Nutrition aspects in obese before and after bariatric surgery

Abstracts

OBJECTIVE: To determine the physical-nutritional profile of obese patients submitted to bariatric surgery at the HC/UFPE. MEHTODS: Two-hundred-and-five patients were evaluated retrospectively during the period of 2002 through 2006. Analysis considered clinical history for diabetes type 2 (DM 2), high blood pressure (HBP) and metabolic syndrome (MS). The preoperative nutritional status was evaluated by MBI and the biochemistry (hemoglobin, hematocrit, albumin, total proteins, triglycerides (TG), cholesterol associated with the lipoprotein of high (HDLc) and low (LDLc) density and fasting glycemia (FG). During the postoperative periods (6, 12, 18, 24 months), we evaluated the nutritional status through measures of weight, weight loss, weight loss percentage (%WL), MBI and biochemistry including iron, ferritin, transferrin. RESULTS: Seventy-one and two-tenth percent were female, age was 38.4 ± 9.96 years, and MBI preoperative was 48.6 ± 8.9 Kg /m2. MS diagnosis was present in 26.8%, HBP was present in 52.7% and DM 2 was detected in 11.7%. The biochemistry disclosed TG, it raised LDLc, and FG, and all other parameters were normal. The anthropometrical evolution demonstrated gradual loss, reaching at the 24 months, MBI 31.7±5.82 Kg/m2 (p< 0.001) and greater %WL, 36%. Values of TG, LDLc and FG reached normality at the 6th postoperative month: 104.4mg/dL(p=0.018), 95.5mg/dL(p=0.263) and 84.8g/dL(p=0.004) respectively; the transferrin showed reduced values at the 6th month. A larger prevalence of the symptoms occurred in 6th month: hair loss (19%), vomiting (18%), and food intolerances (12.2%). CONLCUSION: The bariatric surgery was an efficient procedure to promote weight loss and its maintenance in two years, as well as improvement of biochemical parameters and comorbidities, with reduced clinical-nutritional symptoms and/or prevented by nutritional monitoring.

Bariatric surgery; Obesity; Obesity; morbid; Eating disorders; Metabolic syndrome; Nutrition; Preoperative care; Postoperative care

OBJETIVO: Determinar perfil clínico-nutricional de pacientes obesos submetidos à cirurgia bariátrica, no HC/UFPE. MÉTODOS: Foram avaliados retrospectivamente, 205 pacientes, no período 2002/2006. A análise considerou história clínica para diabetes tipo 2 (DM 2), hipertensão arterial (HA) e síndrome metabólica (SM). O estado nutricional pré-operatório foi avaliado pelo IMC e bioquímica (hemoglobina, hematócrito, albumina, proteínas totais, triglicérides (TG), colesterol associado à lipoproteína de alta (HDLc) e baixa (LDLc) densidade e glicemia de jejum (GJ). Nos períodos pós-operatórios (6, 12, 18, 24 meses) a avaliação nutricional foi feita pelas medidas de peso, perda ponderal, percentual de perda de peso (%PP), IMC e bioquímica incluindo ferro, ferritina e transferrina. RESULTADOS: 71,2% eram do sexo feminino, idade de 38,4 ± 9,96 anos, 129,66±27,40 Kg e IMC 48,6 ± 8,9 Kg/m², no pré-operatório. Receberam o diagnóstico de SM 26,8%, HA 52,7% e DM 2 11,7%. A bioquímica revelou TG, LDLc, GJ elevados, estando normais os demais parâmetros. Evolução antropométrica demonstrou perda ponderal progressiva, atingindo aos 24 meses IMC 31,7±5,82 Kg/m² (p< 0,001) e maior %PP (36,05%). Valores de TG, LDLc e GJ atingiram a normalidade a partir do 6° mês pós-operatório: 104,4mg/dL(p=0,018), 95,5mg/dL(p=0,263) e 84,8g/dL(p=0,004), respectivamente; transferrina apresentou valores reduzidos aos 6 meses. Prevalência maior dos sintomas ocorreu no 6° mês: alopécia (19%), vômitos (18%), intolerância alimentar (12,2%). CONCLUSÃO: A Cirurgia bariátrica foi um procedimento eficaz para promover perda ponderal e sua manutenção por dois anos, assim como melhora de parâmetros bioquímicos e co-morbidades, com sintomas clínico-nutricionais reduzidos e/ou evitados por monitorização nutricional.

