Resting Energy Expenditure and Organ-Tissue Body Composition 5 Years After Bariatric Surgery.

INTRODUCTION: Bariatric surgery-induced weight loss may reduce resting energy expenditure (REE) and fat-free mass (FFM) disproportionately thereby predisposing patients to weight regain and sarcopenia. METHODS: We compared REE and body composition of African-American and Caucasian Roux-en-Y gastric bypass (RYGB) patients after surgery with a group of non-operated controls (CON). REE by indirect calorimetry; skeletal muscle (SM), trunk organs, and brain volumes by MRI; and FFM by DXA were measured at post-surgery visits and compared with CON (N = 84) using linear regression models that adjusted for relevant covariates. Ns in RYGB were 50, 42, and 30 for anthropometry and 39, 27, 17 for MRI body composition at years 1, 2, and 5 after surgery, respectively. RESULTS: Regression models adjusted for age, weight, height, ethnicity, and sex showed REE differences (RYGB minus CON; mean ± s.e.): year 1 (43.2 ± 34 kcal/day, p = 0.20); year 2 (- 27.9 ± 37.3 kcal/day, p = 0.46); year 5 (114.6 ± 42.3 kcal/day, p = 0.008). Analysis of FFM components showed that RYGB had greater trunk organ mass (~ 0.4 kg) and less SM (~ 1.34 kg) than CON at each visit. REE models adjusted for FFM, SM, trunk organs, and brain mass showed no between-group differences in REE (- 15.9 ± 54.8 kcal/day, p = 0.8; - 46.9 ± 64.9 kcal/day, p = 0.47; 47.7 ± 83.0 kcal/day, p = 0.57, at years 1, 2, and 5, respectively). CONCLUSIONS: Post bariatric surgery patients maintain a larger mass of high-metabolic rate trunk organs than non-operated controls of similar anthropometrics. Interpreting REE changes after weight loss requires an accurate understanding of fat-free mass composition at both the organ and tissue levels. CLINICAL TRIAL REGISTRATION: Long-term Effects of Bariatric Surgery (LABS-2) NCT00465829.

Fat-Free Mass and Skeletal Muscle Mass Five Years After Bariatric Surgery.

OBJECTIVE: This study investigated changes in fat-free mass (FFM) and skeletal muscle 5 years after surgery in participants from the Longitudinal Assessment of Bariatric Surgery-2 trial. METHODS: A three-compartment model assessed FFM, and whole-body magnetic resonance imaging (MRI) quantified skeletal muscle mass prior to surgery (T0) and 1 year (T1), 2 years (T2), and 5 years (T5) postoperatively in 93 patients (85% female; 68% Caucasian; age 44.2 ± 11.6 years) who underwent gastric bypass (RYGB), sleeve gastrectomy, or adjustable gastric band. Repeated-measures mixed models were used to analyze the data. RESULTS: Significant weight loss occurred across all surgical groups in females from T0 to T1. FFM loss from T0 to T1 was greater after RYGB (mean ± SE: -6.9 ± 0.6 kg) than adjustable gastric band (-3.5 ± 1.4 kg; P < 0.05). Females with RYGB continued to lose FFM (-3.3 ± 0.7 kg; P < 0.001) from T1 to T5. A subset of males and females with RYGB and MRI-measured skeletal muscle showed similar initial FFM loss while maintaining FFM and skeletal muscle from T1 to T5. CONCLUSIONS: Between 1 and 5 years following common bariatric procedures, FFM and skeletal muscle are maintained or decrease minimally. The changes observed in FFM and muscle during the follow-up phase may be consistent with aging.

The Impact of Biliopancreatic Diversion with Duodenal Switch (BPD/DS) Over 9 Years.

