Clinical Nutrition and Human Rights. An International Position Paper.

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political, and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Clinical nutrition and human rights. An international position paper.

The International Working Group for Patients' Right to Nutritional Care presents its position paper regarding nutritional care as a human right intrinsically linked to the right to food and the right to health. All people should have access to food and evidence-based medical nutrition therapy including artificial nutrition and hydration. In this regard, the hospitalized malnourished ill should mandatorily have access to screening, diagnosis, nutritional assessment, with optimal and timely nutritional therapy in order to overcome malnutrition associated morbidity and mortality, while reducing the rates of disease-related malnutrition. This right does not imply there is an obligation to feed all patients at any stage of life and at any cost. On the contrary, this right implies, from an ethical point of view, that the best decision for the patient must be taken and this may include, under certain circumstances, the decision not to feed. Application of the human rights-based approach to the field of clinical nutrition will contribute to the construction of a moral, political and legal focus to the concept of nutritional care. Moreover, it will be the cornerstone to the rationale of political and legal instruments in the field of clinical nutrition.

Zinc absorption and zinc status are reduced after either sleeve gastrectomy or Roux-en-Y gastric bypass in premenopausal women with severe obesity studied prospectively over 24 postoperative months.

BACKGROUND: Roux-en-Y gastric bypass (RYGBP) is known to reduce zinc absorption; the effects of vertical sleeve gastrectomy (SG) and its long-term implications on zinc absorption have not yet been studied. OBJECTIVE: The aim was to evaluate the effects of SG and RYGBP on zinc absorption and zinc status in premenopausal women with severe obesity up to 24 mo after surgery. METHODS: Twenty-six premenopausal women undergoing SG [BMI (in kg/m2): 37.3 ± 3.2] and 32 undergoing RYGBP (BMI: 42.0 ± 4.2) were studied. A series of anthropometric, dietary, and zinc status parameters (plasma and hair zinc), and the size of the exchangeable zinc pool (EZP), as well as percentage zinc absorption from a standardized dose using a stable isotope methodology were evaluated in the patients before the surgical procedure and at 12 and 24 mo after SG or RYGBP. SG patients received 15 mg and RYGBP received 25 mg of supplemental Zn/d. RESULTS: In premenopausal women, zinc absorption was decreased by 71.9% and 52.0% in SG and RYGBP, respectively, 24 mo postsurgery, compared with initial values. According to 2-factor repeated-measures ANOVA, time effect was significant (P = <0.0001), but not time × group interaction (P = 0.470). Plasma zinc below the cutoff point of 70 µg/dL increased from 0 to 15.4% and 38.1% in SG and RYGBP, respectively. Mean EZP was significantly reduced 24 mo after surgery, although no time × group interactions were observed. Hair zinc did not change across time or between groups. CONCLUSIONS: Both SG and RYGBP have profound effects on zinc absorption capacity, which are not compensated for after 24 mo. Although zinc absorption reduction was similar in both types of surgeries, plasma zinc was more affected in RYGBP than SG, despite greater zinc supplementation in RYGBP.This trial was registered at http://www.isrctn.com as ISRCTN31937503.

Calcium absorption may be affected after either sleeve gastrectomy or Roux-en-Y gastric bypass in premenopausal women: a 2-y prospective study.

Background: Although Roux-en-Y gastric bypass (RYGBP) is known to reduce calcium absorption (CA), the effects of vertical sleeve gastrectomy (SG) and its long-term implications on CA have not yet been studied. Objective: The aim of this study was to evaluate changes in CA and its relation with modifications of bone mineral density (BMD), intakes of calcium and vitamin D, vitamin D status, and parathyroid hormone (PTH) concentrations ≤24 mo after SG and RYGBP, respectively. Design: Twenty-six premenopausal women undergoing SG [mean ± SD body mass index (BMI; kg/m2): 37.3 ± 3.2; age: 34.2 ± 10.2 y] and 32 undergoing RYGBP (BMI: 42.0 ± 4.2; age: 37.3 ± 8.1 y) were studied at baseline (presurgery) and followed up at 12 and 24 mo after surgery. BMD, bone alkaline phosphatase activity, and serum PTH, 25-hydroxyvitamin D [25(OH)D], calcium, magnesium, and phosphorus concentrations were determined. Food and supplement intakes were recorded. CA was measured by using a dual stable isotope method. Results: In premenopausal women, CA was significantly reduced from 36.5% ± 2.0% preoperatively to 21.0% ± 2.3% and 18.8% ± 3.4% at 12 and 24 mo post-SG surgery, respectively. CA also decreased significantly from 41.5% ± 2.8% preoperatively to 27.9% ± 3.8% and 18.5% ± 2.2% 12 and 24 mo after RYGBP, respectively. No difference was found between type of surgery (time × group interaction, P = 0.60). Considering both groups combined, 56.6% of the variance in CA at the 12-mo but not at the 24-mo follow-up was explained by serum PTH and 25(OH)D concentrations, together with vitamin D and calcium intakes. Conclusions: CA was similarly reduced in both SG and RYGBP compared with baseline, and it was not associated with changes in BMD or body weight loss. This reduction in CA could be explained only partially by calcium intake increase. This trial is registered at http://www.isrctn.com as ISRCTN31937503.

