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Short-term weight loss before surgery leads to better outcomes

Patients who lose at least 8 percent of excess weight just one month before the bariatric surgery have an increased probability of losing additional in the year following surgery, according to researchers from the University of South Carolina School of Medicine, Greenville, SC. Apart from surgery, diet and weight loss before the operation may also determine how successful a person is in losing weight during the first year after the procedure.

"Currently, controversy exists for the optimal preoperative dietary optimization of patients prior to bariatric surgery,” said study co-author John David Scott, associate professor of surgery, University of South Carolina School of Medicine, Greenville, and the metabolic and bariatric surgery director of Greenville Health System (GHS), SC. “On one side, insurance policies often mandate six or 12 month weight management programmes. This mandate is in direct contrast to many bariatric surgeons, who prefer to use short-term, calorie-restricted diets several weeks prior to surgery in order to optimize outcomes."

The paper, ‘Short-Term Preoperative Weight Loss and Postoperative Outcomes in Bariatric Surgery’, published in the Journal of the American College of Surgeons, sought to determine what impact short-term pre-operative excess weight loss (EWL) has on postoperative outcomes in patients undergoing primary vertical sleeve gastrectomy (SG, n=67) or Roux-en-Y gastric bypass (RYGB, n=188).

Led by Dr Deborah A Hutcheon, a clinical nutrition specialist at GHS, the study involved 355 patients who undertook the recommended four-week low-calorie diet before surgery, between January 2014 and January 2016 at GHS. The study patients were asked to lose at least 8 percent of their excess weight by following a 1,200 calorie diet for four weeks immediately preceding their operations. For the analysis, the patients were divided into two groups based on whether they actually achieved that weight loss goal (224 patients achieved that goal, and 131 did not). Primary endpoints included percent excess weight loss (% EWL) at one, three, six and 12 months postoperatively.

Patients achieving ≥8% EWL preoperatively experienced a greater %EWL at postoperative month three (42.3±13.2% vs 36.1±10.9%, p<0.001), month six (56.0±18.1% vs 47.5±14.1%, p<0.001), and month 12 (65.1±23.3% vs 55.7±22.2%, p=0.003). Median operative duration (117 minutes vs 125 minutes; p=0.061) and mean hospital length of stay (1.8 days vs 2.1 days; p=0.006) were also less in patients achieving ≥8% EWL.

There were no significant differences in follow-up, readmission or reoperation rates were seen. Linear regression analysis revealed that patients who achieved ≥8% EWL during the four-week low-calorie diet lost 7.5% more excess weight at postoperative month 12. This finding was consistent even when other factors such as age, gender, ethnicity, and health problems including high blood pressure and diabetes were considered.

Patients who lose some excess weight prior to weight loss surgery achieve greater weight loss after surgery, and also experience shorter hospital stays and shorter procedures (Credit: American College of Surgeons)

Hutcheon explained that there is this key window of opportunity after bariatric surgery, up to 18 months, when many physical and metabolic changes occur that help facilitate weight loss.

"After that time point, patients will have to rely on diet and exercise and lifestyle management to maintain that weight loss," she said. "One of the things we often say is bariatric surgery is a tool; it's not the end-all-be-all for weight loss. So it's really about making sure this tool is used wisely and proactively by our patients and having it work most effectively in the long run.”

Scott explained that the most important aspect of this study is that it adds to the body of research data showing that it is beneficial for bariatric surgery programmes to encourage and counsel patients to follow a short-term diet or aim to achieve weight loss prior to bariatric surgery.

"Our ultimate goal was to see what makes postoperative outcomes better for our patients undergoing this lifesaving procedure," he said. "We call it the honeymoon period of bariatric surgery. After a year or year and a half, your body starts to figure out what it can and can't do, and your behaviours may change a little bit, so the odds that you are going to lose a significant amount of weight after that time period are definitely decreased. Therefore, the more weight you can lose during that honeymoon period, the better, because that effort will help establish a set point, in terms of where your steady weight is going to be further down the road."

For future investigations, the researchers hope to explore the impact that pre-surgery weight-loss programs have on longer term (more than one year) surgical outcomes.

"Ultimately, we believe that preoperative preparation for bariatric surgery should be mediated by individual surgeons taking care of their patients and this 8 percent target should not be used as a hard set point to qualify patients for bariatric surgery,” he concluded. “Because patients with obesity who weren't able to achieve that 8 percent goal still had dramatic effects in terms of how much weight they lost and comorbidity resolutions."

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Short-term intragastric balloon treatment improves quality of life

Six-month treatment with intragastric balloon (IGB) was associated with significant weight loss and improvements in obese individuals with metabolic syndrome in their health-related quality of life (HRQoL), according to researchers from Federal University of Rio de Janeiro, Rio de Janeiro, Brazil. They reported that weight loss parameters were associated with short-term improvements in HRQoL, although only total fat was independently related to HRQOL perception. The paper, ‘Impact of 6 months of treatment with intragastric balloon on body fat and quality of life in obese individuals with metabolic syndrome’, published online in the journal - Health and Quality of Life Outcomes.

The aim of their study was to investigate the effect of six months of treatment with an IGB on HRQOL (including specific domains) in obese individuals with metabolic syndrome and its relationship with changes in body composition, including fat content measured by dual-energy X-ray densitometry (DXA).

The researchers recruited 50 patients from July 2011 to April 2012 and were implanted with a silicone IGB (Silimed Silicone Instrumental Médico Cirúrgico Hospitalar Ltda). The patients were subsequently followed for up to six months when the IGB was then removed.

