BMI Body Mind Inspiration by The GI and Bariatric Nutrition Center

Winter 2012 Volume 1, Issue 1

A peer-reviewed e-journal providing lifestyle and health information for weight loss surgery patients and candidates

p8 WEIGHT LOSS BEFORE WEIGHT LOSS SURGERY What Do We Know About Dropping Those Preoperative Pounds?

Weight Loss Surgery Preoperative Risk Reduction

The Obesity Action Coalition: The Voice of Those Affected by Obesity

Treatment Considerations for Osteoarthritic Knee Pain in Patients with Obesity

Hair Loss Among Weight Loss Surgery Patients

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Introducing a New e-Journal for Medical and Surgical Weight Loss Patients and Candidates

BMI: BODY • MIND • INSPIRATION A peer-reviewed, evidence-based e-journal providing lifestyle and health information for individuals interested in combating obesity, diabetes, and metabolic disorders and improving their overall health and well being.

• Exciting, New, FREE RESOURCE covering a variety of topics in the field of metabolic and bariatric surgery

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Winter 2012 Volume 1, Issue 1

Dear Readers: Raul J. Rosenthal, MD, FACS, Clinical Editor, Body, Mind, Inspiration, Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship Program, Director of the Bariatric and Metabolic Institute, and Director of the General Surgery Residency Program, Cleveland Clinic Florida— Weston, Fort Lauderdale, Florida.

On behalf of Matrix Medical Communications, I am very proud to welcome you to the first edition of Body • Mind • Inspiration— or BMI. Sadly, the obesity epidemic continues to thrive, not only in America but around the globe. As I am certain we are all aware, obesity is a multifactorial disease that is not yet clearly understood or easily controlled. Obesity seems to be determined, among other causes, by an imbalance between an individual’s genotype and phenotype. Human genetic code has been determined by the struggle of human species to survive the lack of food. Thus, over the last centuries, the human body has evolved to include a defense mechanism against famine by protecting the highest weight attained. The expression of genotype varies among humans, thus making us susceptible to becoming overweight. Conversely, human phenotype is mainly determined by impacting environmental factors. One would imagine that these factors could be easily controlled. However, serious eating and personality disorders, as well as our economic reality, make such changes extremely difficult for many Americans. Sedentary lifestyles, whether by choice or by necessity, as well as the abundance of a palatable and affordable food supply in industrialized nations, are the main negative phenotypic influences predisposing these populations to becoming obese. Recent publications have clearly demonstrated that obesity is indeed a serious medical condition that severely impacts health and shortens life expectancy. BMI was primarily created as a forum in which to deliver the latest updates and important information related to weight management, so that

Americans are educated in the fight against this debilitating disease. The successful treatment of obesity and overweight is primarily based on long-term lifestyle changes and commitment to these changes. New and healthy eating habits must be preserved and routine physical activities must be incorporated into daily lifestyle. Unfortunately, as we are all aware, this is much more easier said than done! This month, Liz Goldenberg, MPH, RD, CDN, discusses the benefits of losing weight before undergoing weight loss surgery, including reduction of comorbid conditions and complications. Adrienne Youdim, MD, lists common comorbidities and provides tips for patients on reducing the severity of these condition. James Choi, MD, and Jonathan Shaffer, MD, MBA, discuss osteoarthritic knee pain in the patient with obesity and present operative and nonoperative treatment modalities. Sylvia Leite Faria, MS, et al present an extensive review of current literature on the causes and treatment of hair loss in weight loss surgery patients. This month, we also highlight the Obesity Action Coalition, the only nonprofit organization whose sole focus is representing those affected by obesity through education, advocacy, and support. This article outlines membership benefits and provides information on how you can get involved. In future issues, we will be bringing you information on a wide variety of topics, including exercise, nutrition, body contouring, skin health, and much more. We hope that BMI will be a valuable resource to you in your efforts to become and remain fit and healthy. Welcome and I hope you will enjoy this first issue.

BMI Sincerely,

Raul J. Rosenthal, MD, FACS Clinical Editor, BMI

BMI Body • Mind • Inspiration—Winter 2012

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Editor’s Message

BMI

Publisher’s Message Winter 2012 Volume 1, Issue 1

Dear Readers: We are pleased to announce the launch of Body • Mind • Inspiration or BMI, a journal inspired by numerous calls and e-mails from individuals requesting information from our company on medical weight loss and weight loss surgical procedures, and health issues weight loss surgery patients should be aware of two, five, and ten years post surgery. BMI will be published quarterly in 2012, providing articles on lifestyle and health for individuals seeking to loose weight, and for pre and post weight loss surgical patients and candidates. Articles will be clear and concise and offer resources on a continual basis. As a community, we need to stay informed and BMI will be a resource available complimentary to assist individuals on their quest to combat obesity, diabetes, and metabolic disorders. The following is a sample of topics that you can expect to see in future issues: • • • • • • • • • • • • • • • •

Insurance Information Nutrition Patient Checklists Body Contouring Association Updates Revisional Surgery Skin Care New Product Reviews Patient Advocacy Overview of Surgical Procedures Exercise Physiology Emotional Issues Communicating with your physicians Weight Regain Programs and Resources Motivational Tips and Techniques

BMI Body • Mind • Inspiration—Winter 2012

As subscriber, you will receive a notification email when each new issue is available for viewing. The BMI publishing platform automatically determines the web-enabled device you are using to access the journal and immediately formats the entire issue for reading on computers, smartphones, and tablets. We are excited to provide a valuable resource such as BMI to individuals interested in improving their health and well being. Additional resources are in development and will be introduced in the coming months. In the meantime, please share the subscriber link with family, friends, coworkers, or anyone that you believe will benefit from the information BMI has to offer. BMI has been designed for readers such as yourself. Please provide feedback on BMI, comment on articles, and feel free to suggest topics that you would like to see featured in upcoming issues. BMI All the best,

Robert L. Dougherty Publisher, BMI

CLINICAL EDITOR Raul J. Rosenthal, MD, FACS Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship Program, Director of the Bariatric Institute, and Director of General Surgery Residency Program, Cleveland Clinic Florida—Weston, Fort Lauderdale, Florida EDITORIAL ADVISORY BOARD Susan Gallagher Camden, RN PhD WOCN, CBN, HCRM CSPHP Senior Clinical Advisor, Celebration Institute, Inc., Houston, Texas Tracy Martinez, RN, BSN, CBN Program Director, Wittgrove Bariatric Center, La Jolla, California Melodie K. Moorehead, PhD, ABPP Board Certified in Clinical Health Psychology, JFK Medical Center, Bariatric Wellness and Surgical Institute, Atlantis, Florida

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Harry Pino, PhD Director of Clinical Exercise Physiology Program, RecoverHealth Center, New York, New York; Medical Center, Stony Brook, New York Craig B. Primack, MD, FAAP Medical Bariatrician/Certified Medical Obesity Specialist/Co-Medical Director, Scottsdale Weight Loss Center PLLC, Scottsdale, Arizona Wendy Scinta, MD, MS, FAAFP, FASBP Medical Director, Medical Weight Loss of NY, BOUNCE Program for Childhood Obesity, Manilus, New York; Clinical Assistant Professor of Family Medicine, Upstate Medical University, Syracuse, New York Kimberley E. Steele, MD, FACS, Assistant Professor of Surgery, The Johns Hopkins Center For Bariatric Surgery,Baltimore, Maryland Christopher D. Still, DO, FACN, FACP Director, Center for Nutrition and Weight Management, Geisinger Health System, Danville, Pennsylvania

BMI

Editorial Advisory Board

BMI BODY MIND INSPIRATION EDITORIAL STAFF Editor Raul J. Rosenthal, MD, FACS Program Director of Minimally Invasive Surgery, Director of the Minimally Invasive Fellowship Program, Director of the Bariatric and Metabolic Institute, and Director of the General Surgery Residency Program, Cleveland Clinic Florida— Weston, Fort Lauderdale, Florida. Vice President, Executive Editor Elizabeth A. Klumpp Matrix Medical Communications West Chester, Pennsylvania

Table of Contents Winter 2012

Volume 1, Issue 1

Associate Editor Angela M. Hayes Matrix Medical Communications West Chester, Pennsylvania Associate Editor Kimberly B. Chesky Matrix Medical Communications West Chester, Pennsylvania

BMI BODY MIND INSPIRATION BUSINESS STAFF President/Group Publisher Robert L. Dougherty Matrix Medical Communications West Chester, Pennsylvania Partner Patrick D. Scullin Matrix Medical Communications West Chester, Pennsylvania Vice President, Business Development Joseph J. Morris Matrix Medical Communications West Chester, Pennsylvania

EDITORIAL CORRESPONDENCE should be directed to Executive Editor, Matrix Medical Communications, 1595 Paoli Pike, Suite 103, West Chester, PA 19380. Toll-free: (866) 325-9907; Phone: (484) 266-0702; Fax: (484) 266-0726; E-mail: eklumpp@matrixmedcom.com ADVERTISING QUERIES should be addressed to Robert Dougherty, President/Group Publisher, Matrix Medical Communications,1595 Paoli Pike, Suite 103, West Chester, PA 19380. Toll-free: (866) 325-9907; Phone: (484) 266-0702; Fax: (484) 266-0726; E-mail: rdougherty@matrixmedcom.com

Weight Loss Surgery Preoperative Risk Reduction

The Obesity Action Coalition: The Voice of Those Affected by Obesity

Treatment Considerations for Osteoarthritic Knee Pain in Patients with Obesity 20

Hair Loss Among Weight Loss Surgery Patients

BMI Body • Mind • Inspiration—Winter 2012

1595 Paoli Pike Suite 103 West Chester, PA 19380 BMI Body Mind Inspiration [ISSN TBD] is published digitally four times yearly by Matrix Medical Communications.Copyright © 2012 Matrix Medical Communications. All rights reserved. Opinions expressed by authors, contributors, and advertisers are their own and not necessarily those of Matrix Medical Communications, the editorial staff, or any member of the editorial advisory board. Matrix Medical Communications is not responsible for accuracy of dosages given in the articles printed herein. The appearance of advertisements in this journal is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality, or safety. Matrix Medical Communications disclaims responsibility for any injury to persons or property resulting from any ideas or products referred to in the articles or advertisements. This publication provides basic information about a broad range or medical conditions. It is not intended to serve as a tool for diagnosing illness, in prescribing treatments, or as a substitute for the physician/patient relationship. All persons concerned about medical symptoms or the possiblity of disease are encouraged to seek professional care from an approprpiate healthcare provider.

