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Weight Loss Surgery Preoperative Risk Reduction
The Obesity Action Coalition: The Voice of Those Affected by Obesity
Treatment Considerations for Osteoarthritic Knee Pain in Patients with Obesity
Hair Loss Among Weight Loss Surgery Patients
18
14
20
25
A peer-reviewed e-journal providing lifestyle and health information for weight loss surgery patients and candidates
WEIGHT LOSS
BEFORE
WEIGHT LOSS
SURGERY
WEIGHT LOSS
BEFORE
WEIGHT LOSS
SURGERY
What Do We Know About Dropping Those Preoperative Pounds?
Winter 2012
Volume 1, Issue 1
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BMI: BODY • MIND • INSPIRATION
A peer-reviewed,
evidence-based e-journal
providing lifestyle and
health information for
individuals interested in
combating obesity,
diabetes, and metabolic
disorders and improving
their overall health and
well being.
w w w. b o d y m i n d i n s p i r a t i o n . c o mTo view the current issue, visit
Digital publishing sponsored by
Introducing a New e-Journal for Medical and SurgicalWeight Loss Patients and Candidates
• Exciting, New, FREERESOURCE covering avariety of topics in thefield of metabolic andbariatric surgery
• FOUR issues in 2012
Editor’s Message
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Copyright © 2012 MMC BMI Body • Mind • Inspiration—Winter 2012 3
Dear Readers:
On behalf of MatrixMedical Communications,I am very proud towelcome you to thefirst edition of Body •
Mind • Inspiration—or BMI.
Sadly, the obesityepidemic continues tothrive, not only inAmerica but around theglobe. As I am certainwe are all aware,
obesity is a multifactorial disease that is not yetclearly understood or easily controlled. Obesityseems to be determined, among other causes, by animbalance between an individual’s genotype andphenotype. Human genetic code has beendetermined by the struggle of human species tosurvive the lack of food. Thus, over the lastcenturies, the human body has evolved to include adefense mechanism against famine by protecting thehighest weight attained. The expression of genotypevaries among humans, thus making us susceptible tobecoming overweight. Conversely, human phenotypeis mainly determined by impacting environmentalfactors. One would imagine that these factors couldbe easily controlled. However, serious eating andpersonality disorders, as well as our economicreality, make such changes extremely difficult formany Americans. Sedentary lifestyles, whether bychoice or by necessity, as well as the abundance of apalatable and affordable food supply in industrializednations, are the main negative phenotypic influencespredisposing these populations to becoming obese.
Recent publications have clearly demonstratedthat obesity is indeed a serious medical conditionthat severely impacts health and shortens lifeexpectancy. BMI was primarily created as a forum inwhich to deliver the latest updates and importantinformation related to weight management, so that
Americans are educated in the fight against thisdebilitating disease.
The successful treatment of obesity andoverweight is primarily based on long-term lifestylechanges and commitment to these changes. New andhealthy eating habits must be preserved and routinephysical activities must be incorporated into dailylifestyle. Unfortunately, as we are all aware, this ismuch more easier said than done!
This month, Liz Goldenberg, MPH, RD, CDN,discusses the benefits of losing weight beforeundergoing weight loss surgery, including reductionof comorbid conditions and complications. AdrienneYoudim, MD, lists common comorbidities andprovides tips for patients on reducing the severity ofthese condition. James Choi, MD, and JonathanShaffer, MD, MBA, discuss osteoarthritic knee painin the patient with obesity and present operativeand nonoperative treatment modalities. Sylvia LeiteFaria, MS, et al present an extensive review ofcurrent literature on the causes and treatment ofhair loss in weight loss surgery patients. This month,we also highlight the Obesity Action Coalition, theonly nonprofit organization whose sole focus isrepresenting those affected by obesity througheducation, advocacy, and support. This articleoutlines membership benefits and providesinformation on how you can get involved.
In future issues, we will be bringing youinformation on a wide variety of topics, includingexercise, nutrition, body contouring, skin health, andmuch more. We hope that BMI will be a valuableresource to you in your efforts to become andremain fit and healthy.
Welcome and I hope you will enjoy this first issue.BMI
Sincerely,
Raul J. Rosenthal, MD, FACSClinical Editor, BMI
Raul J. Rosenthal, MD, FACS,Clinical Editor, Body,Mind,Inspiration, Program Directorof Minimally Invasive Surgery,Director of the MinimallyInvasive Fellowship Program,Director of the Bariatric andMetabolic Institute, andDirector of the GeneralSurgery Residency Program,Cleveland Clinic Florida—Weston, Fort Lauderdale,Florida.
Winter 2012
Volume 1, Issue 1
Publisher’s Message
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Copyright © 2012 MMC4 BMI Body • Mind • Inspiration—Winter 2012
Winter 2012
Volume 1, Issue 1
Dear Readers:
We are pleased to announce the launch of Body
• Mind • Inspiration or BMI, a journal inspired bynumerous calls and e-mails from individualsrequesting information from our company onmedical weight loss and weight loss surgicalprocedures, and health issues weight loss surgerypatients should be aware of two, five, and ten yearspost surgery.
BMI will be published quarterly in 2012,providing articles on lifestyle and health forindividuals seeking to loose weight, and for pre andpost weight loss surgical patients and candidates.Articles will be clear and concise and offerresources on a continual basis. As a community, weneed to stay informed and BMI will be a resourceavailable complimentary to assist individuals ontheir quest to combat obesity, diabetes, andmetabolic disorders.