[Bone mineral density disminution post Roux-Y bypass surgery]. / Disminución de masa ósea post-cirugía bariátrica con by-pass en Y de Roux.

INTRODUCTION: Bariatric surgery has important metabolic complications such as bone mass loss. GOAL: To assess bone mineral density (BMD) after Roux-en-Y gastric by-pass (RYGB) in patients under standard calcium and vitamin D supplementation. METHOD: In patients with morbid obesity submitted to RYGB, 76 women and 22 men of diverse age, all with standard nutritional instruction including vitamin D and calcium, we measured BMD with a dual X-ray densitometer. They had lumbar spine and hips measurement 2-3 years post-surgery. Twenty females were followed up with BMD until of a mean of 54 months. Using World Health Organization (WHO) criteria's, values were compared with young controls and same age and sex population, evaluating osteopenia and osteoporosis. RESULTS: Inverse correlation was observed between BMD and age; positive between BMD and body mass index as well as with preoperative weight excess. In women younger than 45 years, we observed a diminished BMD in 26.8% of them, with no cases of osteoporosis. In older females, BMD was decreased in 65.7% (p = 0.0011); corresponding to 45.7% of osteopenia and 20% osteoporosis, more frequent in lumbar spine. In the female's subgroup followed longer, BMD diminished progressively mainly in left hip. In men, there was 36% of osteopenia and 14% of osteoporosis. CONCLUSION: Patients from both genders and diverse ages after BPYR presented osteopenia and osteoporosis, despite early supplement prescription of calcium and vitamin D. We consider important to perform serial BMD measurements and also to individualize therapy with risk factors control.

Introducción: La cirugía bariátrica tiene complicaciones metabólicas importantes como la pérdida de masa ósea. Objetivo: Evaluar la densidad mineral ósea (DMO) posterior a by-pass gástrico en Y de Roux (BPYR) en pacientes con indicación de suplemento estándar de calcio y vitamina D. Método: En pacientes con BPYR por obesidad mórbida, 76 mujeres y 22 hombres de diversa edad, con instrucción nutricional, suplemento de calcio y vitamina D, se midió la DMO en columna lumbar y caderas con densitómetro radiológico de doble haz 2 a 3 años post-cirugía. Veinte mujeres fueron seguidas con DMO hasta 54 meses en promedio. Según criterios de Organización Mundial de la Salud (OMS), se comparó con población control joven y de su edad según sexo, evaluando osteopenia y osteoporosis. Resultados: Hubo correlación negativa de DMO con edad; positiva de DMO con índice de masa corporal y con exceso de peso preoperatorio. En mujeres menores de 45 años, se observó disminución de DMO en 26,8%, sin casos de osteoporosis y en 65,7% en las mayores de 45 años (p = 0,0011), correspondiendo a 45,7% de osteopenia y 20% de osteoporosis, predominantemente en columna lumbar. El subgrupo de mujeres con mayor seguimiento, presentó disminución progresiva de DMO, especialmente en cadera izquierda. En hombres se observó 36% de osteopenia y 14% de osteoporosis. Conclusión: Pacientes de ambos sexos y diversa edad, despues de un BPYR, presentaron osteopenia y osteoporosis, a pesar de suplemento precoz de calcio y vitamina D. Consideramos importante medir DMO seriada, individualizando terapias y controlando factores de riesgo.

