Evidence for the Necessity to Systematically Assess Micronutrient Status Prior to Bariatric Surgery

Background: Bariatric surgery has been proven the most effective treatment of morbid obesity, but micronutrient deficiency following bariatric surgery is a major concern. Increasing evidence points to a generally poor micronutrient status in obese subjects. Methods: We assessed micronutrient status in 232 morbidly obese subjects (BMI ≥ 35kg/m2) prior to bariatric surgery. Serum albumin, calcium, phosphate, magnesium, ferritin, hemoglobin, zinc, folate, vitamin B12, 25-OH vitamin D3, and intact parathormone (iPTH) were determined. In a sub-sample of 89 subjects, we additionally assessed copper, selenium, vitamin B1, B3, B6, A, and E levels. Results: Deficiencies were found in 12.5% of the subjects for albumin, 8.0% for phosphate, 4.7% for magnesium, 6.9% for ferritin, 6.9% for hemoglobin, 24.6% for zinc, 3.4% for folate, and 18.1% for vitamin B12. In addition, 25.4% showed a severe 25-OH vitamin D3 deficiency, which was accompanied by a secondary hyperparathyroidism in 36.6% cases. Prevalence of albumin deficiency (p < 0.007) and of anemia (p < 0.003; in women only) significantly increased with BMI. Of note, 48.7% of the subjects showed at least one of the most prevalent deficiencies, i.e., vitamin B12, zinc and severe 25-OH vitamin D3 deficiency. In the sub-sample, 32.6% showed a selenium, 5.6% a vitamin B3, 2.2% a vitamin B6, and 2.2% a vitamin E deficiency. Copper, vitamin B1, and vitamin A deficiency was found in none of the subjects. Conclusion: Data indicate a high prevalence of micronutrient deficiencies in morbidly obese subjects. Based on these results, we strongly recommend a systematic assessment of the micronutrient status in all candidates for bariatric surger

A Novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) as a Primary Bariatric Procedure—Complication Rates, Weight Loss, and Nutritional/Metabolic Changes in the First 355 Patients

Proximal Roux-en Y gastric bypass (RYGB) representing the most frequently performed bariatric procedure yields a weight loss failure rate of around 20%. In order to reduce failure rates, we established a novel distal RYGB variant characterized by a very long alimentary (Roux) limb and a short common channel. Up to 5years, follow-up data (complication rates, weight loss, nutritional/metabolic changes) of the first 355 patients (mean ± SD preoperative age, 41.4 ± 10.8years; BMI, 48.5 ± 11.5kg/m2) who underwent the novel Distal Very Long Roux-en Y Gastric Bypass (DVLRYGB) were analysed. Overall follow-up rate was 98.9%, mean follow-up time 1.6 ± 1.4years. Limb lengths were as follows: common channel 76 ± 7cm, biliopancreatic limb 79 ± 14cm, and alimentary (Roux) limb 604 ± 99cm. The operation was performed laparoscopically in 95.2% of the cases. Thirty-day mortality was zero; major and minor complication rate was 4.5% and 10.4%, respectively. Average excess weight loss (EWL) was >74% 3, 4, and 5years after the operation and failure rate defined by an EWL < 50% remained < 6%. Annually blood measurements revealed a relatively low incidence rate of severe nutritional deficiencies, but mild anaemia and hypoproteinemia were frequently observed. Laparoscopic revision with a proximalization of the lower anastomosis was required in 4 (1.1%) patients. Data indicate that our DVLRYGB leads to excellent weight loss results. Furthermore, within the setting of a structured multidisciplinary follow-up program, the incidence of severe malnutrition states was relatively lo

Differential Changes in Dietary Habits after Gastric Bypass Versus Gastric Banding Operations

Background: Reduction of food intake is an important mechanism by which bariatric procedures reduce body weight. However, only few studies have systematically assessed what patients actually eat after different types of bariatric operations. Methods: Dietary habits were assessed by a food frequency questionnaire in 121 bariatric patients (48 gastric bypass patients, 73 gastric banding patients) during follow-up visits in our interdisciplinary obesity center as well as in 45 severely obese (body mass index (BMI) > 35kg/m2) and 45 nonobese (BMI < 27kg/m2) control subjects. Results: As compared with nonobese control subjects, obese control subjects consumed more meat, white bread, and diet soft drinks. Gastric bypass patients showed an enhanced consumption of foods rich in protein such as poultry, fish, and eggs as well as of cooked vegetables, while the consumption of fatty sweets like chocolate, cake, biscuits, and cookies was found to be distinctly reduced in this patient group. In contrast, gastric banding patients reported on a reduced intake of pasta, white bread, and fresh fruits and, just like gastric bypass patients, also on an enhanced intake of poultry and fish. Direct comparison of dietary habits between the two bariatric patient groups revealed that gastric bypass patients consumed more frequently fresh fruits, eggs, and diet soft drinks but strikingly less chocolate than gastric banding patients. Conclusion: Collectively, data clearly point to distinct changes in dietary habits after bariatric operations which markedly differ between gastric bypass and gastric banding patients. Overall, it is tempting to conclude that gastric bypass operations lead to a healthier and a more balanced diet than gastric band implantation

