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Case study: a patient with diabetes and weight-loss surgery.

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Sue Cummings; Case Study: A Patient With Diabetes and Weight-Loss Surgery. Diabetes Spectr 1 July 2007; 20 (3): 173–176. https://doi.org/10.2337/diaspect.20.3.173

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A.W. is a 65-year-old man with type 2 diabetes who was referred by his primary care physician to the weight center for an evaluation of his obesity and recommendations for treatment options, including weight-loss surgery. The weight center has a team of obesity specialists, including an internist, a registered dietitian (RD), and a psychologist, who perform a comprehensive initial evaluation and make recommendations for obesity treatment. A.W. presented to the weight center team reluctant to consider weight-loss surgery;he is a radiologist and has seen patients who have had complications from bariatric surgery.

Pertinent medical history. A.W.'s current medications include 30 and 70 units of NPH insulin before breakfast and before or after dinner, respectively, 850 mg of metformin twice daily, atorvastatin,lisinopril, nifedipine, allopurinol, aspirin, and an over-the-counter vitamin B 12 supplement. He has sleep apnea but is not using his continuous positive airway pressure machine. He reports that his morning blood glucose levels are 100–130 mg/dl, his hemoglobin A 1c (A1C) level is 6.1%, which is within normal limits, his triglyceride level is 201 mg/dl, and serum insulin is 19 ulU/ml. He weighs 343 lb and is 72 inches tall, giving him a BMI of 46.6 kg/m 2 .

Weight history. A.W. developed obesity as a child and reports having gained weight every decade. He is at his highest adult weight with no indication that medications or medical complications contributed to his obesity. His family history is positive for obesity; his father and one sister are also obese.

Dieting history. A.W. has participated in both commercial and medical weight-loss programs but has regained any weight lost within months of discontinuing the programs. He has seen an RD for weight loss in the past and has also participated in a hospital-based, dietitian-led, group weight-loss program in which he lost some weight but regained it all. He has tried many self-directed diets, but has had no significant weight losses with these.

Food intake. A.W. eats three meals a day. Dinner, his largest meal of the day, is at 7:30 p . m . He usually does not plan a mid-afternoon snack but will eat food if it is left over from work meetings. He also eats an evening snack to avoid hypoglycemia. He reports eating in restaurants two or three times a week but says his fast-food consumption is limited to an occasional breakfast sandwich from Dunkin'Donuts. His alcohol intake consists of only an occasional glass of wine. He reports binge eating (described as eating an entire large package of cookies or a large amount of food at work lunches even if he is not hungry) about once a month, and says it is triggered by stress.

Social history. Recently divorced, A.W. is feeling depressed about his life situation and has financial problems and stressful changes occurring at work. He recently started living with his girlfriend, who does all of the cooking and grocery shopping for their household.

Motivation for weight loss. A.W. says he is concerned about his health and wants to get his life back under control. His girlfriend, who is thin and a healthy eater, has also been concerned about his weight. His primary care physician has been encouraging him to explore weight-loss surgery; he is now willing to learn more about surgical options. He says that if the weight center team's primary recommendation is for weight-loss surgery,he will consider it.

Does A.W. have contraindications to weight-loss surgery, and, if not, does he meet the criteria for weight-loss surgery?

What type of weight-loss surgery would be best for A.W.?

Roles of the obesity specialist team members

The role of the physician as an obesity specialist is to identify and evaluate obesity-related comorbidities and to exclude medically treatable causes of obesity. The physician assesses any need to adjust medications and,if possible, determines if the patient is on a weight-promoting medication that may be switched to a less weight-promoting medication.

The psychologist evaluates weight-loss surgery candidates for a multitude of factors, including the impact of weight on functioning, current psychological symptoms and stressors, psychosocial history, eating disorders,patients' treatment preferences and expectations, motivation, interpersonal consequences of weight loss, and issues of adherence to medical therapies.

The RD conducts a nutritional evaluation, which incorporates anthropometric measurements including height (every 5 years), weight (using standardized techniques and involving scales in a private location that can measure patients who weigh > 350 lb), neck circumference (a screening tool for sleep apnea), and waist circumference for patients with a BMI < 35 kg/m 2 . Other assessments include family weight history,environmental influences, eating patterns, and the nutritional quality of the diet. A thorough weight and dieting history is taken, including age of onset of overweight or obesity, highest and lowest adult weight, usual weight, types of diets and/or previous weight-loss medications, and the amount of weight lost and regained with each attempt. 1  

Importance of type of obesity

Childhood- and adolescent-onset obesity lead to hyperplasic obesity (large numbers of fat cells); patients presenting with hyperplasic and hypertrophic obesity (large-sized fat cells), as opposed to patients with hypertrophic obesity alone, are less likely to be able to maintain a BMI < 25 kg/m 2 , because fat cells can only be shrunk and not eliminated. This is true even after weight-loss surgery and may contribute to the variability in weight loss outcomes after weight loss surgery. Less than 5% of patients lose 100% of their excess body weight. 2 , 3  

Criteria and contraindications for weight-loss surgery

In 1998, the “Clinical Guidelines on the Identification, Evaluation,and Treatment of Overweight and Obesity in Adults: The Evidence Report” 4   recommended that weight-loss surgery be considered an option for carefully selected patients:

with clinically severe obesity (BMI ≥ 40 kg/m 2 or ≥ 35 kg/m 2 with comorbid conditions);

when less invasive methods of weight loss have failed; and

the patient is at high risk for obesity-associated morbidity or mortality.

Contraindications for weight-loss surgery include end-stage lung disease,unstable cardiovascular disease, multi-organ failure, gastric verices,uncontrolled psychiatric disorders, ongoing substance abuse, and noncompliance with current regimens.

A.W. had no contraindications for surgery and met the criteria for surgery,with a BMI of 46.6 kg/m 2 . He had made numerous previous attempts at weight loss, and he had obesity-related comorbidities, including diabetes,sleep apnea, hypertension, and hypercholesterolemia.

Types of procedures

The roux-en-Y gastric bypass (RYGB) surgery is the most common weight-loss procedure performed in the United States. However, the laparoscopic adjustable gastric band (LAGB) procedure has been gaining popularity among surgeons. Both procedures are restrictive, with no malabsorption of macronutrients. There is,however, malabsorption of micronutrients with the RYGB resulting from the bypassing of a major portion of the stomach and duodenum. The bypassed portion of the stomach produces the intrinsic factor needed for the absorption of vitamin B 12 . The duodenum is where many of the fat-soluble vitamins, B vitamins, calcium, and iron are absorbed. Patients undergoing RYGB must agree to take daily vitamin and mineral supplementation and to have yearly monitoring of nutritional status for life.

Weight loss after RYGB and LAGB

The goal of weight-loss surgery is to achieve and maintain a healthier body weight. Mean weight loss 2 years after gastric bypass is ∼ 65% of excess weight loss (EWL), which is defined as the number of pounds lost divided by the pounds of overweight before surgery. 5   When reviewing studies of weight-loss procedures, it is important to know whether EWL or total body weight loss is being measured. EWL is about double the percentage of total body weight loss; a 65% EWL represents about 32% loss of total body weight.

Most of the weight loss occurs in the first 6 months after surgery, with a continuation of gradual loss throughout the first 18–24 months. Many patients will regain 10–15% of the lost weight; a small number of patients regain a significant portion of their lost weight. 6   Data on long-term weight maintenance after surgery indicate that if weight loss has been maintained for 5 years, there is a > 95% likelihood that the patient will keep the weight off over the long term.

The mean percentage of EWL for LAGB is 47.5%. 3   Although the LAGB is considered a lower-risk surgery, initial weight loss and health benefits from the procedure are also lower than those of RYGB.

Weight-loss surgery and diabetes

After gastric bypass surgery, there is evidence of resolution of type 2 diabetes in some individuals, which has led some to suggest that surgery is a cure. 7   Two published studies by Schauer et al. 8   and Sugarman et al. 9   reported resolution in 83 and 86% of patients, respectively. Sjoström et al. 10   published 2-and 10-year data from the Swedish Obese Subjects (SOS) study of 4,047 morbidly obese subjects who underwent bariatric surgery and matched control subjects. At the end of 2 years, the incidence of diabetes in subjects who underwent bariatric surgery was 1.0%, compared to 8.0% in the control subjects. At 10 years, the incidence was 7.0 and 24.0%, respectively.

The resolution of diabetes often occurs before marked weight loss is achieved, often days after the surgery. Resolution of diabetes is more prevalent after gastric bypass than after gastric banding (83.7% for gastric bypass and 47.9% for gastric banding). 5   The LAGB requires adjusting (filling the band through a port placed under the skin),usually five to six times per year. Meta-analysis of available data shows slower weight loss and less improvement in comorbidities including diabetes compared to RYGB. 5  

A.W. had diabetes; therefore, the weight center team recommended the RYGB procedure.

Case study follow-up

A.W. had strong medical indications for surgery and met all other criteria outlined in current guidelines. 4   He attended a surgical orientation session that described his surgical options,reviewed the procedures (including their risks and possible complications),and provided him the opportunity to ask questions. This orientation was led by an RD, with surgeons and post–weight-loss surgical patients available to answer questions. After attending the orientation, A.W. felt better informed about the surgery and motivated to pursue this treatment.

The weight center evaluation team referred him to the surgeon for surgical evaluation. The surgeon agreed with the recommendation for RYGB surgery, and presurgical appointments and the surgery date were set. The surgeon encouraged A.W. to try to lose weight before surgery. 11  

Immediately post-surgery. The surgery went well. A.W.'s blood glucose levels on postoperative day 2 were 156 mg/dl at 9:15 a . m . and 147 mg/dl at 11:15 a . m . He was discharged from the hospital on that day on no diabetes medications and encouraged to follow a Stage II clear and full liquid diet( Table 1 ). 12  

Diet Stages After RYBG Surgery

On postoperative day 10, he returned to the weight center. He reported consuming 16 oz of Lactaid milk mixed with sugar-free Carnation Instant Breakfast and 8 oz of light yogurt, spread out over three to six meals per day. In addition, he was consuming 24 oz per day of clear liquids containing no sugar, calories, or carbonation. A.W.'s diet was advanced to Stage III,which included soft foods consisting primarily of protein sources (diced,ground, moist meat, fish, or poultry; beans; and/or dairy) and well-cooked vegetables. He also attended a nutrition group every 3 weeks, at which the RD assisted him in advancing his diet.

Two months post-surgery. A.W. was recovering well; he denied nausea, vomiting, diarrhea, or constipation. He was eating without difficulty and reported feeling no hunger. His fasting and pre-dinner blood glucose levels were consistently < 120 mg/dl, with no diabetes medications. He continued on allopurinol and atorvastatin and was taking a chewable daily multivitamin and chewable calcium citrate (1,000 mg/day in divided doses) with vitamin D (400 units). His weight was 293 lb, down 50 lb since the surgery. A pathology report from a liver biopsy showed mild to moderate steatatosis without hepatitis.