BACKGROUND: There is limited information on the multiple long-term effects of the biliopancreatic diversion with duodenal switch (BPD/DS). METHODS: Patients who consented to a BPD/DS from 1999 to 2010 were evaluated for weight change, complications, comorbidity resolution, body composition, quality of life, and depressive symptoms during visits at 1, 3,5, 7, and 9 years. Descriptive statistics, analysis of variance, and pair-wise comparisons were calculated for each of the five follow-up cohorts vs. the baseline cohort. RESULTS: Between 1999 and 2010, 284 patients received a BPD/DS; 275 patients (69.8 % women) age 42.7 years, BMI 53.4 kg/m2 qualified for baseline analysis. Two hundred seventy-five patients were available in year 1; 275 patients in year 3; 273 patients in year 5; 259 patients in year 7; and 228 patients in year 9. Gender distribution was not different. BMI was 30.1 at 1 year and 32.0 at 9 years. Body fat was reduced to 26 % after 2 years. Complications requiring surgery were significant. Nutritional problems developed in 29.8 % of patients over the course of observation. The baseline Beck Depression Index (BDI) was 13.9 and 7.2 in year 1. Year 1 through 9 remained unchanged. There were significant positive changes in quality of life between baseline and year 1 for most domains. These positive changes were maintained for the follow-up cohorts. After surgery the resolution of comorbidities continued for the 9 years. CONCLUSIONS: Weight loss during the first year was well maintained, resolving comorbidities and improving quality of life. Rates of surgical complications resemble other bariatric procedures. Long-term nutrient deficiencies are of concern.

Urinary Incontinence Before and After Bariatric Surgery.

IMPORTANCE: Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery-induced weight loss is lacking. OBJECTIVES: To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS: The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012). INTERVENTION: Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter. MAIN OUTCOMES AND MEASURES: The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up. RESULTS: Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m2 (range, 34-94 kg/m2), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P < .001). After a mean 1-year weight loss of 29.5% (95% CI, 29.0%-30.1%) in women and 27.0% (95% CI, 25.9%-28.6%) in men, year 1 urinary incontinence prevalence was significantly lower among women (18.3%; 95% CI, 16.4%-20.4%) and men (9.8%; 95% CI, 7.2%-13.4%) (P < .001 for all). The 3-year prevalence was higher than the 1-year prevalence for both sexes (24.8%; 95% CI, 21.8%-26.5% among women and 12.2%; 95% CI, 9.0%-16.4% among men) but was substantially lower than baseline (P < .001 for all). Weight loss was independently related to urinary incontinence remission (relative risk, 1.08; 95% CI, 1.06-1.10 in women and 1.07; 95% CI, 1.02-1.13 in men) per 5% weight loss, as were younger age and the absence of a severe walking limitation. CONCLUSIONS AND RELEVANCE: Among women and men with severe obesity, bariatric surgery was associated with substantially reduced urinary incontinence over 3 years. Improvement in urinary incontinence may be an important benefit of bariatric surgery.

Bariatric surgery in cancer survivorship: does a history of cancer affect weight loss outcomes?

BACKGROUND: Weight loss is recommended for obese cancer survivors who are at increased risk of recurrence and non-cancer-related mortality. It remains unknown if this vulnerable population benefits from bariatric surgery to the same extent as those without a history of cancer. METHODS: A retrospective chart review of 1013 patients identified 29 bariatric surgery patients with a history of cancer who were then matched to patients without a history of cancer. RESULTS: At 1-year postsurgical follow-up, individuals with a history of cancer had lost less weight than those without a history of cancer (14.2 versus 14.8); however, this difference was not significant (P = .76). CONCLUSION: Cancer survivors appear to draw similar benefit from bariatric surgery as those without a history of cancer, although a larger study with greater statistical power to detect differences is needed to confirm these results. These preliminary results are encouraging in light of the increasing focus on weight loss among this population.

Continued loss in visceral and intermuscular adipose tissue in weight-stable women following bariatric surgery.

