Use of alcohol before and after bariatric surgery

Objective: to assess alcohol intake in the bariatric surgery pre and postoperative periods. Methods: Patients were interviewed atSurgery Clinic of the Hospital das Clínicas da Universidade Federal de Pernambuco HC/UFPE (Brazil) from July 2011 to March 2012. We analyzed socioeconomic, anthropometric and clinical variables. We used the Alcohol Use Disorders Identification Test (AUDIT C). Results: One hundred nineteen patients were enrolled (mean age: 41.23+11.30 years), with a predominance of the female gender (83.2%), non-Caucasian race (55%), married individuals or in a stable union (65.5%), with a high school education (40.3%)and active in the job market (37%). Weight and body mass index (BMI) were 128.77+25.28Kg and 49.09+9.26Kg/m,respectively in the preoperative period (class II obesity) and 87.19+19.16Kg and 33.04+6.21Kg/m, respectively in the postoperative period (class I obesity) (p<0.001). Hypertension was the most frequent disease in the pre (66.6%) and postoperative (36.5%) periods. The prevalence of alcohol use was 26.6% in the preoperative period, of which 2.2% of high risk, and 35.1% in the postoperative period, of which 1.4% of probable dependence; this difference did not achieve statistical significance (p=0.337). Conclusion: The prevalence of abusive alcohol intake and/or probable dependence was low in both the pre and postoperative periods, with little evidence of risky consumption among the patients submitted to bariatric surgery.


INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION INTRODUCTION
O besity is a non-transmissible chronic disease characterized by excessive accumulation of body fat 1 . It is a multifactorial condition that involves genetic, behavioral, psychological, social, metabolic and endocrine components 2 .
In its most severe form, it is called morbid obesity, where the body mass index (BMI) is above 40 kg/m 2 and it is a risk factor for developing type 2 diabetes mellitus, hypertension, congestive heart failure, dyslipidemia and atherosclerosis, arthropathies, hypoventilation, sleep apnea syndrome and other diseases that diminish patients' quality of life and self-esteem 2,3 .
Nutritional counseling, the practice of regular physical activity and the use of anti-obesity drugs are the basis for weight loss. However, patients with morbid obesity are unable to maintain this weight loss and therefore do not reduce comorbidities. In this scenario, bariatric surgery has shown to be the best treatment with regard to weight loss and maintenance of long-term and comorbidities 4 .
In recent years, some reports have hypothesized that individuals who underwent surgical treatment of obesity could be at increased risk for alcohol abuse after the operation. This could occur due to inability to continue past eating habits and consume large amounts of palatable foods, generating a search for reward in food like substances, such as alcohol [5][6][7][8][9][10] . Some authors also hypothesized to be a correlation between weight loss after the operation and the consumption of alcohol 5,7 , but there is still no consensus in the literature.
Given the contradictory results and the lack of Brazilian studies on this subject, the objective of this study was to investigate the prevalence of alcohol consumption in bariatric surgery pre and postoperative periods and if there is difference in alcohol consumption between these periods.

METHODS METHODS METHODS METHODS
We conducted a prospective, case-series study involving 119 patients (45 preoperatively to 74 postoperatively), undergoing Roux en-Y gastric bypass at the surgical clinic of the HC/UFPE from July 2011 to March 2012. We included patients of both genders, aged over 20 years, and excluded those with severe psychiatric disorders, reoperation for complications of the previous procedure and those who underwent abdominoplasty. Data collection was done through interviews and transcription of information from medical records. The socioeconomic variables studied were: city, age, gender, ethnicity, marital status, educational level and occupational status. The anthropometric assessment was carried from data on height and the higher weight achieved preoperatively, collected from medical records, to calculate the body mass index (BMI), classified according to the criteria of the American Society for Bariatric Surgery 11 .
Wemeasured the preoperative weight and current weight in times d" 3 months, 3-6 months,6-12 months and 12-18 months postoperatively. The percentage of loss of excess weight was calculated using the equation:% loss of excess weight = (preoperative weight -current weight x100) / preoperative weight -ideal weight. The classification followed the criteria of Higa et al. 12 , who consider appropriate the loss of 15% in three months, 35% at six months and 65% to 75% between 12 and 18 months after the procedure. The clinical data assessed were: diabetes mellitus, dyspnea, sleep apnea, dyslipidemia, gastroesophageal reflux, menstrual changes, endocrine disorders and hypertension. These were referred to by patients at the time of the interview.
For assessment of alcohol consumption, the interviewee was initially questioned whether he/she made use of alcohol and, in positive cases, the questionnaire AUDIT C 13 was applied; we further assessed the type of drink, how the patient used and its association with or without food.
We used the Pearson's Chi-square test or Fisher's exact test when the conditions for the Chi-square test were verified, and the Student t test, for independent samples.