One year post-surgery. A.W.'s weight was 265 lb, down 78 lb since the surgery, and his weight loss had significantly slowed, as expected. He was no longer taking nifedipine or lisinipril but was restarted at 5 mg daily to achieve a systolic blood pressure < 120 mmHg. His atorvastatin was stopped because his blood lipid levels were appropriate (total cholesterol 117 mg/dl, triglycerides 77 mg/dl, HDL cholesterol 55 mg/dl, and LDL cholesterol 47 mg/dl). His gastroesophageal reflux disease has been resolved, and he continued on allopurinol for gout but had had no flare-ups since surgery. Knee pain caused by osteoarthritis was well controlled without anti-inflammatory medications, and he had no evidence of sleep apnea. Annual medical follow-up and nutritional laboratory measurements will include electrolytes, glucose,A1C, albumin, total protein, complete blood count, ferritin, iron, total iron binding capacity, calcium, parathyroid hormone, vitamin D, magnesium, vitamins B 1 and B 12 , and folate, as well as thyroid, liver, and kidney function tests and lipid measurements.

In summary, A.W. significantly benefited from undergoing RYBP surgery. By 1 year post-surgery, his BMI had decreased from 46.6 to 35.8 kg/m 2 ,and he continues to lose weight at a rate of ∼ 2 lb per month. His diabetes, sleep apnea, and hypercholesterolemia were resolved and he was able to control his blood pressure with one medication.

Clinical Pearls

Individuals considering weight loss surgery require rigorous presurgical evaluation, education, and preparation, as well as a comprehensive long-term postoperative program of surgical, medical, nutritional, and psychological follow-up.

Individuals with diabetes should consider the RYBP procedure because the data on resolution or significant improvement of diabetes after this procedure are very strong, and such improvements occur immediately. Resolution in or improvement of diabetes with the LAGB procedure are more likely to occur only after excess weight has been lost.

Individuals with diabetes undergoing weight loss surgery should be closely monitored; an inpatient protocol should be written regarding insulin regimens and sliding-scale use of insulin if needed. Patients should be educated regarding self-monitoring of blood glucose and the signs and symptoms of hypoglycemia. They should be given instructions on stopping or reducing medications as blood glucose levels normalize.

Patient undergoing RYGB must have lifetime multivitamin supplementation,including vitamins B 1 , B 12 , and D, biotin, and iron, as well as a calcium citrate supplement containing vitamin D (1,000–1,500 mg calcium per day). Nutritional laboratory measurements should be conducted yearly and deficiencies repleted as indicated for the duration of the patient's life.

Sue Cummings, MS, RD, LDN, is the clinical programs coordinator at the MGH Weight Center in Boston, Mass.

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Bariatric Surgery Case Study – Gastric Bypass with ICG Leak Test

Johns Hopkins Center for Bariatric Surgery, National Capital Region

Patient presentation

• A 38-year-old female with a history of class 3 obesity (BMI 45.9), gastroesophageal reflux disease (GERD), hypertension and sleep apnea presented with multiple failed attempts at medical weight-loss. She was initially interested in a minimally invasive sleeve gastrectomy, but a gastric bypass was recommended due to her history of GERD. A sleeve gastrectomy can worsen heartburn postoperatively, but a gastric bypass is a surgical treatment for both morbid obesity as well as GERD. The patient was evaluated by the bariatric multidisciplinary team at Sibley Memorial Hospital and approved for surgery.

Treatments received

• The patient underwent a minimally invasive Roux-en-Y gastric bypass using the latest camera technology. After her procedure, a new technique was used to test the gastro-jejunal anastomosis for any signs of a leak. A novel fluid solution containing indocyanine green dye was instilled into the stomach, and a laparoscopic camera with near-infrared fluorescence visualization was used to transilluminate the anastomosis. It gave real-time feedback and confirmed no leak was present.

 Patient outcome after surgery

• The patient was kept overnight and discharged the following day after passing an oral fluid challenge. She was seen two weeks later and was feeling well, tolerating a soft diet and already beginning to see weight loss results.

Johns Hopkins Center for Bariatric Surgery at Sibley Memorial Hospital in Washington, D.C., is accredited from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) as a Comprehensive Center with Adult Qualifications. The team performs open and minimally invasive surgery using state-of-the art equipment. In addition to surgery, the multidisciplinary team provides nutrition counseling, exercise training and close follow-up after surgery. 

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A review on bariatric surgery

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Obesity Case Management: Bariatric Surgery

• First Online: 04 January 2022

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• Bon Hyang Lee 2 &
• Katherine Samaras 2 , 3  

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Bariatric surgery is indicated in those with BMI ≥40 kg/m 2 or ≥35 kg/m 2 with one or more obesity-related complications. Common bariatric surgeries include sleeve gastrectomy; Roux-en-Y gastric bypass; and, less commonly, biliopancreatic diversion with or without duodenal switch. Preoperatively, surgical candidates are ideally placed on a very low-energy diet to reduce the size of the liver, mitigating the intraoperative risk associated with manipulating the liver to gain optimal surgical view. In people with diabetes, glycaemic control should be optimised preoperatively, with careful titration of glucose-lowering medications during calorie restriction, to minimise the risk of hypoglycaemia. Post bariatric surgery, life-long commitment to dietetic monitoring and medical monitoring of electrolytes and micronutrients are required to avoid complications. Adjustments to glucose-lowering, antihypertensive and lipid-lowering medications may be required weeks to years after surgery. The benefits of bariatric surgery are well established resulting in significant weight loss and improved cardiometabolic and cancer outcomes.

• Bariatric surgery
• Very low-energy diet (VLED)
• Sleeve gastrectomy
• Biliopancreatic diversion

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Mechanick JI, Apovian C, Brethauer S, Garvey WT, Joffe AM, Kim J, Kushner RF, Lindquist R, Pessah-Pollack R, Seger J, Urman RD, Adams S, Cleek JB, Correa R, Figaro MK, Flanders K, Grams J, Hurley DL, Kothari S, Seger MV, Still CD. Clinical practice guidelines for the perioperative nutrition, metabolic, and nonsurgical support of patients undergoing bariatric procedures – 2019 update: cosponsored by American Association of Clinical Endocrinologists/American College of endocrinology, the Obesity society, American Society for Metabolic & Bariatric Surgery, Obesity Medicine Association, and American Society of Anaesthesiologists – Executive Summary. Endocr Pract. 2019;25(12):1346–59.

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Bon Hyang Lee & Katherine Samaras

Clinical Obesity, Nutrition and Adipose Biology Laboratory, Healthy Ageing Theme, Garvan Institute of Medical Research, Darlinghurst, NSW, Australia

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Lee, B.H., Samaras, K. (2022). Obesity Case Management: Bariatric Surgery. In: Davies, T.F. (eds) A Case-Based Guide to Clinical Endocrinology. Springer, Cham. https://doi.org/10.1007/978-3-030-84367-0_47

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Efficacy of laparoscopic sleeve gastrectomy for patient with morbid obesity and type 1 diabetes mellitus: a case report

• Hidetaka Ichikawa 1 ,
• Hirofumi Imoto   ORCID: orcid.org/0000-0003-2037-4643 1 ,
• Naoki Tanaka 1 ,
• Hiroaki Musha 1 ,
• Shojiro Sawada 2 , 4 ,
• Takeshi Naitoh 1 , 3 ,
• Takashi Kamei 1 &
• Michiaki Unno 1  

Surgical Case Reports volume  7 , Article number:  7 ( 2021 ) Cite this article

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Bariatric surgery is effective for the treatment of patients with morbid obesity and type 2 diabetes mellitus (T2DM), for body weight loss and glycemic control. However, in Japan, there has been no previous report of the effectiveness bariatric surgery in a case of morbid obesity associated with acute onset type 1 diabetes mellitus (T1DM), in which pancreatic β-cells were destroyed and endogenous insulin was depleted.

Case presentation

A 36-year-old woman with morbid obesity and T1DM, diagnosed when she was 6 years, was admitted for bariatric surgery. At her first consultation, she had a body weight of 106.7 kg and a body mass index of 42.2 kg/m 2 . Her HbA1c level was 9.0%, with a required daily insulin dose of 75 units. She underwent laparoscopic sleeve gastrectomy. At 1 year after surgery, her body weight had decreased to 81.0 kg and her body mass index to 32.2 kg/m 2 . In addition, her daily required dose of insulin had decreased to 24 units, with an improvement in her HbA1c level to 7.7%.

Conclusions

Although further evidence needs to be accumulated, including long-term outcomes, laparoscopic sleeve gastrectomy may provide an effective treatment for patients with morbid obesity and T1DM for body weight loss, improvement in HbA1c level, and insulin dose reduction.

Bariatric surgery for morbid obesity is widely performed around the world [ 1 ], with demonstrated effectiveness in improving type 2 diabetes mellitus (T2DM) [ 2 , 3 ]. Furthermore, the improvement effect on glycemic control after this surgery are observed prior to body weight loss, with the metabolic effects being markedly greater than can be explained by the loss of body weight alone. In recent years, "Metabolic Surgery" has been introduced as a new concept. However, it is not clear how this concept might apply differently to type 1 diabetes mellitus (T1DM) compared to T2DM.

T1DM is a disease in which pancreatic β-cells are destroyed and insulin secretion becomes impaired. Almost in the same way as T2DM, failure of glycemic control in the chronic phase of T1DM can lead to microangiopathy (retinopathy, nephropathy, neuropathy) and macroangiopathy (atherosclerosis), which can worsen the prognostic outcomes of patients. The main treatment for T1DM is insulin therapy. In recent years, the number of patients with morbid obesity and T1DM has increased. Bae et al. reported that analyzed electronic health records in the United States estimated that 47.8% of patients with T1DM are obese [ 4 ]. Several studies on the usefulness of bariatric surgery for these cases having emerged [ 5 , 6 , 7 , 8 , 9 ]. In Japan, only two studies have described the effect of bariatric surgery on slowly progressive insulin-dependent diabetes mellitus (SPIDDM), which is included in T1DM [ 10 , 11 ], and no studies on bariatric surgery for patients with severe obesity and T1DM with insulin secretion deficiency. In this case report, we describe the effectiveness of laparoscopic sleeve gastrectomy (LSG), by reducing the size of the stomach, in a patient with morbid obesity and T1DM, without endogenous insulin, achieving weight loss, a marked reduction in insulin requirement, and improved glycemic control.

A 36-year-old Japanese female was referred to our hospital with morbid obesity and T1DM. She was diagnosed with T1DM at the age of 6 years, thereafter, treatment with multiple daily insulin was started. By the age of 20 years, she had a body weight of 70 kg, increasing to > 100 kg at the age of 34 years. Her required daily dose of insulin increased as a function of her body weight. At her initial assessment, she required 45 units of insulin aspart and 30 units of insulin glargine per day. Although a temporary weight loss and reduction in daily insulin dose was achieved with an in-hospital treatment, her weight rebounded shortly after discharge and the patient experienced difficulty in controlling her body weight. The patient expressed her intention for surgical treatment for weight loss, and she was referred to our department.