Cirurgia bariátrica; Obesidade; Obesidade mórbida; Transtornos da alimentação; Síndrome metabólica; Nutrição; Cuidados pré-operatórios; Cuidados pós-operatórios

ORIGINAL ARTICLE

Nutrition aspects in obese before and after bariatric surgery

Isabella Valois Pedrosa^I; Maria Goretti Pessoa de Araújo Burgos^II; Niedja Cristina Souza^III; Caroline Neves de Morais^IV

^ISpecialist in Food and Nutrition, Universidade Federal de Pernambuco, PE, Brazil

^IIPhD in Food and Nutrition, Universidade Federal de Pernambuco, PE, Brazil

^IIIDietitian, Universidade Federal de Pernambuco, PE, Brazil

^IVResident Dietitian, Universidade Federal de Pernambuco, PE, Brazil

Correspondence address

ABSTRACT

OBJETIVE: To determine the physical-nutritional profile of obese patients submitted to bariatric surgery at the HC/UFPE.

METHODS: Two-undred-and-five patients were retrospectively evaluated in the period from 2002 through 2006. The analysis took account of the clinical history for type-2 diabetes (DM2), arterial hypertension (AH) and metabolic syndrome (MS). Preoperative nutritional status was assessed through BMI and blood biochemistry (hemoglobin, hematocrit, albumin, total proteins, triglycerides (TG), cholesterol associated with high (HDLc) and low (LDLc) density lipoprotein and fasting glycemia (FG). In the postoperative periods (6, 12, 18, 24 months) nutritional evaluation was carried out made by measures of weight, weight loss, weight loss percentage (%WL), BMI and biochemistry including iron, ferritin and transferrin.

RESULTS: In the study sample, 71.2% of patients were female, the mean age was 38.4 ± 9.96 years, preoperative BMI 48.6 ± 8.9 Kg/m². Metabolic syndrome was diagnosed in 26.8% of the patients, AH in 52.7% and DM2, 11.7%. Biochemistry revealed TG, elevated LDLc, FG, while the other parameters were normal. Anthropometrical evolution demonstrated gradual weight loss, reaching, at 24 months, a BMI of 31.7±5.82 Kg/m² (p<0.001) and greater %WL, 36%. Values of TG, LDLc and FG reached normality in the sixth postoperative month: 104.4mg/dL (p=0.018), 95.5mg/dL (p=0.263) and 84.8g/dL (p=0.004), respectively; transferrin showed reduced values at six months. A greater prevalence of the symptoms occurred in the 6th month: hair loss (19%), vomiting (18%), food intolerance (12.2%).

CONCLUSION: The bariatric surgery was an efficacious procedure to promote weight loss and its maintenance for two years, as well as to improve biochemical parameters and comorbidities, with reduced clinical-nutritional symptoms and/or prevented by dietary monitoring.

Key words: Bariatric surgery. Obesity/metabolism. Obesity, morbid. Eating disorders. Metabolic syndrome. Nutrition. Preoperative care. Postoperative care.

INTRODUCTION

Morbid obesity, a condition of insulin resistance par excellence^1,2, is frequently associated with metabolic syndrome (MS), a disorder that increases overall mortality approximately 1.5 times and cardiovascular mortality around 2.5 times^3,4. The prevalence of MS in morbidly obese individuals is found to be over 50% in most studies ^2,5.

There is evidence that moderate weight losses (5-10% of the baseline weight) with conventional treatments, through dietary and pharmacological approaches as well as physical exercise, promote beneficial metabolic effects⁶. Currently, however, the most effective tool in the treatment and control of morbid obesity is the surgical intervention⁷. Despite being an invasive approach, it has achieved satisfactory outcomes, with a decrease of more than 50% in excess body weight or 30 to 40% of the baseline weight⁸. Those benefits are maintained over the long term, thus leading to an improvement in metabolic parameters^9,10 with a positive effect in the metabolism of lipids and carbohydrates. This reduces insulin resistance and, in many cases, contributes to the control of type-2 diabetes (DM2) and hyperlipidemias^11,12.

Investigations have demonstrated alterations in the nutritional status of patients who underwent bariatric surgery, which may show after weeks and/or years¹³. Nutritional disorders range from vitamin and mineral deficiency (iron, zinc, thiamine, niacin, folic acid, cobalamine, vitamins A, D and E) to signs of protein-calorie malnutrition^14,15. The likely mechanisms are deficient nutritional intake, malabsorption resulting from the surgical technique, poor compliance with polyvitamin replacement and the presence of gastrointestinal symptoms¹⁶.

Given the repercussions of bariatric surgery for the morbidly obese, the objective of the present study was to evaluate the clinical-nutritional profile of those patients, pre- and postoperatively, as well as the presence of food intolerance and symptoms that are common in this setting.

