|Year : 2014 | Volume
| Issue : 2 | Page : 95-98
Post Bariatric Surgery Nutrition and Health Dr. Vandana Bambawale Oration at AIAAROCON at Kolkata on 21st December 2013
Centre for Metabolic Surgery, Hinduja Healthcare, Khar and Nova Specialty Hospitals, Mumbai, India
|Date of Submission||17-Feb-2014|
|Date of Decision||12-Mar-2014|
|Date of Acceptance||01-Jun-2014|
|Date of Web Publication||12-Jun-2014|
102 B, Rising Sun Apartment, Juhu Church Road, Juhu, Mumbai 400 049, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Goel R. Post Bariatric Surgery Nutrition and Health Dr. Vandana Bambawale Oration at AIAAROCON at Kolkata on 21st December 2013. J Obes Metab Res 2014;1:95-8
|How to cite this URL:|
Goel R. Post Bariatric Surgery Nutrition and Health Dr. Vandana Bambawale Oration at AIAAROCON at Kolkata on 21st December 2013. J Obes Metab Res [serial online] 2014 [cited 2020 Jan 18];1:95-8. Available from: http://www.jomrjournal.org/text.asp?2014/1/2/95/134414
| Introduction|| |
It is now generally accepted that the procedures of bariatric surgery, besides inducing the sustained weight loss and a reduction in the gastrointestinal anatomy, also change the metabolic physiology and dietary habits. As a consequence, remission of diabetes, reduction in cardiovascular (CV) risk factors and decrease in mortality (23% from 40%) have been documented.  Notwithstanding, these benefits after a bariatric surgery, the meal portion size is so drastically reduced (30-100 ml) that getting a balanced diet is not always feasible, which may compromise adequate nutrition intake. Usually, the family too is concerned about the adequacy of energy required for work, travel and special situations such as pregnancy, lactation, etc. Hence, bariatric nutrition is a specialty by itself and plays an important role in the successful outcome of surgery and for the long term benefits cited above.
| Gastrointestinal Tract|| |
It is important for the post-surgical bariatric nutritionist to understand that the gastro-intestinal tract has well-defined windows and mechanisms for the differential absorption of the macro- and micro-nutrients.  This is vital for appropriate and rational nutrient-adequate meal plans, based on the alteration in the anatomy and physiology after surgery.
The stomach and duodenum are the prime sites for the absorption of water, alcohol, calcium, iron, magnesium, selenium, copper, iodide, fluoride, molybdenum, intrinsic factor, niacin, biotin, folate, phosphorus, thiamin, riboflavin, and vitamins A, D, E, and K. The jejunum, while continuing to be the site of absorption for minerals and vitamins, cited above, also starts absorbing amino acids, di- and tri-peptides. The ileum absorbs vitamins B12, C, D, K, folate, magnesium, and bile salts and acids.
The impact of various bariatric surgeries on nutrition differs depending on the part of gastrointestinal (GI) tract operated upon. Only stomach is included in gastric band and sleeve gastrectomy while stomach, duodenum and jejunum are involved in surgeries like gastric bypass and biliopancreatic diversion.  Thus, the effect of bariatric surgery on nutrition increases with complexity of surgery from band to sleeve gastrectomy to gastric bypass to biliopancraeatic diversion.  Usually, the mechanism of bariatric surgery is believed to be restrictive, mal-absorptive and/or a combination of both. However, there is gradual realisation that the mechanism is much more complex, which may include neural, hormonal, inflammatory factors and GI microbes. 
Pre-operative nutritional status
Those patients who are morbidly obese in the pre-operative period are in a phase of hyper-caloric malnutrition. Most of them do have multiple pre-existing deficiencies. These are of iron, vitamins D, A, B 1 , B 6 , B 12 , C, folic acid, zinc and selenium. There is also a reduction in parathyroid hormone.  It is essential that the pre-operative assessment includes the testing the levels of these macro- and micro-nutrients as baseline values. The deficiencies need to be corrected before surgery.