At the time of admission, her height was 159 cm and her weight 106.7 kg, BMI of 42.2 kg/m 2 . Blood analyses indicated HbA1c of 9.0%, and blood C-peptide levels were undetectable (< 0.01 ng/mL), suggesting her insulin secretion capacity was completely depleted. With medication, her blood lipid levels were within normal range. On computed tomography (CT) examination, the calculated visceral fat area was 162.6 cm 2 , with a subcutaneous fat area of 527.9 cm 2 , measured at level of the umbilicus (Fig.  1 a, b). Upper gastrointestinal endoscopy revealed no abnormalities in the esophagus, stomach, or duodenum.

Computed tomography images. a Overall image before surgery, showing b a preoperative visceral fat area of 162.6 cm 2 and subcutaneous fat area of 527.9 cm 2 . c Overall image, 1-year after the surgical procedure, showing a decrease in d the visceral fat area to 44.8 cm 2 and the subcutaneous fat area to 408.8 cm 2

To prevent complications associated with rapid postoperative blood glucose improvement, she was admitted to our hospital 2 weeks before operation for strict glycemic control, dietary restrictions, and exercise therapy. As a result, preoperative HbA1c was reduced to 7.8% and body weight was reduced to 101.1 kg.

We performed a laparoscopic sleeve gastrectomy (LSG) [ 12 ], using five ports,, as shown in Fig.  2 a. The blood vessel along the wall of the greater curvature of the stomach was first dissected. We then inserted a 36 Fr (12 mm) bougie into the stomach and resected the greater curvature of the stomach, from a point, on the oral side, 4 cm from the pylorus to the His angle, using a linear stapler. The staple line was reinforced with continuous seromuscular sutures using non-absorbable stitches (Fig.  2 b, c).

Surgical schema and gastric tube. a Schema of skin incisions (red lines), with the layout and size of ports shown. b Surgical schema, showing a drain placed below the left diaphragm. c Intraoperative photograph, with the complete gastric tube shown

After the operation, a unit of insulin aspart was mixed with 5 g of glucose contained in the infusion solution and sliding scale insulin was added as needed. From postoperative day 2, insulin glargine was administered. Sliding scale insulin was added depending on fasting blood sugar level and oral intake and her daily insulin dose was determined accordingly.

There were no postoperative complications, including severe hypoglycemic episodes. One year after the procedure, her body weight had decreased to 81.0 kg, with a BMI of 32.2 kg/m 2 , with this decrease being mainly due to a decrease in the body fat mass. Her HbA1c level improved to 7.7%, and her daily required insulin dose had been reduced to 24 units (10 units of insulin aspart and 14 units of insulin glargine per day: Fig.  3 a–d). On abdominal CT images, the visceral fat area, measured at level of the umbilicus, was 44.8 cm 2 , with a subcutaneous fat area of 408.8 cm 2 (Fig.  1 c, d). Therefore, there was a marked decrease in both visceral and subcutaneous fat.

Postoperative changes. The change, from preoperative to 12 months postoperatively, in a body weight, body mass index (BMI); b skeletal muscle mass and body fat mass; c HbA1c; and d insulin dose/day. At 1-year after the procedure, the patient’s body weight had decreased to 81 kg and her BMI to 32.2 kg/m 2 , mainly due to a decrease in body fat mass, with the skeletal muscle mass being maintained. The HbA1c level improved to 7.7%, and the daily insulin dose required reduced to 24 units

According to the International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO), about 340,000 bariatric surgeries were performed, worldwide, in 2008, with this number doubling by 2016 to over 680,000, most of which were performed laparoscopically [ 1 ]. In Japan, only LSG has been covered by national insurance since 2014, with the number of LSG procedures performed having increased every year since then. It is well known that bariatric surgery is effective for weight-loss effect, as well as improving T2DM for a prolonged period after surgery [ 2 , 3 ] and lowering the risk for obesity-related diseases, such as cardiovascular disorders [ 13 ]. However, there are few reports of the therapeutic effect of LSG in patients with T1DM, and it has not yet been elucidated and remains controversial.

T1DM is caused by the destruction of pancreatic β cells due to the interaction between genetic factors, environmental factors, and autoimmune mechanisms. According to a survey of the incidence of childhood T1DM in countries around the world, the age-adjusted incidence is high in Europe and in the United States, and low in Japan, at about 2.37 per 10,000 individuals [ 14 , 15 ]. T1DM presents with a variety of clinical features and is classified into three types, according to the mode of onset: typical acute-onset type; SPIDDM, which presents with T2DM pathology at the time of diagnosis and endogenous insulin secretion gradually decreases, with progression to insulin dependence; and fulminant type, characterized by a rapid destruction of pancreatic β cells, leading to severe hyperglycemia which can sometimes be fatal. For all three types of T1DM, insulin therapy is the main treatment. Poor glycemic control over a prolonged period of time causes microangiopathy (retinopathy, nephropathy, neuropathy) and macroangiopathy (atherosclerosis), as with T2DM, with a significant negative impact on patient prognosis.

The cause of poor glycemic control in T2DM is mainly due to obesity and insulin resistance. This is important to note as the rate of obesity among adults with T1DM has been increasing. In recent years, the concept of “double diabetes” [ 16 , 17 ] has been proposed. This is a new expression of the disease in children and adolescents, with the characteristics of a mixture of the two types of diabetes as patients with T1DM diagnosed in infancy acquire the T2DM factor from adolescence to adulthood. This mixed presentation induces obesity and insulin resistance, which leads to poor glycemic control and an increase in the amount of required daily insulin.

There have been a few reports on the efficacy of bariatric surgery in patients with morbid obesity and T1DM [ 5 , 6 , 7 , 8 , 9 ]. The systematic review by Chow et al. summarizes the outcomes of bariatric surgery in 86 patients with T1DM [ 5 ]. Before surgery, the average BMI was 42.5 ± 2.65 kg/m 2 , with an average HbA1c level of 8.46 ± 0.78% and average required insulin dose of 98 ± 26 IU/day. One year after surgery, the BMI had decreased to 29.55 ± 1.76 kg/m 2 , the HbA1c level to 7.95 ± 0.55%, and the required insulin dose to 36 ± 15 IU/day. Furthermore, the risk for obesity-related diseases had also been reduced after surgery [ 8 , 9 ].

In Japan, bariatric surgery for T1DM has been reported only for cases of SPIDDM [ 10 , 11 ]; in these cases, it was possible to reduce or discontinue insulin preparations and oral glycemic drugs after surgery. As an explanatory mechanism, the authors proposed that postoperative weight loss improved insulin resistance, resulting in a protective effect on residual pancreatic β cells. However, there has been no previous report of the effectiveness bariatric surgery in a case of morbid obesity associated with typical acute-onset T1DM, in which pancreatic β-cells were destroyed and endogenous insulin was depleted. This is the first case report of typical acute-onset T1DM with endogenous insulin depletion in Japan. In this case, weight loss and improved glycemic control were achieved in the postoperative follow up period, especially the amount of daily insulin requirement was decreased more dramatically than the weight reduction. This suggests that the observed metabolic effect is not just as a result of the restrictive effect of the surgery or due to the loss in body weight alone. In considering this mechanism of improvement, the concept of “double diabetes” [ 16 , 17 ] is thought to be useful. In other words, it is presumed that the effectiveness of the bariatric surgery is mediated by an improvement in the T2DM factor among patients with double diabetes. Ashrafian et al. reported that after bariatric surgery, β cell dysfunction persisted and, thus, patient still required baseline insulin therapy, although the overall insulin requirement was reduced [ 7 ]. Incretin hormones may also play an important role. In T2DM, change in the dynamics of incretin hormone secretion, such as glucagon-like peptide-1 (GLP-1), after gastric bypass surgery, contributes to the postoperative improvement in glycemic control [ 18 ]. It is plausible that incretin hormones may also contribute to the improvement of glucose metabolism in patients with T1DM after bariatric surgery through an inhibition of glucagon secretion via α cells, even in patients without residual β cells [ 19 ]. However, the underlying mechanisms remain to be elucidated.

Our case shows the possible usefulness of bariatric surgery for the treatment of patients with morbid obesity and T1DM, without endogenous insulin, to achieve postoperative weight loss and to improve glycemic control 1 year after surgery. On the other hand, Vilarrasa et al. described that HbA1c, which had improved in the first year after surgery, returned to the preoperative baseline after 5 years [ 6 ]; therefore, our case also requires long-term strict follow-up. Accumulation of more cases and evaluation of long-term results are warranted to improve our understanding of the role of bariatric surgery for patients with obesity and T1DM.

In the short term, LSG would provide an effective treatment strategy for patients with morbid obesity and T1DM to achieve body weight loss, improve HbA1c level, and reduce the required daily insulin dose.

Availability of data and materials

The dataset supporting the conclusions of this article is included within the article.

Abbreviations

Type 2 diabetes mellitus

• Type 1 diabetes mellitus
• Laparoscopic sleeve gastrectomy

Computed tomography

Slow progressive insulin dependent diabetes mellitus

Glucagon-like peptide-1

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We would like to thank Editage ( https://www.editage.jp ) for English language editing.

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Department of Surgery, Tohoku University Graduate School of Medicine, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan

Hidetaka Ichikawa, Hirofumi Imoto, Naoki Tanaka, Hiroaki Musha, Takeshi Naitoh, Takashi Kamei & Michiaki Unno

Department of Metabolism and Diabetes, Tohoku University Graduate School of Medicine, 1-1, Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan

Shojiro Sawada

Department of Colorectal Surgery, Kitasato University School of Medicine, 1-15-1, Kitasato, Minami-ku, Sagamihara, 252-0374, Japan

Takeshi Naitoh

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HI contributed to drafting the manuscript and study design and concept. HI, HI, NT, HM, SS, TN, TK, and MU performed critical revision of the manuscript. MU provided final approval of the manuscript. All authors read and approved the final manuscript.

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Ichikawa, H., Imoto, H., Tanaka, N. et al. Efficacy of laparoscopic sleeve gastrectomy for patient with morbid obesity and type 1 diabetes mellitus: a case report. surg case rep 7 , 7 (2021). https://doi.org/10.1186/s40792-020-00989-5

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• Morbid obesity
• Metabolic surgery

Nurse-led case management of bariatric-surgery patients shows promise

Nurse-led case management for bariatric surgery patients offered better outcomes compared to usual care, a literature review indicates.

A review of 10 studies found that a multidisciplinary approach that began in the preoperative period and emphasized behavioral change offered better results, including increased weight loss and physical activity as well as improved quality of life.

“The care planning and the interventions found in the selected studies revealed a diversity of findings that mostly converge on a PCC ( Patient-centered Care ) model,” wrote the authors in their study published in Obesity Reviews . “The PCC models promote a notably increased adherence to the treatment and patient satisfaction supported by patient-centered communication.”

The authors note, however, that it is unclear how long these interventions should last. Most of the studies they looked at started behavioral intervention prior to survey but only one was still being evaluated a year after. They note that other research has suggested that post-surgery intervention should be longer than six months.