BMI

Letters to the Editor

Childhood/Adolescent Obesity and State Intervention: Parents Not Solely to Blame in the Battle Dear Editor: This letter is in response to the an article published in The Journal of the American Medical Association (JAMA) by Ludwig and Murtagh entitled, “State intervention in lifethreatening childhood obesity.”1 As a frontline childhood obesity physician, I strongly disagree with the premise of this article. Genetic predisposition, environment in utero, and birth weight all affect obesity rates long before any active parenting occurs.2 Race, ethnicity, poverty, infant feeding practices, and the well-recognized cost disparity between healthy and less healthy foods play a role.3 Children do not expend energy as in the past, and school vending machines, poor-quality school lunches, and the regrettable removal of physical education, recess, and health education classes are also factors in this issue.4,5 This is not to say that parents are completely defenseless to our obesogenic environment.5 Simple changes, such as sitting down to dinner as a family, decreasing fast food consumption, controlling use of electronics, and modeling good behavior, can have a significant impact on a child’s weight. But what happens when an engaged family has made these changes and the child remains severely obese (body mass index [BMI] at or beyond the 99th percentile)?6 Are our only answers to put him or her through surgery or remove the child from his or her home? Approximately two million children in the United States have severe obesity,6 clearly more than an overburdened foster care system can handle. Children with obesity are discriminated against by peers and teachers and are bullied relentlessly. The added insult of removing a child from his or her home will, in most cases, do more harm than good. In addition, with 75 percent of our society being overweight, the chances that a child will be placed in a home where the family members also struggle with a weight problem is more likely than not.7 Choices do exist for a child with obesity besides experimental surgery and state intervention. The 2007 Expert Committee on Child and Adolescent Overweight and Obesity (of which Dr. Ludwig was a member) developed an eloquent algorithm that involves early identification and assessment by Copyright © 2012 MMC

primary care providers followed by prevention and treatment by clinical obesity experts. Bariatricians and other childhood obesity experts are in the process of rolling out these recommendations nationally while simultaneously conducting outcomes research, with initial results that look very promising. Certainly, the premise of turning a child with severe obesity over to the state is thought provoking, but unless there are clear signs of neglect or abuse in conjunction with the obesity, it is unnecessary, unrealistic, and likely damaging to that child long term. References

1. 2. 3.

Murtagh L, Ludwig DS. State intervention in life-threatening childhood obesity. JAMA. 2011;306(2):206–207. Zhao J, Grant SF. Genetics of childhood obesity. J Obes. 2011;2011:845148. Van Cleave J, Gortmaker SL, Perrin JM. Dynamics of obesity and chronic health conditions among children and youth. JAMA. 2010;303(7):623–630. Rahman T, Cushing RA, Jackson RJ. Contributions of built environment to childhood obesity. Mt Sinai J Med. 2011;78(1):49–57. Eisenmann JC, Gundersen C, Lohman BJ, et al. Is food insecurity related to overweight and obesity in children and adolescents? A summary of studies, 1995–2009. Obes Rev. 2011;12(5):e73–83. Skelton JA, Cook SR, Aulinger P, et al. Prevalence and trends of severe obesity among US children and adolescents: what could be better? Acad Peds. 2009;9(5): 322–329. Hadfield SC, Preece PM. Obesity in looked after children: is foster care protective from the dangers of obesity? Child Care Health Dev. 2008;34(6):710–712.

With regards, Wendy Scinta, MD, MS, FAAFP, FASBP Medical Director, Medical Weight Loss of NY, BOUNCE Program for Childhood Obesity, Manilus, New York; Clinical Assistant Professor of Family Medicine, Upstate Medical University, Syracuse, New York BMI

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Weight Loss before Weight Loss Surgery: What Do We Know About Dropping Those Preoperative Pounds? by Liz Goldenberg, MPH, RD, CDN This article reviews the issues surrounding weight loss before surgical weight loss, and aims to answer the questions that weight loss surgery centers might have when making decisions about including a preoperative weight loss component in their surgical programs. eight loss surgery is growing in popularity. According to the American Society for Metabolic and Bariatric Surgery (ASMBS), there were 220,000 bariatric surgeries performed in 2008 and this number is on the rise. Considering that approximately five percent of American adults meet the criteria for morbid obesity, a large pool of surgical candidates remain.1 As more operations are being performed and the morbidity and mortality statistics of these surgeries remain favorable, older and sicker patients may be finding their way to the bariatric surgeon’s office. These patients are considered to be at higher risk for complications, since age and the presence of medical comorbidities, along with male gender, body mass index (BMI), and fat distribution, have been identified among the factors that negatively impact the safety of the operation. Of these factors, few can be altered except BMI and fat distribution. Physicians can choose to operate on higher risk patients by modifying the procedure, perhaps by performing a sleeve instead of, or prior to, a Roux-en-Y gastric bypass (RYGB). Another option for bariatric programs to deal with higher risk candidates is by recommending, or in some cases mandating, weight loss prior to undergoing weight

loss surgery. Some surgery centers recommend preoperative weight reduction for all of their patients, for the reasons listed in Tables 1 and 2

BENEFITS TO PREOPERATIVE WEIGHT LOSS The liver, operative time, and length of stay. A number of studies have found benefits to preoperative weight loss. Liu et al2 compared patients who did and who did not lose weight before surgery and found that those who lost weight were more likely to undergo surgery that did not deviate from the standard RYGB operation. Additionally, patients who did not lose weight were more likely to have their surgeon comment that the patients’ livers were enlarged. The authors did not find differences in operative time, length of stay, major complications, or wound infections between the groups. There are a number of studies that look at the effects of weight loss on the liver. Benjaminov et al3 found a reduction in liver volume of 8.1 percent, as well as a nonobjective observation by surgeons that this facilitated surgery, in patients who lost weight in the four weeks prior to surgery. In the six weeks prior to surgery, Lewis et al4 accomplished an even greater reduction in mean liver volume of 14.7 percent, as well as a 43-percent decrease in mean liver fat. Both a reduction in liver size

Ms. Goldenberg is from New-York Presbyterian Hospital, Weill Cornell College of Medicine of Cornell University, Department of Surgery, New York, New York.

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and operative time was achieved in a small group of patients who lost an average of 4.8kgs, also in a six-week time frame prior to surgery.5 Operative times were found to be a highly significant 36 minutes shorter in 62 out of 90 patients who were able to lose more than five percent of their preoperative weight.6 Still et al1 calculated that length of stay was less likely to be greater than four days in high-risk patients who were able to lose 5 to 10 percent of their excess weight before undergoing RYGB. It has been pointed out that high-risk patients may experience a greater benefit from preoperative weight loss.15 Overall complications. The overall major complication and mortality rates of bariatric surgery are quite low, less than 3.0 percent and 0.3 percent, respectively. Studies have shown mixed results as to whether preoperative weight loss lessens postoperative complications. Not only have some studies been unable to find fewer complications for those that lost,6,7 but in one study8 even preoperative weight gain did not negatively impact complication rates. However, considering the low overall complication rates of bariatric surgery, among the criticisms of these studies are that they involved inadequate sample sizes of 200 patients or less. Benotti et al9 reviewed the records of 881 RYGB patients for categories of complications including the following: respiratory issues, bleeding, gastrointestinal issues, feeding intolerance, cardiac issues, leakage, infection, thromboembolism, acute renal failure, urinary issues, wound issues, and stricture. The reviewers found statistically significant trends that confirmed a diminishing likelihood of any complication with increasing preoperative weight loss. Impact on postoperative weight loss. There has been some conflicting data as to whether successful weight loss preoperatively will translate into more successful postoperative weight loss. In 2005, Alvarado et al6 reported that preoperative weight loss was associated with greater weight loss at one year postoperatively, specifically an increase of one percent of preoperative weight loss for a 1.8-percent increase after surgery. This occurred despite the fact that 83 percent of the patients in the study failed to achieve the recommended 10-percent weight loss. In 2008, AlgerMayer et al10 described a more successful weight loss achievement, as well as a significant correlation between weight lost before and at three years after surgery. Onehundred and fifty patients who were advised to lose 10 percent of their initial presenting weight were able to realize a 9.5±6.8-percent loss before undergoing gastric bypass. The authors attribute their positive results to the implementation of physical activity and positive dietary changes early, and they point out that their patients credit their success to the same factors. Another possible

TABLE 1. Weight loss before weight loss surgery WEIGHT LOSS BEFORE WEIGHT LOSS SURGERY HAS BEEN LINKED TO Co-morbidity reduction Improved patient selection • Those who cannot lose weight before will not be successful after? • Those who comply with the program before will comply with the after-surgery follow up, diet, and exercise guidelines? More successful weight loss postoperatively Technically easier, safer surgery with lower complication rates

TABLE 2. Questions that a center might ask Are there benefits? What are they? Are there drawbacks? What are they? How do insurance carrier-mandated weight loss requirements impact our patients and our program? How can the weight loss be accomplished? How much weight should be lost?

explanation is that those patients who were able to achieve greater weight loss before surgery are the same patients who are more likely to follow up and adhere to the guidelines afterwards. A review article by Livhits et al11 compiled data from 15 different papers comparing weight loss before and after surgery. This large synopsis came to the same conclusion that preoperative weight loss results in greater total postoperative weight loss. Contrary to the collection of studies mentioned previously are papers by Jantz et al12 and Ochner et al.13 In 2009, Jantz et al12 failed to find a correlation between the percentage of excess weight loss (EWL) at one year postoperatively and the maximum amount of weight loss achieved prior to surgery. However, this was looking at self-reported weight loss and did not necessarily occur in the short period of time prior to surgery. In an even more recent paper published in Obesity in February 2010, Ochner et al13 found that more weight gain was predictive of more weight loss after surgery. This study only looked at the three-month postoperative visit and, perhaps more importantly, compared patients who were mandated to undergo a six-month, physician-supervised weight loss program prior to surgery to those who did have this requirement. On average, more than 75 percent of patients in both groups gained weight before surgery.

