Protocol for a 1-year prospective, longitudinal cohort study of patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy: the BARI-LIFESTYLE observational study

INTRODUCTION: Roux-en-Y gastric bypass and sleeve gastrectomy are the two most common bariatric surgery performed in the UK that result in comparable weight loss and remission of obesity-associated comorbidities. However, there is a paucity of studies examining the impact of these procedures on body composition, physical activity levels, sedentary behaviour, physical function and strength, dietary intake, health-related quality of life and costs. METHODS AND ANALYSIS: The BARI-LIFESTYLE observational study is a 1-year prospective, longitudinal cohort study within a real-world routine clinical care setting aiming to recruit 100 patients with severe obesity undergoing either primary Roux-en-Y gastric bypass or sleeve gastrectomy from two bariatric centres in London, UK. Participants will be followed up four times during the study period; presurgery baseline (T0) and at 3 (T1), 6 (T2) and 12 months (T3) postsurgery. In addition to the standard follow-up investigations, assessments including dual-energy X-ray absorptiometry scan, bioelectric impedance analysis, 6 min walk test, sit-to-stand test and handgrip test will be undertaken together with completion of questionnaires. Physical activity levels and sedentary behaviour will be assessed using accelerometer, and dietary intake will be recorded using a 3-day food diary. Outcome measures will include body weight, body fat mass, lean muscle mass, bone mineral density, physical activity levels, sedentary behaviour, physical function and strength, dietary intake, health-related quality of life, remission of comorbidities, healthcare resource utilisation and costs. ETHICS AND DISSEMINATION: This study has been reviewed and given a favourable ethical opinion by London-Dulwich Research Ethics Committee (17/LO/0950). The results will be presented to stakeholder groups locally, nationally and internationally and published in peer-reviewed medical journals. The lay-person summary of the findings will be published on the Centre for Obesity Research, University College London website (http://www.ucl.ac.uk/obesity)

A case of severe anorexia, excessive weight loss and high peptide YY levels after sleeve gastrectomy

Sleeve gastrectomy (SG) is the second most commonly performed bariatric procedure worldwide. Altered circulating gut hormones have been suggested to contribute post-operatively to appetite suppression, decreased caloric intake and weight reduction. In the present study, we report a 22-year-old woman who underwent laparoscopic SG for obesity (BMI 46 kg/m2). Post-operatively, she reported marked appetite reduction, which resulted in excessive weight loss (1-year post-SG: BMI 22 kg/m2, weight loss 52%, >99th centile of 1-year percentage of weight loss from 453 SG patients). Gastrointestinal (GI) imaging, GI physiology/motility studies and endoscopy revealed no anatomical cause for her symptoms, and psychological assessments excluded an eating disorder. Despite nutritional supplements and anti-emetics, her weight loss continued (BMI 19 kg/m2), and she required nasogastric feeding. A random gut hormone assessment revealed high plasma peptide YY (PYY) levels. She underwent a 3 h meal study following an overnight fast to assess her subjective appetite and circulating gut hormone levels. Her fasted nausea scores were high, with low hunger, and these worsened with nutrient ingestion. Compared to ten other post-SG female patients, her fasted circulating PYY and nutrient-stimulated PYY and active glucagon-like peptide 1 (GLP1) levels were markedly elevated. Octreotide treatment was associated with suppressed circulating PYY and GLP1 levels, increased appetite, increased caloric intake and weight gain (BMI 22 kg/m2 after 6 months). The present case highlights the value of measuring gut hormones in patients following bariatric surgery who present with anorexia and excessive weight loss and suggests that octreotide treatment can produce symptomatic relief and weight regain in this setting

Patients' views and experiences of live supervised tele-exercise classes following bariatric surgery during the COVID-19 pandemic: The BARI-LIFESTYLE qualitative study

The BARI-LIFESTYLE trial is a randomized controlled trial evaluating the efficacy of a post-surgery nutritional and behavioural tele-counselling, and supervised exercise programme to maximize the health benefits of bariatric surgery. Due to the coronavirus disease 2019 (COVID-19) pandemic, the in-person supervised exercise component had to be converted to remote tele-exercise. However, patients' acceptability of this method of exercise provision is unknown. Between 3 and 6 months following bariatric surgery, 13 adults participated in weekly, structured, 60-min supervised exercise classes delivered via Zoom by a trained exercise therapist. A total of 12 participants (n = 8 female), with a mean age of 46.3 (range 33–63) years, who had undergone either sleeve gastrectomy (n = 8) or Roux-en-Y gastric bypass (n = 4) surgery, participated in one-to-one semi-structured interviews following the tele-exercise classes. Interviews were audio-recorded, transcribed verbatim and analysed using thematic analysis. Participants described how the tele-exercise classes helped them to cope with the changes to their lives brought about by the COVID-19 pandemic. Participants found the tele-exercise schedule, content and intensity to be acceptable, and were satisfied with the privacy, security and safety of the technology and classes. Professional supervision and guidance from an exercise therapist were described as central to the tele-exercise provision. Importantly, participation in the tele-exercise provided physical, emotional and social benefits. Few participants reported barriers to participation. Overall, the tele-exercise classes were deemed acceptable and compared favourably to in-person exercise classes