OBJECTIVE: To assess changes in total (TAT), subcutaneous (SAT), visceral (VAT), and intermuscular (IMAT) adipose tissue by whole-body MRI before surgery and at 12 months and 24 months post-surgery in a subset of participants of the Longitudinal Assessment of Bariatric Surgery-2. METHODS: From 0 to 12 months, n = 20 females and 3 males; from 12 to 24 months, n = 42 females and 7 males. Paired t-tests and GLM repeated measures examined changes in TAT, SAT, VAT, and IMAT at 12 and 24 months, with sex and age as covariates. RESULTS: Changes from 0 to 12 months included weight (-41.9 ± 12.1 kg; -36%), TAT (-33.5 ± 9.6 kg; -56%), SAT (-29.2 ± 8.2 kg; -55%), VAT (-3.3 ± 1.6 kg; -73%), and IMAT (-0.99 ± 0.68 kg; -50%), all P < 0.001. In females, from 12 to 24 months, despite relative weight stability (-1.8 ± 6.5 kg, -2%; P = 0.085), VAT (-0.5 ± 0.7 kg; -30%; P < 0.001) and IMAT (-0.2 ± 0.4 kg; -14%; P = 0.012) decreased further. In males, from 12 to 24 months, weight increased (5.1 ± 5.2 kg; 6%; P = 0.04) with no significant changes in TAT or sub-depots. CONCLUSIONS: Bariatric surgery continues to induce favorable changes in body composition, i.e., persistent adipose tissue loss at 24 months in the absence of further significant weight loss.

Lipid profile changes in the severely obese after laparoscopic sleeve gastrectomy (LSG), 1, 3, and 5 years after surgery.

BACKGROUND: Since there is an increasing acceptance of the laparoscopic sleeve gastrectomy (LSG) and limited information regarding its effect on cardiac risk factors, we assessed lipid profiles. METHODS: A retrospective review of patient records pre and post LSG was performed. Analysis of variance evaluated group differences and paired t tests compared variable changes. RESULTS: Eighty two patients (67 % female, age 46.4 ± 13.9) had presurgery lipid profiles and follow-up (43 at 1 year, 28 at 3 years, and 26 at 5 years). Groups were not different in gender distribution. The presurgery mean body mass index (BMI) was 55.7 kg/m(2); 65.9 % of the subjects were super obese. After surgery, percentage of excess BMI loss was 58.1 % year (yr) 1, 61.3 % yr 3, and 39.0 % yr 5. Lipids were within the normal ranges for all parameters at all times; however, at baseline 77 % had at least one abnormality. At 1 year, triglycerides decreased significantly from baseline (adjusted p value (adj-p) = 0.004) and high-density lipoprotein (HDL) increased (adj-p = 0.025). Year 3 HDL was significantly different from baseline, adj-p = 0.0001. Yr 3 cholesterol increased from baseline, (adj-p = 0.027). Negative linear correlations with weight loss were present for low-density lipoprotein (LDL) at yr 3(r = 0.46, p = 0.02) and triglyceride change at year 5 (r = 0.48, p = 0.02). The percentage of patients with dyslipidemia or medicated did not change significantly during these 5 years. CONCLUSIONS: For this population electing LSG, mean lipid profiles were within normal ranges for all parameters before surgery. However, 77 % showed at least one abnormality presurgery. Weight change correlated with some changes of triglycerides, HDL, and LDL over time, but the impact was limited.

Adding chemoprophylaxis to sequential compression might not reduce risk of venous thromboembolism in bariatric surgery patients.