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Body • Mind • Inspiration Surprisingly, at three months postoperatively, these same “gainers” had lost more weight than those who has lost weight prior to their operation. Authors propose that diet fatigue or the “last supper syndrome,” which occurs

assumed to improve outcomes by increasing weight loss and subsequently the positive aspects of weight reduction. Many feel that these programs are meant to be a test of patients’ motivation. Two studies aimed to Insurance-mandated preoperative weight loss programs have challenge the merit of this prerequisite by comparing become a routine delay. Preoperative weight loss interventions sets of patients who were required to undergo an are assumed to improve outcomes by increasing weight loss and insurance-mandated subsequently the positive aspects of weight reduction. preoperative program with those who did not have this when patients intentionally over-eat, or binge on their requirement. Researchers in one study reported that 28 favorite foods for fear that they will miss this habit or percent of patients commanded to follow the registered these foods after surgery, may be responsible. This dietitan-supervised 13-week program dropped out of the binge-eating behavior is squelched postoperatively by the program, as compared to only 19 percent of the group new, tiny pouch. Finally, the authors point out that the free from this requirement.14 Both groups were more biological set-point theory may play a role in why likely to gain versus lose weight prior to surgery. Both patients who lose more weight prior to surgery lose less groups had similar total weight loss at one year, yet the after. patients who did not have the mandated delay achieved a greater percentage of EWL that was significant at the DRAWBACKS TO PREOPERATIVE WEIGHT LOSS OR one-year mark. The recent study in Obesity by Olchner PREOPERATIVE WEIGHT LOSS PROGRAMS et al13 came to a similar conclusion when comparing While there is some trepidation over the safety of groups of patients with or without insurance encouraging rapid weight loss in patients who are months requirements.13 The 94 patients who had to fulfill the or weeks away from major surgery, this author is requirement gained weight preoperatively; an average of unaware of any negative clinical outcome reports. 2.9±4.4 percent of their initial body weight. Nevertheless, there are a handful of drawbacks to Olchner et al propose that some patients fear that consider by a surgery center looking to implement this successful weight loss may lead to insurance denial for type of program. One downside is the cost to the the surgery. Both studies accused insurance-required program in staffing and other resources. The programs programs of being obstacles to patient access to surgical are usually administered by registered dietitians, treatment of obesity, in addition to not being effective at physicians who are part of a medical weight loss arm of bringing about preoperative weight loss. the program, or, in some programs, surgeons or In contrast to the studies by Olchner et al13 and Jamal et al,14 the 150 patients in the study by Alger-Mayer et gastroenterologists who may place a device, such as an al10 were required by their surgeon and not by their intragastric balloon. While programs usually include an insurance carrier to undergo a diet and exercise exercise component to them, few studies mention the program. All patients that wished to undergo surgery at utilization of a trained exercise specialist. Another possible deterrent may be the concern of this practice, regardless of presenting BMI, were patients dropping out of the program. A well-designed expected to follow the program and lose 10 percent of preoperative weight loss program may go on for as little their initial documented weight. Instead of a 28-percent as two weeks or as long as six months, which is a drop out rate, reportedly only one of their patients left to significant delay. Programs may argue that delaying go to another practice that did not require preoperative surgery may deter patients from ultimately having the weight loss. surgery. Alami et al7 discuss this fear but did not find a delay; the times from consultation to operation PREOPERATIVE WEIGHT LOSS METHODS (approximately five months) were similar in the groups Many patients with obesity seeking weight loss surgery that did and did not undergo a preoperative weight loss are actually quite adept at losing weight. They are able to program. One patient in this study left to have surgery at take off the weight for a short period, usually through a center that did not have this requirement. diet and/or exercise, but then find themselves rebounding, gaining back part, all, or even more weight Weight loss attempts required by insurance than they initially lost. Others find that the difficulty carriers versus the surgeon. Insurance-mandated preoperative weight loss programs have become a routine occurs when they reach that plateau of 10, 20, or 50 delay. Preoperative weight loss interventions are pounds and the scale is at a stand-still. On the other

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hand, some patients have never in their lives successfully lost weight. Regardless of the history, patients who appear in the surgeon’s office can become a highly motivated bunch if told by the surgeon that they will not be operated on unless they lose weight beforehand. As described previously, aside from or in addition to surgeons making these demands on patients, many insurance providers place demands on doctors to supervise their patients’ weight loss efforts in order for them to get coverage. However, most health insurance plans do not specify any particular type of program for providers to follow. As surgical programs looking to accomplish preoperative weight loss, what are the options? Diets, medication, and a device. Dieting is the method of weight loss most often cited in studies that look at weight loss prior to surgery. This could be because most weight loss surgery programs already have dietitians either as part of their team or as consultants who carry out preoperative evaluations (as required to fulfill National Institutes of Health [(NIH)] criteria, by insurance companies, and for ASMBS Centers of Excellence [(COE)] or American College of Surgeons [(ACS)] Bariatric Surgery Center Network [(BSCN)] certification). As pointed out previously, few programs have exercise experts on their teams, probably because they are not required by the above organizations. Yet plenty of evidence backs the synergism of diet plus exercise, or the effects of an entire multidisciplinary team including these providers previously noted along with psychologists or behavioral therapists, in bringing about weight loss. The diets that have reportedly been used for bringing about preoperative weight loss range from a vague “healthy balanced diet,” to a strict very low-calorie, liquid diet,2,4 to a very low carbohydrate (30g) diet,3 to a highly involved and resource-consuming, supervised 11week inpatient weight loss program.15 Which type of diet is the most effective is the topic of another paper, but there are two common denominators to be found among the conclusions to studies that compare the efficacy of various weight loss diets. The first is that those who stay on the diet lose the most weight, and the second is that patients who have a say in which diet they follow (versus having to follow a diet that is chosen for them) will be more successful.16,17 One can see how these two suggestions are interdependent. A

final point on choice of diet is that although these may seem to be common-sense recommendations, they can be easily overlooked by programs that routinely use standard diet plans and thus fail to individualize plans according to patients’ preferences. One study5 looked at the effectiveness of sibutramine (Abbott Laboratories, North Chicago, Illinois) in preoperative weight loss. Twenty patients received 15mg of this medication once daily for six weeks, while another 20 patients did not. The medication group lost 4.8kg while the control group gained 7.0kg and spent an additional 20 minutes in the operating room when compared to the patients who took sibutramine. There are two reports on the use of an intragastric balloon for preoperative weight loss.18,19 Thirty-one and 75 patients achieved 22 and 16-percent EWL, respectively, after the device was implanted for at least six months. There was no operative mortality and only two patients in each of the studies suffered from intolerance and had to have the balloon removed soon after implantation.

HOW MUCH WEIGHT SHOULD BE LOST? There is a scarcity of data comparing the pros and cons of how much weight should be lost. Though insurance companies often mandate that the attempt must be made, they rarely make specific recommendations as to the amount of weight loss.13 This is likely because it is difficult to draw conclusions from existing data. One reason for the difficulty is that a standard definition for how to report weight loss is lacking. Some studies report on total weight loss or percentage of total weight loss, while others use EWL or percentage of EWL, and still others use excess BMI loss. Another issue is a lack of prospective, randomized trials; most papers are retrospective reviews.20 Many papers support 5- to 10-percent total weight loss or the same amount of excess weight loss as a desirable goals.1,7,11 Evidence for this goal is seemingly derived from studies that link this range of weight loss to significant reductions in obesity-related comorbidities. Most would agree that more quality data are needed in order to draw evidence-based conclusions on the ideal amount of weight loss that should be recommended. Even if studies were forthcoming, realistic versus optimistic weight loss is an important distinction in this group. Patients who are typically 100 or more pounds

Many patients with obesity seeking weight loss surgery are actually quite adept at losing weight. They are able to take off the weight for a short period, usually through diet and/or exercise, but then find themselves rebounding, gaining back part, all, or even more weight than they initially lost. Copyright © 2012 MMC

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Body • Mind • Inspiration away from their ideal body weight and have a history of “failed” dieting attempts will continue to be challenged by the irony of trying to lose weight before undergoing an operation that will give them help to achieve the same result.

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CONCLUSION In summary, whether programs should suggest or require weight loss before weight loss surgery and whether it should be for all patients or only for select groups, such as high-risk patients, will probably continue to be a controversial decision to make. Barring any mandates from insurance carriers or accreditation programs, surgery centers will likely continue to decide for themselves whether it is in theirs, and of course their patients’ best interests to promote the dropping of those preoperative pounds.

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REFERENCES 1.

Still CD, Benotti P, Wood GC, et al. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass surgery. Arch Surg. 2007;142(10):994–998. Liu RC, Sabnis AA, Forsyth C, Chand B. The effects of acute preoperative weight loss on laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2005;15(10):1396–1402. Benjaminov O, Beglaibter N, Gindy L, et al. The effect of a low-carbohydrate diet on the nonalcoholic fatty liver in morbidly obese patients before bariatric surgery. Surg Endosc. 2007;21(8):1423–427. Lewis MC, Phillips ML, Slavotinek JP, et al. Change in liver size and fat content after treatment with Optifast very low calorie diet. Obes Surg. 2006;16(6):697–701. Aberle J, Freier A, Busch P, et al. Treatment with sibutramine prior to Roux-en-Y gastric bypass leads to an improvement of metabolic parameters and to a reduction of liver size and operative time. Obes Surg. 2009;19(11):1504–1507. Alvarado R, Alami RS, Hsu G, et al. The impact of preoperative weight loss in patients undergoing laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2005;15(9):1282–1286. Alami RS, Morton JM, Schuster R, et al. Is there a benefit to preoperative weight loss in gastric bypass patients? A prospective randomized trial. Surg Obes Relat Dis. 2007;3(2):141–145; discussion 145–146. Harnisch MC, Portenier DD, Pryor AD, et al. Preoperative weight gain does not predict failure of weight loss or comorbidity resolution of laparoscopic Roux-en-Y gastric bypass for morbid obesity. Surg Obes Relat Dis. 2008;4(3):445–450. Benotti PN, Still CD, Wood GC, et al. Preoperative weight loss before bariatric surgery. Arch Surg. 2009;144(12):1150–1155.

