OBES SURG DOI 10.1007/s11695-015-1700-0

ORIGINAL PAPER

Short-Term Changes in Body Composition and Response to Micronutrient Supplementation After Laparoscopic Sleeve Gastrectomy A. Belfiore 1 & M. Cataldi 2 & L. Minichini 1 & M. L. Aiello 1 & R. Trio 1 & G Rossetti 3 & B. Guida 1

# Springer Science+Business Media New York 2015

Abstract Background We evaluated dietary intakes, body composition, micronutrient deficiency, and response to micronutrient supplementation in 47 patients before and for 6 months after laparoscopic sleeve gastrectomy (LSG). Methods Before, 3, and 6 months after LSG, we measured dietary intakes with food-frequency questionnaires, body composition with bioimpedance analysis (BIA) and bioelectrical vector analysis (BIVA), and plasma concentrations of iron, Zn, water-, and lipo-soluble vitamins. Results After LSG, energy intake significantly decreased and patients lost weight, fat mass, and free-fat mass. BIVA showed a substantial loss of soft tissue body cell mass (BCM) with no change in hydration. Before surgery, 15 % of patients were iron deficient, 30 % had low levels of zinc and/or water-soluble vitamins, and 32 % of vitamin 25(OH)-D3. We treated iron deficiency with ferrous sulfate, isolated folate deficiency with N 5 methyiltetrahydrofolate-Ca-pentahydrate, and deficiencies in vitamin B1, B12, or Zn, with or without concomitant folate deficiency, with multivitamin. No supplementation was given to vitamin 25(OH)-D3 deficient patients. At first follow-up, 7 % of patients developed new deficiencies in iron, 7 % in * B. Guida [email protected] 1

Department of Clinical Medicine and Surgery, Division of Physiology, Federico II University of Naples, Via Pansini n 5, 80131 Naples, Italy

2

Division of Pharmacology, Department of Neuroscience, Reproductive and Odontostomatologic Sciences, Federico II University of Naples, Naples, Italy

3

Division of General Surgery, Department of Surgery, Second University of Naples, Naples, Italy

folic acid (n=3), and 36 % in water-soluble vitamins and/or zinc whereas no new deficit in vitamin 25(OH)-D3 occurred. At final follow-up, deficiencies were corrected in all patients treated with either iron or folate but only in 32 % of those receiving multivitamin. Vitamin 25(OH)-D3 deficiency was corrected in 73 % of patients even though these patients were not supplemented. Conclusion LSG-induced weight loss is accompanied by a decrease in BCM with no body fluid alterations. Deficiencies in water-soluble vitamins and Zn respond poorly to multivitamin supplementation. Keywords Laparoscopic sleeve gastrectomy . Body composition . Bioimpedence analysis . Vitamin B1 . Vitamin B12 . Folic acid . Iron . Vitamin A . Vitamin E . Vitamin D . Zinc . Trace metals

Introduction Current guidelines recommend bariatric surgery in highly motivated patients with body mass index (BMI) ≥40 kg/m2 and in patients with BMI ≥35 kg/m2 and obesity-related comorbidities [1]. It is still debated whether any of the available procedures should be preferred to the others as all of them may cause short-term surgical risks and longer-term unwanted effects. Special emphasis has been given to risk of malnutrition considering that bariatric surgery may exacerbate pre-existing deficiencies [2] and cause new deficiencies in micronutrients such as vitamins B1, B12, and D, iron, and zinc [3]. These nutritional deficiencies may have a role in long-term complications such as anemia and metabolic bone disease [4]. Laparoscopic sleeve gastrectomy (LSG) is a bariatric procedure consisting in the resection of majority of the greater curvature that reduces gastric size and leaves a narrow