Post-operative nutrition status and care
Most of macro-nutrient deficiencies like protein, fat and micro-nutrient deficiencies like vitamin and minerals are seen after a malabsorptive surgery. 
Malnutrition due to protein deficiency is common as a result of reduced intake, post-surgery nausea, etc. This manifests within 3-6 months after surgery.  Management of protein deficiency is a challenge in vegetarian patients. Prevention of protein deficiency can be achieved by monitoring protein intake, regular assessment of albumin and pre-albumin levels and protein supplementation. Usually, patients are advised to consume 60-120 g of protein/day depending on the procedure and as per the ideal body weight.  The various sources of proteins include protein concentrates derived from milk, soy, eggs, collagen and mixtures of amino acids and peptide-based diets. Rarely, owing to persistent protein deficiency, patient may require parenteral nutrition. 
Fat mal-absorption is an expected effect after procedures like biliopancraetic diversion and gastric bypass. This also results in associated fat soluble vitamins deficiency. It is essential that 100 cm of common channel near ileocaecal junction is maintained to avoid severe degree of fat mal-absorption.  In refractory cases, surgical revision may be necessary to either lengthen the common channel or a reversal.
Micro-nutrient deficiencies are more common after bariatric surgery and these include iron, vitamins B 1 , B 12 , A, D, K, calcium, folate, copper, zinc, linoleic acid and linolenic acid.  Anaemia may be present in 17-50% of bariatric patients.  The common reasons include decreased absorption, reduced intake of iron, B 12 , folate, copper, zinc, vitamin A and E, etc. Rarely, it may be related to blood loss from an ulcer. Regular monitoring of iron deficiency anaemia includes complete blood counts, iron studies, etc. Regular supplementation with ferrous sulphate 325 mg along with vitamin C 250 mg (to improve iron absorption) would help prevent iron deficiency. It is advisable to avoid simultaneous intake of calcium and dairy products with iron. 
Vitamin B 12 deficiency is reported after all types of bariatric surgeries. The causes of deficiency include inadequate intake, achlorhydria and inadequate intrinsic factor. B 12 deficiency presents as macrocytic anaemia, pancytopenia and glossitis. Neurological manifestations are rarely seen.  All patients are prescribed vitamin B 12 routinely. Sublingual 350 μg/day is sufficient to avoid deficiency. Weekly intra-muscular injections are advised only in severe deficiency cases.  Folic acid deficiency, after bariatric surgery, is usually associated with a low intake, inadequate absorption or with vitamin B 12 deficiency. The clinical presentation includes macrocytic anaemia, pancytopenia, glossitis and megaloblastic bone marrow.  Folic acid in a dose of 1 mg/day supplementation is adequate to avoid any deficiency.
The deficiency of calcium and vitamin D is seen in almost 50% patients after bariatric surgery. The reasons for deficiency could vary from reduced intake, diversion of food from duodenum/jejunum and due to bone resorption secondary to weight loss. The clinical presentation includes bone pain, muscle weakness, cramps and even cardiac failure. Usually serum calcium levels are not reflective of their cellular levels. Simultaneous parathyroid hormone and vitamin D assessment can help evaluate possible deficiency. After bariatric surgery, as calcium citrate is better absorbed, its daily dose of 1200-2000 mg is required to avoid deficiency.  Simultaneous vitamin D supplementation is essential for adequate calcium metabolism.
An uncommon but devastating clinical condition may be precipitated with vitamin B 1 (thiamin) deficiency, due to persistent vomiting or jejunal bypass. Body has limited thiamin reserves and thus the early signs of deficiency may be noticed within 3-4 days of vomiting after surgery. The deficiency syndrome (Wernicke's encephalopathy) involves acute neurological deficit resulting in imbalance, diplopia, confusion and even memory loss. Bariatric beri-beri may present as high output failure and cardiomegaly.  However, it can be corrected with intravenous thiamine injections (100 mg daily for 7-10 days).