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Alger-Mayer S, Polimeni JM, Malone M. Preoperative weight loss as a predictor of long-term success following Roux-en-Y gastric bypass. Obes Surg. 2008;18(7):772–775. Livhits M, Mercado C, Yermilov I, et al. Does weight loss immediately before bariatric surgery improve outcomes: a systematic review. Surg Obes Relat Dis. 2009;5(6):713–721. Jantz EJ, Larson CJ, Mathiason MA, et al. Number of weight loss attempts and maximum weight loss before Roux-en-Y laparoscopic gastric bypass surgery are not predictive of postoperative weight loss. Surg Obes Relat Dis. 2009;5(2):208–211. Ochner CN, Puma LM, Raevuori A, et al. Effectiveness of a prebariatric surgery insurance required weight loss regimen and relation to postsurgical weight loss. Obesity (Silver Spring). 2010;18(2):287–292. Jamal MK, DeMaria EJ, Johnson JM, et al. Insurancemandated preoperative dietary counseling does not improve outcome and increases dropout rates in patients considering gastric bypass surgery for morbid obesity. Surg Obes Relat Dis. 2006;2(2):122–127. Huerta S, Li Z, Anthony T, Livingston EH. Feasibility of a supervised inpatient low-calorie diet program for massive weight loss prior to RYGB in superobese patients. Obes Surg. 2010;20(2):173–180. Brehm BJ, D’Alessio DA. Weight loss and metabolic benefits with diets of varying fat and carbohydrate content: separating the wheat from the chaff. Nat Clin Pract Endocrinol Metab. 2008;4(3):140–146. Dansinger ML, Gleason JA, Griffith JL, et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA. 2005;293(1):43–53. Frutos MD, Morales MD, Luján J, et al. Intragastric balloon reduces liver volume in super-obese patients, facilitating subsequent laparoscopic gastric bypass. Obes Surg. 2007;17(2):150–154. Mills S, Bassona S, Cornisha J, et al. Intragastric balloon use to reduce weight before bariatric surgery. Surg Obes Relat Dis. 2010;6(2):224. Tarnoff M, Kaplan LM, Shikora S. An evidenced-based assessment of preoperative weight loss in bariatric surgery. Obes Surg. 2008;18(9):1059–1061. BMI

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Weight Loss Surgery Preoperative Risk Reduction by Adrienne Youdim, MD

besity remains a growing and ongoing problem in the United States. While recent reports have shown obesity rates have stabilized, severe classes of obesity are on the rise,1 having important implications in regard to treatment. Weight loss surgery remains a durable treatment for obesity, effectively resulting in remission of many obesity-related conditions.2 In addition, recent reports have demonstrated a mortality benefit in patients who have had The presence of bariatric surgery.3 As a hypertension is a result, weight loss significant risk factor surgeries are on the rise. Studies have shown a for perioperative 14 five-fold increase in the complications. number of bariatric Validated risk scores surgeries between 1998 have demonstrated and 2003.4 The number of weight loss surgeries hypertension to be performed in the United associated with higher States has increased in all 30-day mortality groups despite age, following bariatric income, or insurance status or type. However, this elective surgery...8 surgery is not without complications. Surgeon experience appears to be a significant predictor of postoperative morbidity and mortality,5 however, patient-inherent risks have also

been identified. While studies have been conflicting, age, smoking history, superobesity, and certain comorbidities are factors implicated in increasing morbidity and mortality with bariatric surgery.6–8 One validated risk score identified five perioperative variables that predicted 30-day mortality. These variables include superobesity, male gender, hypertension, age greater than 45, and risk factors for pulmonary embolism, including obstructive sleep apnea. Patients who had 4 to 5 of the above risk factors had a 12-fold greater (2.4%) 30-day mortality than patients who had none to one risk factor (0.2%).8 Certain high-risk patient groups may benefit from optimizing their medical status prior to weight loss surgery through medical nutritional therapy and preoperative weight loss.

DIABETES The relationship between type 2 diabetes and obesity is well documented as the incidence of diabetes increases incrementally with rising body mass index (BMI).9,10 Recent guidelines recommend long-term glycemic control with HbA1c of 7.2 percent or less prior to bariatric surgery.11 While pharmacotherapy is appropriate, medical nutritional therapy remains the mainstay of treatment. Studies have shown weight loss of as little as 5 to 10 percent results in effective reduction of fasting blood glucose and HbA1c. In one study,12 weight loss of up to 14 percent resulted in a two-point

Dr. Youdim is Medical Director, Comprehensive Weight Loss Center, Cedars Sinai Medical Center, Los Angeles, California, and Assistant Clinical Professor of Medicine, David Geffen School of Medicine, University of California Los Angeles, California.

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A diagnosis of OSA is an independent risk factor for 30-day morbidity and mortality following bariatric surgery.18,19 Surgical patients with OSA are vulnerable to the effects of sedation, anesthesia, and analgesia. reduction in HbA1c, comparable to targets achieved by pharmacotherapy.12 Given the favorable effect of modest weight loss on glycemic control, preoperative weight loss should be used to achieve glycemic targets in bariatric surgery patients.

HYPERTENSION Obesity is associated with other cardiometabolic conditions, including hypertension. Mechanisms of this association are multifactorial and include secretion by adipocytes of many proteins of the renin-angiotensin system, the pathway that mediates hypertension through sodium and water reabsorption and increased vascular tone.13 The presence of hypertension is a significant risk factor for perioperative complications.14 Validated risk scores have demonstrated hypertension to be associated with higher 30-day mortality following bariatric surgery,8 and guidelines recommend optimal hypertensive control prior to bariatric surgery.11 Modest weight loss has been shown to reduce both systolic and diastolic blood pressure. Prior studies have shown reductions in blood pressure of 1mmHg per kilogram weight loss.15 A more recent systemic review16 suggests that for 10kg weight loss there is a 4.6mmHg and 6.0mmHg reduction in diastolic and systolic blood pressure, respectively.16 Moreover, change in macronutrient intake to reduce sodium and increase fruits, vegetables, and limit saturated fats can itself result in reductions in blood pressure independent of weight loss.17 While pharmacotherapy is often necessary to control hypertension, medical nutritional therapy and preoperative weight loss is a useful adjunct to optimize hypertensive control in patients with morbid obesity.

OBSTRUCTIVE SLEEP APNEA Concomitant obstructive sleep apnea (OSA) is frequently present in the patient population with morbid obesity. Obesity is a leading cause of OSA, and a 10percent increase in BMI results in a 32-percent increase in apnea-hypopnea index (AHI). A diagnosis of OSA is an independent risk factor for 30-day morbidity and mortality following bariatric surgery.18,19 Surgical patients with OSA are vulnerable to the effects of sedation, anesthesia, and analgesia. Patients with OSA have been shown to have a higher number of postoperative complications, including but not limited to respiratory complications, and patients with more severe OSA (higher AHI or more significant oxygen desaturations) can be at greater risk for these complications.20 Modest

weight loss can result in significant improvements in OSA. In one study,21 an average weight loss of 13.5 percent at 6 and 12 months resulted in reduction of the oxygen desaturation index (desaturation events per hour of sleep exceeding 4% from baseline) by 28 and 26 points, respectively. Modest weight reduction will improve OSA and may optimize patient-inherent risk related to OSA prior to bariatric surgery.

SUPEROBESITY Superobesity, as defined by a BMI of 50kg/m2 or greater, has consistently been implicated in increasing surgical risk with bariatric surgery.6–8,18,22 In one study,22 BMI ?50kg/m2 was independently associated with higher 30-day mortality with an odds ratio of 3.6. Additionally, preoperative weight loss of 5 to 10 percent has been associated with more rapid postoperative weight loss and greater one-year excess weight loss (EWL).23–24 This may be particularly relevant to a patient with super obesity who requires a greater overall weight loss to achieve normal BMI.

PREOPERATIVE WEIGHT LOSS Studies have specifically evaluated the effect of preoperative weight loss prior to bariatric surgery. Studies25,26 have shown preoperative weight loss resulted in reduced liver size and visceral fat. In one study,25 4.1percent weight loss resulted in 5.1-percent mean reduction in liver size and fat. In another study,26 patients who participated in a 12-week very low energy diet (VLED) lost an average of 11 percent (80% of which occurred in the first two weeks of the dietary intervention) and achieved 28.7- and 24.1-percent reduction in liver size and visceral adipose tissue, respectively. Smaller liver size and reduced visceral adiposity may improve technical feasibility of the surgery. In a study by Liu et al,27 preoperative weight loss resulted in a reduced likelihood to encounter an enlarged liver and reduced likelihood of deviating from standard operative procedure. Specifically, average weight loss of 3.3kg resulted in a 17-percent reduction in the number of cases that deviated from standard operation, including use of additional trocars and conversion to an open procedure during laparoscopic Roux-en-Y gastric bypass (RYGB) surgery.27 Preoperative weight loss has also been associated with reduced probability of surgical complications after gastric bypass surgery, particularly in open gastric bypass. In one study,28 EWL of up to 10 percent resulted

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Body • Mind • Inspiration in reduced major and minor complications. Statistically significant trends revealed reduced likelihood of any complication with increasing preoperative weight loss for the entire cohort of 881 patients (p=0.004) and for those who underwent open gastric bypass (p=0.02). This relationship was preserved after adjusting for age, BMI, number of comorbidities, and type of surgery. In addition, the degree of weight loss was significant in the reduction of complications. When compared to those who lost 10 percent or more excess body weight (EBW), those who gained five percent or more EBW had a twofold increased likelihood of a complication.28 Patients who underwent preoperative weight loss have also shown reduced intraoperative blood loss, shorter operative times,27,29 and reduced length of hospital stay,23 which may have important implications in resource utilization and reducing cost of surgery.

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CONCLUSIONS Bariatric surgery remains safe and effective for the treatment of obesity with recent studies placing 30-day mortality at 0.03 percent.18 Determining patient-inherent risk factors allows clinicians to appropriately advise patients of individual surgical risk and to optimize that risk when possible prior to surgery. Several studies have identified patient-inherent variables that portend higher morbidity and mortality with bariatric surgery. Superobesity and certain comorbidities, including diabetes, OSA, and hypertension, are factors implicated in increasing surgical risk. Routine preoperative weight loss may not be indicated in all weight loss surgery patients given low overall complication rates, but may be of benefit in the higher-risk patient population.