QT interval shortening after bariatric surgery depends on the applied heart rate correction equation

A shortening of electrocardiographic QT interval has been observed in obese subjects after weight loss, but previous results may have been biased by inappropriate heart rate (HR) correction.Methods Electrocardiography (ECG) recordings of 49 (35 females) severely obese patients before and 12 months after Roux-en-Y gastric bypass (RYGB) surgery were analysed. QT interval (QTc) was calculated by using four different equations, i.e. Bazett, Fridericia, Framingham and Hodges.Results Irrespectively of the used correction formula, QTc interval length was reduced after the surgery (QTcBazett −31 ± 18 ms; QTcFridericia −12 ± 15 ms; QTcFramingham −14 ± 15 ms; QTcHodges −9 ± 15 ms; all Ps Bazett reduction was significantly greater than the reduction in QTc calculated upon the other three equations (all Ps Bazett (P Fridericia, QTcFramingham and QTcHodges (all Ps > 0.05) were significantly correlated with concurrent changes in HR. Multivariate regression analyses revealed a significant independent association of serum insulin levels with QTcFridericia, QTcFramingham and QTcHodges values (all Ps < 0.05) preoperatively, whilst changes in QTc interval length after the surgery were not consistently associated to concurrent changes in metabolic traits.Conclusions Our data show that the extent of weight loss-associated QTc interval shortening largely depends on the applied HR correction equation and appears to be overestimated when the most popular Bazett’s equation is used

Seasonal Variation in the Deficiency of 25-Hydroxyvitamin D3 in Mildly to Extremely Obese Subjects

Background: Vitamin D deficiency is a common finding in obese subjects even before any bariatric operation. However, most previous studies reporting on high rates of vitamin D deficiency in obese subjects have not systematically controlled for seasonal variations. Furthermore, the existence of seasonal variation in serum 25-hydroxyvitamin D3 levels has not been well documented in obese subjects so far. Methods: Serum 25-hydroxyvitamin D3 levels were measured in 248 obese subjects (body mass index: range, 30.1-68.9kg/m2). Fat mass was determined using standard bioelectrical impedance analysis. Results: Serum 25-hydroxyvitamin D3 levels decreased with the increasing body mass index and fat mass (both P < 0.001) and showed a marked variation across the seasons of the year (P < 0.001), which was not affected by the degree of obesity. According to the variation in absolute levels, the prevalence of vitamin D deficiency (<50nmol/l) was 3.8-fold higher during winter than during summer (91.2% vs. 24.3%; P < 0.001). Conclusion: Data show a marked seasonal variation in absolute serum 25-hydroxyvitamin D3 concentrations and prevalence of vitamin D deficiency in subjects with mild to extreme obesity. Considering the increasing number of studies reporting on vitamin D deficiency in obesity, the present finding points to season as a crucial factor that should not be neglected when assessing serum levels of this vitamin in obese subject

Erratum to: Differential Changes in Exercise Performance After Massive Weight Loss Induced by Bariatric Surgery

Background: Exercise performance and pulmonary function are often impaired in severely obese subjects. Bariatric surgery represents the most effective therapy for severe obesity, but data on changes in exercise performance after massive weight loss induced by bariatric surgery have rarely been assessed so far. Methods: Exercise performance was obtained by bicycle spiroergometry in 18 severely obese patients before and at least 1year after bariatric surgery. Additionally, pulmonary function was assessed by spirometry. Results: BMI was reduced from 46.3 ± 1.6 to 33.5 ± 1.4kg/m2 after surgery. Pulmonary function (forced expiratory volume within 1s; inspiratory vital capacity) improved after weight loss (both p ≤ 0.01). At peak exercise, heart rate (HR) peak, absolute oxygen uptake (VO2) peak, and load peak did not differ between both assessments (all p > 0.25). However, relative (related to actual body weight) VO2 peak and workload peak were higher after than before surgery (both p ≤ 0.005), while gross efficiency peak and ventilatory equivalent peak remained unchanged (both p > 0.30). At anaerobic threshold (AT), patients showed lower HR AT and absolute VO2 AT after than before surgery (both p < 0.05), while absolute workload AT did not differ (p = 0.58). In turn, relative VO2 AT did not change (p = 0.30), whereas relative workload AT was higher after surgery (p = 0.04). Also, ventilatory efficiency AT and gross efficiency AT tended to be improved (both p = 0.08). Before surgery, the patients performed 27.0% of VO2 peak above their AT, while this fraction increased to 35.3% (p = 0.006). Conclusions: Results indicated differential changes in exercise performance, with the relative but not the absolute peak performance being improved after massive weight loss. Interestingly, anaerobic exercise tolerance was markedly improved after surger