Disminución de masa ósea post-cirugía bariátrica con by-pass en Y de Roux / Bone mineral density disminution post y de roux by-pass surgery

Introducción: La cirugía bariátrica tiene complicaciones metabólicas importantes como la pérdida de masa ósea. Objetivo: Evaluar la densidad mineral ósea (DMO) posterior a by-pass gástrico en Y de Roux (BPYR) en pacientes con indicación de suplemento estándar de calcio y vitamina D. Método: En pacientes con BPYR por obesidad mórbida, 76 mujeres y 22 hombres de diversa edad, con instrucción nutricional, suplemento de calcio y vitamina D, se midió la DMO en columna lumbar y caderas con densitómetro radiológico de doble haz 2 a 3 años post-cirugía. Veinte mujeres fueron seguidas con DMO hasta 54 meses en promedio. Según criterios de Organización Mundial de la Salud (OMS), se comparó con población control joven y de su edad según sexo, evaluando osteopenia y osteoporosis. Resultados: Hubo correlación negativa de DMO con edad; positiva de DMO con índice de masa corporal y con exceso de peso preoperatorio. En mujeres menores de 45 años, se observó disminución de DMO en 26,8%, sin casos de osteoporosis y en 65,7% en las mayores de 45 años (p = 0,0011), correspondiendo a 45,7% de osteopenia y 20% de osteoporosis, predominantemente en columna lumbar. El subgrupo de mujeres con mayor seguimiento, presentó disminución progresiva de DMO, especialmente en cadera izquierda. En hombres se observó 36% de osteopenia y 14% de osteoporosis. Conclusión: Pacientes de ambos sexos y diversa edad, despues de un BPYR, presentaron osteopenia y osteoporosis, a pesar de suplemento precoz de calcio y vitamina D. Consideramos importante medir DMO seriada, individualizando terapias y controlando factores de riesgo (AU)

INTRODUCTION: Bariatric surgery has important metabolic complications such as bone mass loss. GOAL: To assess bone mineral density (BMD) after Roux-en-Y gastric by-pass (RYGB) in patients under standard calcium and vitamin D supplementation. METHOD: In patients with morbid obesity submitted to RYGB, 76 women and 22 men of diverse age, all with standard nutritional instruction including vitamin D and calcium, we measured BMD with a dual X-ray densitometer. They had lumbar spine and hips measurement 2-3 years post-surgery. Twenty females were followed up with BMD until of a mean of 54 months. Using World Health Organization (WHO) criteria's, values were compared with young controls and same age and sex population, evaluating osteopenia and osteoporosis. RESULTS: Inverse correlation was observed between BMD and age; positive between BMD and body mass index as well as with preoperative weight excess. In women younger than 45 years, we observed a diminished BMD in 26.8% of them, with no cases of osteoporosis. In older females, BMD was decreased in 65.7% (p = 0.0011); corresponding to 45.7% of osteopenia and 20% osteoporosis, more frequent in lumbar spine. In the female's subgroup followed longer, BMD diminished progressively mainly in left hip. In men, there was 36% of osteopenia and 14% of osteoporosis. CONCLUSION :Patients from both genders and diverse ages after BPYR presented osteopenia and osteoporosis, despite early supplement prescription of calcium and vitamin D. We consider important to perform serial BMD measurements and also to individualize therapy with risk factors control (AU)

Heme- and nonheme-iron absorption and iron status 12 mo after sleeve gastrectomy and Roux-en-Y gastric bypass in morbidly obese women.

BACKGROUND: The effect of bariatric surgery on iron absorption is only partially known. OBJECTIVE: The objective was to study the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGBP) on heme- and nonheme-iron absorption and iron status. DESIGN: Fifty-eight menstruating women were enrolled in this prospective study [mean (±SD) age: 35.9 ± 9.1 y; weight: 101.7 ± 13.5 kg; BMI (in kg/m²): 39.9 ± 4.4]. Anthropometric, body-composition, dietary, and hematologic indexes and heme- and nonheme-iron absorption-using a standardized meal containing 3 mg Fe-were determined before and 12 mo after surgery. Forty-three subjects completed the 12-mo follow-up. Iron supplements were strictly controlled. RESULTS: Heme-iron absorption was 23.9% before and 6.2% 12 mo after surgery (P < 0.0001). Nonheme-iron absorption decreased from 11.1% to 4.7% (P < 0.0001). No differences were observed by type of surgery. Iron intakes from all sources of supplements were 27.9 ± 6.2 mg/d in the SG group and 63.2 ± 21.1 mg/d in the RYGBP group (P < 0.001). Serum ferritin and total-body iron decreased more after RYGBP than after SG. CONCLUSIONS: Iron (heme and nonheme) absorption is markedly reduced after SG and RYGBP. The magnitude of the decrease in heme-iron absorption is greater than that of nonheme iron. The amounts suggested as iron supplements may need to be increased to effectively prevent iron-status impairment.