BACKGROUND: Anticoagulation, the use of sequential compression devices on the lower extremities perioperatively, and early ambulation are thought to reduce the incidence of venous thromboembolism (VTE) postoperatively and are recommended to reduce VTE risk. However, the evidence on which this recommendation has been based is not particularly strong. We have demonstrated that even a large, multicenter cohort with carefully collected prospective data is inadequate to provide sufficient evidence to support, or refute, this recommendation. METHODS: Longitudinal Assessment of Bariatric Surgery participants from 10 centers in the United States who underwent their first bariatric surgery between March 2005 and December 2007 constituted the study group. We examined the ability to address the question of whether anticoagulation therapy, in addition to sequential compression, reduces the 30-day incidence of VTE or death sufficiently to recommend the use of prophylactic anticoagulation, a therapy that is not without risk. RESULTS: Of 4416 patients, 396 (9.0%) received sequential compression alone, and 4020 also received anticoagulation therapy. The incidence of VTE within 30 days of surgery was low (.25% among those receiving sequential compression alone and .47% when anticoagulation therapy was added), and the 30-day incidence of death was also low (.25% versus .34%, respectively, P = .76, for sequential compression alone versus sequential compression plus anticoagulation therapy). Estimates of the number of cases required to address the question of whether a difference exists in the outcome related to VTE chemoprophylaxis or whether the outcome rates are equivalent have ranged from 13,680 to ≥ 35,760 patients, depending on whether superiority or equivalence was being analyzed. CONCLUSION: Sufficient evidence from a clinical trial study to determine whether prophylactic anticoagulation added to compression devices further prevents VTE is not available, and such a trial is likely to be impractical. The data presented are insufficient to make a final recommendation concerning prophylactic treatment to prevent VTE in the 30 days after bariatric surgery.

Psychopathology before surgery in the longitudinal assessment of bariatric surgery-3 (LABS-3) psychosocial study.

BACKGROUND: Current and previous psychopathology in bariatric surgery candidates is believed to be common. Accurate prevalence estimates, however, are difficult to obtain given that bariatric surgery candidates often wish to appear psychiatrically healthy when undergoing psychiatric evaluation for approval for surgery. Also, structured diagnostic assessments have been infrequently used. METHODS: The present report concerned 199 patients enrolled in the longitudinal assessment of bariatric surgery study, who also participated in the longitudinal assessment of bariatric surgery-3 psychopathology substudy. The setting was 3 university hospitals, 1 private not-for-profit research institute, and 1 community hospital. All the patients were interviewed independently of the usual preoperative psychosocial evaluation process. The patients were explicitly informed that the data would not be shared with the surgical team unless certain high-risk behaviors, such as suicidality, that could lead to adverse perioperative outcomes were reported. RESULTS: Most of the patients were women (82.9%) and white (nonwhite 7.6%, Hispanic 5.0%). The median age was 46.0 years, and the median body mass index was 44.9 kg/m2. Of the 199 patients, 33.7% had ≥1 current Axis I disorder, and 68.8% had ≥1 lifetime Axis I disorder. Also, 38.7% had a lifetime history of a major depressive disorder, and 33.2% had a lifetime diagnosis of alcohol abuse or dependence. All these rates were much greater than the population-based prevalence rates obtained for this age group in the National Comorbidity Survey-Replication Study. Also, 13.1% had a lifetime diagnosis and 10.1% had a current diagnosis of a binge eating disorder. CONCLUSION: The current and lifetime rates of psychopathology are high in bariatric surgery candidates, and the lifetime rates of affective disorder and alcohol use disorders are particularly prominent. Finally, binge eating disorder is present in approximately 1 in 10 bariatric surgery candidates.

Medical versus surgical treatment of type 2 diabetes: the search for level 1 evidence.

Data from observational and nonrandomized comparative studies have shown a dramatic effect of bariatric surgery on type 2 diabetes mellitus (T2DM), including in nonobese patients. However, a relative paucity of level 1 evidence is available to define the exact role of surgery as a treatment modality for T2DM, especially in less obese subjects. Performing randomized clinical trials in this field, however, poses significant and specific challenges for the study design. We have addressed such challenges in a carefully designed randomized controlled trial comparing glycemic control with optimal medical management versus Roux-en-Y gastric bypass in overweight to mildly obese patients with T2DM mellitus (body mass index 26-35 kg/m(2)). The present report describes the rationale and design of the Weill Cornell Medical College study. In addition to glycemic endpoints, however, clinical trials should also investigate the effect of surgery on cardiovascular risk or T2DM-specific morbidity. Addressing these endpoints would entail large, randomized clinical trials with prolonged period of observation and ideally a multicenter study design. Such a multisite trial poses substantial logistical and financial challenges, which would predictably delay rather than accelerate progress of research in this field. A consortium of centers performing independent small and medium size randomized clinical trials may provide a more realistic and feasible approach. In this paper, we present an overview of on-going randomized clinical trials in this field and propose a worldwide consortium of randomized controlled trials (WORLDCoRDS) using the Weill Cornell Medical College protocol. The aim of this consortium is to standardize research in T2DM surgery and timely accumulate homogeneous data that can help assess the effects of GI surgery on cardiovascular risk and T2DM-related mortality and morbidity.