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stomach tube [5]. While LSG was originally considered as a purely restrictive procedure that caused weight loss by causing early stomach filling, later studies showed that its pathopysiological effects are more complex than expected. Indeed, LSG may affect food ingestion and body weight by multiple mechanisms also including the decrease in the secretion of the orexigenic peptide ghrelin and the activation of farnesoid receptors caused by the increase in circulating bile acids concentration [6, 7]. It is gaining popularity as a standalone bariatric procedure for moderately severe obesity because it is perceived as safer and easier to perform than more invasive procedures such as gastric bypass [8]. However, evidence is mounting that LSG could be not so safe as initially proposed [9]. Several studies showed detrimental effects on nutritional status contradicting the widespread assumption that malnutrition should not be an issue with this procedure [10, 11]. Few data are available on the consequences of LSG on body composition, and it is still unclear whether and when micronutrient supplementation should be given to LSG patients. Here, we report the changes in body composition and micronutrient plasma concentrations that we observed during a 6-month follow-up in 47 consecutive patients that underwent LSG at our institution. The effect of micronutrient supplementation is presented as well.

Materials and Methods We retrospectively evaluated the medical records of 47 patients that underwent LSG at our institution between 2011 and 2013. Records from postmenopausal women were excluded to prevent the confounding effect of hormonal changes after menopause. Before, 3, and 6 months after LSG, a full evaluation was performed including body weight and height measurement; food-frequency questionnaires to calculate energy, protein, fat, and carbohydrate intakes based on food conversion tables [12]; bioelectrical impedance analysis; and blood sample collection for routine chemistry and determination of plasma micronutrients. LSG was performed as described elsewhere [11]. Food and beverages were forbidden until upper GI X-ray was carried out on the fifth postoperative day. During this time interval, patients only received intravenous hydration and proton pump inhibitors (PPI) [11]. Patients were discharged 6 days after surgery with prescription of oral PPI therapy for 6 months [13]. Postgastrectomy Diet and Nutritional Follow-Up After discharge on the sixth postoperative day, patients assumed a liquid diet that was changed to a puree-based diet after 10–15 days and, after 3–4 additional weeks, to a soft

solid food diet [14] Consistent with current recommendations [15], diet composition was adjusted to provide 1.0 g/Kg/ideal body weight proteins without exceeding 130 g/day carbohydrate and 20 g/day fat. A concentrate whey protein powder (PROther®, DMF Dietetic Metabolic Food) was administered to match protein requirements (Table 1) [16]. The recommended carbohydrate foods were cream of wheat, cream of rice, mashed potatoes, rusk soaked in milk until soft, dairy products (including low-fat milk, ricotta cheese, low-fat yogurt, and parmesan), dried foods, and smoothies. Pureed legumes and cooked vegetable were slowly added to the diet based on individual tolerance. Diet composition was gradually changed to progressively increase carbohydrate content up to a maximum of 130 g/day. Patients continued to assume the protein shake in progressively smaller amounts as protein content of the diet increased. Because of the small size of the gastric tube remaining after surgery, LSG patients poorly tolerate food ingestion and are at risk of vomiting. Therefore, we instructed the patients to stop eating as soon as they felt any sense of pressure or fullness after assuming food. Using this approach, we were successful in keeping the prevalence of vomiting around 6 % of patients. Compliance with diet was determined with the foodfrequency questionnaires described above [12]. Weight loss from baseline values was computed both as percent excess weight loss (%EWL) and as percent decrease of body mass index (BMI).

Vitamin and Mineral Supplementation Plasma concentrations of iron, folate, Zn, and vitamins A, E, B1, B12, and 25(OH)D3 were measured before and 3 and 6 months after surgery. Pharmacological supplementation was started in all patients showing deficiencies in one or more of these micronutrients, also including those in which micronutrient deficiencies were detected preoperatively. We used the same supplementation protocol in all patients. Specifically, when plasma levels of one or more micronutrients among Zn and vitamins B1 and B12 were below the lower limit of Table 1 Composition of the whey protein concentrate (PROther®)

