## Sunday, March 1, 2020

### Intuitive eating may be an effective eating behaviour for weight loss after bariatric surgery

10 Principles of Intuitive Eating

2019 Jul 1;110(1):10-15. doi: 10.1093/ajcn/nqz046.

# Intuitive eating is associated with weight loss after bariatric surgery in women.

### Abstract

#### BACKGROUND:

Although the data on eating behavior after bariatric surgery are substantial, data on "intuitive eating" are lacking.

#### OBJECTIVE:

The aim of this study was to evaluate the link between intuitive eating and weight loss after bariatric surgery.

#### METHODS:

This cross-sectional study used a self-administered questionnaire freely available on social networks and targeted women who had undergone bariatric surgery. Intuitive eating was evaluated with the Intuitive Eating Scale-2 (IES-2). The 3 questionnaire subscores (Eating for Physical Rather than Emotional Reasons, Reliance on Hunger and Satiety Cues, and Unconditional Permission to Eat) were also analyzed. The relation between IES-2 scores and the relative variation in body mass index [BMI (in kg/m2)] was assessed with linear regression models. Adjusted β (βAdj) and standardized β $( {{\rm{\beta }}_{{\rm{Adj}}}^{{\rm{STD}}}} )$ were reported.

#### RESULTS:

We analyzed the responses of 401 women with a mean age of 39 ± 11 y, a mean preoperative BMI of 45.5 ± 7.9, and a mean current BMI of 30.5 ± 7. The mean relative BMI loss was 32.7 ± 12.9%, and the mean IES-2 score was 3.3 ± 0.6. The total IES-2 score was associated with the relative BMI loss, with ∼2.6% BMI loss for each 1-point increase in the IES-2 score [PAdj = 0.007; βAdj = -2.57 (95% CI: -4.44, -0.70); ${\rm{\beta }}_{{\rm{Adj}}}^{{\rm{STD}}}$= -0.12] after adjusting for elapsed time since surgery and type of surgery. Eating for Physical Rather than Emotional Reasons was the subscore most strongly associated with BMI change after adjustment [PAdj = 0.002; βAdj = -2.08 (95% CI: -3.37, 0.79); ${\rm{\beta }}_{{\rm{Adj}}}^{{\rm{STD}}}$ = -0.14].

#### CONCLUSIONS:

This study highlights a significant association between intuitive eating and BMI decrease after bariatric surgery. Furthermore, eating behaviors changed with increasing time since surgery. An intuitive nutritional approach may be complementary with bariatric surgery in the postoperative phase, which should prompt complementary prospective studies to evaluate the effectiveness of therapeutic education programs centered on intuitive eating in the postoperative period.

## Saturday, March 30, 2019

### Why is Iron Deficiency Such a Problem after Bariatric Surgery and What Can Be Done?

March 1, 2019
Iron deficiency is tightly linked to adipose tissue inflammation associated with obesity, involving impaired absorption of iron in the duodenum along with elevated hepcidin levels. Low iron status in individuals with obesity might result from nutritional (lowered absorption) as well as functional (higher sequestration) iron deficiency.1
Proper selection of the suitability of candidates for bariatric surgery involving adequate nutritional assessment and dietary guidance are essential when preparing the patient for surgery and achieving optimal surgical outcomes. Iron deficiency anemia is a long-term problem common after bariatric surgery. While studies on the preoperative micronutritional status of a patient have widely indicated low iron and ferritin serum concentrations, postoperative causes, such as anatomical changes after surgery, increased iron requirements, reduced acid production in the stomach, use of drugs to suppress gastric acid secretion, and aversion to certain foods, exacerbate the deficiency.
When adhering to the guidelines of the American Society for Metabolic and Bariatric Surgery (ASMBS), iron status should be evaluated at the patient’s follow-up visit after bariatric surgery. Routine supplementation to prevent iron deficiencies are 45 to 60mg elemental iron per day, or 150 to 200mg elemental iron supplements per day in case of deficiencies.2 Vitamin C supplementation can be concurrently prescribed to increase iron absorption. According to the recommended dietary allowance (RDA), 90mg of vitamin C for men and 75mg or more of vitamin C for females is recommended. It is also recommended to separate the intake of calcium supplements from iron intake.
There are two forms of iron in food: heme and non-heme. While heme iron comes from animal foods and is the most absorbed, non-heme iron is plant based and has a limited absorption of 30 to 60 percent of the total iron serving.
Due to the underlying mechanism of iron absorption being impaired through the gut, oral supplementation of iron is frequently insufficient, meaning intravenous iron is necessary, particularly in patients who undergo bariatric surgery.
Studies suggest liver biopsies were performed in all patients, and if no signs of hemosiderosis were seen, prophylactic parenteral infusions of iron were given periodically, in addition to oral iron supplementation.3 Early parenteral supplementation was provided during the first postoperative year with the first signs of iron deficiency before it developed to anemia.
Lab work should include iron panel, ferritin level, C-reactive protein (CRP), and total iron binding capacity (TIBC). Vitamin and mineral status assessments should be conducted every three months during the first year after surgery, every six months during the second year, and annually thereafter.2 Recent evidence suggest the effects of inflammation on iron nutrition can be assessed by measuring a patient’s CRP level. A level of more than 3mg/L of CRP denotes inflammation, which in turn leads to a ferritin level likely to be consistent with the diagnosis of iron deficiency.1
References
1. Cepeda-Lopez AC, Allende-Labastida J, Melse-Boonstra A, et al. The effects of fat loss after bariatric surgery on inflammation, serum hepcidin, and iron absorption: a prospective 6-mo iron stable isotope study. Am J Clin Nutr. 2016;104(4):1030–1038.
2. Sherf Dagan S, Goldenshluger A, Globus I, et al. Nutritional recommendations for adult bariatric surgery patients: clinical practice. Adv Nutr. 2017;8(2):382–394.
3. Salgado Wilson Jr, Modotti C, Nomino CB, Ceneviva R. Anemia and iron deficiency before and after bariatric surgery. Surg Obes Relat Dis. 2014;10(1):49–54.