Other micro-nutrient deficiencies are relatively rare. Copper and vitamin E deficiency may present as haematological abnormalities and/or neuromuscular symptoms. Zinc and essential fatty acid deficiency may result in hair fall, dysgeusia and poor wound healing, while vitamin A and E deficiency may result in visual disturbances.
Practical nutritional issues (regimens)
After bariatric surgery, patients are typically advised to be on a liquid diet for 2 weeks, mashed foods for another 2 weeks, soft solids for 2 weeks and at 6 weeks are allowed to eat solid food. The regimen helps to allow healing. Adequate nutrition after surgery is not merely a food type issue, but it helps in ensuring a long term successful outcome and a path to co-morbidity resolution. Occasionally, patients are concerned about the taste change and aroma intolerance after surgery. The use of flavour enhancers may help overcome these temporary phases. Constipation remains a major issue after surgery due to the lack of adequate fibre in diet. Constant focus on whole grains, vegetables, fruits, nuts, seeds and regular exercise may help avoid this major problem.
Post-bariatric health status
The quantum of weight loss after bariatric surgery varies with each procedure and patient compliance. At least 50% excess weight loss qualifies for success of a surgery. The average weight loss after gastric band (48%) and after biliopancreatic diversion (97%) reflect two ends of the success spectrum of the bariatric surgery.  Bariatric surgery is believed to benefit morbidly obese in ways more than weight loss alone. The quality of life (QOL), comorbidity resolution, mortality reduction and an associated prolongation of life are other benefits. Questions are repeatedly raised about the degree of evidence supporting claimed benefits and their long term sustenance. Various meta-analyses and prospective long-term comparative studies results are now available showing potential benefits of bariatric and metabolic surgery.
Diabetes remission is increasingly recognised as a weight loss-independent benefit of bariatric surgery. Depending on the procedure 50-97%  of type 2 diabetes patients may have diabetes resolution within a short span after surgery. Even though gastric band surgery results in diabetes resolution in 50%, a significant improvement in glycaemic control is noticed in 80%  diabetic patients after surgery. In 2013 in a joint publication, the American Association of Clinical Endocrinologists, the Obesity Society and the American Society of Metabolic and Bariatric Surgeons have recommended that bariatric surgery may be offered for treatment of type 2 diabetes in >35 body mass index (BMI) (kg/m 2 ) patients.  In view of the evidence of lower musculoskeletal mass amongst the Indian patients, at a consensus meeting (2009) it was recommended bariatric surgery offers an option for Indian patients with a BMI > 32.5.  While the International Diabetes Federation has, in a position statement, agreed to offer surgery for Asian diabetic patients with a BMI > 27.5 and with an uncontrolled type 2 diabetes with cardiac risk factors. 
The interest generated by bariatric surgery has resulted in first consensus meeting to define diabetes remission  - (1) partial remission - HbA1c < 6.5 and fasting blood sugar (FBS) 100-125 mg/dl for >1 year and with no active pharmacologic therapy/on-going procedures, (2) complete remission - HbA1c < 6 and FBS < 100 for >1 year with no active pharmacologic therapy/on-going procedures and (3) prolonged remission - complete remission for >5 years. However, in India, a large number of type 2 diabetics are normal in weight or are just overweight. Hence, at the current BMI cut off points they may not have beneficial outcomes of bariatric/metabolic surgery.
In our clinical trial in Indian patients (BMI 23-35), ileal transposition with sleeve gastrectomy surgery was performed. Only uncontrolled type 2 diabetics, psychologically stable individuals in the age range 25-65 years were included. The primary endpoint of study (HbA1c < 7) was achieved in 100% patients, while the mean homeostasis model assessment (HOMA) index was reduced by 95% within 6 months of surgery. The insulin therapy could be stopped in all within 10 days after surgery. However, 40% of patients still required oral hypoglycaemic agents to maintain HbA1c < 7, irrespective of the pre-operative glycaemic control.  The mean HOMA index declined steadily from the pre-operative value of 33.48 to post-operative values: 15.72 (1 month), 2.03 (3 months) and 1.67 (6 months), despite the discontinuation of insulin.