Randomised evaluation of assertive community treatment: 3-year outcomes

The only randomised controlled trial to test high-fidelity assertive community treatment (ACT) in the UK (the Randomised Evaluation of Assertive Community Treatment (REACT) study) found no advantage over usual care from community mental health teams in reducing the need for inpatient care and in other clinical outcomes, but participants found ACT more acceptable and engaged better with it. One possible reason for the lack of efficacy of ACT might be the short period of follow-up (18 months in the REACT study). This paper reports on participants' service contact, in-patient service use and adverse events 36 months after randomisation

Increased voluntary activation of the elbow flexors following a single session of spinal manipulation in a subclinical neck pain population

© 2019 by the authors. Licensee MDPI, Basel, Switzerland. To investigate the effects of a single session of spinal manipulation (SM) on voluntary activation of the elbow flexors in participants with subclinical neck pain using an interpolated twitch technique with transcranial magnetic stimulation (TMS), eighteen volunteers with subclinical neck pain participated in this randomized crossover trial. TMS was delivered during elbow flexion contractions at 50%, 75% and 100% of maximum voluntary contraction (MVC) before and after SM or control intervention. The amplitude of the superimposed twitches evoked during voluntary contractions was recorded and voluntary activation was calculated using a regression analysis. Dependent variables were analyzed with two-way (intervention × time) repeated measures ANOVAs. Significant intervention effects for SM compared to passive movement control were observed for elbow flexion MVC (p = 0.04), the amplitude of superimposed twitch (p = 0.04), and voluntary activation of elbow flexors (p =0.03). Significant within-group post-intervention changes were observed for the superimposed twitch (mean group decrease of 20.9%, p < 0.01) and voluntary activation (mean group increase of 3.0%, p < 0.01) following SM. No other significant within-group changes were observed. Voluntary activation of the elbow flexors increased immediately after one session of spinal manipulation in participants with subclinical neck pain. A decrease in the amplitude of superimposed twitch during elbow flexion MVC following spinal manipulation suggests a facilitation of motor cortical output

Feasibility and Impact of a Combined Supervised Exercise and Nutritional-Behavioral Intervention following Bariatric Surgery: A Pilot Study

Background. Lifestyle intervention programs after bariatric surgery have been suggested to maximise health outcomes. This pilot study aimed to investigate the feasibility and impact of an 8-week combined supervised exercise with nutritional-behavioral intervention following Roux-en-Y gastric bypass and sleeve gastrectomy. Methods. Eight female patients (44 ± 8 years old, BMI = 38.5 ± 7.2 kgm−2) completed the program. Before and after intervention, anthropometric measures, six-minute walk test (6MWT), physical activity level, eating behavior, and quality of life (QoL) were assessed. Percentage weight loss (%WL) outcomes were compared with a historical matched control group. Results. The program significantly improved functional capacity (mean increment in 6MWT was 127 ± 107 meters, p=0.043), increased strenuous intensity exercise (44 ± 49 min/week, p=0.043), increased consumption of fruits and vegetables (p=0.034), reduced consumption of ready meals (p=0.034), and improved “Change in Health” in QoL domain (p=0.039). The intervention group exhibited greater %WL in the 3–12-month postsurgery period compared to historical controls, 12.2 ± 7.5% versus 5.1 ± 5.4%, respectively (p=0.027). Conclusions. Lifestyle intervention program following bariatric surgery is feasible and resulted in several beneficial outcomes. A large randomised control trial is now warranted

Is Pre-operation Social Connectedness Associated with Weight Loss up to 2 Years Post Bariatric Surgery?

BACKGROUND: To date, little attention has been paid to supportive relationships as factors contributing to weight loss from bariatric surgery. MATERIAL AND METHODS: This prospective study examined whether total percentage weight loss (%TWL) at 3, 12 and 24 months post-surgery varies by distinct aspects of pre-surgery social support (received emotional and practical support and contact with friends and family) in a sample of bariatric surgery candidates (n = 182). These associations were tested with linear regression models adjusted for gender, age, ethnicity, employment status, self-esteem, mastery and time elapsed since the day of surgery. RESULTS: One hundred fifty-four participants underwent a bariatric procedure, and all but seven provided weight loss data at least at one occasion. Emotional support and contact with friends were positively associated with %TWL at 3, 12 and 24 months, and the magnitude of these associations was large. For instance, in the fully adjusted models, %TWL at 24 months increased by 2.36% (SE 1.17, p = 0.048) with each increase of one standard deviation in emotional support and was higher by 9.23% (SE 4.31, p = 0.035) for participants who reported seeing 1–5 friends per month compared with those who saw none. There was some evidence for a positive association between practical support and %TWL at 3 and 12 months post-surgery. CONCLUSION: Supportive relationships are important contributors to weight loss from bariatric surgery. If replicated in future studies, these findings could inform clinical care and interventions aimed at improving support systems of bariatric surgery candidates