The follow-up visits were performed at weeks 0 (baseline), eight, 16 and 24. During each visit, body weight (kg) and height (m) for calculation of their BMI was taken, as well as waist circumference (WC, cm). The body fat content (%) was evaluated at weeks 0 and 24 by DXA using a Prodigy-GE densitometer (GE Healthcare).

The authors utilised the World Health Organization Quality of Life (WHOQOL), an internationally widely used questionnaire to evaluate quality of life, translated and validated for the Brazilian population. This questionnaire evaluates and individual’s overall quality of life (question 1), general health (question 2), Physical Domain (pain, fatigue, energy, sleep, and rest), Psychological Domain (self-esteem, memory, positive and negative feelings, perceptions of body image, and appearance), Social Domain (assessment of personal relationships), and Environmental Domain (safety, financial resources, leisure time, home environment, transportation, convenience of getting information, and medical service). The WHOQOL-BREF questionnaire was applied to the study group at baseline and soon after removal of the IGB. WHOQOL-BREF was used with permission from WHO, even though the permission was obtained after the completion of the trial.

Of the 50 patients included in the protocol, 11 did not complete the study due to gastric intolerance in four, balloon rupture in five, uterus cancer in one and loss of follow-up in another one. Therefore, prospective data were analysed for 39 patients who completed the study.


The mean age of the cohort was 34.6±7.1 years and the mean BMI40.0±6.3. After six months of treatment with IGB, the mean reduction in weight, BMI, WC, fat free mass and total body fat analysed with DXA was 11.7±9.6kg (p<0.0001), 4.4±3.5kg/m2 (p<0.0001), 9.3±8.2 cm (p<0.0001), 3.7±4.8kg and 7.53±7.62kg (p<0.0001), respectively.

Patients who completed the study also displayed a significant improvement in almost all aspects of HRQOL measured by the WHOQOL-BREF, except the Social Domain, which presented only a trend toward significance.

The researchers then performed a correlation analysis to investigate whether the amount of weight loss would correlate with the improvement in different aspects of quality of life . The reduction in all markers of excess weight (BMI, WC, weight, and total fat [%]) was directly related to the improvement in general aspects of HRQOL (questions 1 and 2 of the WHOQOL-BREF).

These results were not observed for the specific domain of the questionnaires. For the Physical Domain, only the reduction in WC was associated with the improvement. For the Environmental Domain, only the reduction in body fat measured by DXA correlated with the improvement in the scores. Among all domains of the WHOQOL-BREF, Physicological did not meet the requirements.

Therefore, the authors stress that the results of their study are not applicable to patients with psychiatric syndromes and they state additional studies are necessary to clarify the impact of IGB in this specific population.

Multiple linear regression was used to identify which variables (anthropometric and DXA) independently correlated with the improvements in quality of life. ‘Question 1’ and ‘Question 2’ were used as the dependent variable and three different factors indicative of weight excess as independent variables (i.e., BMI, WC, fat free mass and total fat [%]).

Both models were also adjusted for age and gender. After regression, only total fat (%) remained independently related to question 1 (p=0.047). On the other hand, no variable (i.e. BMI, WC, and total fat [%]) reached statistical significance after regression for Question 2.

“Our study demonstrated that weight loss, particularly the reduction in body fat, was associated with improvement in general HRQOL,” the authors write. “These results strongly suggest that, although several different mechanisms may be proposed to explain the improvement in specific aspects of HRQoL after rapid weight loss, the reduction in body fat seems to be one of the main determinant in this improvement.”

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UK: Public do not recognise link between obesity and cancer

The majority of people in the United Kingdom do not understand the connection between weight issues and cancer, according to a study by Cancer Research UK. Despite the fact that 63% of the English and 67% of the Scottish adult population is overweight, only 25.4% of this population listed cancer as a health issue related to being overweight when asked an unprompted question.

The study, ‘Public awareness and healthcare professional advice for obesity as a risk factor for cancer in the UK: a cross-sectional survey’, published in the Journal of Public Health, after surveyed 3,293 adults, taken as representative of the UK population, researchers found that only a quarter of respondents were aware of the link between obesity and cancer

"We're very concerned that most people simply don't connect cancer with obesity. This study shows that only one in four know that excess weight increases the risk of cancer so we need to make the link very clear. This may go some way towards tackling the obesity epidemic which all too often begins in childhood,” said Dr Jyotsna Vohra from Cancer Research UK and study co-author. "Our study also showed that GPs aren't discussing weight with patients who are too heavy as often as they might. GPs have very little time during their appointments and should have more support to introduce sensitive issues such as obesity, with patients."

There study found that there were also several misconceptions about cancer types linked to obesity. Researchers found greater levels of awareness about cancers of the digestive system organs, than for those of the reproductive organs, such as womb or breast.

The study's authors also examined the impact of respondents' socio-economic background and found that those in a lower income group were more likely to be overweight or obese and were less aware of the link between weight issues and cancer. Modelled projections show obesity trends will increase by 2035 and the gap between the highest and lowest income groups will widen further.

Although there are currently several healthcare initiatives to address obesity issues, the study found that not all participants had seen a healthcare professional in the last 12 months. Of those who had, only 17.4% had received advice about their weight, despite 48.4% being overweight.

Those who received advice were mainly instructed on how to lose weight, rather than given information about the range of health issues associated with being overweight or obese.

“Cancer is not at the forefront of people’s minds when considering health conditions associated with overweight or obesity,” the authors concluded. “Socio-economic disparities exist in health knowledge across the UK population, with adults from more affluent groups being most aware. Healthcare professionals are uniquely positioned to provide advice about weight, but opportunities for intervention are currently under-utilised in healthcare settings

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