The following is a sample of topics that you canexpect to see in future issues:
• Insurance Information• Nutrition• Patient Checklists• Body Contouring• Association Updates• Revisional Surgery• Skin Care• New Product Reviews• Patient Advocacy• Overview of Surgical Procedures• Exercise Physiology• Emotional Issues• Communicating with your physicians• Weight Regain• Programs and Resources• Motivational Tips and Techniques
As subscriber, you will receive a notification e-mail when each new issue is available for viewing.The BMI publishing platform automaticallydetermines the web-enabled device you are usingto access the journal and immediately formats theentire issue for reading on computers,smartphones, and tablets.
We are excited to provide a valuable resourcesuch as BMI to individuals interested in improvingtheir health and well being. Additional resourcesare in development and will be introduced in thecoming months. In the meantime, please share thesubscriber link with family, friends, coworkers, oranyone that you believe will benefit from theinformation BMI has to offer. BMI has beendesigned for readers such as yourself. Pleaseprovide feedback on BMI, comment on articles, andfeel free to suggest topics that you would like tosee featured in upcoming issues. BMI
All the best,
Robert L. DoughertyPublisher, BMI
Editorial Advisory Board
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CLINICAL EDITOR
Raul J. Rosenthal, MD, FACSProgram Director of Minimally InvasiveSurgery, Director of the Minimally InvasiveFellowship Program, Director of theBariatric Institute, and Director of GeneralSurgery Residency Program, ClevelandClinic Florida—Weston, Fort Lauderdale,Florida
EDITORIAL ADVISORY BOARD
Susan Gallagher Camden, RN PhD WOCN,CBN, HCRM CSPHPSenior Clinical Advisor, CelebrationInstitute, Inc., Houston, Texas
Tracy Martinez, RN, BSN, CBNProgram Director, Wittgrove BariatricCenter, La Jolla, California
Melodie K. Moorehead, PhD, ABPPBoard Certified in Clinical HealthPsychology, JFK Medical Center, BariatricWellness and Surgical Institute, Atlantis,Florida
Harry Pino, PhDDirector of Clinical Exercise PhysiologyProgram, RecoverHealth Center, New York,New York; Medical Center, Stony Brook, NewYork
Craig B. Primack, MD, FAAPMedical Bariatrician/Certified MedicalObesity Specialist/Co-Medical Director,Scottsdale Weight Loss Center PLLC,Scottsdale, Arizona
Wendy Scinta, MD, MS, FAAFP, FASBPMedical Director, Medical Weight Loss of NY,BOUNCE Program for Childhood Obesity,Manilus, New York; Clinical AssistantProfessor of Family Medicine, UpstateMedical University, Syracuse, New York
Kimberley E. Steele, MD, FACS,Assistant Professor of Surgery, The JohnsHopkins Center For BariatricSurgery,Baltimore, Maryland
Christopher D. Still, DO, FACN, FACPDirector, Center for Nutrition and WeightManagement, Geisinger Health System,Danville, Pennsylvania
Copyright © 2012 MMC5 BMI Body • Mind • Inspiration—Winter 2012
Winter 2012 Volume 1, Issue 1
Table of Contents
The Obesity Action Coalition:
The Voice of Those Affected by Obesity 18
Treatment Considerations for Osteoarthritic
Knee Pain in Patients with Obesity 20
Hair Loss Among Weight Loss
Surgery Patients 25
Weight Loss Surgery Preoperative Risk
Reduction 14
BMI BODY MIND INSPIRATION EDITORIAL STAFF
Editor
Raul J. Rosenthal, MD, FACS
Program Director of Minimally Invasive Surgery,
Director of the Minimally Invasive Fellowship
Program, Director of the Bariatric and Metabolic
Institute, and Director of the General Surgery
Residency Program, Cleveland Clinic Florida—
Weston, Fort Lauderdale, Florida.
Vice President, Executive Editor
Elizabeth A. Klumpp
Matrix Medical Communications
West Chester, Pennsylvania
Associate Editor
Angela M. Hayes
Matrix Medical Communications
West Chester, Pennsylvania
Associate Editor
Kimberly B. Chesky
Matrix Medical Communications
West Chester, Pennsylvania
BMI BODY MIND INSPIRATION BUSINESS STAFF
President/Group Publisher
Robert L. Dougherty
Matrix Medical Communications
West Chester, Pennsylvania
Partner
Patrick D. Scullin
Matrix Medical Communications
West Chester, Pennsylvania
Vice President, Business Development
Joseph J. Morris
Matrix Medical Communications
West Chester, Pennsylvania
EDITORIAL CORRESPONDENCE should be directed to
Executive Editor, Matrix Medical Communications,
1595 Paoli Pike, Suite 103, West Chester, PA 19380.
Toll-free: (866) 325-9907; Phone: (484) 266-0702;
Fax: (484) 266-0726;
E-mail: eklumpp@matrixmedcom.com
ADVERTISING QUERIES should be addressed to Robert
Dougherty, President/Group Publisher, Matrix
Medical Communications,1595 Paoli Pike, Suite 103,
West Chester, PA 19380. Toll-free: (866) 325-9907;
Phone: (484) 266-0702; Fax: (484) 266-0726;
E-mail: rdougherty@matrixmedcom.com
1595 Paoli Pike
Suite 103
West Chester, PA 19380
BMI Body Mind Inspiration [ISSN TBD] is published
digitally four times yearly by Matrix Medical
Communications.Copyright © 2012 Matrix Medical
Communications. All rights reserved. Opinions
expressed by authors, contributors, and advertisers
are their own and not necessarily those of Matrix
Medical Communications, the editorial staff, or any
member of the editorial advisory board. Matrix
Medical Communications is not responsible for
accuracy of dosages given in the articles printed
herein. The appearance of advertisements in this
journal is not a warranty, endorsement, or approval
of the products or services advertised or of their
effectiveness, quality, or safety. Matrix Medical
Communications disclaims responsibility for any
injury to persons or property resulting from any
ideas or products referred to in the articles or
advertisements. This publication provides basic
information about a broad range or medical
conditions. It is not intended to serve as a tool for
diagnosing illness, in prescribing treatments, or as a
substitute for the physician/patient relationship. All
persons concerned about medical symptoms or the
possiblity of disease are encouraged to seek
professional care from an approprpiate healthcare
provider.