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REFERENCES

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Sturm R. Increases in clinically severe obesity in the United States: 1986–2000. Arch Intern Med. 2003;163(18):2146–2148. Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and cardiovascular risk factors 10 Years after bariatric surgery. N Engl J Med. 2004;351:2683–2693. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. N Engl J Med. 2007;357:753–761. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical procedures. JAMA. 2005;294:1909–1917. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg. 2004;199:543. Livingston EH, Arterburn D, Schifftner TL, et al. National surgical quality improvement Pprogram analysis of bariatric operations: modifiable risk factors contribute to bariatric surgical adverse Outcomes. J Am Coll Surg. 2006;203(5):625–633. Lautz DB, Jackson TD, Clancy KA, et al. Bariatric operations in veterans affairs and selected university medical centers. J Am Coll Surg. 2007;204:1261–1272.

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DeMaria EJ, Murr M, Byrne TK, et al. Validation of the obesity surgery mortality risk score in a multicenter study proves it stratifies mortality risk in patients undergoing gastric bypass for morbid obesity. Ann Surg. 2007;246(4):578–582. Chan JM, Rimm EB, Colditz GA, et al. Obesity, fat distribution and weight gain as risk factors for clinical diabetes in men. Diabetes Care. 1994;17:961–969. Colditz GA, Willett WC, Rotnitzky A, Manson JE.. Weight gain as a risk factor for clinical diabetes mellitus in woman. Ann Intern Med. 1995;122:481–486. Mechanick JI, Kushner RF, Sugerman HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Endocr Pract. 2008;14 Suppl 1:1–83. Wing RR, Koeske R, Epstein LH, et al. Long-term effects of modest weight loss in type II diabetic patients. Arch Intern Med. 1987;147(10):1749–1753. Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J Clin Endocrinol Metab. 2004;89(6):2548–2556. Watson K. Surgical risk in patients with metabolic syndrome: Focus on lipids and hypertension. Curr Cardiol Rep. 2006;8(6):433–438. Neter JE, Stam BE, Kok FJ, et al. Influence of weight reduction in blood pressure: a metal-analysis of randomized controlled trials. Hypertension. 2003;42:878–884. Aucott L, Poobalan A, Smith WC, et al. Effects of weight loss in overweight/obese individuals and long-term hypertension outcomes: A systemic review. Hypertension. 2005;45:1035–1041. Appel LJ, Sacks FM, Carey VJ, et al. Effects of protein, monounsaturated fat, and carbohydrate intake on blood pressure and serum lipids: results of the OmniHeart randomized trial. JAMA. 2005;294:2455–2464. Flum DR, Belle SH, King WC, et al. The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium. Perioperative safety in the longitudinal assessment of bariatric surgery. N Engl J Med. 2009;361:445–454. Flancbaum L, Belsley S. Factors affecting morbidity and mortality of Roux en-Y gastric bypass for clinically severe obesity: an analysis of 1,000 consecutive open cases by a single surgeon. J Gastrointest Surg. 2007;11:500–507. Chung SA, Yuan H, Chung F. A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg. 2008;107:1543–1563. Romero-Corral A, Caples SM, Lopez-Jimenez F, Somers VK. Interactions between obesity and obstructive sleep apnea: Implications for treatment. Chest. 2010;137(3):711–719. DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk score: proposal for clinically useful score to predict mortality risk in patients undergoing gastric bypass. Surg Obes Relat Dis. 2007;3:34–40. Still CD, Benotti P, Wood GC, et al. Outcomes of preoperative weight loss in high-risk patients undergoing gastric bypass

surgery. Arch Surg. 2007;142(10):994–998. 24. Solomon H, Liu GY, Alami R, et al. Benefits to patients choosing preoperative weight loss in gastric bypass surgery: New results of a randomized trial. J Am Coll Surg. 2009;208:241–245. 25. Fris RJ. Preoperative low energy diet diminishes liver size. Obes Surg. 14;1165–1170. 26. Colles SL, Dixon JB, Marks P, et al. Preoperative weight loss with a very-low-energy diet: quantitation of changes in liver and abdominal fat by serial imaging. Am J Clin Nutr. 2006;84(2):304–311. 27. Rockson CL. Pre-operative weight loss and intraoperative outcomes. Obes Surg. 2005;15:1396–1402. 28. Benotti PN, Still CD, Wood GC, et al. Preoperative weight loss before bariatric surgery. Arch Surg. 2009;144(12):1150–1155. 29. Alvarado R, Alami RS, Hsu G, et al. The impact of preoperative weight loss in patients undergoing laparoscopic Roux-en-Y gastric bypass. Obes Surg. 2005;15;(9):1282–1286. BMI

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Body • Mind • Inspiration THE OBESITY ACTION COALITION: The Voice of those Affected by Obesity by Joe Nadglowski

JOE NADGLOWSKI, President and CEO of the Obesity Action Coalition The Obesity Action Coalition is a registered 501(c)3 nonprofit organization founded in 2005. The Obesity Action Coalition is the only nonprofit whose sole focus is representing those affected by obesity through education, advocacy, and support. A MEMBERSHIP ORGANIZATION The Obesity Action Coalition (OAC) is a membership organization. We have three levels of membership; one for individuals and two for organizations and companies that would like to support the OAC. Individual membership benefits include the following: • Official membership card and welcome letter • A subscription to the OAC’s official publication titled, Your Weight Matters • Subscriptions to Obesity Action Alert and OAC Members Make a Difference e-Newsletters • Advocacy alerts • “Bias Busters” alerts • The ability to lend your voice to the cause of fighting obesity Membership in the OAC also qualifies you to purchase one of our “educational add-ons.” These “educational add-on” packages allow you to order OAC educational resources in bulk. There are three different packages available, based on the number of materials an individual is interested in ordering. To learn more about OAC membership, please visit www.obesityaction.org/ membership/overview.php.

EDUCATION The OAC offers a wide variety of free educational resources on obesity, severe obesity, and childhood obesity, as well as resources on the consequences and treatments of the disease. One of our most popular

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educational resources is our quarterly publication, Your Weight Matters. This publication is geared toward individuals affected by obesity and contains a wide variety of educational and advocacy information. Each issue features information on a broad range of weightrelated topics and includes features on weight-loss surgery, obesity-related conditions, childhood obesity, nutrition, current advocacy news, and much more. To learn more about the OAC’s educational resources, please visit www.obesityaction.org/educationaltools /brochuresandguides.php. Other educational materials available include the following: • Understanding Obesity brochure series • Understanding Obesity • Understanding Severe Obesity • Understanding Childhood Obesity • Understanding Obesity Stigma • Understanding Childhood Obesity poster • Understanding Obesity poster • Understanding Excess Weight and Type 2 Diabetes brochure series • Understanding Excess Weight and its Role in Type 2 Diabetes • Understanding Prediabetes and Excess Weight • Understanding Excess Weight and Type 2 Diabetes • OAC Insurance Guide: Working with Your Insurance Provider

LEARN MORE, GET INVOLVED For more information on the OAC and how you can get involved, visit the following websites: GENERAL INFORMATION www.obesityaction.org

MEMBERSHIP www.obesityaction.org/membership/overview.php.

EDUCATIONAL RESOURCES www.obesityaction.org/educationaltools/brochuresandguides.php.

ADVOCACY EFFORTS www.obesityaction.org/advocacy/overview.php.

“BIAS BUSTERS” www.obesityaction.org/gettinginvolved/biasbusters/overview.php.

ADVOCACY The OAC conducts a variety of advocacy efforts throughout the United States on both the federal and state level, and encourages individuals to become proactive advocates. The primary focus of our advocacy efforts is improving access to obesity treatments. A recent advocacy victory that the OAC was involved in was the state of Missouri restoring their bariatric surgery benefit for state employees in 2012. Several OAC members testified before the Missouri legislature in support of this. Currently, the OAC has been hard at work advocating for obesity treatments to be included in the Essential Health Benefits (EHB) package for the new state-based health exchange plans under healthcare reform law. Toward the end of 2011, the United States Department of Health and Human Services (HHS) held a number of regional listening sessions across the country to hear from local stakeholders about which services should be included in the EHB. OAC member advocates spoke at each of these sessions about the “essential” nature of obesity treatment and why it is important that HHS include these services in the EHB package. To learn more about the OAC’s advocacy efforts, please visit www.obesityaction.org/advocacy/overview.php.

bias. Weight bias issues addressed so far include the creation of a petition directed at Facebook concerning “obesity hate” pages that were found on the popular social networking site, an Entertainment Tonight segment where a reality TV star dressed up in a “fat suit,” as well as targeting stock photography websites, asking them to remove offensive photos of individuals affected by obesity. To learn more about “Bias Busters” please visit www.obesityaction.org/gettinginvolved/biasbusters/overvi ew.php.

HOW TO GET INVOLVED Whether you are personally affected by obesity or just passionate about the cause, membership in the OAC is one of the easiest ways that you can give back to the fight against obesity. Individual membership in the OAC is just $20/year. You can learn more about the OAC at www.obesityaction.org. BMI

SUPPORT The OAC offers support to those affected by obesity through everything we do. One of the biggest ways we support our members is by representing them in the battle against weight bias. Recently, the OAC started our “Bias Busters” initiative to bring attention to weight bias and discrimination, as well as to activate our membership on these issues and ask their help in speaking out against

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Body • Mind • Inspiration Treatment Considerations for Osteoarthritic Knee Pain in Patients with Obesity by James Choi, MD; Jonathan Schaffer, MD, MBA

This article discusses treatment modalities for osteoarthritic knee pain in the patient with obesity. Nonoperative options include physical therapy, orally administered analgesia, and knee injections. Operative intervention options include total knee arthroplasty as definitive treatment. nee pain is among the most common of health concerns in the population, and the subset of bariatric patients is no exception.1,2 Independently, in the United States, obesity has prevalence in excess of 33 percent, and a 2006 Centers for Disease Control and Prevention (CDC) survey of adults reported an 18percent incidence of knee pain within the past 30 days.3,4 Bariatric patients have a well-established positive association with knee osteoarthritis, and it has been previously noted that body mass index (BMI) in young adulthood, a time when many patients are now choosing to pursue bariatric surgical options, may be a good predictor of subsequent osteoarthritis in later years.5–7 While the etiology of knee pain and treatment modalities can be wide ranging, this article will focus on existing medical knowledge of knee pain secondary to osteoarthritis in the bariatric population, considerations of the treatment options available for those afflicted with that diagnosis, and a discussion of the “best questions to address” in terms of future collaboration between and treatment options available to primary care physicians, orthopedic surgeons, and bariatric physicians and surgeons.

