Relationship between nutrient intake and body composition one year after bariatric surgery

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1 International Research Journal of Applied and Basic Sciences 2013 Available online at ISSN X / Vol, 7 (14): Science Explorer Publications Relationship between nutrient intake and body composition one year after bariatric surgery Solmaz Sadre-Jahani 1, Maryam Abolhassani 1,2, Sahar Dehghani 1, Mahsa Jalili 3, Mohammad Talebpour 4, Hossein Imani 3, Soodeh Razeghi Jahromi 1 * 1. Endocrine and metabolism research center, obesity group, Sina Hospital, Tehran University of Medical Sciences 2. Sport medicine group, Sina Hospital, Tehran University of Medical Sciences 3. PhD student in nutrition, Shahid Beheshti University of Medical Sciences 4. department, Sina Hospital, Tehran University of Medical Sciences Corresponding Author razeghi@razi.tums.ac.ir ABSTRACT: Reduction in fat mass and fat free mass have been observed with weight loss induced by surgery or dietary interventions. There are concerns that decrease in fat free mass have some negative health consequence. The aim of the current study was to assess the effect of dietary intake after bariatric surgery on fat mass and fat free mass (FFM). In this prospective observational study, 24 female patients with severe obesity (BMI 35) or morbid obesity (BMI 40) and age between years, underwent Ruex- en- Y gastric bypass-rygb- (11 patients) or laparoscopic sleeve gastrectomy-lsg(13 patients). Anthropometric measurements, body composition, physical activity level, and nutritional intake were assessed before and 1 year after surgery. 24-hours food recall for 3 days was used to assess nutrients intake. Nutritionist IV software was used to analyze the dietary intake. After surgery more than 50% of studied population consumed less than 50% of recommended daily allowance for protein, calcium, iron, phosphorous, magnesium, zinc, vitamin B1, B2, B3, B6, D, and C. There is a significant reduction in energy (p<0.001), protein (p<0.001), potassium (p=0.019), phosphorous (p=0.001), iron (p=0.015), magnesium (p=0.017), zinc (p=0.003), vitamin B1 (p=0.046), B3 (p=0.001), B6 (p=0.034), B9 (p=0.023), and B12 (p=0.043). Patients in RYGB had significantly less intake of vitamin B12 (p= 0.048) and vitamin C (p=0.046) comparing to LSG. In RYGB group, there is a strong relationship between protein intake and the amount of FFM reduction (r= 0.794, p= 0.019). Nutrient inadequacy observed widely after bariatric surgery. Inadequate intake of protein can negatively affect FFM. Keywords: Bariatric surgery, Protein, Fat free mass, Body composition, Nutrient INTRODUCTION The prevalence of overweight and obesity has increased sharply in recent years. Obesity is known as one of the major public health concern worldwide. Obese individuals are at increased risk of several co morbidities including 2 diabetes mellitus, cardiovascular diseases, certain cancers, and infertility (Krause, Mahan, Escott- Stump, & Raymond, 2012). More ever, morbid obesity reduced life expectancy especially in young adults (Carrasco, et al., 2009). Surgical interventions are known as the most efficient and durable therapeutic approach for morbid obese individuals (BMI 40) or sever obese patients (BMI 40) with obesity co morbidities. Today s most commonly used procedures are Roux-en-Y gastric bypass (RYGB), laparoscopic sleeve gastrectomy (LSG) and the laparoscopic adjustable gastric band (LAGB) (Dixon, Straznicky, Lambert, Schlaich, & Lambert, 2011). In RYGB small (<30 ml) gastric pouch with a Roux limb (typically cm) was created that reroutes a portion of the gastrointestinal tract to bypass proximal small bowel and the distal stomach. LSG involves a vertical resection of the greater curvature of the stomach which creates a long tubular stomach. As part of the antrum and pylorus are preserved, the stomach does not empty its contents rapidly into the small intestine (Blackburn, et al., 2009). Bariatric surgery due to reduction in food intake, maldigestion and/or malabsorption might result in nutritional deficit. Previous data named calcium, iron, zinc, vitamin D, and vitamin B12 as the most frequent nutritional deficiencies after bariatric surgery (Carrasco, et al., 2009). Little studies compared the effect of LSG and RYGB on nutritional intake. However, a few