Poly-cystic ovarian syndrome (PCOS) is related to insulin resistance and it improves significantly after bariatric surgery. Eid & al in a study showed that 100% of oligoamenorrhic women undergoing gastric bypass, 83% stopped medication intake, hirsutism improved in 77%, menstrual irregularity normalized in 100%. And in women who sought to conceive, 100% could do so without any medication or assisted reproductive intervention. 
Mummadi et al. in a meta-analysis biopsies were done before and after surgery, the impact of bariatric surgery on non-alcoholic fatty liver disease was analysed. An improvement of steatosis was seen in 91.6%, of steatohepatitis in 81.3% and of fibrosis in 65.5%. The resolution of nonalcoholic steatohepatitis was reported in 69.5%. Long-term follow-up studies are required to appreciate the impact of this improvement on cirrhosis reduction.  The impact on the incidence of hepato-cellular carcinoma needs to be studied.
Vest et al. in another meta-analysis of 73 studies analysed impact of bariatric surgery on CV risk factors, spanning duration of over 60 years (1950-2012) in which 19,543 patients were covered with a mean follow-up period of 57.8 months. The authors concluded, "This systematic review highlights the benefits of bariatric surgery in reducing risk factors for CV disease." The mean weight loss was 54% (range 16-87%). Hypertension, dyslipidaemia and diabetes improved in more than 60%. In 713 patients who had two dimensional echocardiography there was a significant reduction in left ventricular mass and an improvement in E/A ratio. 
A long-term prospective Swedish Obese Subject (SOS) study comparing ~2000 bariatric surgery patients with an equal number of medically managed individuals have shown 30% reduction in first time cardiovascular events and 50% reduction in cardiovascular deaths.  Another publication of SOS study  with a mean follow-up period of 10.9 years and cancer follow-up rate of 99.9% has shown that first time cancer rate was lower in the surgical group (n = 117) compared to the control group (n = 167, hazard ratio: 0.67), however this was significantly different only in women and not in men.
The purpose of weight loss and comorbidity remission is prolongation of life or mortality reduction. In a comparative 7-year follow-up study  of 9949 gastric bypass patients with 9628 matched non-surgical individuals, showed: (1) 40% reduction in all cause long term mortality, (2) 56% reduction from cardiovascular diseases, (3) 92% reduction from diabetes related mortality and (4) 60% reduction from cancer related mortality. However, in the surgical group 58% increase in mortality was noticed from non-disease causes (accidents and suicides).
Quality of life
Though weight loss and comorbidity reduction remain focus of the surgical team, majority of post-surgical patients are more excited about improvement in their QOL. Their ability to chase/run with their children uphill, increased working capability, enhanced social acceptance and improved mobility occupies the major part of their discussion with family, friends and even surgical team. Most believe that they have regained control of their life, which they had lost, after repeated failed conservative attempts to lose and maintain their weight in the past.
| Conclusion|| |
Obese have hypercaloric malnutrition with multiple deficiencies & comorbidities. Their evaluation and correction in the pre-operative period ensures safer surgical outcome and uniform post-operative supplementation. Bariatric surgery creates lifelong changes in physiology and anatomy of the GI tract. Balanced diet after surgery is not possible and thus supplementation, regular nutrition counselling and monitoring are absolutely essential.