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Copyright © 2012 MMC6 BMI Body • Mind • Inspiration—Winter 2012
Dear Editor:
This letter is in response to the an article published in The
Journal of the American Medical Association (JAMA) by
Ludwig and Murtagh entitled, “State intervention in life-
threatening childhood obesity.”1 As a frontline childhood
obesity physician, I strongly disagree with the premise of this
article.
Genetic predisposition, environment in utero, and birth
weight all affect obesity rates long before any active parenting
occurs.2 Race, ethnicity, poverty, infant feeding practices, and
the well-recognized cost disparity between healthy and less
healthy foods play a role.3 Children do not expend energy as in
the past, and school vending machines, poor-quality school
lunches, and the regrettable removal of physical education,
recess, and health education classes are also factors in this
issue.4,5
This is not to say that parents are completely defenseless to
our obesogenic environment.5 Simple changes, such as sitting
down to dinner as a family, decreasing fast food consumption,
controlling use of electronics, and modeling good behavior,
can have a significant impact on a child’s weight. But what
happens when an engaged family has made these changes and
the child remains severely obese (body mass index [BMI] at or
beyond the 99th percentile)?6 Are our only answers to put him
or her through surgery or remove the child from his or her
home?
Approximately two million children in the United States
have severe obesity,6 clearly more than an overburdened foster
care system can handle. Children with obesity are
discriminated against by peers and teachers and are bullied
relentlessly. The added insult of removing a child from his or
her home will, in most cases, do more harm than good. In
addition, with 75 percent of our society being overweight, the
chances that a child will be placed in a home where the family
members also struggle with a weight problem is more likely
than not.7
Choices do exist for a child with obesity besides
experimental surgery and state intervention. The 2007 Expert
Committee on Child and Adolescent Overweight and Obesity
(of which Dr. Ludwig was a member) developed an eloquent
algorithm that involves early identification and assessment by
primary care providers followed by prevention and treatment
by clinical obesity experts. Bariatricians and other childhood
obesity experts are in the process of rolling out these
recommendations nationally while simultaneously conducting
outcomes research, with initial results that look very
promising.
Certainly, the premise of turning a child with severe obesity
over to the state is thought provoking, but unless there are
clear signs of neglect or abuse in conjunction with the obesity,
it is unnecessary, unrealistic, and likely damaging to that child
long term.
References
1. Murtagh L, Ludwig DS. State intervention in life-threatening
childhood obesity. JAMA. 2011;306(2):206–207.
2. Zhao J, Grant SF. Genetics of childhood obesity. J Obes.
2011;2011:845148.
3. Van Cleave J, Gortmaker SL, Perrin JM. Dynamics of obesity and
chronic health conditions among children and youth. JAMA.
2010;303(7):623–630.
4. Rahman T, Cushing RA, Jackson RJ. Contributions of built
environment to childhood obesity. Mt Sinai J Med.
2011;78(1):49–57.
5. Eisenmann JC, Gundersen C, Lohman BJ, et al. Is food insecurity
related to overweight and obesity in children and adolescents? A
summary of studies, 1995–2009. Obes Rev. 2011;12(5):e73–83.
6. Skelton JA, Cook SR, Aulinger P, et al. Prevalence and trends of
severe obesity among US children and adolescents: what could
be better? Acad Peds. 2009;9(5): 322–329.
7. Hadfield SC, Preece PM. Obesity in looked after children: is
foster care protective from the dangers of obesity? Child Care
Health Dev. 2008;34(6):710–712.
With regards,
Wendy Scinta, MD, MS, FAAFP, FASBPMedical Director, Medical Weight Loss of NY, BOUNCEProgram for Childhood Obesity, Manilus, New York; Clinical Assistant Professor of Family Medicine, UpstateMedical University, Syracuse, New York BMI
Letters to the Editor
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Childhood/Adolescent Obesity
and State Intervention: Parents
Not Solely to Blame in the Battle
Copyright © 2012 MMC BMI Body • Mind • Inspiration—Winter 2012 7
Weight loss surgery is growing in popularity.
According to the American Society for Metabolic
and Bariatric Surgery (ASMBS), there were
220,000 bariatric surgeries performed in 2008 and this
number is on the rise. Considering that approximately
five percent of American adults meet the criteria for
morbid obesity, a large pool of surgical candidates
remain.1 As more operations are being performed and the
morbidity and mortality statistics of these surgeries
remain favorable, older and sicker patients may be
finding their way to the bariatric surgeon’s office. These
patients are considered to be at higher risk for
complications, since age and the presence of medical
comorbidities, along with male gender, body mass index
(BMI), and fat distribution, have been identified among
the factors that negatively impact the safety of the
operation. Of these factors, few can be altered except
BMI and fat distribution.
Physicians can choose to operate on higher risk
patients by modifying the procedure, perhaps by
performing a sleeve instead of, or prior to, a Roux-en-Y
gastric bypass (RYGB).
Another option for bariatric programs to deal with
higher risk candidates is by recommending, or in some
cases mandating, weight loss prior to undergoing weight
loss surgery. Some surgery centers recommend
preoperative weight reduction for all of their patients, for
the reasons listed in Tables 1 and 2
BENEFITS TO PREOPERATIVE WEIGHT LOSSThe liver, operative time, and length of stay. A
number of studies have found benefits to preoperative
weight loss. Liu et al2 compared patients who did and
who did not lose weight before surgery and found that
those who lost weight were more likely to undergo
surgery that did not deviate from the standard RYGB
operation. Additionally, patients who did not lose weight
were more likely to have their surgeon comment that the
patients’ livers were enlarged. The authors did not find
differences in operative time, length of stay, major
complications, or wound infections between the groups.