2 reports suggested that RYGB leads to more nutritional deficit(gehrer, Kern, Peters, Christoffel-Courtin, & Peterli, 2010; Toh, Zarshenas, & Jorgensen, 2009). Although the goal of bariatric surgery in morbid obese individuals is the reduction of fat mass, weight loss modifications are accompanied by some degree of fat free mass (FFM) deduction. Little is known about the relationship between calorie and nutrient intake after bariatric surgery and body composition. Previous studies showed an inverse relationship between protein intake and FFM loss (Andreu, Moizé, Rodríguez, Flores, & Vidal, 2010). We designed the current study to compare the difference in nutrient intake between patients underwent RYGB and LSG and to assess the relationship between nutrient intake and with body composition one year after bariatric surgery. METHODS AND SUBJECTS This prospective observational study was conducted in obesity clinic of Sina University Hospital, Tehran- Iran from July 2012 to July Twenty-four women years old, with severe obesity (BMI 35) with or without comorbidity such as diabethis mellitus 2, sleep apnea or hypertention and morbid obesity (BMI 40) with or without underwent bariatric surgery. From these participants, 11 obese women underwent RYGB and 13 participant underwent sleeve surgery. Written informed consent was obtained from all participants. Study procedures were approved by the obesity group, endocrine and metabolism research center, Sina University Hospital, Tehran University of Medical Science. All participants were assessed before surgery and 1 year after this by one expert dietitian. Weight was measured by Seca 755 dial column medical scale to the nearest 0.5 KG. Height was measured by a standard stadiometer to the nearest 0.1 CM. Waist circumference was measured by the standard tape meter at the maximal narrowing of the waist from anterior view. BMI was measured by dividing weight in Kg to height in square meters. BMI 35 was defined as sever obesity and BMI 40 was defined as morbid obesity. Body composition was analysed by body composition analyser BC-418 MA TANITA. The participants were asked has not eaten or consumed a beverage within 4 hours of the test, has not exercised within 12 hours of the test, has not consumed alcohol or diuretics before testing, has completely voided the bladder within 30 minutes of the test and has had minimal consumption of diuretic agents such as chocolate or caffeine. The body composition analyser measured tatal fat mass in percent and kilogram, total fat free fass in kilogram, total body water, segmental analysis for fat mass and fat free mass in right and left arm and right and left leg and trunk. Dietary intake of all participants were assessed by expert dietitian before and 1 year after surgery with three-day food recall. Intake of calorie, micro and macronutriants were analyzed by Nutritionist 4 software. Physical activity of all participants were assessed by Ipaq (international physical activity questionnaire) with sports medicine specialists before and 1 year after surgery. This questionnaire is valid and reliable for Iranian population. All participants were received following recommendations for physical activity and exercise after surgery. They should try to get out of bed and walk as soon as possible after surgery and slowly increase their walking at a pace that they feel comfort, taking stairs instead elevator, doing housework, yard work in daily physical activity program. The goal of these activities is to get 30 