Post-surgical health status in patients improves with a remission of comorbidity and a reduction in mortality. Like any other treatment modality surgical intervention has its inherent risk and post-operative issues, which have been identified and can be reduced/avoided in most with scientific intervention and counselling. For the well-selected patients satisfaction, QOL changes and comorbidities remission, bariatric surgery offers a gratifying experience when appropriate follow up and a long term nutritional and medical care are judiciously combined.
| References|| |
|1.||Shikora SA, Kim JJ, Tarnoff ME. Nutrition and gastrointestinal complications of bariatric surgery. Nutr Clin Pract 2007;22:29-40. |
|2.||Fujioka K, DiBaise JK, Martindale RG. Nutrition and metabolic complications after bariatric surgery and their treatment. JPEN J Parenter Enteral Nutr 2011;35 5 Suppl:52S-9. |
|3.||Valentino D, Sriram K, Shankar P. Update on micronutrients in bariatric surgery. Curr Opin Clin Nutr Metab Care 2011;14:635-41. |
|4.||Torres AJ, Rubio MA. The Endocrine Society's Clinical Practice Guideline on endocrine and nutritional management of the post-bariatric surgery patient: Commentary from a European Perspective. Eur J Endocrinol 2011;165:171-6. |
|5.||Buchwald H, Avidor Y, Braunwald E, Jensen MD, Pories W, Fahrbach K, et al. Bariatric surgery: A systematic review and meta-analysis. JAMA 2004;292:1724-37. |
|6.||Mechanick JI, Youdim A, Jones DB, Garvey WT, Hurley DL, McMahon MM, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient - 2013 update: Cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery. Endocr Pract 2013;19:337-72. |
|7.||Misra A, Chowbey P, Makkar BM, Vikram NK, Wasir JS, Chadha D, et al. Consensus statement for diagnosis of obesity, abdominal obesity and the metabolic syndrome for Asian Indians and recommendations for physical activity, medical and surgical management. J Assoc Physicians India 2009;57:163-70. |
|8.||Diabetes Atlas. 2 nd ed. Available from: http://www.idf.org/sites/default/files/IDF_Diabetes_Atlas_2ndEd.pdf. [Last accessed on 2014 Feb 24]. |
|9.||Buse JB, Caprio S, Cefalu WT, Ceriello A, Del Prato S, Inzucchi SE, et al. How do we define cure of diabetes? Diabetes Care 2009;32:2133-5. |
|10.||Goel R, Amin P, Goel M, Marik S. Early remission of type 2 diabetes mellitus by laparoscopic ileal transposition with sleeve gastrectomy surgery in 23-35 BMI patients. Int J Diabetes Dev Ctries 2011;31:91-6. |
|11.||Eid GM, Cottam DR, Velcu LM, Mattar SG, Korytkowski MT, Gosman G, et al. Effective treatment of polycystic ovarian syndrome with Roux-en-Y gastric bypass. Surg Obes Relat Dis 2005;1:77-80. |
|12.||Mummadi RR, Kasturi KS, Chennareddygari S, Sood GK. Effect of bariatric surgery on nonalcoholic fatty liver disease: Systematic review and meta-analysis. Clin Gastroenterol Hepatol 2008;6:1396-402. |
|13.||Vest AR, Heneghan HM, Agarwal S, Schauer PR, Young JB. Bariatric surgery and cardiovascular outcomes: A systematic review. Heart 2012;98:1763-77. |
|14.||Sjöström L, Peltonen M, Jacobson P, Sjöström CD, Karason K, Wedel H, et al. Bariatric surgery and long-term cardiovascular events. JAMA 2012;307:56-65. |
|15.||Sjöström L, Gummesson A, Sjöström CD, Narbro K, Peltonen M, Wedel H, et al. Effects of bariatric surgery on cancer incidence in obese patients in Sweden (Swedish Obese Subjects Study): A prospective, controlled intervention trial. Lancet Oncol 2009;10:653-62. |
|16.||Adams TD, Gress RE, Smith SC, Halverson RC, Simper SC, Rosamond WD, et al. Long-term mortality after gastric bypass surgery. N Engl J Med 2007;357:753-61. |
| Authors|| |