ANATOMY The knee is a modified hinge joint that experiences high contact and shear forces during ambulation. There are three alignments commonly observed in the knee: neutral, valgus (knock-knee), and varus (bow-legged).8 Existing alignment of the knee can be exacerbated or altered by degenerative changes, which can significantly impact force distribution and wear patterns affecting the three compartments of the knee: medial, lateral, and patellofemoral. In level walking, the force experienced by the knee with each step is approximately four times the total weight of the body, and this increases to approximately eight times when ambulating down an incline.9 In effect, the average bariatric patient’s knees will experience forces comparable to downhill walking at baseline and much higher forces with additional activity. The joint is stabilized by four primary ligaments— anterior cruciate ligament, posterior cruciate ligament, and medial and lateral collateral ligaments, as well as the surrounding musculature. Additionally, the knee is cushioned by synovial fluid and layers of cartilage and meniscus. Injury or degeneration of any of these components can lead to knee pain. A history of prior injury and the effects of advancing age can lead to degeneration of the

Dr. Choi, is from the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, Massachusetts. Dr. Schaffer is from the Orthopaedic and Rheumatologic Institute, Cleveland Clinc, Cleveland, Ohio.

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cartilage (osteoarthritis) with an unpredictable expression of pain and level of functional impairment. Previous studies have not correlated obesity with radiographic progression of osteoarthritis. Notably, it has been observed that obesity can increase the risk of osteoarthritis progression in those patients with neutral or valgus (knock-knee) alignment, but varus (bowlegged) aligned knees did not show the same risk progression.10,11

analgesics can be effective for intermittent and mild-tomoderate symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDS) are often effective for osteoarthritis pain.14 The use of NSAIDS is complicated in the gastric bypass patient population due to an increased risk of adverse gastrointestinal side effects, which include development of marginal ulcers at the previously created anastomosis sites. NSAIDs should be used with caution and possibly with proton pump inhibitor therapy.15 In the

In effect, the average bariatric patient’s knees will experience forces comparable to downhill walking at baseline and much higher forces with additional activity. EVALUATION AND THERAPY OPTIONS FOR KNEE PAIN Osteoarthritic pain characteristically worsens with increased activity, particularly weight bearing, and improves with rest. Generally, patients report no systemic symptoms and on physical exam may have decreased range of motion, crepitus, mild joint effusion, and palpable osteophytic changes at the knee joint, though these findings may be more difficult to elucidate in patients with obesity.12 Pain that continues and progresses warrants radiographic evaluation with joint space narrowing representing cartilage degeneration, characteristic of osteoarthritic changes. Unless there is suspicion of soft tissue injury, there is generally no need for further radiographic evaluation by computed tomography (CT) or magnetic resonance imaging (MRI) modalities. Treatment for osteoarthritic knee pain is symptom based and relies heavily on the patient’s report of symptoms and functional limitations. There is not a predictive correlation between a patient’s complaint of symptoms to radiographic evaluation of osteoarthritis. The dependence on patient-reported symptoms for treatment action makes the understanding of pain reporting especially helpful. The results of the Swedish obese subjects study13 indicate that patients with a higher BMI tend to have a higher prevalence of workrestricting pain (including the knees) than their general population counterparts. This same study also noted that postoperative female bariatric patients reported a greater level of improvement in their symptoms as compared to their nonoperative peers and that work-restricting knee, hip, and ankle pain was more responsive than axial musculoskeletal complaints.13 At present, treatment of osteoarthritic knee pain is based upon relief of symptoms beginning with nonoperative options, and treatment modalities generally do not differ for patients with obesity as compared to their nonobese counterparts. Pharmacologic therapy is primarily targeted at analgesia, and periodic use of

gastric bypass population, there has been little definitive guidance on the most effective pharmacologic alternatives given the risks of NSAID use in this patient subset. Narcotics are generally considered a pharmacologic last option for advanced osteoarthritis pain that is refractory to other treatments, and systemic corticosteroids have not been shown to be effective for pain relief although localized injections that are discussed later can be effective for relief of symptoms.14 Physical therapy targeted at the surrounding musculature, specifically quadriceps strengthening, can be effective in providing pain relief.16 Among more invasive interventions, knee injections fall under two categories: corticosteroid and viscosupplementation. Corticosteroid injections reduce the inflammatory response within the knee joint and can provide good relief of variable duration of weeks to months, but rarely are more than two or three intraarticular injections to the same joint administered per year for concern of potentially progressive cartilage damage.14 Additionally, recent studies have demonstrated that bupivacaine, a commonly used intra-articular local anesthetic often combined with a corticosteroid, has a significantly increased in-vitro toxicity to human articular chondrocytes when compared to ropivacaine, and further research on long-term effects should be followed closely.17 Viscosupplementation of hyaluronates is intended to counteract the reduction of concentration and size of hyaluronan, a key component of synovial fluid, which occurs in osteoarthritis. Clinical trials of viscosupplementation have yielded highly variable results ranging from no effect to improvement in symptoms lasting up to one year. Physicians should also be aware of patient-directed therapies as well. In the context of osteoarthritis, this primarily consists of the nutritional supplements glucosamine and chondroitin, and National Institute of Health-sponsored research studies to date have not shown significant efficacy in symptom relief.14,18 The end-stage therapy for osteoarthritic knee pain is

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Body • Mind • Inspiration surgical intervention, including arthroscopy, osteotomy, partial knee arthroplasty, and total knee arthroplasty.19 Should this be required, total knee arthroplasty is the definitive treatment. Other operative modalities that can potentially be offered include a partial knee arthroplasty, including patello-femoral arthroplasty for patients with specifically isolated compartment osteoarthritis. Knee arthroplasty is generally regarded as a highly successful procedure with predictably good outcomes. Historically, orthopedic surgery has been somewhat reticent to embrace operative treatment for patients with high BMIs. This is perhaps no better exemplified than by the decision of the East Suffolk (UK) health board to prioritize lower extremity arthroplasty for those patients that are not overweight or obese. The two most cited reasons for not proceeding with arthroplasty in the obese patient set are a high rate of perioperative complications (e.g., wound healing and infections) and concern for the longevity and efficacy of the implant. Winiarsky et al20 showed a significantly increased postoperative infection rate (26% vs. 2%) for patients with morbid obesity undergoing a total knee arthroplasty. A review article by Gillespie and Porteous21 showed a trend of increasing complication rates with increasing BMI though no definitive cutoff could be determined. A study by Amin et al23 in 2006 showed that arthroplasty patients with BMIs greater than 40kg/m2 had clinical outcome scores significantly lower than the control group and a higher rate of revision and perioperative complications. Amin et al recommended that patients lose weight and maintain that weight loss prior to arthroplasty and should be counseled about the potential for inferior results without weight loss.22 In 2000, Parvizi et al24 reported seeing excellent hip and knee arthroplasty results in patients who were postoperative from bariatric procedures with a mean BMI change from 49kg/m2 to 29kg/m2.

DISCUSSION/CONCLUSIONS Although the connection between these two morbidities is strong, the course of treatment is not well defined. From the orthopedist’s perspective, a high BMI may be viewed as potentially exclusionary from surgical treatment of osteoarthritis, at least until the patient achieves some degree of stable and sustained weight

loss. Looking from the bariatric surgeon’s perspective, bariatric procedures have not historically promoted any efficacy in improving musculoskeletal concerns to the extent that has been the case for improving cardiovascular and endocrine morbidities. In the literature today, there is a paucity of publications addressing the long-term outcomes of joint arthroplasty in the context of osteopenia that is generated by the malabsorptive state created by a gastric bypass procedure. This leads us to a number of questions as to the appropriate path of care for the patient with obesity and progressive knee osteoarthritis. 1. For patients meeting criteria for both bariatric surgery and knee arthroplasty, which procedure should be performed first? 2. How do we best minimize the exposure of patients to perioperative risk? 3. Can we better understand the outcomes of postbariatric procedure patients as compared to their general population and conservatively treated obese controls? 4. What is the appropriate timing of procedures? Should there be absolute BMI cutoffs? 5. What are the cost benefits and comparisons as well as quality of life considerations regarding bariatric and arthroplasty procedures? Some points for future consideration include the following: 1) understanding noncongruence in age of the typical bariatric versus arthroplasty patient; 2) determining whether or not primary care physicians and orthopedists who have patients with BMIs of greater than 35 presenting to their clinic with knee pain should consider referring those patients for evaluation by a bariatric clinic; and 3) determining when a “suboptimal” arthroplasty procedure is in the best interest of the patient. Bariatric patients tend to present at a younger age than the typical arthroplasty candidate. The youngest bariatric patients would generally not be considered for arthroplasty; however, patients progressing into their 40s to 50s may be a potential subset for future outcomes studies. If weight loss through invasive restrictive procedures or nonoperative

There is evidence that correlation exists between obesity and progression of knee pain.5–7 In the patient population with BMI in excess of 40, research indicates that these patients tend to have suboptimal postoperative arthroplasty results and a higher incidence of perioperative complications than their knee pain control peers. A gray area exists for patients with BMIs between 30 and 40 with a noted increasing trend to suboptimal results and higher complication rates but no definitive cutoff mark. 22

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methods can improve symptoms and delay the need for a primary orthopedic procedure, it may be worthwhile to further investigate outcomes of each population group as well as gain a better understanding of the pain response and symptom reporting as compared to current weight for bariatric patients. It may also be worthwhile to consider the appropriateness of arthroplasty in specific high BMI patients. Amin et al23 demonstrated a significant difference in Knee Society Scores between patients with obesity and control patients; however, an additional consideration may be that the arthroplasty patient with obesity may not need to generate the same quantitative score to experience an improvement in function and decrease in pain. Is it acceptable to expect less than standard results from the surgeon’s perspective as long as the patient is aware of the increased risks and diminished benefits when compared to patients with lower BMIs? There is evidence that correlation exists between obesity and progression of knee pain.5–7 In the patient population with BMI in excess of 40, research indicates that these patients tend to have suboptimal postoperative arthroplasty results and a higher incidence of perioperative complications than their knee pain control peers. A gray area exists for patients with BMIs between 30 and 40 with a noted increasing trend to suboptimal results and higher complication rates but no definitive cutoff mark. In limited studies, patients who require knee arthroplasty after bariatric surgery have done well, and long-term follow up of those patients will yield useful information. Presently, it may be worthwhile to consider a referral to a bariatric surgeon by a primary care physician or orthopedic surgeon for patients with obesity presenting with knee pain. After undergoing bariatric surgery, these patients may see improvement in the common comorbidities of high BMI patients as well as improvement in their osteoarthritic knee pain symptoms. This also generates the potential for delaying the need for any orthopedic surgical intervention and reducing the likelihood of perioperative complications and need for revision surgery should there be a need for arthroplasty in the future. Further study of outcomes of bariatric patients with osteoarthritic knee pain would be helpful to further delineate appropriate treatment protocols in the future.