Weight loss during the first six months is a result of surgery, but that’s also the time when adoption of long-term lifestyle changes is more likely to occur.

The multidisciplinary nature of the team working with bariatric-surgery patients makes coordination key.

“Behavioral change and self-management of these patients are the main focus of the interventions. Factors addressed by the multidisciplinary team responsible for the follow up are dietary and exercise guidance to continue the path to weight loss and reduction of comorbidities along with increased self-esteem and the sense of well-being,” they conclude. “Case- managing highlights the importance of continuous monitoring in the long-term, tackling these interventions as chronic disease management interventions.”

The views and opinions expressed here are those of the author and do not necessarily reflect the opinions or recommendations of the American Nurses Association, the Editorial Advisory Board members, or the Publisher, Editors and staff of American Nurse Journal . This has not been peer reviewed.

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Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study

• Brit Torunn Bechensteen 1 , 2 ,
• Cindhya Sithiravel 3 ,
• Ellen Marie Strøm-Roum 4 ,
• Heidi Kathrine Ruud 2 ,
• Gunnhild Kravdal 3 ,
• Jacob A. Winther 1 &
• Tone G. Valderhaug 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  229 ( 2024 ) Cite this article

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Maternal obesity is associated with adverse outcome for pregnancy and childbirths. While bariatric surgery may improve fertility and reduce the risk of certain pregnancy-related complications such as hypertension and gestational diabetes mellitus, there is a lack of evidence on the optimal nutritional monitoring and supplementation strategies in pregnancy following bariatric surgery. We aimed to assess the impact of bariatric surgery on micronutrients in post-bariatric pregnancy and possible differences between gastric bypass surgery and sleeve gastrectomy.

In this prospective case control study, we recruited 204 pregnant women (bariatric surgery n  = 59 [gastric bypass surgery n  = 26, sleeve gastrectomy n  = 31, missing n  = 2] and controls n  = 145) from Akershus university hospital in Norway. Women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17–20. A clinical questionnaire was completed and blood samples were drawn at mean gestational week 20.4 (SD 4.5).

The women with bariatric surgery had a higher pre-pregnant BMI than controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m2, p  < 0.001). There were no differences between groups regarding maternal weight gain (bariatric surgery 13.3 kg (9.6) vs. control 14.8 kg (6.5), p  = 0.228) or development of gestational diabetes ( n  = 3 [5%] vs. n  = 7 [5%], p  = 1.000). Mean levels of vitamin K1 was lower after bariatric surgery compared with controls (0.29 [0.35] vs. 0.61 [0.65] ng/mL, p  < 0.001). Multiadjusted regression analyses revealed an inverse relationship between bariatric surgery and vitamin K1 (B -0.26 ng/mL [95% CI -0.51, -0.04], p  = 0.047) with a fivefold increased risk of vitamin K1 deficiency in post-bariatric pregnancies compared with controls (OR 5.69 [1.05, 30.77] p  = 0.044). Compared with sleeve gastrectomy, having a previous gastric bypass surgery was associated with higher risk of vitamin K1 deficiency (OR 17.1 [1.31, 223.3], p  = 0.030).

Post-bariatric pregnancy is negatively associated with vitamin K1 with a higher risk of vitamin K1 deficiency in pregnancies after gastric bypass surgery compared with after sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be explored in future studies.

Peer Review reports

Obesity is common in women of reproductive age, increasing the risk of several complications for mother and child [ 1 , 2 ]. Maternal metabolism in obesity may reduce the likelihood of successful pregnancy [ 3 ]. Moreover, given that weight loss before pregnancy mitigates the adverse outcomes of pregnancy related outcomes from obesity, bariatric surgery in women of reproductive age in increasing [ 4 , 5 ]. However, although bariatric surgery may reduce the risks of certain obesity related complications in pregnancy, pregnancy after bariatric surgery may carry adverse events such as malnutrition, vitamin deficiencies and inadequate weight gain as well as changes in endocrine and metabolic homeostasis [ 6 , 7 , 8 , 9 , 10 ]. Pregnancy following bariatric surgery has been associated with increased risk of preterm birth, nutritional deficiency and small for gestational age [ 7 , 8 , 11 , 12 , 13 , 14 ]. The causality of these effects are not known, but personalized nutritional counseling during post-bariatric pregnancy has been shown to improve nutrient intake of mothers and may contribute to higher weight of offspring [ 15 ].

There is a growing body of evidence suggesting that maternal nutrition and lifestyle affect fetal growth and development [ 16 , 17 ]. Micronutrients are vitamins and minerals that enable the body to produce enzymes, hormones and other substances essential for normal growth and development [ 18 ]. Micronutrient deficiencies contribute to poor growth, intellectual impairments and increased risk of morbidity and mortality [ 19 ]. Widespread global micronutrient deficiencies exist, with pregnant women and young children at highest risk [ 19 ]. Micronutrient interventions such as supplementation of folate to prevent neural tube defects zinc to reduce risk of preterm birth, and iron to reduce the risk of low birthweight are established [ 20 , 21 , 22 ]. The micronutritional deficiencies seen after bariatric surgery might be explained by poor dietary pattern in combination with gastrointestinal modification and reduced intestinal transit time [ 23 , 24 , 25 , 26 , 27 ]. Deficiencies of fatty soluble vitamins seem to be particularly prevalent in post-bariatric pregnancies, with potential risks of impaired vision, neuronal disorders, impairment of the immune system and hypocoagulability for mother and child [ 24 , 28 , 29 , 30 ].

While sleeve gastrectomy is the most common surgical procedure for the treatment of obesity worldwide, there is conflicting evidence on the optimal surgical procedure before subsequent pregnancy [ 10 , 31 ]. A large registry study showed no difference between gastric bypass and sleeve gastrectomy for preterm birth or small for gestational age [ 12 ]. Studies indicates increased risk of prematurity in pregnancy occurring less than 2 years after bariatric surgery [ 12 , 32 ]. However, other studies have not confirmed increased risks in pregnancies related to time-interval between bariatric surgery and conception [ 13 , 33 ]. As such, there is an evident knowledge gap on the impact of bariatric surgery on micronutrient status in pregnancies as well as outcomes for mother and child in order to provide optimal obstetric care in this group.

The aim of this study was to assess the impact of bariatric surgery on concentrations of micronutrients in post-bariatric pregnancies compared with non-surgical controls. Specifically, we hypothesized that fatty soluble micronutrients, including vitamin K1, was impaired after bariatric surgery. We also wanted to assess differences in maternal micronutrients concentrations following sleeve gastrectomy versus gastric bariatric surgery.

Materials and methods

Design and study population.

This observational case control study compared micronutritional status in pregnancy after bariatric surgery with non-surgical controls. Study participants were recruited from Akershus university hospital, between October 18th 2018 and December 9th 2022. Pregnant women with previous bariatric surgery were consecutively invited to study participation at referral to the clinic for morbid obesity and the controls were recruited from the routine ultrasound screening in gestational week 17–20. A total of 59 women with a previous bariatric surgery was included in the study and information on surgical procedure was available for 57 women (gastric bypass surgery n  = 26 and sleeve gastrectomy n  = 31). All women with post-bariatric pregnancies were closely monitored individually by a clinical doctor and a registered clinical dietitian focusing on micronutrient status and gestational weight gain. The controls received standard hospital care and dietary advice with additional advice if the blood samples revealed deficiencies.

A total of 204 women were included in this study with 92% of Caucasian ethnicity ( n  = 185). We compared micronutrient status in pregnancy in women with previous bariatric surgery ( n  = 59) to controls ( n  = 145). Women with known intestinal conditions (i.e. known inflammatory bowel disease, uncontrolled coeliac disease) were not included in the study. The study was approved by the Regional Committee for Medical and Health Research Ethics (reference 25829). All study participants provided written informed consent before study commencement, and the study was performed in accordance with the Declaration of Helsinki [ 34 ].

Definitions

The reference intervals for micronutrients in non-pregnant women and the chosen cut-offs defining micronutrient deficiencies in pregnancy are presented in Table  1 . We defined micronutrient deficiency according to known physiological changes in blood during pregnancy combined with established reference intervals in a non-pregnant population [ 30 , 35 , 36 , 37 ]. Time interval between bariatric surgery and conception was categorized into < 18 and ≥ 18 months.

Data collection

Clinical and laboratory data were retrieved at mean gestational week 20.4 (SD 4.5) (Bariatric surgery 23.9 [6.5] vs. controls 19.0 [2.0] weeks, p  < 0.001). Follow-up blood sample was available in a subgroup of 32 women with post-bariatric pregnancies at mean 30.4 (SD 5.6) gestational week. All patients completed a questionnaire on comorbidities, medications and dietary supplements. Additional information including maximum weight, time of bariatric surgery, type of bariatric surgery was retrieved during the first visit.

Blood samples and analysis

The blood samples were obtained by venipuncture and collected in Vacuette® tubes. EDTA tubes were used for analysis of hemoglobin, hemoglobin A1c and thiamine (vitamin B1). Lithium heparin gel tubes were used for analysis of zinc and selenium, and serum gel tubes for the remaining analyses. All the blood samples were non-fasting. After blood collection, all tubes were handled according to established procedures. The standard clinical chemistry parameters were analysed at the laboratory at Akershus University Hospital. Hemoglobin was analysed on Sysmex instruments (Sysmex Corporation, Kobe, Japan) and hemoglobin A1c on Tosoh instruments (Tosoh Corporation, Tokyo, Japan). Magnesium and homocysteine were analysed on Vitros 5.1 FS (Ortho Clinical Diagnostics, Raritan, NJ) until May 2021, thereafter on cobas c503 (Roche Diagnostics, Mannheim, Germany). Folate, cobalamin, ferritin and vitamin D were analysed on cobas e801 (Roche Diagnostics). Zinc and selenium were analysed using inductive coupled plasma – mass spectrometry (ICP-MS) and methylmalonic acid (MMA) with a liquid chromatography – mass spectrometry method (LC-MS/MS). Thiamine, pyridoxal 5-phosphate (vitamin B6), vitamin A and vitamin E were analysed at Oslo University Hospital, Aker and vitamin K1 was analysed at Fürst Medical Laboratorium, Oslo, all with chromatographic methods.

Statistical analysis

We estimated that the prevalence of micronutrient deficiency would be 30% in post-bariatric pregnancies and 5% in controls. To confirm a similar difference with a statistical power of more than 80% and a significance level (α) of 0.05, a total of 200 patients had to be included in the study with a 4:1 ratio of cases vs. controls (40 post-bariatric pregnancies and 160 controls). Proportions are reported as numbers with percent, continuous variables as mean ± standard deviation (SD) as appropriate. Differences between treatment groups were analysed using Pearson’s chi-square test or Fishers exact test for categorical data and Student’s t-test for continuous data. Paired sample t-test was used to assess paired observations of micronutrients in baseline and follow-up blood samples. Skewed distributed data were log-transformed to achieve normal distribution. Correlations between possible confounders and vitamin K1 variables were assessed by Spearman’s correlation (rho). Two-sided P values < 0.05 were considered statistically significant. The Bonferroni Holm correction was applied to mitigate the risk of type 1 statistical error. We used linear regression analyses to explore possible associations between bariatric surgery and vitamin K1 and logistic regression analyses to explore possible associations between bariatric surgery and vitamin K1 deficiency. Possible confounders were identified using a stepwise selection approach in which variables with p-values below 0.10 were included along with clinically significant confounders. Coefficients and odds ratio (OR) from regression analysis are presented with 95% confidence interval (CI). The analyses were performed using IBM SPSS Statistics (version 729.0.0).