There are a number of studies that look at the effects
of weight loss on the liver. Benjaminov et al3 found a
reduction in liver volume of 8.1 percent, as well as a
nonobjective observation by surgeons that this facilitated
surgery, in patients who lost weight in the four weeks
prior to surgery. In the six weeks prior to surgery, Lewis
et al4 accomplished an even greater reduction in mean
liver volume of 14.7 percent, as well as a 43-percent
decrease in mean liver fat. Both a reduction in liver size
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Copyright © 2012 MMC8 BMI Body • Mind • Inspiration—Winter 2012
Weight Loss before
Weight Loss
Surgery: What Do We
Know About Dropping
Those Preoperative
Pounds?
by Liz Goldenberg, MPH, RD, CDN
Ms. Goldenberg is from New-York Presbyterian Hospital, Weill Cornell College of Medicine of
Cornell University, Department of Surgery, New York, New York.
This article reviews the issues surrounding weight loss before surgical weight loss, and aims to answer the questions that
weight loss surgery centers might have when making decisions about including a preoperative weight loss component in their
surgical programs.
Body • Mind • Inspiration
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Copyright © 2012 MMC BMI Body • Mind • Inspiration—Winter 2012 9
and operative time was achieved in a small group of
patients who lost an average of 4.8kgs, also in a six-week
time frame prior to surgery.5 Operative times were found
to be a highly significant 36 minutes shorter in 62 out of
90 patients who were able to lose more than five percent
of their preoperative weight.6 Still et al1 calculated that
length of stay was less likely to be greater than four days
in high-risk patients who were able to lose 5 to 10
percent of their excess weight before undergoing RYGB.
It has been pointed out that high-risk patients may
experience a greater benefit from preoperative weight
loss.15
Overall complications. The overall major
complication and mortality rates of bariatric surgery are
quite low, less than 3.0 percent and 0.3 percent,
respectively. Studies have shown mixed results as to
whether preoperative weight loss lessens postoperative
complications. Not only have some studies been unable
to find fewer complications for those that lost,6,7 but in
one study8 even preoperative weight gain did not
negatively impact complication rates.
However, considering the low overall complication
rates of bariatric surgery, among the criticisms of these
studies are that they involved inadequate sample sizes of
200 patients or less. Benotti et al9 reviewed the records
of 881 RYGB patients for categories of complications
including the following: respiratory issues, bleeding,
gastrointestinal issues, feeding intolerance, cardiac
issues, leakage, infection, thromboembolism, acute renal
failure, urinary issues, wound issues, and stricture. The
reviewers found statistically significant trends that
confirmed a diminishing likelihood of any complication
with increasing preoperative weight loss.
Impact on postoperative weight loss. There has
been some conflicting data as to whether successful
weight loss preoperatively will translate into more
successful postoperative weight loss. In 2005, Alvarado
et al6 reported that preoperative weight loss was
associated with greater weight loss at one year
postoperatively, specifically an increase of one percent of
preoperative weight loss for a 1.8-percent increase after
surgery. This occurred despite the fact that 83 percent of
the patients in the study failed to achieve the
recommended 10-percent weight loss. In 2008, Alger-
Mayer et al10 described a more successful weight loss
achievement, as well as a significant correlation between
weight lost before and at three years after surgery. One-
hundred and fifty patients who were advised to lose 10
percent of their initial presenting weight were able to
realize a 9.5±6.8-percent loss before undergoing gastric
bypass. The authors attribute their positive results to the
implementation of physical activity and positive dietary
changes early, and they point out that their patients
credit their success to the same factors. Another possible
explanation is that those patients who were able to
achieve greater weight loss before surgery are the same
patients who are more likely to follow up and adhere to
the guidelines afterwards. A review article by Livhits et
al11 compiled data from 15 different papers comparing
weight loss before and after surgery. This large synopsis
came to the same conclusion that preoperative weight
loss results in greater total postoperative weight loss.
Contrary to the collection of studies mentioned
previously are papers by Jantz et al12 and Ochner et al.13
In 2009, Jantz et al12 failed to find a correlation between
the percentage of excess weight loss (EWL) at one year
postoperatively and the maximum amount of weight loss
achieved prior to surgery. However, this was looking at
self-reported weight loss and did not necessarily occur in
the short period of time prior to surgery. In an even more
recent paper published in Obesity in February 2010,
Ochner et al13 found that more weight gain was predictive
of more weight loss after surgery. This study only looked
at the three-month postoperative visit and, perhaps more
importantly, compared patients who were mandated to
undergo a six-month, physician-supervised weight loss
program prior to surgery to those who did have this
requirement. On average, more than 75 percent of
patients in both groups gained weight before surgery.
TABLE 1. Weight loss before weight loss surgery
WEIGHT LOSS BEFORE WEIGHT LOSS SURGERY HAS BEEN LINKED TO
Co-morbidity reduction
Improved patient selection• Those who cannot lose weight before will not be successful after?
• Those who comply with the program before will comply with the
after-surgery follow up, diet, and exercise guidelines?
More successful weight loss postoperatively
Technically easier, safer surgery with lower complication rates
TABLE 2. Questions that a center might ask
Are there benefits? What are they?
Are there drawbacks? What are they?
How do insurance carrier-mandated weight loss requirements impactour patients and our program?
How can the weight loss be accomplished?
How much weight should be lost?