Values for 100 g Energy kcal (kJ) Protein (g) Carbohydrate (g) Fat (g) Phosphorus (g) Calcium (g) Sodium (g) Potassium (g) Iron (mg)

369 (1550) 89.0 1.0 0.8 0.21 0.6 0.25 0.4 9.3

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normal, we administered one tablet a day of Berocca Plus® (Roche), a multivitamin containing the following (content per tablet): vitamin B1 (1.54 mg), vitamin B2 (1.76 mg), nicotinamide (18 mg), pantotenic acid (6.6 mg), vitamin B6 (2.2 mg), biotin (172.5 mg), folic acid (250 mg), vitamin B12 (1.25 mg), vitamin C (66 mg), calcium (120 mg), magnesium (120 mg), and zinc (9.5 mg). Patients with isolated deficits of folate were treated with one tablet a day of Prefolic® (Zambon, Italia) that contains 19.18 mg N 5 -methyiltetrahydrofolate-Capentahydrate corresponding to 15 mg N5methyiltetrahydrofolate. Patients with iron deficiency received one tablet a day of Ferrograd® (Teofarma, Italy) containing 329.7 mg of ferrous sulfate and providing 105 mg of Fe2+. The single patient that showed with vitamin A deficiency (in the absence of any other micronutrient deficiency) assumed for 1 month one vial a week p.o. of Adisterolo® (Abiogen Pharma) containing 6.88 mg of retinol. At the end of the first month of treatment, therapy was changed to one vial Adisterolo® every 20 days. No supplementation was given to patients with deficiency in vitamin 25(OH)-D3 because plasma levels of this vitamin spontaneously increase after surgery [17]. In all cases, treatment was started as soon as the deficit was diagnosed and continued till the end of the study. In patients with multiple micronutrient deficiencies, Berocca Plus®, Prefolic®, and Ferrograd® were variably associated according to the individual need. Body Composition Assessment Body composition was assessed by bioelectrical impedance analysis (BIA) as described elsewhere [18]. Conventional BIA uses regression equations to calculate total body water (TBW), fat mass (FM), fat-free mass (FFM), body cell mass (BCM), and extracellular water (ECW). Bioelectrical Vector analysis (BIVA) semiquantitatively evaluates soft tissue hydration and mass through the analysis of the RXc graph that plots height-normalized reactance (XCH) as a function of height-normalized resistance (RH) [19]. The BIVA software (Biavector®, Akern Bioresearch, Firenze, Italy) determines RXc vector position in space through the measurement of phase angle and vector length. The shorter is vector, the lower is hydration. Conversely, a decrease in phase angle with no change in vector length indicates decrease of BCM content in soft tissues without changes in hydration. Statistical analysis of BIVA data is performed comparing with the Hotelling’s T2 test the overlap of confidence ellipses specifying vector positions in the groups under comparison [19]. Statistical Analysis Values are given as mean±SD. Paired Student’s t test or repeated measure ANOVA with Bonferroni post hoc test were

used for group comparisons, as appropriate. Significance in the difference in numbers of patients with micronutrient deficiencies before, 3, and 6 months after LSG was assessed with χ 2 test with Yates correction. p < 0.05 was considered significant.