We included 204 women in the study (bariatric surgery n  = 59 and controls n  = 145). Data on the specific type of surgical procedure were available for 57 women who had undergone bariatric surgery prior to conception (gastric bypass surgery n  = 26 and sleeve gastrectomy = 31). The women in the surgical group lost on average 39.0 (16.9) kg from the time of surgery to the start of pregnancy and the time interval from bariatric surgery to pregnancy was mean 63.7 (39.2) months. Patients’ characteristics by surgical status are presented in Table  2 .

The women with bariatric surgery had a higher pre-pregnant body mass index (BMI) compared with controls (30.8 [SD 6.0] vs. 25.2 [5.4] kg/m 2 , p  < 0.001). There was no difference between groups regarding age (32.1 [5.7] vs. 31.2 [4.2] years, p  = 0.215), maternal weight gain (13.3 [9.6] vs. 14.8 [6.5] kg, p  = 0.228), HbA1c (30.2 [7.1] vs. 31.1[3.6] mmol/mol, p  = 0.234) or development of gestational diabetes (5% vs. 5%, p  = 1.000). Fewer women with bariatric surgery had completed higher education and more women with bariatric surgery currently smoked compared with controls (24 [43%] vs. 103 [72%], p  < 0.001 and 5 [9%] vs. 0, p  = 0.001, respectively. Children of post-bariatric pregnancies had lower gestational age and lower birthweight, however neither reached statistical significance (38.5[3.1] vs. 39.3[2.1] weeks, p  = 0.054 and 3363 [624] vs. 3520 [521] g, p  = 0.081, respectively).

Dietary supplements and micronutrient status by surgical status are presented in Table  3 . Concentrations of ferritin, magnesium, pyridoxal 5-phosphate, vitamin A, E and K1 and selenium were significantly lower post-bariatric pregnancies compared with controls. Using micronutrients as categorical variables (deficiency yes/no) conferred a higher prevalence of micronutrient deficiencies such as iron, magnesium, pyridoxal 5-phosphate, vitamin K1 and selenium in pregnancies after bariatric surgery compared with controls and a higher prevalence of vitamin K1 deficiency after gastric bariatric surgery vs. sleeve gastrectomy (Fig.  1 ). The distribution of vitamin K1 concentrations in women with post-bariatric pregnancies and controls is presented in Fig.  2 . Paired sample t-test showed increased concentrations vitamin K1 in a subgroup of women with post-bariatric pregnancies (0.29 [0.29] ng/mL to 0.64 [0.92] ng/mL, p  = 0.070).

Micronutritional deficiency in pregnancy. A : pregnancy following bariatric surgery vs. non-surgical controls. B : pregnancy after gastric bypass surgery vs. sleeve gastrectomy. * denotes statistically significance after corrections for multiple comparisons

Distribution of vitamin K1 concentrations in women with post-bariatric pregnancies and controls

The women with gastric bariatric surgery underwent surgery at a younger age and with a longer time-interval between surgery and conception compared with the women with sleeve gastrectomy (23.5 vs. 27.5 years, p  = 0.002 and 85 [40] vs. 45 [28] months, p = < 0.001, respectively). One woman (4%) after gastric bariatric surgery and five women (16%) after sleeve gastrectomy, p  = 0.205 became pregnant < 18 months after surgery. Both surgical groups had lost comparable weight since surgery (gastric bypass surgery 41.4 [17.1] vs. sleeve gastrectomy 37.0 [16.8] kg, p  = 0.342) and they had comparable pre-pregnant BMI (gastric bypass surgery 31.9 [5.5] vs. sleeve gastrectomy 29.9 [6.4] kg/m 2 , p  = 0.222). The proportion of women with vitamin K1 deficiency was higher after gastric bariatric surgery compared with sleeve gastrectomy (gastric bypass surgery 9 [38%] vs. 1 [3%], p  = 0.003 and Fig.  1 ).

Univariate linear regression analysis showed that bariatric surgery was inversely associated with vitamin K1 levels (B -0.33 [95% CI -0.51, -0.15, p  < 0.001]. The result remained statistically significant after multivariable adjustments (-0.26 ng/mL [-0.51, -0.04], p  = 0.047) (Table  4 A). In addition, compared with sleeve gastrectomy, gastric bariatric surgery was inversely associated with vitamin K1 in univariate linear regression analysis (0.20 [0.019, 0.387], p  = 0.031), but not after multivariate adjustment (Table  4 B). Using vitamin K1 as a categorical variable (deficiency yes/no), bariatric surgery was associated with a fivefold increased risk of vitamin K1 deficiency compared with controls and that gastric bariatric surgery was associated with higher adjusted risk of vitamin K1 deficiency compared with sleeve gastrectomy (Table  5 ).

In this study, we compare micronutrient concentrations in post-bariatric pregnancy with matched non-surgical controls. The study shows that the concentrations of vitamin K1, magnesium, and selenium were significantly impaired in post-bariatric pregnancies vs. controls. Moreover, our results show that bariatric surgery was consistently associated with vitamin K1 levels, both as a continuous outcome variable and as a categorical variable (vitamin K1 deficiency) in post-bariatric pregnancy compared with controls. Moreover, the associations might be driven by gastric bariatric surgery rather than sleeve gastrectomy. However, the number of pregnant women with vitamin K1 concentration below the lower reference limit was overall small and the confidence intervals were large. Thus, these results should be interpreted with caution.

Maternal nutrition and micronutrients in pregnancy after bariatric surgery

In pregnancy, there is an increased need for nutrients to support fetal and placental growth and development [ 20 ]. A detailed dietary information was not available in this study and we cannot exclude that the women with bariatric surgery had a different nutritional composition compared with controls. In a subgroup of women with post-bariatric pregnancies, an increment in vitamin K was seen. However, the changes did not reach statistical significance. Follow-up blood samples for the controls were not available. A healthy diet after bariatric surgery may differ from the general population in the composition of lean protein, fruits and vegetables and starchy carbohydrates. Nonetheless, the combination of diet, intestinal modifications and increased metabolism in pregnancy might explain the deficiencies in fatty soluble vitamins seen in this study [ 23 , 24 , 25 , 26 , 27 ]. Improved nutrient intake of mothers was seen after personalized nutritional counseling during post-bariatric pregnancy and might contribute to higher birth weight of offspring [ 15 ]. Given the complexity and heterogeneity of nutritional status in post-bariatric pregnancies, focusing on sub-groups including pre-gestational nutritional deficiencies, and type of surgery performed is of vital importance. A recent consensus report recommended specialized care in pregnancies after bariatric surgery [ 38 ]. There is however a paucity of data to support clinical practice [ 38 , 39 ]. As such, there is an imperative need to identify pregnancy and trimester specific reference intervals and clinical decision limits in order to help clinical advice on dietary supplement.

Lifelong dietary supplement is recommended after bariatric surgery, however adherence to adequate dietary supplements seems to decrease over time [ 26 , 40 , 41 ]. Our study also confers inadequate use of dietary supplements in pregnancy after bariatric surgery with 30–70% of the women not taking recommended post-bariatric surgery dietary supplements (Table  3 ). Thus, a need for increased awareness to ensure adequate microntutrional care before, during and after pregnancy is imperative.

The role of vitamin K1 in pregnancy after bariatric surgery

In line with our results, a systematic review on vitamin K1 concentrations in patients with a history of bariatric surgery reported high risk of vitamin K1 deficiency after bariatric surgery and opted for better monitoring [ 23 ]. Our results also cohere with another study of 49 pregnant women with previous bariatric surgery, showing that vitamin K1 concentrations were lower in women with a history of bariatric surgery compared with 27 controls [ 30 ]. The increased fat storage in pregnancy may lead to less bioavailability for activation of fatty soluble vitamins [ 42 ]. Furthermore, the highly fat-soluble vitamin K1 depend upon conjugated bile salts for adequate absorption. Consequently, reduced stomach acid production, reduced absorption surface and shorter interaction time between conjugated bile salts and vitamin K1 might explain the lower serum concentrations of vitamin K1 after bariatric surgery [ 43 ]. Screening for vitamin K1 deficiency is usually recommended after malabsorptive surgical procedures including biliopancreatic diversion with or without duodenal switch [ 43 ]. However, restrictive procedures may also cause vitamin deficiencies due to digestive symptoms such as vomiting and food intolerance. Interestingly, lower levels of vitamin K1 were found in the first trimester compared to a control group of women without bariatric surgery [ 30 ]. Vomiting and food intolerance may also be the main symptoms of hyperemesis gravidarum, which calls for increased vigilance of vitamin K1 insufficiency in post-bariatric pregnancies in women with symptoms of hyperemesis in pregnancy.

The impact of vitamin K1 deficiency in post-bariatric pregnancies is not clear. Low circulating levels of vitamin K1 might lead to a hypocoaguble state in mother and child [ 30 ]. Some cases of neonatal intracranial bleeding have been reported, possible due to vitamin K1 deficiency [ 44 ]. Another study reported that obesity had stronger impact on hypercoagulability than pregnancy itself [ 45 ]. Nonetheless, insufficient data exist in order to recommend interventions of vitamin K1 deficiency in post-bariatric pregnancy [ 38 ]. While optimal monitoring of vitamin K1 during pregnancy following bariatric surgery remains unclear, a major concern is raised about the consistent finding of vitamin K1 deficiency in post-bariatric pregnancy.

Bariatric surgery before pregnancy: timing and selection of procedure – dose it matter?

Few studies have assessed the impact of different surgical procedures before pregnancy. One study of 119 pregnant women found no effect of maternal weight gain on maternal and perinatal outcome after sleeve gastrectomy [ 46 ]. However, the study did not include pregnancies after gastric bariatric surgery for comparison. Another retrospective observational study showed no differences between gastric bariatric surgery and sleeve gastrectomy regarding re-interventions or obstetric outcomes [ 4 ]. Conflicting evidence exists on the possible adverse effects of sleeve gastrectomy such as dyspepsia and weight regain as compared with gastric bariatric surgery [ 47 , 48 , 49 ]. Our study adds important knowledge about the different surgical procedures, suggesting that gastric bariatric surgery holds greater risk of vitamin K1 deficiency compared with sleeve gastrectomy. The optimal surgical procedure for obesity treatment in women of reproductive age is however not clear and a person-centered approach should be advocated in future guidelines.