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Copyright © 2012 MMC10 BMI Body • Mind • Inspiration—Winter 2012
Surprisingly, at three months postoperatively, these same
“gainers” had lost more weight than those who has lost
weight prior to their operation. Authors propose that diet
fatigue or the “last supper syndrome,” which occurs
when patients intentionally over-eat, or binge on their
favorite foods for fear that they will miss this habit or
these foods after surgery, may be responsible. This
binge-eating behavior is squelched postoperatively by the
new, tiny pouch. Finally, the authors point out that the
biological set-point theory may play a role in why
patients who lose more weight prior to surgery lose less
after.
DRAWBACKS TO PREOPERATIVE WEIGHT LOSS ORPREOPERATIVE WEIGHT LOSS PROGRAMS
While there is some trepidation over the safety of
encouraging rapid weight loss in patients who are months
or weeks away from major surgery, this author is
unaware of any negative clinical outcome reports.
Nevertheless, there are a handful of drawbacks to
consider by a surgery center looking to implement this
type of program. One downside is the cost to the
program in staffing and other resources. The programs
are usually administered by registered dietitians,
physicians who are part of a medical weight loss arm of
the program, or, in some programs, surgeons or
gastroenterologists who may place a device, such as an
intragastric balloon. While programs usually include an
exercise component to them, few studies mention the
utilization of a trained exercise specialist.
Another possible deterrent may be the concern of
patients dropping out of the program. A well-designed
preoperative weight loss program may go on for as little
as two weeks or as long as six months, which is a
significant delay. Programs may argue that delaying
surgery may deter patients from ultimately having the
surgery. Alami et al7 discuss this fear but did not find a
delay; the times from consultation to operation
(approximately five months) were similar in the groups
that did and did not undergo a preoperative weight loss
program. One patient in this study left to have surgery at
a center that did not have this requirement.
Weight loss attempts required by insurance
carriers versus the surgeon. Insurance-mandated
preoperative weight loss programs have become a routine
delay. Preoperative weight loss interventions are
assumed to improve outcomes by increasing weight loss
and subsequently the positive aspects of weight
reduction. Many feel that these programs are meant to be
a test of patients’ motivation.
Two studies aimed to
challenge the merit of this
prerequisite by comparing
sets of patients who were
required to undergo an
insurance-mandated
preoperative program with
those who did not have this
requirement. Researchers in one study reported that 28
percent of patients commanded to follow the registered
dietitan-supervised 13-week program dropped out of the
program, as compared to only 19 percent of the group
free from this requirement.14 Both groups were more
likely to gain versus lose weight prior to surgery. Both
groups had similar total weight loss at one year, yet the
patients who did not have the mandated delay achieved a
greater percentage of EWL that was significant at the
one-year mark. The recent study in Obesity by Olchner
et al13 came to a similar conclusion when comparing
groups of patients with or without insurance
requirements.13 The 94 patients who had to fulfill the
requirement gained weight preoperatively; an average of
2.9±4.4 percent of their initial body weight.
Olchner et al propose that some patients fear that
successful weight loss may lead to insurance denial for
the surgery. Both studies accused insurance-required
programs of being obstacles to patient access to surgical
treatment of obesity, in addition to not being effective at
bringing about preoperative weight loss.
In contrast to the studies by Olchner et al13 and Jamal
et al,14 the 150 patients in the study by Alger-Mayer et
al10 were required by their surgeon and not by their
insurance carrier to undergo a diet and exercise
program. All patients that wished to undergo surgery at
this practice, regardless of presenting BMI, were
expected to follow the program and lose 10 percent of
their initial documented weight. Instead of a 28-percent
drop out rate, reportedly only one of their patients left to
go to another practice that did not require preoperative
weight loss.
PREOPERATIVE WEIGHT LOSS METHODSMany patients with obesity seeking weight loss surgery
are actually quite adept at losing weight. They are able to
take off the weight for a short period, usually through
diet and/or exercise, but then find themselves
rebounding, gaining back part, all, or even more weight
than they initially lost. Others find that the difficulty
occurs when they reach that plateau of 10, 20, or 50
pounds and the scale is at a stand-still. On the other
Insurance-mandated preoperative weight loss programs have
become a routine delay. Preoperative weight loss interventions
are assumed to improve outcomes by increasing weight loss and
subsequently the positive aspects of weight reduction.
Body • Mind • Inspiration
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hand, some patients have never in their lives successfully
lost weight. Regardless of the history, patients who
appear in the surgeon’s office can become a highly
motivated bunch if told by the surgeon that they will not
be operated on unless they lose weight beforehand. As
described previously, aside from or in addition to
surgeons making these demands on patients, many
insurance providers place demands on doctors to
supervise their patients’ weight loss efforts in order for
them to get coverage. However, most health insurance
plans do not specify any particular type of program for
providers to follow. As surgical programs looking to
accomplish preoperative weight loss, what are the
options?
Diets, medication, and a device. Dieting is the
method of weight loss most often cited in studies that
look at weight loss prior to surgery. This could be
because most weight loss surgery programs already have
dietitians either as part of their team or as consultants
who carry out preoperative evaluations (as required to
fulfill National Institutes of Health [(NIH)] criteria, by
insurance companies, and for ASMBS Centers of
Excellence [(COE)] or American College of Surgeons
[(ACS)] Bariatric Surgery Center Network [(BSCN)]
certification). As pointed out previously, few programs
have exercise experts on their teams, probably because
they are not required by the above organizations. Yet
plenty of evidence backs the synergism of diet plus
exercise, or the effects of an entire multidisciplinary
team including these providers previously noted along
with psychologists or behavioral therapists, in bringing
about weight loss.