Evaluation of nutrient status after laparoscopic sleeve gastrectomy 1, 3, and 5 years after surgery.

BACKGROUND: Laparoscopic sleeve gastrectomy evolved as a primary bariatric procedure with little information on its nutritional effects. Our objective was to assess the longer term micronutrient and vitamin status after laparoscopic sleeve gastrectomy at a university hospital. METHODS: Measurements of ferritin, iron, total iron binding capacity, hemoglobin, hematocrit, parathyroid hormone, albumin, calcium, magnesium, phosphorus, zinc, folate, and vitamins A, B1, B12, and D were obtained at baseline and 1, 3, and 5 years after surgery. Two-sample t tests with multiple adjusted comparisons and Fisher's exact test were used to determine deficiency. RESULTS: A total of 82 patients (67% women), with a mean age of 46.4 years and a baseline body mass index 55.7 kg/m2 were included in the present study (35 at 1, 27 at 3, and 30 at 5 years postoperatively). The percentage of excess body mass index loss was 58.5% at year 1 in 35 patients, 63.1% at year 3 in 27 patients, and 46.1% at year 5 in 30 patients. The parathyroid hormone level decreased from 75.0 to 49.6 ng/mL in year 1 to 40.7 ng/mL in year 3. The year 5 levels increased to 99.6 ng/mL. The mean vitamin D level increased from 23.6 ng/mL to 35.0, 32.1 and 34.8 at years 1, 3, and 5 (P = .05 for baseline to year 1). The vitamin D level was less than normal in 42% of the patients at year 5. After normalization from baseline, by year 5, parathyroid hormone had increased in 58.3% of patients. At year 5, vitamin B1 was less than normal in 30.8% of patients, and hemoglobin and hematocrit were less than normal in for 28.6% and 25% of patients, respectively. Finally, 28.9% of patients reported taking supplements in year 1, 42.9% in year 3, and 63.3% in year 5. The other variables were not significantly different. CONCLUSIONS: Laparoscopic sleeve gastrectomy resulted in health improvements through year 3. At year 5, the nutrient levels had reverted toward the baseline values. These observations provide focus for necessary clinical monitoring.

Comparison of fat-free mass in super obesity (BMI ≥ 50 kg/m2) and morbid obesity (BMI <50 kg/m2) in response to different weight loss surgeries.