### BT Online Editor | March 1, 2019

Abstract
Iron deficiency is a well-known and common nutritional complication of metabolic surgery. In addition to the known adverse effects of metabolic surgery on iron absorption, recent evidence suggests that the chronic low-grade systemic inflammation which commonly accompanies severe obesity alters iron availability and absorption, rendering patients with severe obesity at increased risk for iron deficiency and explains the high prevalence of iron deficiency among candidates for metabolic surgery.
Awareness of the physiology of the inflammatory response, its effects on iron homeostasis, and its complicating effects on the diagnosis and management iron deficiency should be a priority for those providing nutritional care for metabolic surgery patients.

During the past decade, metabolic surgery has led all surgical specialties in quality improvement with many important advances in surgical safety and perioperative management, which have resulted in sharply reduced levels of morbidity and mortality. These advances have established metabolic surgery as the most effective treatment for severe obesity and its adverse health consequences.1
Metabolic surgical procedures are designed to cause permanent changes in gastrointestinal anatomy and physiology that lead to life-long nutritional consequences, thus mandating close monitoring by skilled providers on a long-term basis. The most well-known and prevalent nutritional concern is the effect of metabolic surgery on iron nutrition. Recent discoveries suggest that obesity, in association with systemic inflammation, is also associated with iron deficiency and that this has an important impact on the postoperative risks of iron deficiency and anemia, conditions that can detract from the health restoring effects of metabolic surgery. The purpose of this review is to summarize the current knowledge related to obesity, metabolic surgery, and iron nutrition and to suggest opportunities for quality improvement.

## Saturday, April 7, 2018

### Bariatric surgery could have an impact on relationship status

Source- Bariatric News

Two new Swedish studies have reported that bariatric surgery could have an impact on relationships, with one finding that major weight loss after bariatric surgery was associated with more divorces, and a second study noting that singles were more likely to form new relationships or marry after a weight-loss operation.

"Those of us who take care of bariatric surgery patients notice that many patients experience a pretty profound change in their lives," said Dr Luke Funk, an assistant professor of surgery at the University of Wisconsin in Madison, and co-author of an editorial published with the study. "Their significant weight loss and improvements in other health problems, like high blood pressure and diabetes, cause changes in both their physical and mental well-being. They often take up new hobbies, become much more physically active, and feel much more confident about themselves. They also tend to have an improved self-image. I think this leads many to re-examine their relationships with others.”

One of the new studies, tracked the relationship histories of nearly 2,000 obese Swedish patients who underwent bariatric surgery over ten years. The investigators compared patients from the Swedish Obese Subjects (SOS) study with about 1,900 obese adults who did not have surgery. The other study using data from the Scandinavian Obesity Surgery Registry (SOReg) - looked at post-surgical data on about 29,000 patients who underwent gastric bypass surgery and compared with over 280,000 individuals in the general public, three years post-surgery.