The diets that have reportedly been used for bringing
about preoperative weight loss range from a vague
“healthy balanced diet,” to a strict very low-calorie,
liquid diet,2,4 to a very low carbohydrate (30g) diet,3 to a
highly involved and resource-consuming, supervised 11-
week inpatient weight loss program.15
Which type of diet is the most effective is the topic of
another paper, but there are two common denominators
to be found among the conclusions to studies that
compare the efficacy of various weight loss diets. The
first is that those who stay on the diet lose the most
weight, and the second is that patients who have a say in
which diet they follow (versus having to follow a diet
that is chosen for them) will be more successful.16,17 One
can see how these two suggestions are interdependent. A
final point on choice of diet is that although these may
seem to be common-sense recommendations, they can be
easily overlooked by programs that routinely use
standard diet plans and thus fail to individualize plans
according to patients’ preferences.
One study5 looked at the effectiveness of sibutramine
(Abbott Laboratories, North Chicago, Illinois) in
preoperative weight loss. Twenty patients received 15mg
of this medication once daily for six weeks, while another
20 patients did not. The medication group lost 4.8kg
while the control group gained 7.0kg and spent an
additional 20 minutes in the operating room when
compared to the patients who took sibutramine.
There are two reports on the use of an intragastric
balloon for preoperative weight loss.18,19 Thirty-one and
75 patients achieved 22 and 16-percent EWL,
respectively, after the device was implanted for at least
six months. There was no operative mortality and only
two patients in each of the studies suffered from
intolerance and had to have the balloon removed soon
after implantation.
HOW MUCH WEIGHT SHOULD BE LOST?There is a scarcity of data comparing the pros and
cons of how much weight should be lost. Though
insurance companies often mandate that the attempt
must be made, they rarely make specific
recommendations as to the amount of weight loss.13 This
is likely because it is difficult to draw conclusions from
existing data. One reason for the difficulty is that a
standard definition for how to report weight loss is
lacking. Some studies report on total weight loss or
percentage of total weight loss, while others use EWL or
percentage of EWL, and still others use excess BMI loss.
Another issue is a lack of prospective, randomized trials;
most papers are retrospective reviews.20
Many papers support 5- to 10-percent total weight loss
or the same amount of excess weight loss as a desirable
goals.1,7,11 Evidence for this goal is seemingly derived from
studies that link this range of weight loss to significant
reductions in obesity-related comorbidities. Most would
agree that more quality data are needed in order to draw
evidence-based conclusions on the ideal amount of
weight loss that should be recommended.
Even if studies were forthcoming, realistic versus
optimistic weight loss is an important distinction in this
group. Patients who are typically 100 or more pounds
Copyright © 2012 MMC BMI Body • Mind • Inspiration—Winter 2012 11
Many patients with obesity seeking weight loss surgery are actually quite adept at losing
weight. They are able to take off the weight for a short period, usually through diet and/or
exercise, but then find themselves rebounding, gaining back part, all, or even more
weight than they initially lost.
away from their ideal body weight and have a history of
“failed” dieting attempts will continue to be challenged
by the irony of trying to lose weight before undergoing
an operation that will give them help to achieve the same
result.
CONCLUSION
In summary, whether programs should suggest or
require weight loss before weight loss surgery and
whether it should be for all patients or only for select
groups, such as high-risk patients, will probably continue
to be a controversial decision to make. Barring any
mandates from insurance carriers or accreditation
programs, surgery centers will likely continue to decide
for themselves whether it is in theirs, and of course their
patients’ best interests to promote the dropping of those
preoperative pounds.
REFERENCES
1. Still CD, Benotti P, Wood GC, et al. Outcomes of
preoperative weight loss in high-risk patients undergoing
gastric bypass surgery. Arch Surg.
2007;142(10):994–998.
2. Liu RC, Sabnis AA, Forsyth C, Chand B. The effects of
acute preoperative weight loss on laparoscopic Roux-en-Y
gastric bypass. Obes Surg. 2005;15(10):1396–1402.
3. Benjaminov O, Beglaibter N, Gindy L, et al. The effect of
a low-carbohydrate diet on the nonalcoholic fatty liver in
morbidly obese patients before bariatric surgery. Surg
Endosc. 2007;21(8):1423–427.
4. Lewis MC, Phillips ML, Slavotinek JP, et al. Change in
liver size and fat content after treatment with Optifast
very low calorie diet. Obes Surg. 2006;16(6):697–701.
5. Aberle J, Freier A, Busch P, et al. Treatment with
sibutramine prior to Roux-en-Y gastric bypass leads to an
improvement of metabolic parameters and to a reduction
of liver size and operative time. Obes Surg.
2009;19(11):1504–1507.
6. Alvarado R, Alami RS, Hsu G, et al. The impact of
preoperative weight loss in patients undergoing
laparoscopic Roux-en-Y gastric bypass. Obes Surg.
2005;15(9):1282–1286.
7. Alami RS, Morton JM, Schuster R, et al. Is there a benefit
to preoperative weight loss in gastric bypass patients? A
prospective randomized trial. Surg Obes Relat Dis.
2007;3(2):141–145; discussion 145–146.
8. Harnisch MC, Portenier DD, Pryor AD, et al. Preoperative
weight gain does not predict failure of weight loss or co-
morbidity resolution of laparoscopic Roux-en-Y gastric
bypass for morbid obesity. Surg Obes Relat Dis.
2008;4(3):445–450.
9. Benotti PN, Still CD, Wood GC, et al. Preoperative weight
loss before bariatric surgery. Arch Surg.
2009;144(12):1150–1155.
10. Alger-Mayer S, Polimeni JM, Malone M. Preoperative
weight loss as a predictor of long-term success following
Roux-en-Y gastric bypass. Obes Surg.
2008;18(7):772–775.
11. Livhits M, Mercado C, Yermilov I, et al. Does weight loss
immediately before bariatric surgery improve outcomes: a
systematic review. Surg Obes Relat Dis.
2009;5(6):713–721.