BACKGROUND: Differences in excess weight loss, body mass index (BMI) change, and body composition have been related to different types of bariatric procedures. Our objective was to explore these alterations related to body mass in superobese (SO) and morbidly obese (MO) patients in a university hospital setting. METHODS: Patients provided written informed consent and had their body composition measured before and after surgery using bioimpedance (Tanita 310). The t test was used to compare MO and SO. Pearson's correlations were used to examine the BMI, excessive BMI loss, percentage of body fat (BF) change, and fat-free mass. RESULTS: A total of 133 MO patients had a BMI of 43.3 kg/m(2) and 88 SO patients had a BMI of 59.4 kg/m(2). The percentage of BF was 46.7% and 51.9% (P < .0001). The differences in the follow-up period after surgery (21.5 and 20.6 months; P = .62) and patient age (43.4 and 42.5 yr) were not significant, but the gender distribution was significant (P = .003). After surgery, the MO patients had a BMI of 30.9 ± 5.7 kg/m(2) and the SO patients had a BMI of 37.3 ± 9.0 kg/m(2). The percentage of BF was not different between the 2 groups (MO, 33.1% ± 9.6% and SO, 35.0% ± 12.4%; P = .21). Gender differences in the percentage of BF were present before surgery; however, after surgery, these were absent for the men in the 2 groups (24.8% and 26.6%; P = .51). The change in the BMI and the change in the BF had a stronger correlation for the MO patients (r = .83 versus r = .53) than for the SO patients. The fat-free mass loss correlated with the change in BMI without regard to procedure. The percentage of excessive BMI loss was 65.1% for the MO and 63.4% for the SO patients (P = .64). CONCLUSIONS: The SO patients achieved excessive BMI loss similar to that of the MO patients, with more SO men choosing biliopancreatic diversion/duodenal switch. At a BMI of 37.3 kg/m(2), the SO patients had a percentage of BF that was not different from that of the MO patients at 30.9 kg/m(2). The fat-free mass losses correlated with the change in BMI.

Cross-sectional review of effects of laparoscopic sleeve gastrectomy at 1, 3, and 5 years.

BACKGROUND: Laparoscopic sleeve gastrectomy evolved as a primary bariatric procedure without data on longer term outcomes. Our objective was to measure the weight changes and quality of life after laparoscopic sleeve gastrectomy at a university hospital. METHODS: The patients scheduled follow-up visits for clinical measurements, blood sampling, and form completion, including the Medical Outcomes Study 36-item short-form questionnaire, the Impact of Weight on the Quality of Life-Lite questionnaire, and Beck depression inventory. Comparisons were performed among patients with a follow-up of 1, 3, and 5 years after laparoscopic sleeve gastrectomy. RESULTS: A total of 77 patients (35 at 1, 19 at 3, and 23 at 5 yr) were similar in gender (70.1% women), percentage of body fat, and body mass index by analysis of variance (P = .12; 1 versus 3 yr, P = .04). The 5-year group was older (P = .07). The 3 groups were different in the percentage of excess body mass index loss (P = .04). Differences in the Beck depression inventory were not significant by analysis of variance but were for 1 year versus 5 years (P = .04). For the Impact of Weight on the Quality of Life-Lite total scores, the difference was significant (P = .06; 1 versus 5 yr, P = .027; and public distress subscore at 1 and 5 yr, P = .04). The differences in the other domains were not significant. For the Medical Outcomes Study 36-item short-form, differences in the physical differences domain was significant (P = .001). The differences in physical function, social function, general health, vitality, body pain, and role physical were significant. The differences in mental health and role emotional were not. The differences in the Beck depression inventory scores were not significant using analysis of variance but were between the 1-year and 5-year scores (P = .04). CONCLUSION: Patients undergoing laparoscopic sleeve gastrectomy had a similar body mass index at 1, 3, and 5 years. However, the percentage of excess body mass index loss was different. No differences were found in the percentage of body fat. The health-related quality of life scores resembled community norms, although the physical health differences in the 3 groups were significant, The Beck depression inventory scores were elevated at 5 years compared with at 1 year.

Reproductive health of women electing bariatric surgery.

