUCTION: Data on vegetarianism and bariatric surgery (BS) are scarce. We herein describe the health and nutritional status of vegetarian patients who plan to undergo BS and propose combined recommendations for vegetarian patients who undergo BS, based on our clinical experience and current scientific literature in both nutrition fields. METHODS: Cross-sectional analysis of a prospectively maintained database of all primary laparoscopic sleeve gastrectomies (LSG) performed at a bariatric center of excellence between January 2014 and November 2016 was carried out querying patients who declared a vegetarian or vegan lifestyle before surgery. Preoperative data collected included demographics, anthropometrics, dietary patterns, supplementation use, physical activity, smoking habits, co-morbidities, and blood tests. Each vegetarian was matched to five different omnivores based on age, gender, and BMI. RESULTS: During the study period, 1470 patients underwent primary LSG surgery (63.7% females). Twenty-one declared a vegetarian or vegan lifestyle (1.4%) pre-surgery. Most were classified as lacto-ovo (57.1%) and were driven from ethical reasons (85.7%). No differences were found between vegetarian and omnivore LSG candidates regarding co-morbidities and nutritional deficiencies, except for lower prevalence of impaired fasting glucose (14.3 vs. 47.1%;P = 0.007), lower ferritin levels (54.3 ± 50.5 vs. 96.8 ± 121.8 ng/ml; P = 0.052) and higher transferrin levels (313.9 ± 42.7 vs. 278.4 ± 40.4 mg/dl; P = 0.009) among the vegetarian cohort. Preoperative use of vitamin B12 and iron supplementation was higher among vegetarian LSG candidates than their omnivore counterparts (57.1 vs. 6.7%;P < 0.001 and 23.8 vs. 6.7%; P = 0.015, respectively). CONCLUSIONS: Vegetarians have comparable health status and nutritional deficiencies, lower iron stores, and higher supplementation use before surgery compared to omnivore LSG candidates.

Dihydrofolate reductase 19-bp deletion polymorphism modifies the association of folate status with memory in a cross-sectional multi-ethnic study of adults.

BACKGROUND: Folate status has been positively associated with cognitive function in many studies; however, some studies have observed associations of poor cognitive outcomes with high folate. In search of an explanation, we hypothesized that the association of folate with cognition would be modified by the interaction of high-folate status with a common 19-bp deletion polymorphism in the dihydrofolate reductase (DHFR) gene. To our knowledge, the cognitive effects of this gene have not been studied previously. OBJECTIVE: We examined the association between cognitive outcomes with the 19-bp deletion DHFR polymorphism, folate status, and their interaction with high or normal plasma folate. DESIGN: This was a pooled cross-sectional study of the following 2 Boston-based cohorts of community living adults: the Boston Puerto Rican Health Study and the Nutrition, Aging, and Memory in Elders study. Individuals were genotyped for the DHFR 19-bp deletion genotype, and plasma folate status was determined. Cognitive outcomes included the Mini-Mental State Examination, Center for Epidemiologic Studies Depression Scale, and factor scores for the domains of memory, executive function, and attention from a set of cognitive tests. RESULTS: The prevalence of the homozygous deletion (del/del) genotype was 23%. In a multivariable analysis, high folate status (>17.8 ng/mL) was associated with better memory scores than was normal-folate status (fourth-fifth quintiles compared with first-third quintiles: ß ± SE = -0.22 ± 0.06, P < 0.01). Carriers of the DHFR del/del genotype had worse memory scores (ß ± SE = -0.24 ± 0.10, P < 0.05) and worse executive scores (ß = -0.19, P < 0.05) than did those with the del/ins and ins/ins genotypes. Finally, we observed an interaction such that carriers of the del/del genotype with high folate had significantly worse memory scores than those of both noncarriers with high-folate and del/del carriers with normal-folate (ß-interaction = 0.26 ± 0.13, P < 0.05). CONCLUSIONS: This study identifies a putative gene-nutrient interaction that, if confirmed, would predict that a sizable minority carrying the del/del genotype might not benefit from high-folate status and could see a worsening of memory. An understanding of how genetic variation affects responses to high-folate exposure will help weigh risks and benefits of folate supplementation for individuals and public health.