minutes of moderate physical activity every day of week. After achieving this goal by increasing physical activity level, we recommended they begin to try aerobic exercise such as brisk walking, biking and swimming, at least 10 minute in every day and gradually increase to achieving 30 minute of aerobic exercise in moderate intensity. In this intensity pulse rate and heart rate will increase. Statistical package for the social sciences, version 21.0 (IBM Corporation, NY) was used for analysis of the data. The quality of variances was tested by Q-Q plot and the most of data were distributed non paramethrically. For comparison between prevalence of normal and abnormal amounts of nutrients with standard amounts in diet, before and after surgery, Wilcoxon signed rank test was recruited. The correlation between fat free mass and intake of protein were determined by Spearman rho test. The level of significance is p<0.05. RESULTS In this retrospective cross-sectional study, nutritional intake and body composition of 24 patients (37.54±2.15 years) were assessed one year after bariatric surgery. As table 1 presents, mean weight, BMI, fat percent, whole body fat mass and fat free mass were decreased significantly one year after bariatric surgery. No significant differences were observed in body composition parameters (fat mass, fat free mass, and fat %) between two studied groups. As shown in table 2,3, and 4, according to three-days food recall, the daily intake of energy (p<0. 001), protein (p<0.001), potassium (p=0.019), phosphorous (p=0.001), iron (p=0.015), magnesium (p=0.017), zinc (p=0.003), vitamin B1 (p=0.046), B3 (p=0.001), B6 (p=0.034), B9 (p=0.023), and B12 (p=0.043) were significantly 1178

3 reduced after bariatric surgery. Comparison of the nutrient intake between RYGB and LSG groups revealed that, Patients who underwent RYGB had significantly less intake of vitamin B12 (p= 0.048) and vitamin C(p=0.046). As presented in figure 1, one year after bariatric surgery, more than half of the studied population consumed less than 50% of RDA for protein, calcium, iron, phosphorous, magnesium, zinc, vitamin B1, B2, B3, B6, D, and C. In RYBG group, there was a strong significant relationship between protein intake and the percent of FFM reduction (r=0.794, p= 0.019, and CI=0.95%). DISCUSSION RYGB and LSG had almost similar effect on the body composition. No significant differences were observed in FM and FFM, one year after surgery between RYGB and LSG. In both groups the ratio of fat mass/fat free mass reduction was about 4/1 which was in line with previous observations (Fujioka, 2005). In current study more than half of the studied population in both studied groups received less than 50% of the recommended daily intake for protein, calcium, iron, phosphorous, magnesium, zinc, vitamin B1, B2, B3, B6, D, and C. As nutritional deficiency after bariatric surgery might occur as a result of inadequate intake, maldigestion, and malabsorption, in order to include all mentioned problems, most of the previous studies used biochemical measurements to assess the nutritional status(alvarez-leite, 2004; DeLegge & Petitpain, 2012; DJ Davies MB, 2007; Gjessing, Nielsen, Mellgren, & Gudbrandsen, 2013; Schweiger, Weiss, Berry, & Keidar, 2010; Shankar, Boylan, & Sriram, 2010). According to their results vitamins A, D, E, K, B 1, B9, B12, C, as well as minerals selenium, iron, copper, and zinc are common post-surgery (Shankar, et al., 2010). They reported that deficiency of vitamin D, vitamin B12, calcium, and iron are more prevalent following RYGB (Alvarez-Leite, 2004). Calcium deficiency is reported to be predominant after LSG(Gjessing, et al., 2013). In current study as we wanted to assess the effect of micronutrients intake from food on body composition, we have focused on dietary intake. The observed differences in nutritional status between the results of our study and previous findings might be due