RESULTS RESULTS
Among the 119 patients studied, 79 (66.4%) were in the Metropolitan Region of Recife, with a mean age 41.23 + 11.30 years60 (50.4%) between 20 and 39 years. Females presented in greater proportion, 83.2% of patients, 55% non-white,65.5% were married or were in stable union,40.3% attended up to high school and 37% were in the active labor market. The weight in the preoperative period was 128.77 ± 25.28Kg and the BMI, 49.09 ± 9.26Kg/m 2 , classified as class III obesity, and in the postoperative period, 87.19 ± 19.16Kg and BMI, 33.04 ± 6.21Kg/m 2 , classified as class I obesity, with p < 0.001. Hypertension was the most common associated disease (Table 1).
We found that in the preoperative period 26.6% of patients consumed alcoholic beverages, and in the postoperative period, 35.1%. There was no statistical difference between groups, p = 0.337. The risk classification of alcohol use according to the AUDIT C showed that the majority of patients were at low risk, both before and after the bariatric procedure ( Table 2).
The most widely used type of beverage before (91.6%) and after surgery (88.5%) was beer. Among the respondents, 91.6% of the preoperative group and 88.5% of the postoperative group consumed food during alcohol intake. The peanut was the most consumed food before surgery (91.6%) and the whole cheese, after (73.1%). A low percentage did not eat before drinking, and 16.6% in the preoperative period and 11.5% in the postoperative one. We have not found any significant result between drinking habits in the pre and postoperative periods and their association with the socioeconomic variables studies (Tables 3 and 4).
The percentage of excess weight loss in the times < 3 months, 3-6 months, 6-12 months and 12-18   9 suggest that less than 3% of patients may develop alcohol problems.
Among the socioeconomic variables, we saw a predominance of females, similar to the Brazilian studies of Prevedelloet al. 2 and Barhouchet al. 3 . This is probably due to the greater concern of women with weight, health, in addition to the high prevalence of overweight in Brazilian patients, especially among those of less favorable conditions 15 . The average age and race  Table 3 - Table 3 - Table 3 - Table 3 - Table 3 -Association of the use of alcoholic beverages in the preoperative period with socioeconomic factors. Amorim Amorim Amorim Amorim Amorim Use of alcohol before and after bariatric surgery differ from the findings of Costa et al. 16 , who observed, in a group of patients in the pre and postoperative periods, an average age of 36.07 ± 10.16 years, with a predominance of Caucasians (86.53%). Herman et al. 17 , detected a predominance of married individuals with professional activity in a bariatric population, data similar to ours. On the other hand, they reported a prevalent low level of education, differing from our results, since most of our patients had completed high school. The preoperative weight average found by Costa et al. 18 was 138 ± 28.8kg and BMI, 52 ± 8.6kg/m 2 , while 12 months after surgery, these were 90 ± 19.5kg and 34 ± 6.6 kg/ m 2 ,respectively, higher than our findings. Hypertension was the most common associated disease, corroborating other studies, where its prevalence was 21.97% 17 and 35.9% 19 .
Erteltet al. 9 observed a low preoperative alcohol consumption,7.1% of individuals having alcohol dependency and 1.4% abusing it, when assessed by the Diagnostic and Statistical Manual of Mental Disorders IV (DSM IV). In our work, with the AUDIT C we found that 2.2% of patients were high risk alcohol users preoperatively. In the postoperative period we obtained a percentage of 1.4%, with likely dependency. These are much lower results than the ones of Buffington 10 , according to whom 84% of patients consumed alcohol after surgery. Data from the First Brazilian survey of alcohol consumption patterns in the Brazilian population 20 showed that the most consumed beverage in the country was beer (61%), confirming the pattern found in our patients. According to Wendlinget al. 8 , after surgery, compulsive individuals unable to consume excess food can replace it with alcohol. In our study group, there was no replacement, but the association, with food. When associated with fat or protein foods, there is significant reduction in alcohol absorption 21 , this being a beneficial habit.
As for the use of alcohol and socioeconomic factors, it is evident that although there was no significant Table 4 -Table 4 -Table 4 -Table 4 - Table 4 -Association of use of alcoholic beverages in the postoperative period with socioeconomic factors. association with drinking habits, those who drank were aged up to 39 years (44%), predominantly male, a fact common at this age in our region in non-operated in men. Higher percentages in this gender were seen in the Ministry of Health research 20 , where 11% of men consumed alcohol very often and 28%, often. There is evidence that the consumption of palatable foods produces in the brain effects similar to those produced after alcohol intake 22 . Substances such as sugar or fat cause an increase of endogenous opioids in the mesolimbic reward system and dopamine, although not as dramatically as alcohol and other drugs 23 . The use of alcohol is not predictive of proper weight loss 24 . The percentage ofexcess weight loss after surgery and its association with alcohol, similar to other studies 7,25 , showed no positive nor negative association with weight loss.