The timing of pregnancy after bariatric surgery is moreover under debate. Current recommendations suggest waiting at least 12 months after bariatric surgery before planning a pregnancy [ 12 , 38 , 50 ]. In our study, women with previous sleeve gastrectomy had a shorter time interval between surgery and conception than the women with gastric bariatric surgery. This might reflect that the women who underwent gastric bariatric surgery underwent surgery in an era where gastric bariatric surgery was the most common surgical procedure for weight loss [ 31 ]. Interestingly, after adjustments for the time interval since bariatric surgery, gastric bariatric surgery was not associated with vitamin K1 in the linear regression model (Table  4 B). Thus, as adherence to dietary supplements is reduced with time after bariatric surgery, we cannot rule out that patient’ adherence to dietary supplement might have influenced the differences between surgical procedure seen in the present study [ 26 , 40 , 41 ]. On the other hand, the time interval between sleeve gastrectomy and conception did not impact maternal and neonatal outcomes in a study of 15 women conceived > 18 months after surgery. The authors concluded that pregnancy after sleeve gastrectomy was overall safe and well-tolerated [ 33 ]. Furthermore, a study of 30 women who became pregnant within a mean time of 17 months after gastric bariatric surgery did not appear to confer any serious risks in pregnancy with 90% of the children were born at term with normal birthweight [ 13 ]. In our study, only six patients (11%) became pregnant earlier than 18 months after surgery and the study was not designed to assess pregnancy or birth related complications.

Future implications?

The results of this study underscore the need for increased awareness of nutritional and microntutrional status to ensure adequate obstetric care both before and during post-bariatric pregnancies. Also, this study present important information on adherence to dietary supplement that should be considered in the planning of post-bariatric pregnancies. Moreover, the results of our study rises important questions on the impact of micronutrients deficiencies on future child development.

Strengths and limitations

The strengths of this study include the prospective design with matched controls. Moreover, definitions for the chosen cut-offs for micronutrient deficiency were chosen according to pregnancy specific reference intervals if established. However, we cannot rule out that the concentrations of the micronutrients change in pregnancy. Thus, the validity of the chosen cut-offs for defining micronutrient deficiency should be assessed in future studies. This study was a small single center study and did not have the statistical power to assess pregnancy related or birth related complications. The majority of the women in this study was Caucasian and the results may not be valid in populations of other ethnicities. The observational design does not provide any causality between variables. Also, we cannot rule out if the difference in gestational week for blood sampling or non-fasting blood samples might have influenced the micronutrient analyses. Finally, use of dietary supplements was self-reported and we cannot be sure that all the study participants adhered with the recommendation.

This study shows that concentrations of the micronutrients vitamin K1, magnesium, and selenium were significantly impaired in post-bariatric pregnancies compared with controls. We found a negative association between bariatric surgery and vitamin K1 and a higher risk of vitamin K1 deficiency after gastric bariatric surgery compared with sleeve gastrectomy. Vitamin K1 deficiency in post-bariatric pregnancy have potential risk of hypocoaguble state in mother and child and should be assessed in future studies.

Data availability

The data used in the present study is not open access or publicly available. The datasets are available from the corresponding author on reasonable request.

Abbreviations

Body mass index

Confidence interval

Standard deviation

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Acknowledgements

We acknowledge the work of the staff at the Section for Morbid Obesity at Akershus University Hospital HF for the persistent effort of data collection.

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Brit Torunn Bechensteen, Jacob A. Winther & Tone G. Valderhaug

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Cindhya Sithiravel & Gunnhild Kravdal

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TGV and EMRS designed the study. BTB, EMRS and TGV collected the data for the study. TGV analysed the data. BTB and TGV drafted the manuscript. CS ad GK were responsible for the laboratory analyses. TGV and JAW were responsible for the statistical analyses. All authors contributed to the interpretation of data, reviewed and edited the manuscript and gave their final approval of the final version to be published.

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Bechensteen, B.T., Sithiravel, C., Strøm-Roum, E.M. et al. Post-bariatric pregnancy is associated with vitamin K1 deficiency, a case control study. BMC Pregnancy Childbirth 24 , 229 (2024). https://doi.org/10.1186/s12884-024-06407-0

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Long-term changes in body image after bariatric surgery: An observational cohort study

Laurène bosc.

1 Endocrinology Department, Bordeaux University Hospital, Pessac, France

Flore Mathias

Maud monsaingeon, caroline gronnier.

2 Digestive Surgery Department, Bordeaux University Hospital, Pessac, France

3 University of Bordeaux, Bordeaux, France

Emilie Pupier

Blandine gatta-cherifi.

4 Neurocentre Magendie, Physiopathologie de la Plasticité Neuronale, University of Bordeaux, U1215, Bordeaux, France

Associated Data

All relevant data are within the manuscript and its Supporting Information files.

While body image improves in the first few months after surgery, data on long-term changes in body image after bariatric surgery are scarce and contradictory.

We assessed body image through the Stunkard Figure Rating Scale and the Multidimensional Body-Self Relations Questionnaire-Appearance Scale, which measures appearance evaluation and orientation, overweight preoccupation, and self-classified weight. Surveys were conducted before surgery and at regular intervals until 5 years after bariatric surgery.

61 patients were included in the study. No patients were lost to follow-up until 18 months after bariatric surgery. At 5 years, there were 21 patients (34%) lost to follow-up. We detected an overall improvement in body image until 12–18 months post-surgery. Scores declined after 5 years post-surgery but were still higher than preoperative evaluations. Overweight preoccupation did not change throughout the follow-up period. There was a positive correlation between body weight lost and appearance evaluation. There was also a positive correlation between weight loss and the Body Areas Satisfaction Scale. There was a negative correlation between weight loss and overweight preoccupation. Appearance orientation and self-classified weight were not correlated with weight loss.

Conclusions

Body image improved after bariatric surgery but was not maintained for all 5 years after surgery.

Introduction

Body image dissatisfaction is prevalent among the general population [ 1 ] and common in patients suffering from obesity [ 2 ], women [ 3 ], White, and those with a ‘Western lifestyle’ [ 1 ]. In patients with obesity, early-onset obesity, obesity-related stigmas, eating disorders, underlying depression, yo-yo dieting effects, and body image distortion are correlated with poorer body image satisfaction [ 4 , 5 ].

Bariatric surgery (BS) is the most efficient treatment for morbid obesity. Depending on the procedure, it allows for 13–27% body weight loss for up to 15 years post-surgery and reduces obesity mortality by 5% [ 6 ]. It also has a dramatic positive effect on obesity-related comorbidities: especially type 2 diabetes but also cardiovascular diseases including hypertension, obstructive sleep apnea-hypopnea syndrome and also non-alcoholic steatohepatitis, osteoarticular disorders [ 7 ].

Health is the primary reason reported by patients for seeking bariatric surgery but patients also report a strong desire for surgery to change the appearance of their body [ 8 , 9 ]. Indeed, approximately one in five bariatric surgery patients identifies appearance concerns as the primary motivator for bariatric surgery [ 10 ]. While the weight loss and metabolic outcomes of bariatric surgery have been well-documented, the evolution of body image following bariatric surgery is less investigated [ 11 ]. Most studies report only short-term results and the literature on post-operative body image changes and weight outcome is mixed [ 12 – 15 ]. Therefore, if general improvement is typically observed among adults, some also reported improvements in specific body image domains only. The mixed literature may perhaps be related to methodological factors including the variety of body image measures used (more than 20 different body measures which have not been validated most of the time for body image assessment after bariatric surgery) which tap different aspects of body image (cognitive, affective, behavioral or perceptual aspects). Above all, most studies assessed patients through the first 2 years post bariatric surgery while weight regain is observed after the initial post surgical period [ 6 ]. The aim of our study was to describe the evolution of body image in a prospective observational cohort for up to 5 years after BS.

Materials and methods

We carried out a single-center prospective observational cohort study in the Obesity Department of Bordeaux University Hospital between October 2011 to April 2012.The inclusion criteria required patients to be over 18 years of age, to speak and to write French and undergoing a preoperative assessment for BS according to international guidelines [ 16 ]. Patients undergoing bariatric surgery during this period and who agreed to participate in the study were included. Data were collected during the preoperative assessment, and between 1 and 3 months (M1–M3), 6 and 9 months (M6–M9), 12 and 18 months (M12–M18), and 60 and 72 months (M60–M72) after BS. Body weight, height, body mass index (BMI), and percentage of weight lost after BS were assessed at each of these time points.

The Multidimensional Body-Self Relations Questionnaire-Appearance Scale (MBSQR-AS) [ 17 ] and the Stunkard Figure Rating Scale were used to assess body image satisfaction.

The MBSQR-AS assesses self-attitudinal aspects of the body-image construct and is composed of 34 questions divided into five sections: 1) ‘appearance evaluation’ measures feelings of physical attractiveness or unattractiveness, with a high score indicating satisfaction with one’s own appearance; 2) ‘appearance orientation’ measures the extent of investment in one’s appearance. A high score indicates a greater investment; 3) ‘body areas satisfaction scale’ (BASS), where a high score indicates general satisfaction with most areas of one’s body and a low score indicates dissatisfaction in the size or appearance of several areas; 4) ‘overweight preoccupation’ measures fat anxiety, weight vigilance, dieting, and eating restraint; and 5) ‘self-classified weight’ measures how one perceives his/her weight, from very underweight to very overweight. The MBSRQ–AS has been translated and validated in French [ 18 ]. The five subscales of the MBSRQ–AS have good psychometric qualities: the internal consistency ranges from .66 to .88 and test-retest reliability ranges from .78 to .85 for the five subscales in French. The scale has been used in numerous studies focusing on obesity and bariatric surgery.

The Stunkard Figure Rating Scale [ 19 ] presents a series of nine male and female schematic silhouettes ranging from skinny to obese. Participants are asked to choose the silhouette that corresponds to their ideal body size (IBS) and the silhouette that reflects their current body size (CBS). Body dissatisfaction (BD) is calculated by subtracting the ideal body size from the current body size. A positive score indicates a desire to be thinner, while a negative score indicates a desire to be heavier.

Statistical analyses were performed using GraphPadPrism software. Quantitative variables were compared by an analysis of variance (ANOVA). Correlation coefficients (Spearman or Pearson coefficient, depending on the distribution of continuous or non-continuous variables) were calculated. A P -value< 0.05 was considered statistically significant. All quantitative variables are expressed as the mean ± standard error of the mean (SEM).

Each participant received a study information sheet and signed an informed consent form.

Patient baseline characteristics

Sixty one white patients (female, n = 47, (77%)) were included in the study. Their mean age was 45 ± 10 years. The average baseline bodyweight was 125.6 ± 22.7 kg corresponding to an average BMI of 42.4 ± 7.9 kg/m 2 . A Roux-en-Y Gastric Bypass (RYGB) was performed in 32 patients (52%) while 29 patients (48%) underwent a sleeve-gastrectomy.