to use of multivitamin-mineral supplementation after bariatric surgery. Comparison of the nutrient intake between LSG and RYGB group revealed no significant difference in energy and macronutrient intake. Among micronutrients, the daily intake of vitamin C and B12 were significantly lower in RYGB group. Vitamin B12 deficiency is one of the most prevalent vitamin deficiencies after RYGB based on serum level (Alvarez-Leite, 2004). We found that B12 intake was also lower in RYGB group. As B12 deficiency results in irreversible neurologic problems, careful attention should be paid to B12 status (Alvarez-Leite, 2004). Animal protein foods are known as the richest source of vitamin B12. Nausea after eating animal food, a couple of months after RYGB might resulted in animal food aversion (Lemanu, et al., 2012). In agreement to our study, Hakeam et al observed B12 deficiency only 3 months after LSG, which resolved there after (Hakeam, O Regan, Salem, Bamehriz, & Eldali, 2009). Our results showed that the reduction in protein intake correlated significantly with FFM loss in RYGB group. Preciously Andreu et al. assessed the effect of protein supplementation on FFM and they found no significant differences between FFM of patients who received different amounts of protein from supplement (Andreu, et al., 2010). The difference between our results and previous data might be due to overall lower protein intake among our study population. 66.7% of patients in RYGB group received less than 50% of RDA for protein. Our study is limited by the small size of the study population. To minimize the effect of the small sample size, before analyzing we tested the data for the equality of variances. More ever, we did not assess the dietary intake and body composition three and six months after surgery. Under reporting is a well-known limitation in assessing dietary intake of obese individuals. We tried to minimize this problem by using three-day food recall. CONCLUSION In our study population, LSG resulted in as much weight loss as RYGB. But in LSG group, patients experience fewer problems with nutrient intake according to RDA. More ever, in RYGB group reduction in protein intake paralleled with FFM reduction. More studies on larger study population are warranted. ACKNOWLEDGMENT We thanked Sina hospital Research Development Center for their kind help. None of the authors had any conflict of interests. 1179

4 REFERENCES Alvarez-Leite JI Nutrient deficiencies secondary to bariatric surgery. Current Opinion in Clinical Nutrition & Metabolic Care, 7(5), Andreu A, Moizé V, Rodríguez L, Flores L, Vidal J Protein intake, body composition, and protein status following bariatric surgery. Obesity surgery, 20(11), Blackburn GL, Hutter MM, Harvey AM, Apovian CM, Boulton HR, Cummings S, et al Expert panel on weight loss surgery: executive report update. Obesity, 17(5), Carrasco F, Ruz M, Rojas P, Csendes A, Rebolledo A, Codoceo J, et al Changes in bone mineral density, body composition and adiponectin levels in morbidly obese patients after bariatric surgery. Obesity surgery, 19(1), DeLegge M, Petitpain D Bariatric and Post Bariatric Nutrition Needs. Advancing Medicine with Food and Nutrients, 331. Dixon, J. B., Straznicky, N. E., Lambert, E. A., Schlaich, M. P., & Lambert, G. W. (2011). Surgical approaches to the treatment of obesity. Nature Reviews Gastroenterology and Hepatology, 8(8), DJ Davies MB, B Nutritional deficiencies after bariatric surgery. Obesity surgery, 17(9), Fujioka K Follow-up of nutritional and metabolic problems after bariatric surgery. Diabetes Care, 28(2), Gehrer S, Kern B, Peters T, Christoffel-Courtin C, Peterli R Fewer nutrient deficiencies after laparoscopic sleeve gastrectomy (LSG) than after laparoscopic Roux-Y-gastric bypass (LRYGB) a prospective study. Obesity surgery, 20(4), Gjessing HR, Nielsen HJ, Mellgren G, Gudbrandsen OA Energy intake, nutritional status and weight reduction in patients