The study authors found that bariatric surgery was tied to increased odds for divorce or separation for those in a prior relationship, especially for those who lost the most weight. Among those who had been unattached, significant weight loss was associated with higher odds for a new relationship or marriage. The report, ‘Associations of Bariatric Surgery With Changes in Interpersonal Relationship Status: Results From 2 Swedish Cohort Studies’, published in JAMA Surgery.

The SOS study included 1,958 patients who had bariatric surgery (of whom 1,389 [70.9%] were female) and 1,912 matched obese controls (of whom 1,354 [70.8%] were female. The SOReg cohort included 29,234 patients who had gastric bypass surgery (of whom 22,131 [75.6%] were female) and 283,748 comparators from the general population (of whom 214,342 [75.5%] were female).

"Unfortunately, our study can only give limited insights to why some couples separate after bariatric surgery."

In the SOS study, the surgical patients received gastric banding (n=368; 18.8%), vertical banded gastroplasty (n=1,331; 68.0%) or gastric bypass (n=259; 13.2%); controls received usual obesity care. In SOReg, all 29,234 surgical participants received gastric bypass surgery. In the SOS study, bariatric surgery was associated with increased incidence of divorce/separation compared with controls for those in a relationship (adjusted hazard ratio [aHR] = 1.28; 95% CI, 1.03-1.60; p=0.03) and increased incidence of marriage or new relationship (aHR = 2.03; 95% CI, 1.52-2.71; p<.001) in those who were unmarried or single at baseline.

In the SOReg and general population cohort, gastric bypass was associated with increased incidence of divorce compared with married control participants (aHR = 1.41; 95% CI, 1.33-1.49; p<0.001) and increased incidence of marriage in those who were unmarried at baseline (aHR = 1.35; 95% CI, 1.28-1.42; p<0.001). Within the surgery groups, changes in relationship status were more common in those with larger weight loss.

"In solid partner relationships, weight loss after bariatric surgery is probably not an issue, and in many cases the relationships can even be strengthened,” said Svensson. "However, in partner relationships that are somewhat unstable or non-functional, weight loss may increase the risk of partner separation. Unfortunately, our study can only give limited insights to why some couples separate after bariatric surgery."

Funk explained that it may be presumed that existing relationships would strengthen as bariatric patients experienced an improvement in their mental well-being and self-image. However, perhaps bariatric patients want to experience new relationships and/or maybe the partners of those patients felt less connected to the 'new person' that they were married to.

Another possibility, he said, is that previously healthy relationships suffered when things that couples may have had in common before surgery perhaps were no longer shared interests after surgery. He cautioned that this research did not establish a direct cause-and-effect relationship and the cautioned that the findings might not apply outside of Sweden.

"Many patients have told me that bariatric surgery was the best decision they've ever made, and they really do have a new outlook on life. A fresh beginning," he said. Nevertheless, he cautioned that healthcare professionals need to discuss the potential impact of bariatric surgery on their patients' relationships with others.

JAMA Surg. Published online March 28, 2018. doi:10.1001/jamasurg.2018.0215
Original Investigation
March 28, 2018

# Associations of Bariatric Surgery With Changes in Interpersonal Relationship StatusResults From 2 Swedish Cohort Studies

## Tuesday, March 27, 2018

### Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial.

2018 Jan 16;319(3):255-265. doi: 10.1001/jama.2017.20897.

# Effect of Laparoscopic Sleeve Gastrectomy vs Laparoscopic Roux-en-Y Gastric Bypass on Weight Loss in Patients With Morbid Obesity: The SM-BOSS Randomized Clinical Trial.

Peterli R1, Wölnerhanssen BK2,3, Peters T4, Vetter D5, Kröll D6, Borbély Y6, Schultes B7, Beglinger C2, Drewe J8, Schiesser M9, Nett P6, Bueter M5.

Abstract

#### IMPORTANCE:

Sleeve gastrectomy is increasingly used in the treatment of morbid obesity, but its long-term outcome vs the standard Roux-en-Y gastric bypass procedure is unknown.

#### OBJECTIVE:

To determine whether there are differences between sleeve gastrectomy and Roux-en-Y gastric bypass in terms of weight loss, changes in comorbidities, increase in quality of life, and adverse events.

#### DESIGN, SETTING, AND PARTICIPANTS:

The Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, was conducted from January 2007 until November 2011 (last follow-up in March 2017). Of 3971 morbidly obese patients evaluated for bariatric surgery at 4 Swiss bariatric centers, 217 patients were enrolled and randomly assigned to sleeve gastrectomy or Roux-en-Y gastric bypass with a 5-year follow-up period.