OBJECTIVE: To describe the reproductive health history and characteristics of women having bariatric surgery and to determine whether this differs by age of onset of obesity. DESIGN: Retrospective and cross-sectional analyses of self-reported survey data. SETTING: Six sites of the Longitudinal Assessment of Bariatric Surgery-2 study. PATIENT(S): The study included 1,538 females having bariatric surgery. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Reported polycystic ovary syndrome (PCOS), pregnancy and fertility history, contraceptive use, and plans for pregnancies. RESULT(S): Mean age was 44.8 years (range, 18-78 years); mean body mass index was 47.2 kg/m2 (range, 33.8-87.3 kg/m2). PCOS had been diagnosed by a health care provider in 13.1% of subjects. Of women who had tried to conceive, 41.9% experienced infertility and 61.4% had a live birth after experiencing infertility. In the whole group, prior live birth was reported by 72.5%. Women who were obese by 18 years old were more likely to report PCOS and infertility and less likely to have ever been pregnant, compared with women who became obese later in life. Future pregnancy was important to 30.3% of women younger than 45 years, whereas 48.6% did not plan to become pregnant in the future. In the year before surgery, 51.8% used contraception. CONCLUSION(S): Self-reporting of obesity by age 18 appears to be related to reproductive morbidity. Women undergoing bariatric surgery have important reproductive health care needs, including reliable contraception and counseling about plans for postoperative pregnancy.

Comparison of weight loss and body composition changes with four surgical procedures.

BACKGROUND: A paucity of information is available on the comparative body composition changes after bariatric procedures. The present study reports on the body mass index (BMI) and body composition changes after 4 procedures by a single group. METHODS: At the initial consultation, the weight and body composition of the patients undergoing 4 different bariatric procedures were measured by bioimpedance (Tanita 310). Follow-up examinations were performed at 1 year and at subsequent visits after surgery. Analysis of variance was used to compare the postprocedure BMI and body composition. Analysis of covariance was used to adjust for baseline differences. RESULTS: A total of 101 gastric bypass (GB) patients were evaluated at 19.1 + or - 10.6 months, 49 biliopancreatic diversion with the duodenal switch (BPD/DS) patients at 27.5 + or - 16.3 months, 41 adjustable gastric band (AGB) patients at 21.4 + or - 9.2 months, and 30 sleeve gastrectomy (SG) patients at 16.7 + or - 5.6 months (P <.0001). No differences were found in patient age or gender among the 4 groups. The mean preoperative BMI was significantly different among the 4 groups (P <.0001): 61.4 kg/m(2), 53.2, 46.7, and 44.3 kg/m(2) for the SG, BPD/DS, GB, and AGB group, respectively. The postoperative BMI adjusted for baseline differences was 27.8 (difference 23.6 + or - 8.3), 32.5 (difference 15.6 + or - 5.0), 37.2 (difference 18.2 + or - 8.2), and 39.5 kg/m(2) (difference 7.5 + or - 4.3) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The percentage of excess weight loss was 84%, 70%, 49%, and 38% for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The postoperative percentage of body fat adjusted for baseline differences was 25.7% (23.9% + or - 7.0%) 32.7% (16.1% + or - 10.5%) 37.7% (16.7% + or - 5.6%), and 42% (6.0% + or - 6.8%) for the BPD/DS, GB, SG, and AGB groups, respectively (P <.0001). The lean body mass changes were reciprocal. CONCLUSION: Although the BPD/DS procedure reduced the BMI the most effectively and promoted fat loss, all the procedures produced weight loss. The AGB procedure resulted in less body fat loss within 21.5 months than SG within 16.7 months. Longer term observation is indicated.

Bioimpedance for severe obesity: comparing research methods for total body water and resting energy expenditure.

OBJECTIVE: As the acceptance of surgical procedures for weight loss in morbid obesity is increasing, clinically useful baseline and follow-up measures of total body water (TBW) and resting energy expenditure (REE) are important. Research methods such as deuterium (D(2)O) dilution and metabolic carts are problematic in the clinical setting. We compared bioimpedance analysis (BIA) predicted (Tanita TBF-310) and measured TBW and REE. METHODS AND PROCEDURES: Forty-two paired presurgery studies were completed using BIA and D(2)O in patients with BMI (mean +/- s.d.) 50.2 +/- 8.8 kg/m(2) for TBW, and 30 patients with BMI 51.0 +/- 13 kg/m(2) completed paired determinations of REE with metabolic carts and the Tanita balance with weight, height, sex, and age modifiers. Regression analysis and Bland-Altman plots were applied. RESULTS: When regression analysis was completed for TBW, regression line was consistent with the identity line "y = x." The intercept was not different from 0 (95% confidence interval -2.5 +/- 7.0). The slope of the line was not different from 1.0 +/- 0.1. The measured TBW 51.2 +/- 10.1 l had a correlation with the predicted 49.5 +/- 11.27 l of 0.92. There also was no significant difference (P = 0.33) between predicted (2,316 +/- 559 kcal/day) and measured REE (2,383 +/- 576 kcal/day);delta 66.7 +/- 273 kcal/day. The two measures were highly correlated (r = 0.88) with no bias detected. DISCUSSION: These observations support the use of the BIA system calibration in subjects with severe obesity. Without the use of complex, costly equipment and invasive procedures, BIA measurements can easily be obtained in clinical practice to monitor patient responses to treatment.