12. Jantz EJ, Larson CJ, Mathiason MA, et al. Number of
weight loss attempts and maximum weight loss before
Roux-en-Y laparoscopic gastric bypass surgery are not
predictive of postoperative weight loss. Surg Obes Relat
Dis. 2009;5(2):208–211.
13. Ochner CN, Puma LM, Raevuori A, et al. Effectiveness of
a prebariatric surgery insurance required weight loss
regimen and relation to postsurgical weight loss. Obesity
(Silver Spring). 2010;18(2):287–292.
14. Jamal MK, DeMaria EJ, Johnson JM, et al. Insurance-
mandated preoperative dietary counseling does not
improve outcome and increases dropout rates in patients
considering gastric bypass surgery for morbid obesity.
Surg Obes Relat Dis. 2006;2(2):122–127.
15. Huerta S, Li Z, Anthony T, Livingston EH. Feasibility of a
supervised inpatient low-calorie diet program for massive
weight loss prior to RYGB in superobese patients. Obes
Surg. 2010;20(2):173–180.
16. Brehm BJ, D’Alessio DA. Weight loss and metabolic
benefits with diets of varying fat and carbohydrate
content: separating the wheat from the chaff. Nat Clin
Pract Endocrinol Metab. 2008;4(3):140–146.
17. Dansinger ML, Gleason JA, Griffith JL, et al. Comparison
of the Atkins, Ornish, Weight Watchers, and Zone diets
for weight loss and heart disease risk reduction: a
randomized trial. JAMA. 2005;293(1):43–53.
18. Frutos MD, Morales MD, Luján J, et al. Intragastric
balloon reduces liver volume in super-obese patients,
facilitating subsequent laparoscopic gastric bypass. Obes
Surg. 2007;17(2):150–154.
19. Mills S, Bassona S, Cornisha J, et al. Intragastric balloon
use to reduce weight before bariatric surgery. Surg Obes
Relat Dis. 2010;6(2):224.
20. Tarnoff M, Kaplan LM, Shikora S. An evidenced-based
assessment of preoperative weight loss in bariatric
surgery. Obes Surg. 2008;18(9):1059–1061. BMI
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Copyright © 2012 MMC14 BMI Body • Mind • Inspiration—Winter 2012
Obesity remains a growing and ongoing problem in
the United States. While recent reports have
shown obesity rates have stabilized, severe classes
of obesity are on the rise,1 having important implications
in regard to treatment. Weight loss surgery remains a
durable treatment for obesity, effectively resulting in
remission of many obesity-related conditions.2 In
addition, recent reports have
demonstrated a mortality benefit
in patients who have had
bariatric surgery.3 As a
result, weight loss
surgeries are on the rise.
Studies have shown a
five-fold increase in the
number of bariatric
surgeries between 1998
and 2003.4 The number
of weight loss surgeries
performed in the United
States has increased in all
groups despite age,
income, or insurance status
or type. However, this elective
surgery is not without
complications. Surgeon experience appears
to be a significant predictor of postoperative morbidity
and mortality,5 however, patient-inherent risks have also
been identified. While studies have been conflicting, age,
smoking history, superobesity, and certain comorbidities
are factors implicated in increasing morbidity and
mortality with bariatric surgery.6–8 One validated risk
score identified five perioperative variables that
predicted 30-day mortality. These variables include
superobesity, male gender, hypertension, age greater
than 45, and risk factors for pulmonary embolism,
including obstructive sleep apnea. Patients who had 4 to
5 of the above risk factors had a 12-fold greater (2.4%)
30-day mortality than patients who had none to one risk
factor (0.2%).8 Certain high-risk patient groups may
benefit from optimizing their medical status prior to
weight loss surgery through medical nutritional therapy
and preoperative weight loss.
DIABETESThe relationship between type 2 diabetes and obesity
is well documented as the incidence of diabetes
increases incrementally with rising body mass index
(BMI).9,10 Recent guidelines recommend long-term
glycemic control with HbA1c of 7.2 percent or less prior
to bariatric surgery.11 While pharmacotherapy is
appropriate, medical nutritional therapy remains the
mainstay of treatment. Studies have shown weight loss of
as little as 5 to 10 percent results in effective reduction
of fasting blood glucose and HbA1c. In one study,12
weight loss of up to 14 percent resulted in a two-point
Weight Loss
Surgery
Preoperative
Risk Reduction
by Adrienne Youdim, MD
The presence ofhypertension is asignificant risk factorfor perioperativecomplications.14
Validated risk scoreshave demonstratedhypertension to beassociated with higher30-day mortalityfollowing bariatricsurgery...8
Dr. Youdim is Medical Director, Comprehensive Weight Loss Center, Cedars Sinai Medical
Center, Los Angeles, California, and Assistant Clinical Professor of Medicine, David Geffen
School of Medicine, University of California Los Angeles, California.
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reduction in HbA1c, comparable to targets achieved by
pharmacotherapy.12 Given the favorable effect of modest
weight loss on glycemic control, preoperative weight loss
should be used to achieve glycemic targets in bariatric
surgery patients.
HYPERTENSIONObesity is associated with other cardiometabolic
conditions, including hypertension. Mechanisms of this
association are multifactorial and include secretion by
adipocytes of many proteins of the renin-angiotensin
system, the pathway that mediates hypertension through
sodium and water reabsorption and increased vascular
tone.13 The presence of hypertension is a significant risk
factor for perioperative complications.14 Validated risk
scores have demonstrated hypertension to be associated
with higher 30-day mortality following bariatric surgery,8
and guidelines recommend optimal hypertensive control
prior to bariatric surgery.11 Modest weight loss has been
shown to reduce both systolic and diastolic blood
pressure. Prior studies have shown reductions in blood
pressure of 1mmHg per kilogram weight loss.15 A more
recent systemic review16 suggests that for 10kg weight
loss there is a 4.6mmHg and 6.0mmHg reduction in
diastolic and systolic blood pressure, respectively.16
Moreover, change in macronutrient intake to reduce
sodium and increase fruits, vegetables, and limit
saturated fats can itself result in reductions in blood
pressure independent of weight loss.17 While
pharmacotherapy is often necessary to control
hypertension, medical nutritional therapy and
preoperative weight loss is a useful adjunct to optimize
hypertensive control in patients with morbid obesity.