METHODS

This retrospective study was conducted at the Nutrition/General Surgery ward of the HC/UFPE. The evaluation comprised 205 patients of either gender who underwent bariatric surgery by the Fobi-Capella technique (Roux-en-Y Gastric Bypass) in the period from 2002 through 2006.

The assessment involved the investigation of clinical history for DM2, arterial hypertension (AH) and MS. The identification of MS took five parameters into account: waist circumference (WC), arterial blood pressure and serum levels of fasting glucose (FG), triglycerides (TG) and the cholesterol fraction of high-density lipoprotein (HDLc), as proposed by the NCEP-ATPIII¹⁷ in 2001. The guidelines established the diagnosis of MS when at least three of the following criteria were met: WC > 88 cm for women or > 102 cm for men; HDLc < 50 mg/dL for women or <40mg/dL for men; TG >150 mg/dL; arterial blood pressure with cutpoints of 130/85 mmHg, and FG > 110 mg/dL.

Preoperative nutritional status was evaluated through the body mass index (BMI) and blood biochemistry for hemoglobin (Hb), hematocrit (Ht), albumin, total proteins, TG, HDLc and LDLc, and FG, all carried out at the HC/UFPE. For the different postoperative periods (6, 12, 18, 24 months), nutritional assessment consisted of measures of weight, weight loss, percentage of weight loss (%WL), BMI and blood biochemistry, including iron, ferritin and transferrin. The classification of obesity was defined according to the World Health Organization (WHO) criteria of 1997¹⁸.

In order to identify clinical-nutritional symptoms such as food intolerance, nausea/vomiting, diarrhea, gases, constipation, dumping syndrome and alopecia, data were collected from the medical forms for the respective periods.

The data were analyzed by the statistical software SPSS (Statistical Package for the Social Sciences) version 13¹⁹, with the level of significance set to 5.0%. Student's paired t-test was applied, and absolute and percent distributions were calculated. Results were shown as means, medians, standard deviations and coefficients of variation.

This study was previously evaluated and approved by the Human Research Ethics Committee of the Centro de Ciências da Saúde (Health Sciences Center) of the Universidade Federal de Pernambuco (CEP/CCS/UFPE), in compliance with Resolution 196/96 of the Conselho Nacional de Saúde (National Health Council), registration No. 194/07.

RESULTS

The study evaluated 146 (71.2%) female and 59 (28.8%) male patients with a mean age of 38.4±9.6 years (20-59 years); the prevalent age group was = 31 years and nutritional status was established as class III obesity (Table 1).

Preoperative data showed MS in 26.8% of the patients, while DM2 and AH were diagnosed in 11.7% and 52.7%, respectively. In the sixth postoperative month, only 2% still sustained AH, while remission occurred in 100% of DM2 cases.

The evaluation of the postoperative periods showed a gradual decrease in body weight and BMI, reaching the lowest weight and BMI as well as the greatest %WL at 18–24 months. Statistical differences were found in all phases (Table 2).

Baseline biochemistry – Hb, Ht, albumin, total proteins, HDLc – was within the reference values; TG, LDLc and FG levels were elevated, yet showed a significant decrease at 6, 12 and 18 months and reached mean values within normal limits. Transferrin showed reduced levels at 6 and 24 months (Table 3).

Clinical-nutritional symptoms were more prevalent in the sixth month, with alopecia (19%) and vomiting (18%) (figure 1). At the same time, food intolerance was prominent in that period, showing variability in the evaluated postoperative period (Figure 2).

Some variables could not be statistically compared in the four postoperative periods due to the reduced return rate: 6 (61.5%), 12 (48.3%), 18 (31.2%) and 24 (24.9%) months.

DISCUSSION

According to WHO data, the increase in the incidence of obesity is occurring in both genders, independently of social class and cultural level²⁰, yet more prevalently in the female gender, as found in our service. Rangel et al²⁰ and Lehmann et al²¹ support those data, with 76.6% and 75% of female patients, respectively, in their study samples. Regarding age range, Quadros et al²² reported a mean of 40 years, similar to that of the present study as well as Rangel et al's study²⁰.

Regarding MS, Lee et al.⁵ analyzed 645 morbidly obese patients according to the NCEP-ATP III criteria and identified the syndrome in 52.2%, a higher figure compared with the present study population.