one year after laparoscopic sleeve gastrectomy. SpringerPlus, 2(1), 1-7. Hakeam HA, O Regan PJ, Salem AM, Bamehriz FY, Eldali AM Impact of laparoscopic sleeve gastrectomy on iron indices: 1 year followup. Obesity surgery, 19(11), Krause MV, Mahan LK, Escott-Stump S, Raymond JL Krause's food & the nutrition care process: Elsevier Health Sciences. Lemanu DP, Srinivasa S, Singh PP, Johannsen S, MacCormick AD, Hill AG Optimizing perioperative care in bariatric surgery patients. Obesity surgery, 22(6), Schweiger C, Weiss R, Berry E, Keidar A Nutritional deficiencies in bariatric surgery candidates. Obesity surgery, 20(2), Shankar P, Boylan M, Sriram K Micronutrient deficiencies after bariatric surgery. Nutrition, 26(11), Toh SY, Zarshenas N, Jorgensen J Prevalence of nutrient deficiencies in bariatric patients. Nutrition, 25(11), Table 1. Anthropometric measurements before and after bariatric surgery RYGB: Ruex-en-Y Gastric Bypass, LSG: Laparoscopic Sleeve Gastrectomy, BMI: Body Mass Index, FFM: Fat Free Mass. P. Value < 0.05 considered valid. P.Value weight RYGB ± ±26.92 <0.001 SG ± ±18.73 <0.001 All ± ±21.23 < BMI RYGB ± ±6.21 <0.001 SG ± ±4.84 <0.001 All ± ±5.33 < FAT% RYGB ± ±4.79 <0.001 SG ± ± All ± ± FAT mass RYGB ± ±13.04 <0.001 SG ± ±10.88 <0.001 All ± ±11.96 < FFM RYGB ± ± SG ± ±12.92 <0.001 All ± ±14.58 < P. Value of the difference between LSG and RYGB 1180

5 Table 2. Comparison of the energy and macronutrient intake between Ruex-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy P.Value P. Value of the difference between LSG and RYGB Energy RYGB ± ± LSG ± ±779.8 <0.001 All ± ± < Carbohydrate RYGB ± ± LSG ± ±87.89 <0.001 All ± ± < Protein RYGB ± ± LSG ± ±38.52 <0.001 All ± ±36.27 < Fat RYGB ± ± LSG ± ± All ± ± Fiber RYGB ± ± LSG ± ± All ± ± RYGB: Ruex-en-Y Gastric Bypass, LSG: Laparoscopic Sleeve Gastrectomy. P. Value < 0.05 considered valid. Table 3. Comparison of the mineral intake between Ruex-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy P.Value P. Value of the difference between LSG and RYGB Sodium RYGB ± ± LSG ± ±779.7 <0.001 All ± ± < Potassium RYGB ± ± LSG ± ±87.89 <0.001 All ± ± < Calcium RYGB ± ± LSG ± ±38.52 <0.001 All ± ±36.27 < Iron RYGB ± ± LSG ± ± All ± ± Phosphor RYGB ± ± LSG ± ± All ± ± Magnesium RYGB ± ± LSG ± ± All ± ± Zinc RYGB ± ± LSG ± ± All ± ± RYGB: Ruex-en-Y Gastric Bypass, LSG: Laparoscopic Sleeve Gastrectomy. P. Value < 0.05 considered valid. 1181

6 Table 4. Comparison of the vitamin intake between Ruex-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy P.Value P. Value of the difference between LSG and RYGB Vitamin B1 RYGB ± ± LSG ± ± All ± ± Vitamin B2 RYGB ± ± LSG ± ± All ± ± Vitamin B3 RYGB ± ± LSG ± ± All ± ± Vitamin B6 RYGB ± ± LSG ± ± All ± ± Vitamin B9 RYGB ± ± LSG ± ± All ± ± Vitamin B12 RYGB ± ± LSG ± ± All ± ± Vitamin C RYGB ± ± LSG ± ± All ± ± Vitamin D RYGB ± ± LSG ± ± All ± ± Vitamin A RYGB ± ± LSG ± ± All ± ± Vitamin E RYGB ± ± LSG ± ± All ± ± Macronutrient Table 5. Relationship between nutrient intake and percent of fat free mass reduction r P.Value Macronutrient r approach approach P.Value P. Value of the difference between P.Value LSG and RYGB Energy RYGB Vitamin B2 RYGB LSG LSG Carbohydrate RYGB Vitamin B3 RYGB LSG LSG Protein RYGB Vitamin B6 RYGB LSG LSG Fat RYGB Vitamin B9 RYGB LSG LSG Fiber RYGB Vitamin B12 RYGB LSG LSG Sodium RYGB Vitamin C RYGB LSG < LSG Potassium RYGB Vitamin D RYGB LSG LSG Calcium RYGB Vitamin A RYGB LSG LSG Iron RYGB Vitamin E RYGB LSG LSG Phosphor RYGB Cholesterol RYGB LSG LSG Magnesium RYGB SFA RYGB LSG LSG Zinc RYGB MUFA RYGB LSG LSG Vitamin B1 RYGB PUFA RYGB LSG LSG RYGB: Ruex-en-Y Gastric Bypass, LSG: Laparoscopic Sleeve Gastrectomy, P. Value < 0.05 considered valid. 1182

7 A B C Figure 1. Dietary intake after bariatric surgery (A: Laparoscopic sleeve gastrectomy, B: Roux-en-Y gastric bypass, C: all patients) according to percent of RDA. RDA: Recommended dietary allowance. 1183