Weight loss and treatment patterns in a real-world population of adults receiving liraglutide 3.0 mg for weight management in routine clinical practice in Switzerland (ADDRESS study)

AIM To assess weight loss associated with liraglutide 3.0 mg treatment in individuals with obesity (body mass index [BMI] ≥30 kg/m$^{2}$ ) or overweight (BMI > 27 to <30 kg/m$^{2}$ ) in a reimbursed, real-world setting in Switzerland. MATERIALS AND METHODS ADDRESS was a non-comparative, multicentre, retrospective exposure cohort study in Switzerland, examining weight loss in individuals with obesity or overweight whose treatment was reimbursed (divided into BMI subgroups) or non-reimbursed. The primary outcomes were proportions of participants in the reimbursed cohort achieving predefined weight loss targets with liraglutide 3.0 mg at Week 16 (≥5% and ≥7% for the lower BMI [28 to <35 kg/m$^{2}$ with weight-related comorbidities] and higher BMI [≥35 kg/m$^{2}$ ] subgroups, respectively) and Month 10 (additional ≥5% from Week 16; per Swiss reimbursement criteria). RESULTS The full analysis set comprised 258 individuals (195 reimbursed; 63 non-reimbursed). In the reimbursed cohort, 139 individuals (71.3%) achieved their weight loss targets at Week 16. Of individuals who met the Week-16 criteria, 43.2% attained an additional 5% weight loss at Month 10. In 162 individuals for whom data were recorded at Month 10, the mean (standard deviation) relative weight loss from baseline to Month 10 was -12.4% (6.4%). CONCLUSIONS Although reimbursement criteria may be difficult to achieve, particularly the additional weight loss of 5% from Week 16 to Month 10, a clinically relevant overall weight loss from baseline to Month 10 was shown in most individuals with obesity or overweight who received liraglutide 3.0 mg

Short Hypoxia Does not Affect Plasma Leptin in Healthy Men under Euglycemic Clamp Conditions

Leptin is involved in the endocrine control of energy expenditure and body weight regulation. Previous studies emphasize a relationship between hypoxic states and leptin concentrations. The aim of this study was to investigate the effects of acute hypoxia on leptin concentrations in healthy subjects. We examined 14 healthy men. Hypoxic conditions were induced by decreasing oxygen saturation to 75% for 30 minutes. Plasma leptin concentrations were determined at baseline, after 3 hours of euglycemic clamping, during hypoxia, and repeatedly the following 2.5 hours thereafter. Our results show an increase of plasma leptin concentrations in the course of 6 hours of hyperinsulinemic-euglycemic clamping which may reflect diurnal rhythmicity. Notwithstanding, there was no difference between levels of leptin in the hypoxic and the normoxic condition (P = .2). Since we did not find any significant changes in leptin responses upon hypoxia, plasma leptin levels do not seem to be affected by short hypoxic episodes of moderate degree

C-Reactive Protein 2 Days After Laparoscopic Gastric Bypass Surgery Reliably Indicates Leaks and Moderately Predicts Morbidity

Background: The aim of the present study was to evaluate whether serum C-reactive protein (CRP) is a useful predictor of early post-operative complications, particularly of intestinal leaks after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery. Methods: The present study was a retrospective analysis of a prospectively maintained database with 809 patients who underwent LRYGB from 2002 until 2011. For 410 of these patients, at least one CRP measurement within the first seven post-operative days was available. The diagnostic value was determined by the area under the curve (AUC) of the receiver operating characteristic (ROC) curve. Results: Forty-nine of 410 patients (12.0%; 95% confidence intervals [95% CI], 9.2-15.5%) developed surgery-related complications. Leaks occurred in 17 patients (4.1%; 95% CI, 2.6-6.5%) at a median of 5days after surgery. CRP levels 2days after surgery showed the highest diagnostic value for post-operative complications (AUC, 0.74; 95% CI, 0.60-0.89). Sensitivity was 0.53 (95% CI, 0.31-0.74) and specificity was 0.91 (95% CI, 0.79-0.96) on day 2 (cutoff level, 229mg/l). The sensitivity for intestinal leaks was 1.00 (95% CI, 0.51-1.00). Conclusion: CRP on post-operative day 2 is a valuable predictor of post-operative complications, in particular intestinal leaks. Radiological imaging studies for intestinal leaks could be restricted to patients with CRP values exceeding 229mg/