At baseline the mean scores for the MBSQR-AS sections were as follows: appearance evaluation = 2.30 ± 0.66, appearance orientation = 3.58 ± 0.56, BASS = 2.44 ± 0.51, overweight preoccupation = 3.29 ± 0.68, and self-classified weight = 4.58 ±0.60. The average anxiety score was 7.43 ± 3.42, and the mean depression score was 4.97 ± 3.17. The average BD score from the Stunkard Figure Rating Scale was 3.30 ± 1.01. The patients’ characteristics are summarized in Table 1 .

Quantitative variables are expressed as the mean ± SEM.

BMI = Body Mass Index.

Body weight loss after BS

No patients were lost to follow-up until 18 months after BS. At M60–M72, 21 patients (34%) were lost to follow-up (12 dropouts and 9 missing answers on the questionnaires).

The percentage of body weight loss increased significantly fromM1–M3 (10.62 ± 4.40) until M12–M18 (28.44 ± 7.99%; P <0.05) before decreasing significantly to 22.82 ± 12.05% at M60–M72 ( P <0.05). The average BMI decreased significantly from the preoperative assessment (39.59 ± 7.34 kg/m 2 )until M12–M18 (M1–M3 = 33.80 ± 6.69 kg/m 2 , M6–M9 = 33.80 ± 6.69 kg/m 2 and M12–M18 = 31.63 ± 6.38 kg/m 2 ; P <0.05), but increased significantly between M12–M18(31.63 ± 6.38 kg/m 2 ) and M60–M72 (34.12 ± 8.22 kg/m 2 ; P <0.05).

Changes in MBSRQ-AS scores during follow-up

The appearance evaluation scores increased significantly from the preoperative period (2.30 ± 0.66) to the M12–M18 assessment (3.15 ± 0.78; P <0.05) and remained significantly elevated through M60–M72 ( Table 2 ). There were positive correlations between weight loss and appearance evaluation at M1–M3 (r = 0.44; P <0.05), M6–M9 (r = 0.42; P <0.05), and M60–M72 (r = 0.33; P <0.05).

Means with different superscripts are significantly different from each other ( P < 0.05).

BASS = Body Areas Satisfaction Scale.

The appearance orientation scores increased significantly fromM1–M3 to M6–M9 but decreased significantly between M12–M18 and M60–M72. At that last time point scores were not statistically different from the pre-surgery scores. There was no correlation between weight loss and appearance orientation during follow-up.

The BASS scores increased significantly from the preoperative assessment to M6-M9 (2.44 ± 0.5 vs 2.76 ± 0.56 vs 3.05 ± 0.61, preoperative assessment vs M1-M3 vs M6-M9, P <0.05). The scores did not change between M6–M9 and M12–M18 (3.24 ± 0.64) but decreased significantly until M60–M72 (2.90 ± 0.74), though they remained significantly higher than at the preoperative evaluation ( Table 2 ). There were positive correlations between weight loss and BASS at M1–M3(r = 0.4, P <0.05), M6–M9 (r = 0.41, P <0.05), M12–M18 (r = 0.39, P <0.05), and M60–M72 (r = 0.36, P <0.05).

The overweight preoccupation scores did not change significantly until M6–M9 (preoperative = 3.29 ± 0.68, M1–M3 = 3.18 ± 0.67, and M6–M9 = 3.19 ± 0.75; P <0.05). Between M6-M9 and M12–M18, the score decreased significantly and did not change until M60–M72 ( Table 2 ). There was a negative correlation between weight loss and overweight preoccupation at M1–M3 (r = -0.39, P <0.05). The self-classified weight scores decreased significantly from M1–M3 (4.43 ± 0.71) to M6–M9 (3.90 ± 0.76) and M12–M18 (3.67 ± 0.72; P <0.05). These scores increased at M60–M72 (3.96 ± 0.63) but remained lower than the preoperative scores (4.58 ± 0.60). There was no correlation between weight loss and self-classified weight score during follow-up. Changes in the MBSRQ-AS scores are summarized in Table 2 .

At last follow-up, the appearance evaluation was significantly higher in patients that had achieved a BMI <30 kg /m2 compared to those who did not (3.44 ± 0.65 vs 2.83 ± 0.79). There was no differences between patients with BMI under or over 30 for the other scores that composed the MBSRQ-AS score.

Changes in BD score during follow-up

The mean BD score decreased significantly between the preoperative assessment (3.30 ± 1.01), M1–M3 (2.61 ± 1.04), M6–M9 (1.85 ± 0.95), and M12–18 (1.33 ± 0.96; P <0.05). The mean BD score at M60–M72 was 1.77 ± 1.37 ( Table 3 ). There was a significant negative correlation between weight loss and BD score at M60–M72 only (r = -0.47, P <0.05). Changes in the BD scores are summarized in Table 3.

BD = Body Dissatisfaction.

While bariatric surgery is by far the most effective treatment for long-term obesity and its comorbidities, less is known about body image following BS especially after the first 2 years after BS. The current analysis, which includes a longitudinal characterization of body image through 5 years provides interesting results about the durability of body image changes after BS. In our study, the appearance evaluation and self-classified weight scores improved until M12–M18 after BS and declined at M60-72 but remained higher than the preoperative scores. These results have already been highlighted in the literature although the follow-up is most often of shorter duration and most studies have a post-operative sample size of fewer than 50 individuals. Indeed, in the systematic review of the literature of Ivezaj et al. [ 12 ], out of the 31 observational longitudinal studies, 52% (n = 16) had up to 12 months of follow-up and only 6% (n = 2) up to 48 months. All the studies have shown an improvement in body image after bariatric surgery and some studies have already shown stabilization or a decline of satisfaction scores from 12 or 24 months [ 20 – 22 ]. The studies with the longest follow-up agree that the satisfaction scores stay higher 48 months after BS than before surgery [ 23 – 25 ].

These results have to be faced to the evolution of the BASS. Therefore, the BASS scores only improved until M6–M9 reflecting dissatisfaction with one or more body regions. This could be linked to the appearance of excessive skin that is quite common after massive weight [ 26 , 27 ]. Body contouring surgery (BCS) could improve body image in these patients [ 28 ]. However little is known about the trajectory of body image post-BCS among bariatric surgery patients. BCS after BS seems to improve body image satisfaction only in areas involved in the surgery (not untreated areas) [ 29 ] while one longitudinal study suggests that body image satisfaction needs three or more plastic surgeries following BS [ 30 ] to score comparable to standards. Only 8 patients from our cohort had undergone BCS after BS but the different types of surgery, the different delays between BS and BCS and short-term follow-up did not allow us to analyze their data.

This dynamic change of body image according to time after BS mirrors the weight loss trajectories that happen after BS [ 31 ]. Therefore, viewing post BS events (not only weight outcome) as a dynamic process is more a realistic view of post BS outcomes. This also emphasizes the need for a careful and long-life follow-up after BS. This follow-up needs to include body weight, nutritional status but also body image. Indeed, in non-surgical population, various features of body image dissatisfaction may be a signal for greater eating-disorder psychopathology, which could ultimately impact long-term weight loss outcomes following bariatric surgery [ 32 , 33 ].

The literature on post-operative body image changes and weight outcome is mixed. Consistent with findings from some previous studies [ 34 , 35 ], we found a positive correlation between weight loss and appearance evaluation at M1-M3, M6-M9 and M60-M72. There were also positive correlations between weight loss and BASS at all time points between M1-M3 and M60-M72. These positive associations are likely to be of clinical importance. Therefore, improving these dimensions could increase the amount of weight lost after BS. Targeted psychoeducation and assessment of body image throughout the bariatric surgery process both before and after bariatric surgery is mandatory to optimize body weight loss after BS [ 36 ].

The overweight preoccupation and appearance orientation scores were only slightly modified during follow-up and the average score at 5 years was not significantly different from the preoperative average. The lack of improvement in this aspect of body image has already been described in the literature [ 22 , 23 , 37 ]. This indicates that body weight remains a major concern for BS patients even after significant weight loss [ 38 , 39 ]. Indeed, these scores remained positive throughout the follow-up period, suggesting: i) a persistent desire of patients to be thinner than they are, ii) that their perceived body remains different from their ideal body, and iii) that they constantly see themselves as heavy even after significant weight loss. These results are similar to those of previous studies [ 40 , 41 ], although one study showed a significant reduction in the determination for weight loss at 6 months post-BS [ 42 ].

These results suggest that patients may still identify as obese, even after BS, as indicated by their tendency to overestimate their weight [ 43 ]. In patients suffering from anorexia nervosa, weight overestimation is well described and may correlate with dysfunction of the parietal cortex [ 44 ]. A similar mechanism has been suggested after rapid weight loss in BS patients where proprioceptive information is not updated, which leads to a distorted body schema. Consequently, patients feel heavier than they actually are [ 45 ].

Although we can’t claim causality between body weight loss and body image, we suppose that the decline of body image satisfaction long after bariatric surgery should prompt clinicians to think about ways to improve body image. Virtual reality could be an option. Indeed, according to the ‘allocentric lock hypothesis’, patients suffering from obesity may approach their body image from an allocentric frame of reference by adopting the point of view of an outside observer toward their own body, and this point of view is not updated after weight loss [ 46 – 48 ]. Memories of stigmatizing experiences can contribute to allocentric locking. The inability to update the allocentric representation therefore locks the patient into a dissatisfying body. Despite efforts to modify their weight, they will always be present in a body that differs from reality [ 49 , 50 ]. Two case series showed significant improvements in the satisfaction scores of BS patients after 6 weeks of virtual reality [ 51 , 52 ]. However, more studies and longer follow-up periods are needed to clarify the impact of this practice.

To our knowledge, it is the only study with so many body image assessments 5 years after bariatric surgery [ 53 , 54 ]. The duration of our study allowed us to detect changes between 1 and 5 years after BS. Interestingly, we studied individuals from the same ethnic background that can potentially influence body image [ 55 ]. To our knowledge, this element has never been studied after bariatric surgery. In addition, we used 2 measures of body image.

However, none of the questionnaires we used were specific to BS. However, this is also the case for most published studies in this field. Indeed, a recent review identified only six questionnaires specific to assessing body image in patients after BS [ 56 ]. The BODY-Q questionnaire, developed specifically in 2012 for BS patients, seems to be the most appropriate for addressing these specific issues [ 57 ]. However, none of these questionnaires are translated or validated in French. The Figure Rating Scale has many limitations: limited range of figures are presented on the scale (it is indeed not a tool for subjects with super obesity), illustrations may not capture all the different body types, and validity may vary by ethnic group. Nevertheless, this tool was used frequently when we started collecting data and is still used today [ 58 ]. In addition, it has the advantage of being quickly administered, showing a strong correlation with the body mass index. It provides a simple, self-administered technique of collecting estimates of body dissatisfaction, and avoids variability that might be caused by language deficits. An interesting option could have been the use of the Body-Image Assessment for obesity or BIA-O as a figural rating scale (the first one adapted specifically for use in obesity) [ 59 ].