8. 9.

10.

11.

12.

13.

14. 15.

16.

17.

REFERENCES 1.

Lawrence RC, Felson DT, Helmick CG, et al. Estimates of the prevalence of arthritis and other rheumatic conditions in the United States. Part II. Arthritis Rheum. 2008;58(1):26–35. Grotle M, Hagen KB, Natvig B, et al. Obesity and osteoarthritis in knee, hip and/or hand: An epidemiological study in the general population with 10

18.

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years follow-up. BMC Musculoskelet Disord. 2008;9:132. United States Obesity Trends. http://www.cdc.gov/obesity/data/trends.html. Accessed October, 28, 2009. Adults Reporting Joint Pain or Stiffness in the Past 30 Days, 2006. http://www.cdc.gov/Features/dsJointPain/. Accessed October 28, 2009. Stürmer T, Günther KP, Brenner H. Obesity, overweight and patterns of osteoarthritis: the Ulm Osteoarthritis Study. J Clin Epidemiol. 2000;53(3):307–313. Felson DT, Zhang Y, Hannan MT, et al. Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum. 1997;40(4):728–733. Gelber AC, Hochberg MC, Mead LA, et al. Body mass index in young men and the risk of subsequent knee and hip osteoarthritis. Am J Med. 1999;107(6):632–633. Hoppenfeld S. Physical Examination of the Spine and Extremities. Prentice Hall, Upper Saddle River, NJ, 1976. Kuster MS, Wood GA, Stachowiak GW, Gächter A. Joint load considerations in knee replacement. J Bone Joint Surg BR. 1997;79(1):109–113. Felson DT, Goggins J, Niu J, et al. The effect of body weight on progression of knee osteoarthritis is dependent on alignment. Arthritis Rheum. 2004;50(12):3904–3909. Niu J, Zhang YQ, Torner J, et al. Is obesity a risk factor for progressive radiographic knee osteoarthritis? Arthritis Rheum. 2009;61:329–335. Evaluation of Patients Presenting with Knee Pain. http://www.aafp.org/afp/20030901/917.html. Accessed October 28, 2009. Peltonen M, Lindroos AK, Torgerson JS. Musculoskeletal pain in the obese: a comparison with a general population and long-term changes after conventional and surgical obesity treatment. Pain. 2003;104:549–557. Klippel JH et al. Primer on Rheumatic Diseases, edition 12. Arthritis Foundation 2001: 295–296. Wilson JA, Romagnuolo J, Byrne TK, et al. Predictors of endoscopic findings after Roux-en-Y Gastric Bypass. Am J Gastroenterol. 2006;101(10):2194–2199. Fransen M, Crosbie J, Edmonds J. Physical therapy is effective for patients with osteoarthritis of the knee: a randomized controlled clinical trial. J Rheumatol. 2001;28(1):156–164. Piper SL, Kim HT. Comparison of ropivacaine and bupivacaine toxicity in human articular chondrocytes. J Bone Joint Surg Am. 2008;90:986–991. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine, chondroitin sulfate, and the two in combination for painful knee osteoarthritis. N Engl J Med. 2006;354(8):795–808. Gidwani S, Fairbank A. The orthopaedic approach to managing osteoarthritis of the knee. BMJ. 2004;329(7476):1220–1224.

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21.

22. 23.

24.

Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in morbidly obese patients. J Bone Joint Surg Am. 1998;80:1770–1774. Mantilla CB, Horlocker TT, Schroeder DR, et al. Risk factors for clinically relevant pulmonary embolism and deep venous thrombosis in patients undergoing primary hip or knee arthroplasty. Anesthesiology. 2003;99(3):552–560; discussion 5A. Gillespie GN, Porteous AJ. Obesity and knee arthroplasty. Knee. 2007; 14:81–86. Amin AK, Clayton RA, Patton JT, et al. Total knee replacements in morbidly obese patients. J Bone Joint Surg Br. 2006;88(10): 1321–1326. Parvizi J, Trousdale RT, Sarr MG. Total joint arthroplasty in patients surgically treated for morbid obesity. J Arthroplasty. 2000;15(8):1003–1008. BMI

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Hair Loss Among Weight Loss Surgery Patients by Silvia Leite Faria, MS; Orlando Pereira Faria, MD; Renato Diniz Lins, MD; and Heloisa Rodrigues de Gouvea

Bariatric surgery may lead to nutritional deficiencies due to reduced food intake, the scope of the surgery itself, rapid weight loss, inadequate absorption of nutrients, and the lack of adherence to supplement programs. This article provides an extensive review of current literature relating to hair loss in bariatric patients. A description of current methods of treatments is included. orbid obesity is a refractory disease related to diets and medication.1 Bariatric surgery is seen as the only effective treatment in such cases.2,3 Currently, surgical treatment of obesity is divided into the following two groups: 1) restrictive surgical procedures and 2) mixed surgical procedures, with the restrictive factor described as having more or less of a disabsorptive component. Malnutrition is a risk associated with all bariatric procedures, and hair loss is a frequent complaint that may be associated with nutritional factors, such as lower caloric intake and/or lower absorption of important nutrients for the maintenance and growth of hair.4 Hair loss can seriously impact the lives of individuals and may lead to anxiety, low self-esteem, psychosocial problems, and depression. As a consequence, hair loss can be a stress factor for this population.5,6 The aim of this article is to provide a comprehensive review of the literature on hair loss in patients undergoing bariatric surgery and provide clinicians with a description of the causes and recommended treatments.

LITERATURE SEARCH A broad review of the Medline and Pubmed databases for articles published between the years 1983 and 2009 was conducted, selecting articles related to humans. The key words used in the electronic search included the following: hair loss, bariatric surgery, alopecia, nutritional deficiencies,

biotin, zinc, iron, vitamin B12, and essential fatty acids. A total of 41 articles were found, of which 30 were selected. Among these, 15 were reviews, four compilations of guidelines, eight original articles, two clinical case studies, and one statement of the original article. Articles that addressed other causes of hair loss, outside of the area of nutrition, were excluded. Besides scientific articles, 10 chapters from books and one monograph were also examined.

CAUSES AND TREATMENTS OF HAIR LOSS The most likely causes of hair loss were found to be related to age, sex, disease, and genetic factors. It is therefore important to gather history of each patient who presents with hair loss regarding any current illness, recent illnesses, autoimmune diseases, family history of hair loss, food intake, medications, and the use of cosmetics harmful to the hair.5 Hair follicles have two stages: the anagen (hair growth) stage and the telogen (inactive) phase. All hairs begin their cycle in the anagen phase, grow for a period of time and move into the telogen phase, which lasts about 100 to 120 days. Then the hair falls out. This process, if accelerated, is called telogen effluvium and is the cause of hair loss in bariatric patients.7 The causes for telogen effluvium are drugs, surgery, fever, childbirth, diseases related to the thyroid, such as hyper- and

Ms. Faria is a nutritionist from Gastrocirurgia de Brasília, Brasília, Brazil and is also in private practice; Dr. Pereira Faria is a chief surgeon, Gastrocirurgia de Brasília, Brasília, Brazil; Dr. Lins is a medical doctor from Gastrocirurgia de Brasília, Brasília; and Ms. Rodrigues de Gouvêa is a nutritionist and trainee from Gastrocirurgia de Brasília, Brasília, Brazil. Copyright © 2012 MMC

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The nutrients possibly related to hair loss are protein, iron, zinc, essential fatty acids, vitamin B12, and biotin. hypothyroidism, rapid weight loss, anorexia, low protein intake, iron and zinc deficiency, and toxicity of heavy metals.4–6 In bariatric surgery, telogen effluvium may be associated with patients who are nonadherent to the supplement program or who have had rapid weight loss, difficulty in feeding themselves, or have poor dietary habits (e.g., food intolerances, especially with protein sources).4 Hair loss after bariatric surgery often occurs between the third and sixth month after surgery and can last 6 to 12 months or more. In the first six months, this framework can be reversed without intervention, although there is no consensus on treatment for these cases.8 After six months postsurgery, nutritional causes are involved in hair loss.4 In both cases, there is no harm to the follicle, so the hair can grow back.9 The nutrients possibly related to hair loss are protein, iron, zinc, essential fatty acids, vitamin B12, and biotin. Protein. Protein-energy deficiency is associated with increased hair loss.4,5 A protein deficiency can manifest itself through the reduction of hepatic proteins including albumin, loss of muscle mass, asthenia (weakness), and alopecia.10 Among the factors contributing to protein deficiency are the following: insufficient chewing, since food needs to be better digested in order to compensate for the mechanical barrier imposed by the weight loss surgery (WLS);10 reduction of the availability of pepsin, renin, and hydrochloric acid due to the isolation of the distal stomach, thus limiting protein digestion;11 anorexia; frequent episodes of vomiting; diarrhea; food intolerances; depression; fear of weight regain; abuse of alcohol or drugs; and socioeconomic status. Thus, all patients after surgery are at risk of developing protein deficiency in connection with restrictive and disabsorptive procedures.10 Patients who undergo Roux-en-Y gastric bypass (RYGB) usually have a low-calorie diet of 500 to 800kcal per day. Despite a calorie-protein increase during the first year, such intakes remain at insufficient levels.11 According to Marcason,12 the minimum recommended protein intake for bariatric patients is 60g per day, with emphasis on proteins of high biological value (HBV).12,13 However, in general, the recommended intake is 80g of protein for women and 100g for men per day or 1.5g/kg ideal weight.11,14 In cases of more disabsorptive surgery, such as biliopancreatic diversion (BPD), there is a raised malabsorption of protein. It is therefore recommended that patients intake at least 90g of protein.15 It is believed that a reduction in the availability of protein can cause thinning of the hair, difficulty in the normal hair growth process, and diffuse alopecia.16 In relation to essential amino acids, their deficiency can affect growth and differentiation of hair, since they compose 27 percent of the