Zinc absorption and zinc status are reduced after Roux-en-Y gastric bypass: a randomized study using 2 supplements.

BACKGROUND: Micronutrient deficiencies are common in patients undergoing gastric bypass. The effect of this type of surgery on zinc absorption and zinc status is not well known. OBJECTIVE: The objective was to evaluate the effects of Roux-en-Y gastric bypass (RYGBP) on zinc status and zinc absorption at different stages after surgery. We hypothesized that zinc status would be significantly impaired after surgery and that this impairment would be less severe in subjects receiving increased supplemental zinc. We also hypothesized that zinc absorption would be lower after surgery. DESIGN: Anthropometric and body-composition variables and dietary and biochemical indexes of zinc status and zinc absorption were determined in 67 severe and morbidly obese women [mean (±SD) age: 36.9 ± 9.8 y; BMI (in kg/m(2)): 45.2 ± 4.7] who underwent RYGBP. The subjects were randomly assigned to 1 of 2 vitamin-mineral supplementation groups. Measurements were made before and 6, 12, and 18 mo after surgery. Fifty-six subjects completed the 18-mo follow-up. RESULTS: Mean plasma zinc, erythrocyte membrane alkaline phosphatase activity, and the size of the rapidly exchangeable zinc pool decreased after RYGBP. Percentage zinc absorption decreased significantly from 32.3% to 13.6% at 6 mo after RYGBP and to 21% at 18 mo after surgery. No effect of supplement type was observed. CONCLUSIONS: Zinc status is impaired after RYGBP, despite the finding that dietary plus supplemental zinc doubled recommended zinc intakes in healthy persons. Zinc absorption capacity is significantly reduced soon after RYGBP, with no major changes until 18 mo after surgery.

Calidad de la alimentación de mujeres con obesidad severa y mórbida sometidas a bypass gastrico y gastrectomia vertical en manga

El objetivo de este estudio fue comparar la ingesta de energía y nutrientes y la calidad de la alimentación, en pacientes sometidos a bypass gástrico en Y de Roux y (BPGYR) y gastrectomía vertical en manga (GVM). En 36 mujeres con obesidad severa y mórbida se estudió la alimentación previa y a los 6 meses posteriores a la cirugía, mediante encuesta de registro de tres días, se analizó el grado de adecuación e índice de calidad nutricional (ICN). Se controló estrictamente el consumo de suplementos de vitaminas y minerales. El consumo de energía y nutrientes fue significativamente menor al sexto mes post cirugía comparado con el preoperatorio, sin diferencias significativas entre grupos, excepto calcio y vitamina C. El ICN fue similar entre grupos. La ingesta dietética de calcio, hierro, zinc, cobre, ácido fólico, vitamina C y E fue menor al 100% de adecuación al 6º mes. Sin embargo, al considerar en conjunto el aporte de la dieta como de los suplementos, la adecuación de prácticamente todos los nutrientes estudiados sobrepasa el 100% en ambos grupos, logrando una mayor adecuación el grupo sometido a BPGYR. Las excepciones las constituyen el calcio, el cual no alcanza a cubrir el 100% en ningún grupo y el ácido fólico en el grupo sometido a GVM. En conclusión, estos pacientes presentan reducciones importantes de la ingesta dietética de energía y micronutrientes, sin mayores diferencias dependientes del tipo de cirugía. Las características de los suplementos son críticos para lograr la cobertura de las necesidades.

The objective of this study was to evaluate the changes of dietary intake and quality of the diet in patients undergoing gastric bypass and sleeve surgery. In 36 women with severe and morbid obesity it was assessed their nutrient intakes and dietary quality before and 6 months after bariatric surgery through three-day food records. Vitamin and mineral intakes from supplements were strictly controlled. Energy and nutrient intakes were significantly decreased 6 months after surgery bypass compared to the pre-surgery period, with the exceptions of calcium and vitamin C. No differences were observed between groups. The Dietary quality index was also similar in both groups. Dietary intakes of calcium, iron, zinc, copper, folic acid, vitamin C, and vitamin E were below 100% of adequacy from at the 6th month after the surgery. Nevertheless, by considering both diet and supplements supply, nutrient adequacy of all but calcium and folic acid was above 100% in both groups. Gastric bypass patients presented greater values. In conclusion, these patients present an important reduction of their energy and nutrient intakes, with no major impact of the type of surgery. Supplement characteristics are crucial to cover nutritional needs.