Twenty-one patients (34%) were lost to follow-up during the study. This difficult observance of follow-up after bariatric surgery is indeed well described in the literature and multiple factors have been suggested as risk factors for this attrition (distance to travel to the clinic, younger age, unemployment, financial factors, psychological issues) [ 60 ]. Of note, our data did not allow us to study the relationships between post-BS body image changes and factors associated with greater body image dissatisfaction in obese patients such as early-onset obesity, episodes of obesity-related stigma, eating disorders, underlying depression, yo-yo dieting, and overestimating weight.

Our data show that body image improves after BS, but this effect is only temporary. The use of questionnaires specific to BS, including the BODY-Q, would help us better understand this change over time.

Supporting information

Acknowledgments.

We thank the Bordeaux University Hospital which allowed this work. We thank the subjects who participated to this work. The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www.textcheck.com/certificate/AbjS4I

Funding Statement

The authors received no specific funding for this work.

Data Availability

• PLoS One. 2022; 17(12): e0276167.

Decision Letter 0

15 Mar 2022

PONE-D-21-30163

Long-term changes in body image after bariatric surgery: an observational cohort study

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Additional Editor Comments:

Dear Authors,

The article is interesting and valuable. However, there are some improvements to make:

1. Line 56: The authors mention that bariatric surgery also significantly improves most obese patients' comorbidities. Could you please detail (for example, diabetes, metabolic syndrome, hypertension..)?

2. It would be interesting if you could make some correlations between several factors and the change in body image over time, such as sex, age, the onset of obesity, type of BS, comorbidities, weight loss.

3. Do you have separated the patients who achieved BMI <30? It could show different results between the groups. It is interesting to explain the results, for this cluster of patients .

4. Please explain and extend the discussion about the reasons for the dropouts after 18 months.

5. Refresh the whole manuscript, correct miswriting, and check the punctuation.

[Note: HTML markup is below. Please do not edit.]

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Reviewer #1: Yes

Reviewer #2: Yes

********** 

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Reviewer #1: Dear Authors,

The aim of following patients' body images for a longer period after bariatric surgery is a very important point considering it may help to build strategies to achieve better and prolonged results, even if not using the most appropriate tools. Just wondering if you had separated the patients who achieved BMI <30 it could show different results between the groups. Also, I wondered if wouldn't be interesting to refer to the reasons for the dropouts after 18 months.

I suggest you review the writing as there are a few miswriting and check the punctuation.

Reviewer #2: The paper is an original article regarding the body image perception and its variation in patients that underwent bariatric surgery. The topic is extremely interesting. The paper is written in a fluid English language and based on a solid statistical analysis. Some issues could be improved before publication:

1. Line 56: The authors mention that bariatric surgery also bring important improvement in comorbidities that most obese patients have. Could you please detail (for example: diabetes, metabolic syndrom, hypertension..)?

2. It would be interesting if you could make some correlations between several factors and the change in body image over time, such as sex, age, onset of obesity, type of BS, comorbidities, weight loss

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Reviewer #2: No

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Author response to Decision Letter 0

11 May 2022

Please see below for a point-by-point response to the comments and concerns. All page numbers refer to the revised manuscript file with tracked changes.

We thank the reviewer for this pertinent comment. We detailed that in the manuscript.

We thank the reviewer for this comment. We did not find any correlation between the factors you mentioned above and the change in body image over time.

As you requested, we had a look at patients according to their final BMI i.e > 30 or < 30 and we added a sentence in the manuscript (lines 171-174).

As you suggested, we explained that in the discussion (lines 273-276).

We checked the whole manuscript to ensure that the text is optimally phrased and free from typographical and grammatical errors.

Reviewer #1: Dear Authors,

Reviewer #2: The paper is an original article regarding the body image perception and its variation in patients that underwent bariatric surgery. The topic is extremely interesting. The paper is written in a fluid English language and based on a solid statistical analysis. Some issues could be improved before publication:

As explained before, we did not find any correlation between the factors you mentioned above and the change in body image over time.

Submitted filename: Response to reviewers.docx

Decision Letter 1

11 Aug 2022

PONE-D-21-30163R1Long-term changes in body image after bariatric surgery: an observational cohort studyPLOS ONE

Your manuscript has been seen by two additional reviewers and their comments are attached below. We would like to ask you to address the concerns of reviewer #3 and respond to the comments of reviewer #4, specifically:

• please discuss the limitation regarding the Figure Rating Scale
• please review current literature to ensure that the most recent literature on the topic has been included
• note that citing the reference requested by Reviewer 4 is not a requirement for publication

Could you please revise your manuscript to include their concerns?

Please submit your revised manuscript by Sep 25 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at  gro.solp@enosolp . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Thomas Tischer

Staff Editor

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Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: All comments have been addressed

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #3: No

Reviewer #4: Yes

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: I Don't Know

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #3: Yes

5. Is the manuscript presented in an intelligible fashion and written in standard English?

6. Review Comments to the Author

Reviewer #1: (No Response)

Reviewer #2: The authors responded to the queries in the revised version. I have no further issues. I recommend publication.

Reviewer #3: This manuscript reports on data that is almost a decade old, for reasons that are unclear. Since that time, research in this area has grown to a size larger than suggested here. Much of the referenced literature is dated and many more recent empirical papers and reviews on this topic were missed. Further, the Figure Rating Scale is no longer viewed as an appropriate measure of body image dissatisfaction. It certainly not validated for those with clinically severe obesity. The results of the MBSRQ-AS replicate those from other studies. So, it's not clear what this small, dated study adds to the literature.

Reviewer #4: Long-term changes in body image after bariatric surgery: an observational cohort study.

Bariatric surgery and reconstructive procedures after weight loss are one of the most important and popular surgeries nowadays. On the other hand, the problem lies not only in the body structure and obesity. There is very an important, maybe the most important part how to prepare our patients’ mentally for the surgical journey. The surgery itself may give us a false belief that the patient is treated. But the psychiatric part may be as important as 80% of the treatment. It would be interesting to focus on the surgical outcome in comparison with the mental preparation before the surgery.

I find the study interesting. The manuscript is well organized, and statistically well prepared. Maybe the idea is not new, and the outcome is similar to the other studies, even the one presented by my team in 2020 The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

doi.org/10.1371/journal.pone.0229138 .

The strength of the study is long followed for up to 5 years. The response rate of the study is 66% which is more than needed to assess as a valid study. One of the most important parts of the manuscript is to show that after 5 years there is a decline in the body assessment, but it is still higher than before bariatric surgery. So we can say that the patient qualification process was proper.

There is my summary

1. The authors have responded properly to the reviewers

2. The study is valuable due to the long follow up

3. The response rate is 66% - enough to publish

4. Would be better to have a multicenter study, but thanks to long follow-up it should be considered valuable.

5. Please add the mentioned study

6. In the next studies I would recommend the assessment of the body reception and psychiatric evaluation of the patients.

I recommend this manuscript be accepted as an original article, please add the publication I mentioned.

7. PLOS authors have the option to publish the peer review history of their article ( what does this mean? ). If published, this will include your full peer review and any attached files.

Reviewer #4:  Yes:  Marek A Paul

Author response to Decision Letter 1

20 Sep 2022

Dear Editor and Reviewers,

Thank you for giving us the opportunity to submit another revised version of the manuscript “Long-term changes in body image after bariatric surgery: an observational cohort study” for publication in PLOS ONE.

We appreciate the time and effort that you and the reviewers dedicated to providing feedback on our manuscript and are grateful for the insightful comments on and valuable improvements to our paper. We have incorporated most of the suggestions made by the reviewers. Those changes are highlighted within the manuscript.

Reviewer #3: This manuscript reports on data that is almost a decade old, for reasons that are unclear. Since that time, research in this area has grown to a size larger than suggested here. Much of the referenced literature is dated and many more recent empirical papers and reviews on this topic were missed. Further, the Figure Rating Scale is no longer viewed as an appropriate measure of body image dissatisfaction. It certainly not validated for those with clinically severe obesity. The results of the MBSRQ-AS replicate those from other studies. So, it's not clear what this small, dated study adds to the literature.

Thank you for taking the time to review our article.

Indeed, our data are almost a decade ago since one of our goal was to follow patients during 5 years that means that the study started almost a decade ago.

We agree that the Figure Rating Scale has many limitations: limited range of figures are presented on the scale (it is indeed not a tool for subjects with super obesity), illustrations may not capture all the different body types, and validity may vary by ethnic group. Nevertheless, this tool was used frequently when we started collecting data and is still used today [58].

In addition, it has the advantage of being quickly administered, showing a strong correlation with the body mass index. It provides a simple, self-administered technique of collecting estimates of body dissatisfaction, and avoids variability that might be caused by language deficits.

An interesting option could have been the use of the Body-Image Assessment for obesity or BIA-O as a figural rating scale (the first one adapted specifically for use in obesity) with the BODY-Q as already mentioned in the manuscript [59]. The BIA-O was however much less used than the FRS in the bariatric surgery literature.

We think that the current research could add to the literature because it is the only study with so many body image assessments 5 years after bariatric surgery. We added this information in the manuscript [53, 54].

We thank the reviewer for giving us the opportunity to read again the literature. We have now cited additional recent studies in our paper.

[28] Paul MA, Opyrchał J, Knakiewicz M, Jaremków P, Duda-Barcik Ł, Ibrahim AMS, Lin SJ. The long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery. PLoS One. 2020 Feb 21;15(2):e0229138.

[37] Perdue TO, Schreier A, Swanson M, Neil J, Carels R. Majority of female bariatric patients retain an obese identity 18-30 months after surgery. Eat Weight Disord. 2020 Apr;25(2):357-364.

[53] Mento C, Silvestri MC, Muscatello MRA, Rizzo A, Celebre L, Cedro C, Zoccali RA, Navarra G, Bruno A. The role of body image in obese identity changes post bariatric surgery. Eat Weight Disord. 2022 May;27(4):1269-1278

[54] Bertoletti J, Galvis Aparicio MJ, Bordignon S, and Marceli Trentini C. Body Image and Bariatric Surgery: A Systematic Review of Literature.Bariatric Surgical Practice and Patient Care. Jun 2019.81-92.

[58] Parzer V, Sjöholm K, Brix JM, Svensson PA, Ludvik B, Taube M. Development of a BMI-Assigned Stunkard Scale for the Evaluation of Body Image Perception Based on Data of the SOS Reference Study. Obes Facts. 2021; 14(4):397-404.

[59] Williamson DA, Womble LG, Zucker NL, Reas DL, White MA, Blouin DC, Greenway F. Body image assessment for obesity (BIA-O): development of a new procedure. Int J Obes Relat Metab Disord. 2000 Oct;24(10):1326-32.

Reviewer #4:

I find the study interesting. The manuscript is well organized, and statistically well prepared. Maybe the idea is not new, and the outcome is similar to the other studies, even the one presented by my team in 2020 the long-term effect of body contouring procedures on the quality of life in morbidly obese patients after bariatric surgery

Thanks for your comment. Your study using the BODY-Q is very interesting and we have added your reference to our manuscript at line 211 [28].

Submitted filename: Response to reviewers 2.docx

Decision Letter 2

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Acceptance letter

Long-term changes in body image after bariatric surgery : an observational cohort study

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