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TABLE

1. Recommended micronutrient deficiencies

supplements

for

specific

NUTRIENT

RECOMMENDATION

Protein

Women: 80g/daya Men: 100g/daya

Biotin

2,5 mg/day

Flaxseed oil

2 capsules/day

Multivitamin/Multimineral

200% DRIb

Vitamin B12 (crystalline form)

350–500Ìg /day

Iron (ferrous fumarate or gluconate)c 320mg

320mg

Elemental iron

65mg

With adequate amounts of L–lysine: 1.5 to 2g/day Dietary Reference Intake (Daily Value) c Women in their fertile age b

protein content of hair.16 Among all essential amino acids, a deficiency of L-lysine, in particular, can contribute to hair loss while “full body supplies of L-lysine” improve hair growth after periods of decline and improve the levels of iron in the body. Its bioavailable form is primarily found in fish, meat and eggs and a decrease in consumption of these foods may cause a negative balance of this amino acid affecting hair growt.17 Thus, a supplementation of 1.5–2g of L-lysine is recommended.4 Iron. Iron is the micronutrient most related to hair loss. Its deficiency, in cases without anemia, was related to hair loss for the first time in the early 60s.18 In WLS, specifically RYGB, a decreased intake of foods rich in iron occur. Decreased absorption also occurs, since iron absorption is more efficient in the duodenum and adjacent parts of the jejunum, which are isolated in RYGB. Concomitant with this is a decrease in the reduction process of iron to its most bioavailable form, due to lower production of hydrochloric acid.10 For women, iron deficiency is more prevalent among those who are in a fertile age, and serum ferritin levels below 40Ìg are strongly associated with hair loss.4,10,19 Kantor et al20 related low concentrations of serum ferritin and hemoglobin with hair loss. Researchers have observed in cases of telogen effluvium that a significant number of people respond well when treated with iron. In a study by Rushton et al,21 researchers correlated low serum ferritin with hair loss among women treatment for six months with daily supplementation of 72mg of iron, and

Patients undergoing WLS may have hair loss after surgery due to the lower intake and inadequate absorption of protein, iron, biotin, zinc, vitamin B 12, and essential fatty acids. These patients need an adequate supplementation in order to prevent complications from evolving. 1.5g of L-lysine decreased the percentage of hairs in the telogen phase as well as the hair loss in 39 percent and increased levels of serum ferritin. Iron supplementation recommended for patients with hair loss is 320mg of ferrous fumarate or gluconate or 65mg of elemental iron twice a day, with a volume of approximately 25 percent ingested being absorbed.18,22 Parenteral infusion must be prescribed for bariatric patients who are refractory to iron supplementation or have anemia related to iron deficiency or hemoglobin serum levels below 11g/dL.23 Biotin. A biotin deficiency can cause depigmentation of hair and diffuse alopecia, since this vitamin plays an important role in the development of the hair follicles.16,24 It is believed that supplementation or topical use of biotin can prevent hair loss and accelerate growth after a period of decline.4 Such biotin deficiency related to hair loss was initially observed in patients undergoing total parenteral nutrition (TPN) without prolonged biotin. After starting their supplementation of biotin, patients undergoing TPN improved rapidly in terms of hair loss.9 In 2001, Bruginsky25 evaluated 118 patients and found that 17 percent of women reported alopecia due to surgery. Also, these women presented with inadequate intake of several nutrients, such as folic acid, retinol, fiber, vitamin C, and biotin. In a period of 30 days, the growth of hair in 100 percent of cases was observed after supplementation of 100mcg of biotin and other nutrients, such as folic acid, inositol, choline, B complex, that are known to boost the action of biotin. One must consider that the daily 1 to 2mg of biotin may provide clinical support to cases of hair loss not responding to other types of treatment.17 Daily consumption of 2.5mg was established as a safe limit of intake of biotin, the no observed adverse effects level (NOAEL).24 Zinc. Zinc has several functions and is an important factor for growth and development of hair. Its uptake can be assisted by the presence of glucose and amino acids in the intestinal tract and its deficiency can cause growth retardation, diarrhea, alopecia, skin lesions, and loss of appetite, among others problems.26,27 In cases of hair loss, a supplementation of 15mg/day of zinc chelate is recommended.28 The upper level is 40mg of zinc; a supplementation of 50mg over long periods can lead to copper deficiency.10 Essential fatty acids. Some studies have observed deficiency of essential fatty acids (linoleic and linolenic acids)

in patients after RYGB and adjustable gastric banding (AGB) since these procedures alter the digestion of lipids and, as a consequence, the uptake of essencial fatty acids.10,15,29 In relation to BPD and duodenal switch (DS), only 28 percent of ingested fat is absorbed.29 In patients with biotin deficiency, levels of linoleic acid lower than normal were observed. In cases of functional deficiency of biotin (due to lack of carboxylase) associated to hair loss, supplementation with polyunsaturated fatty acids may reduce this symptom, suggesting that hair loss can be caused by impairment of elongation of polyunsaturated fatty acids as a result of reduced activity of acetyl-CoA carboxylase.24 For patients post-RYGB, flaxseed oil (15mL) is recommended.15 The recommended dose of linolenic acid is 0.5 to 1.0 percent of energy intake and linoleic acid is from 3 to 5 percent. These amounts can be reached with two capsules of 1g of linseed oil and two tablespoons of extra virgin olive oil.22 Vitamin B12. It is known that the human body has stores of vitamin B12, on average, for 3 to 5 years dependent on one’s daily intake. However, since patients undergoing RYGB have lower production of hydrochloric acid and of the intrinsic factor, both of which are needed for its absorption in the terminal ileum, there may be deficiency of vitamin B12 if the supplementation is not adequate. Thus, RYGB patients have digestion, release, and absorption difficulties of vitamin B12.10 Brolin et al30 observed deficiency of vitamin B12 in patients six months after bariatric surgery, becoming more common after one year.10 Deficiency in B12 may alter the pigmentation of hair. This alteration can be reversed with B12 supplementation.16 The supplementation of vitamin B12 must be at least 350 to 500Ìg/day orally in its crystalline for, but patients may need a monthly intramuscular supplement of 1000Ìg.10,22

RECOMMENDATIONS Patients who present with hair loss six months postsurgery should follow the following recommendation daily: intake 80g of protein for women and 100g for men (with sufficient amounts of L-lysine, 1.5 to 2g/day), add 15 mL of flaxseed oil, 2.5g of biotin, one or two multivitamin capsules with minerals (thus providing 200 percent of DRIs), 350 to 500Ìg/day of B12 in its crystalline form, and 320mg of ferrous fumarate or gluconate or 65mg of elemental iron twice daily. (Table 1) The supplementation of zinc recommended in this article is already

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present in sufficient doses in multivitamins that contain minerals.

16.

CONCLUSION Patients undergoing WLS may have hair loss after surgery due to the lower intake and inadequate absorption of protein, iron, biotin, zinc, vitamin B 12, and essential fatty acids. These patients need an adequate supplementation in order to prevent complications from evolving. Further randomized studies on hair loss in bariatric patients are needed in order to know, with accuracy, the adequate levels of supplementation of these nutrients to be administered.

17. 18.

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Geiler CC, Blume-Peytavi U, Orfanos CE. Metabolic disorders involving the hair. In: Camacho FM, Randall VA, Price VH, eds. Hair and its Disorders. Biology, Pathology and Management. London: Martin Dunitz; 2000:275–282. Rushton DH. Nutritional factors and hair loss. Clin Exp Dermatol. 2002;27:396–404. Trost LB, Berfeld WF, Calogeras E. The diagnosis and treatment of iron deficiency and its potencial relationship to hair loss. J Am Acad Dermatol. 2006;54(5):824–844. Kushner R. Managing the obese patient after bariatric surgery: a case report of severe malnutrition and review of the literature. JPEN J Parenter Enteral Nutr. 2000;24:126–132. Kantor J, Kessler LJ, Brooks DG, et al. Decreased serum ferritin is associated with alopecia in women. J Invest Dermatol. 2003;121(5):985–988. Rushton DH, Norris MJ, Dover R, et al. Causes of hair loss and the developments in hair rejuvenation. Int J Cosmet Sci. 2002;24:17–23. Mechanick JI, Kushner RF, Surgeman HJ, et al. American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic and Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgical patient. Surg Obes Relat Dis. 2008;4(Supp):109S–184S. Malinowski SS. Nutritional and metabolic complications of bariatric surgery. Am J Med Sci. 2006;331(4):219–225. Vannucchi H, Chiarello PG. Biotin and Pantothenic Acid. In: Cozzolino SM, ed. Bioavailability of Nutrients, 2nd Ed. São Paulo: Manole; 2007:411. Bruginsky A. Biotin supplementation as a treatment for alopecia post gastroplasty. [Monograph]. Sao Paulo: Brazilian Institute of Homeopathic Studies. Specialization in Orthomolecular Nutrition and longevity. São Paulo, 2001:38. Yuyama LKO, Yonekura L, Aguiar JPL, Rodrigues ML, Cozzolino SM. Zinco. In: Cozzolino SM, ed. Biodisponibilidade de Nutrientes. Second Edition. São Paulo: Manole; 2007:549. Institute of Medicine (IOM). Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chomium, Cooper, Iodine, Iron, Manganese, Molybdenum, Nickel, Silicon, Vanadium and Zinc. Washington, DC: National Academy Press; 2001:420–441. Rhode BM, Maclean LD. Vitamin and mineral supplementation after gastric bypass. In: Deitel M, Cowan GSM, eds. Update: Surgery for the Morbidly Obese Patient. Toronto: FDCommunications Inc; 2000:161. Slater GH, Ren CF, Siegel N, et al. Serum fat-soluble vitamin deficiency and abnormal calcium metabolism after malabsorptive bariatric surgery. J Gastrointest Surg. 2004;8:48–55. Brolin RE, Gorman JH, Gorman RC, et al. Are vitamin B-12 and folate deficiency clinically important after Roux-en- Y gastric bypass? J Gastrointest Surg. 1998;2:436–42. BMI