Reversal of the hypogonadotropic hypogonadism of obese men by administration of the aromatase inhibitor testolactone.

Studies from this laboratory have shown that obese men have elevated serum estrogen levels and diminished levels of follicle-stimulating hormone (FSH) and free and total testosterone, all in proportion to their degree of obesity. The decreases in testosterone and FSH constitute a state of hypogonadotropic hypogonadism (HHG), and we have hypothesized that it results from feedback suppression of the pituitary by the elevated estrogen levels. We tested this hypothesis by lowering the serum estrogens of 6 health obese men (body mass index [BMI], 38 to 73) by administering the aromatase inhibitor testolactone (1 g daily for 6 weeks). Twenty-four-hour mean serum testosterone rose in every subject, from a mean of 290 +/- 165 ng/dL to a mean of 403 +/- 170 (P <.0003); 24-hour mean serum estradiol decreased in every subject, from a mean of 40 +/- 10.8 pg/mL to a mean of 29 +/- 6.7 (P <.004); and 24-hour mean serum luteinizing hormone (LH) increased in every subject, from a mean of 14.3 +/- 4.1 mIU/mL to a mean of 19.3 +/- 5.1 (P <.004). The rise in mean LH was due to an increase in the amplitude of the individual secretory pulses, especially at night. Twenty-four-hour mean serum estrone decreased nonsignificantly, from 48 +/- 14 pg/mL to 39 +/- 6.4, and 24-hour mean serum FSH increased nonsignificantly, from 13.5 +/- 5.3 mIU/mL to 15.0 +/- 5.4. The results are in accordance with the hypothesis, in that inhibition of estrogen biosynthesis (through administration of the aromatase inhibitor testolactone) results in alleviation of the HHG of our obese male subjects.

Position of the American Dietetic Association: weight management.

It is the position of the American Dietetic Association that successful weight management to improve overall health for adults requires a lifelong commitment to healthful lifestyle behaviors emphasizing sustainable and enjoyable eating practices and daily physical activity. Americans are increasing in body fat as they become more sedentary. Obesity has reached epidemic proportions and health care costs associated with weight-related illnesses have escalated. Although our knowledge base has greatly expanded regarding the complex causation of increased body fat, little progress has been made in long-term maintenance interventions with the exception of surgery. Lifestyle modifications in food intake and exercise remain the hallmarks of effective treatment, but are difficult to initiate and sustain over the long term. The dietitian can play a pivotal role in modifying weight status by helping to formulate reasonable goals which can be met and sustained with a healthy eating approach as outlined in the Dietary Guidelines for 2000. Any changes in dietary intake and exercise patterns which decrease caloric intake below energy expenditure will result in weight loss, but it is the responsibility of the dietitian to make sure the changes recommended are directed toward improved physiological and psychological health. A thorough clinical assessment should help define possible genetic, environmental, and behavioral factors contributing to weight status and is important to the formulation of an individualized intervention. The activation of treatment strategies is often limited by available resources and cost. Reimbursement by third party payers for services is limited. Health care dollars are consumed for treatment of weight-related diseases. Public policy must change if the obesity epidemic is to be stopped and appropriate weight management techniques activated.