#### INTERVENTIONS:

Patients were randomly assigned to undergo laparoscopic sleeve gastrectomy (n = 107) or laparoscopic Roux-en-Y gastric bypass (n = 110).

#### MAIN OUTCOMES AND MEASURES:

The primary end point was weight loss, expressed as percentage excess body mass index (BMI) loss. Exploratory end points were changes in comorbidities and adverse events.

#### RESULTS:

Among the 217 patients (mean age, 45.5 years; 72% women; mean BMI, 43.9) 205 (94.5%) completed the trial. Excess BMI loss was not significantly different at 5 years: for sleeve gastrectomy, 61.1%, vs Roux-en-Y gastric bypass, 68.3% (absolute difference, -7.18%; 95% CI, -14.30% to -0.06%; P = .22 after adjustment for multiple comparisons). Gastric reflux remission was observed more frequently after Roux-en-Y gastric bypass (60.4%) than after sleeve gastrectomy (25.0%). Gastric reflux worsened (more symptoms or increase in therapy) more often after sleeve gastrectomy (31.8%) than after Roux-en-Y gastric bypass (6.3%). The number of patients with reoperations or interventions was 16/101 (15.8%) after sleeve gastrectomy and 23/104 (22.1%) after Roux-en-Y gastric bypass.

#### CONCLUSIONS AND RELEVANCE:

Among patients with morbid obesity, there was no significant difference in excess BMI loss between laparoscopic sleeve gastrectomy and laparoscopic Roux-en-Y gastric bypass at 5 years of follow-up after surgery.

#### TRIAL REGISTRATION:

clinicaltrials.gov Identifier: NCT00356213.

## Tuesday, February 20, 2018

### Post-op T2DM treatment -Surgery reduces usage of anti-diabetes treatment after six years

The six-year outcomes from a French study looking at the discontinuation or initiation of anti-diabetes treatment 6 years after adjustable gastric banding (AGB), gastric bypass (GBP) or sleeve gastrectomy (SG), has reported that bariatric surgery was associated with a significantly higher anti-diabetes treatment discontinuation rate, compared with baseline and with an obese control group without bariatric surgery. The discontinuation was particularly associated for patients who had GBP however, the researchers warned that because 50.1% of patients with pre-existing anti-diabetes treatment remained on treatment six years after surgery, the study demonstrates that bariatric patients require lifelong follow-up.

The paper, ‘Association Between Bariatric Surgery and Rates of Continuation, Discontinuation, or Initiation of Antidiabetes Treatment 6 Years Later’, published in JAMA Surgery, included more than 30,000 adults - 15,650 patients (1,633 who were receiving anti-diabetes treatment) had primary bariatric surgery (48.5% undergoing AGB, 27.7% undergoing GBP and 22.0% undergoing SG) and an obese control group included patients with no history of bariatric surgery during 2005 to 2015, as well as no cancer, pregnancy, chronic infectious disease, or serious acute or chronic disease, such as pulmonary embolism or heart failure, in 2008 to 2009.

Patients in the surgery group were then matched 1:1 on age (±5 years), sex, BMI and anti-diabetes treatment at baseline with control patients hospitalised for obesity in 2009 with no bariatric surgery between 2005 and 2015. Several bariatric surgery patients could be matched to the same control patient.
Outcomes

Gastric bypass was the most common procedure (p<0.001) performed in the subgroup of 1,633 bariatric surgery patients with anti-diabetes treatment at baseline and in the subgroup of 330 bariatric surgery insulin users (n=137 or 41.5%).

In the bariatric surgery group, patients receiving anti-diabetes treatment at baseline decreased compared with the control group (−49.9% vs −9.0%, p<0.001), the rate of insulin use also decreased but increased in the control group (−40.0% vs 119.8%, p<0.001).

Interestingly, 30.9% (n=2,348) of the 7,592 patients who had AGB at baseline underwent a revision procedure. The six-year antidiabetes treatment discontinuation rate was higher among patients who underwent conversion to GBP and SG, compared with the small number of patients with band replacement (p<0.001).

The rate of diabetes in the surgery group was 1.4% at six years, compared with 12% in the matched control patients (p<0.001), with a greater association of GBP and SG than AGB. The researchers noted that the findings support the notion that the benefits of bariatric surgery continue years after the procedure.