Similarly to what is found in the literature, the prevalence of comorbidities was high. Rangel et al²⁰ reported AH percent values of 60%, while DM2 was found in 10% of patients. However, Carvalho et al²³ and Santos et al²⁴ showed higher rates for DM2: 31.9% and 35%, respectively. One noteworthy aspect is the considerable improvement in the conditions of the operated patients regarding AH (79.4%) and DM2 (100%) in the period shorter than six months²⁵, which is in agreement with the findings in the patients of our service. Over 12 postoperative months, according to the analysis by Carvalho et al²³, the great majority of patients were able to discontinue the use of anti-hypertensive drugs and all showed normal FG levels. Those findings are supported by Valezi et al²⁶, who evaluated 250 consecutive patients with a minimum follow-up of one year and reported cure in 72.7%(32) of DM2 and 65.4%(34) of AH cases.

The improvement in glycide metabolism can be explained by the severe deprivation of nutrients that takes place after the surgery, leading to weight loss and a negative energy balance – conditions that classically improve glucose tolerance²³. Alterations in gastrointestinal hormones, such as a reduction in the plasma levels of ghrelin and an elevation in GLP1, are a second mechanism that can function in association with the former²⁷. The reduction in hyperinsulinemia, insulin resistance, leptin levels²⁷ and intraabdominal pressure is related to an improvement and/or reduction in arterial blood pressure²⁸.

In the assessment of weight loss, the study detected a reduction that is consistent with the data in the literature. In an evaluation of 250 cases, body weight was reduced by 37.5% after the first year of surgery²⁶. Quadros et al ²², in turn, found lower percentages in that period (30.69%). Several investigators found that the weight reduction is greater over the first six months, after which time it becomes slower and continuous²², until average losses of 35 to 40% of baseline weight are achieved between the 12th and 24th month after surgery²⁹. With respect to the decrease in the BMI, these data are comparable to those found by various investigators, such as Carvalho et al ²³, who reported a BMI decrease from 49.4 ± 7.4 kg/m² to 32.9 ±4.98 kg/m² in one year, comparable to the results in Santos et al²⁴, with the BMI decreasing from 50.4 ± 7.9 kg/m² to 31.9 ± 5.85 kg/m² for the same period. In the present study, as in those by other authors, it was observed that the patients had a BMI of class I obesity after one year – a significant weight reduction, although most of them did not reach the optimum weight.

Regarding Ht, Hb and albumin, Santos et al²⁴ found values within the normal range in the preoperative period, comparable to the findings in the present study. With respect to postoperative blood biochemistry, Farias et al¹⁰ noted normal albumin concentrations after 8 months of surgery. Conversely, Skroubis et al³⁰, evaluating 243 patients, demonstrated low incidence of hypoalbuminemia and 37.7% of the patients with low levels of ferritin two years after bariatric surgery, unlike what was observed in the group of the present study, possibly underestimated by the small number of tests carried out and the low return rate. Reports point to the need for ferritin monitoring, keeping levels above 40 mcg/dL³¹. Literature data regarding nutritional biochemistry in postoperative periods are scarce, making it difficult to compare outcomes.

The prevalence of dyslipidemia is widely variable among morbid obesity patients, ranging from 19 to 82.9%³². Silva et al³³ and Carvalho et al²³ found elevated TG and LDLc and normal HDLc baseline values, with all parameters reaching normal values after 12 months. Such findings were corroborated by those of the present study.

According to Quadros et al²², vomiting (10.5%), dumping syndrome (7.01%), diarrhea (1.75%) and constipation (1.75%) were uncommon in the first six months of surgery. Such values are lower than those found in the present study, with the exception of the dumping syndrome, which did not occur in this group, possibly because of the exclusion of simple carbohydrates from the diet for one month, a practice prescribed in the service protocol. On the other hand, Dias et al³⁴ observed that nausea (5%) and alopecia (12%) predominated, which is comparable with the rates detected in the present sample – except for vomiting, which was higher (45%). Food intolerance was constant postoperatively (46.67%) in the study by Quadros et al ²², unlike the present study, in which the percent values were low and decreasing period by period, likely due to compliance with the dietary guidelines provided.

Antonini et al³⁵ and Cruz et al³⁶ remark that only adequate dietary monitoring ensures the success of the surgery, since complications such as vomiting, food intolerance and insufficient weight loss are prevented. Constant attention must be paid to meal frequency, chewing and the amount of food ingested in one meal.

These results confirm that bariatric surgery is an effective procedure to promote weight loss and maintain it for two years without low weight, as well as afford an improvement in biochemical parameters and comorbidities, with clinical-nutritional symptoms reduced and/or prevented by specialized dietary monitoring.

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Publication Dates

• Publication in this collection
  09 Nov 2009
• Date of issue
  Aug 2009

History

• Received
  10 Nov 2008
• Accepted
  16 Jan 2009