Results Study Population Study population consisted of 47 patients (33 F and 14 M) aged 34.91±10.12 years. Three patients dropped out after 3 months and 10 more after 6 months. Anthropometry, body composition, and blood chemistry data are reported in Table 2. Effect of LSG on Energy Intake and Body Composition Percent decrease of energy intake averaged 75±1.5 and 65± 1.6 % of baseline 3 and 6 months after LSG. Intake of all diet components was similarly affected (Table 3). The decrease in energy intake was paralleled by a rapid weight loss (percent decrease in BMI from baseline 15.7± 4.8 and 26.0±6.8 %, 3 and 6 months after LSG, respectively). Body composition markedly changed after LSG. Three months after surgery, percent decreases of FFM and FM were 8.3±8.9 and 23.8±12.1 %, respectively. Thereafter, FFM loss slowed down whereas FM continued to decrease, and 6 months after LSG their percent decrease from baseline values averaged 14.2±14.9 and 41.6±13.1 %, respectively. Three months after surgery, BIVA showed significant vector displacement without vector shortening. Moreover, the position of vector confidence ellipse was significantly shifted rightward in comparison to baseline. Collectively, these data suggest that a selective decrease of BCM content in soft tissues with no change in body hydration occurred after LSG. These changes in body composition remained stable thereafter, and no difference was observed when comparing BIVA parameters obtained 3 and 6 months after surgery (Table 2 and Fig. 1b). Effect of LSG on Plasma Micronutrients Table 4 reports average micronutrient plasma concentrations at baseline and at first and second follow-up whereas in Fig. 2 the percentages of patients with deficiencies in specific micronutrients at these time point is reported. At presurgery evaluation, 7/47 patients were iron deficient. Oral iron supplementation with ferrous sulfate (105 mg/day p.o.) was started in all of them. At first follow-up, 3 months after surgery, plasma iron was still low in three patients whereas it normalized in the other four. In addition, three patients with normal iron levels

OBES SURG Table 2 Anthropometric data, body composition, energy intake, blood chemistry, and micronutrient plasma concentrations before, 3, and 6 months after laparoscopic sleeve gastrectomy

n Age (years) BW (kg) 2

BMI (kg/m ) %EWL FFM (Kg) FFM (%) FM (Kg) FM (%) TBW (L) ECW (L) BCM (kg) VL (ohm/m) PA (°)

Sex

Presurgery (14 M, 33 F)

3 month follow-up (12 M, 32 F)

6 month follow-up (9 M, 25 F)

M F M

47 34.1±12.7 35.2±9.0 137.5±15.4

44 – – 118.2±15.2*

34 – – 104.1±17.1**

F M F M F M F M F M F M F M F M F M

120.5±12.6 45.7±5.1 46.3±5.3

85.2±18.8 59.3±5.3 62.2±4.6 49.5±4.1 52.2±10.3 61.2±10.1 37.8±4.6 50.5±4.1 62.3±6.5 43.4±3.8 24.8±4.2 18.6±2.2 51.5±6.6

101.5±13.2** 39.1±4.8* 38.9±5.3** 33.5±10.8 36.0±12.6 75.4±8.7* 54.9±5.2** 64.2±4.5 54.7±6.6** 42.0±9.5* 46.3±11.3* 35.5±4.5* 45.0±5.9* 55.2±6.3* 40.7±2.9 23.7±3.9 19.0±1.9 43.0±5.7**

F M F M F

33.6±3.7 218.6±30.8 281.4±38.9 7.5±1.3 6.7±0.88

29.6±3.7** 246.1±30.8 289.8±26.9 6.7±1.0 5.9±1.0

90.4±14.1**, *** 33.8±5.5** 34.2±5.2**, *** 59.5±20.1 58.8±16.5 71.8±8.9** 53.2±4.8** 70.6±5.0**, *** 59.6±6.6**, *** 31.2±10.7**, *** 37.2±11.2**, *** 29.4±5.0**, *** 40.3±6.6**, *** 52.5±6.5* 41.1±11.5 23.2±2.1 18.2±2.2 40.0±8.0** 28.8±3.5** 250.0±28.7 298.9±34.6 6.3±1.1* 6.0±0.8*

F female, M male, BW body weight, IBW ideal body weight, BMI body mass index, FFM fat-free mass, FM fat mass, TBW total body water, ECW extracellular water, BCM body cell mass, VL vector length, PA phase angle *p

Short-Term Changes in Body Composition and Response to Micronutrient Supplementation After Laparoscopic Sleeve Gastrectomy.

We evaluated dietary intakes, body composition, micronutrient deficiency, and response to micronutrient supplementation in 47 patients before and for ...
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