“This large-scale nationwide study based on health care reimbursement data found significant improvement in the frequency and complexity of anti-diabetes treatment six years after bariatric surgery, with a marked association for patients undergoing GBP,” the authors concluded. “In parallel, we demonstrated a low rate of anti-diabetes treatment initiation six years after bariatric surgery. However, patients and physicians should be aware that morbid obesity remains a chronic disease even after bariatric surgery because 50.1% of patients with pre-existing anti-diabetes treatment remained on treatment 6 years after surgery. Our study highlights the message that these patients require careful lifelong follow-up to monitor obesity complications.”

### Weight regain: Post-op adjuvant weight loss medication is effective

Source-bariatricnews

Adjuvant weight loss medications after bariatric surgery can stop weight regain and maintain weight loss, according to a study by researchers from the Bariatric and Metabolic Institute, Department of General Surgery, Cleveland Clinic, Cleveland, OH. The study found that more than one third of patients who received adjuvant weight loss medications achieved>5% weight loss and the response was ‘significantly better’ in gastric bypass and gastric banding patients, compared with sleeve gastrectomy patients.

“Our study showed that adjuvant weight loss medications halted weight regain in patients who underwent bariatric surgery,” the authors write. “More than one third achieved meaningful weight loss with the addition of weight loss medication. The observed response was significantly better in Roux-en-Y gastric bypass and adjustable gastric banding patients compared with sleeve gastrectomy cases. Our data also indicated that adjuvant pharmacotherapy would be more effective in patients with higher BMI at the time of initiation of pharmacotherapy.”

The paper, ‘Efficacy of adjuvant weight loss medication after bariatric surgery’, published in SOARD, sought to determine the effectiveness of adjuvant weight loss medications after surgery for patients undergoing one of these three bariatric procedures.

The researchers retrospectively reviewed all patients who received weight loss medications after bariatric surgery from 2012 to 2015 at their single academic centre. Although 443 patients were prescribed weight loss medications, only 209 patients continued the medication use for at least three months. Weight regain was defined as <50% excess weight loss or regain of at least 5% of their lowest weight despite dietary counselling and behavioural and lifestyle changes.

The weight loss medications included phentermine, phentermine/topiramate extended-release, lorcaserin, and naltrexone slow-release/bupropion slow-release and the weight loss medications were prescribed individually to each patient depending on their co-morbidities and their relative contraindications.
Outcomes

In total, 209 patients received weight loss medications from 2012 until 2015 and were included in the study. One hundred and twenty-six patients received a RYGB, 52 a sleeve gastrectomy and 21 laparoscopic adjustable gastric banding, 4 a gastric plication and 6 underwent revisional bariatric surgery. The mean time between the procedure and the prescription of pharmacotherapy was 38 months. Phentermine was prescribed in the vast majority of cases (n=156, 74.6%), as well as phentermine/topiramate extended release (n=25, 12%), lorcaserin (n=18, 8.6%) and naltrexone slow-release/bupropion slow-release (n=10, 4.8%). Twelve patients were prescribed low-dosage liraglutide by an endocrinologist for diabetes control (1.2–1.8mg daily). Follow up at three months was 95% (n=199) and 76% at 12 months (n=159).

Total weight loss (TWL) at three and 12 months were 3.2% and 2.2%, respectively, with TWL>5% after adjuvant pharmacotherapy at 12 months in 37% of patients. In addition, 19% of patients reported TWL>10% at 12 months.

At 12 months, there was a significant difference in in laparoscopic adjustable gastric banding patients vs sleeve gastrectomy (4.6% vs 0.3%, p=0.02) and RYGB vs sleeve gastrectomy (2.8% versus 0.3%, p=0.01). Furthermore, significantly more patients in the laparoscopic adjustable gastric banding patients and RYGB groups achieved TWL>5% and>10% at 12 months after pharmacotherapy, compared with sleeve gastrectomy patients.

The researcher also reported a significant positive correlation between BMI at the start of adjuvant pharmacotherapy and %TWL at 12 months (p=0.025). The %TWL for patients with BMI ≥36 versus those with BMI<36 were 3.5±7.9% and 0.9±7.0%, respectively (p=0.027). There was no significant correlation between pre-surgery weight and pre-surgery BMI with %TWL 12 months after initiation of pharmacotherapy.

“Given the low risk of medications compared with revisional surgery, adjuvant pharmacotherapy would be a reasonable first option in appropriate patients,” the authors conclude. “However, further study is needed to standardise a protocol for chronic weight loss medications, to define the ideal time to initiate weight loss medication, and to determine the optimal drug choice and dosages in this challenging patient population.”