OBSTRUCTIVE SLEEP APNEAConcomitant obstructive sleep apnea (OSA) is
frequently present in the patient population with morbid
obesity. Obesity is a leading cause of OSA, and a 10-
percent increase in BMI results in a 32-percent increase
in apnea-hypopnea index (AHI). A diagnosis of OSA is an
independent risk factor for 30-day morbidity and
mortality following bariatric surgery.18,19 Surgical patients
with OSA are vulnerable to the effects of sedation,
anesthesia, and analgesia. Patients with OSA have been
shown to have a higher number of postoperative
complications, including but not limited to respiratory
complications, and patients with more severe OSA
(higher AHI or more significant oxygen desaturations)
can be at greater risk for these complications.20 Modest
weight loss can result in significant improvements in
OSA. In one study,21 an average weight loss of 13.5
percent at 6 and 12 months resulted in reduction of the
oxygen desaturation index (desaturation events per hour
of sleep exceeding 4% from baseline) by 28 and 26
points, respectively. Modest weight reduction will
improve OSA and may optimize patient-inherent risk
related to OSA prior to bariatric surgery.
SUPEROBESITYSuperobesity, as defined by a BMI of 50kg/m2 or
greater, has consistently been implicated in increasing
surgical risk with bariatric surgery.6–8,18,22 In one study,22
BMI ?50kg/m2 was independently associated with higher
30-day mortality with an odds ratio of 3.6. Additionally,
preoperative weight loss of 5 to 10 percent has been
associated with more rapid postoperative weight loss and
greater one-year excess weight loss (EWL).23–24 This may
be particularly relevant to a patient with super obesity
who requires a greater overall weight loss to achieve
normal BMI.
PREOPERATIVE WEIGHT LOSSStudies have specifically evaluated the effect of
preoperative weight loss prior to bariatric surgery.
Studies25,26 have shown preoperative weight loss resulted
in reduced liver size and visceral fat. In one study,25 4.1-
percent weight loss resulted in 5.1-percent mean
reduction in liver size and fat. In another study,26 patients
who participated in a 12-week very low energy diet
(VLED) lost an average of 11 percent (80% of which
occurred in the first two weeks of the dietary
intervention) and achieved 28.7- and 24.1-percent
reduction in liver size and visceral adipose tissue,
respectively. Smaller liver size and reduced visceral
adiposity may improve technical feasibility of the
surgery. In a study by Liu et al,27 preoperative weight loss
resulted in a reduced likelihood to encounter an enlarged
liver and reduced likelihood of deviating from standard
operative procedure. Specifically, average weight loss of
3.3kg resulted in a 17-percent reduction in the number
of cases that deviated from standard operation, including
use of additional trocars and conversion to an open
procedure during laparoscopic Roux-en-Y gastric bypass
(RYGB) surgery.27
Preoperative weight loss has also been associated with
reduced probability of surgical complications after
gastric bypass surgery, particularly in open gastric
bypass. In one study,28 EWL of up to 10 percent resulted
A diagnosis of OSA is an independent risk factor for 30-day morbidity and mortality following bariatric
surgery.18,19 Surgical patients with OSA are vulnerable to the effects of sedation, anesthesia, and analgesia.
Copyright © 2012 MMC BMI Body • Mind • Inspiration—Winter 2012 15
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Copyright © 2012 MMC16 BMI Body • Mind • Inspiration—Winter 2012
in reduced major and minor complications. Statistically
significant trends revealed reduced likelihood of any
complication with increasing preoperative weight loss for
the entire cohort of 881 patients (p=0.004) and for those
who underwent open gastric bypass (p=0.02). This
relationship was preserved after adjusting for age, BMI,
number of comorbidities, and type of surgery. In
addition, the degree of weight loss was significant in the
reduction of complications. When compared to those who
lost 10 percent or more excess body weight (EBW),
those who gained five percent or more EBW had a two-
fold increased likelihood of a complication.28 Patients who
underwent preoperative weight loss have also shown
reduced intraoperative blood loss, shorter operative
times,27,29 and reduced length of hospital stay,23 which may
have important implications in resource utilization and
reducing cost of surgery.
CONCLUSIONS
Bariatric surgery remains safe and effective for the
treatment of obesity with recent studies placing 30-day
mortality at 0.03 percent.18 Determining patient-inherent
risk factors allows clinicians to appropriately advise
patients of individual surgical risk and to optimize that
risk when possible prior to surgery. Several studies have
identified patient-inherent variables that portend higher
morbidity and mortality with bariatric surgery.
Superobesity and certain comorbidities, including
diabetes, OSA, and hypertension, are factors implicated
in increasing surgical risk. Routine preoperative weight
loss may not be indicated in all weight loss surgery
patients given low overall complication rates, but may be
of benefit in the higher-risk patient population.
REFERENCES
1. Sturm R. Increases in clinically severe obesity in the United
States: 1986–2000. Arch Intern Med. 2003;163(18):2146–2148.
2. Sjöström L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes,
and cardiovascular risk factors 10 Years after bariatric surgery. N
Engl J Med. 2004;351:2683–2693.
3. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after
gastric bypass surgery. N Engl J Med. 2007;357:753–761.
4. Santry HP, Gillen DL, Lauderdale DS. Trends in bariatric surgical
procedures. JAMA. 2005;294:1909–1917.
5. Flum DR, Dellinger EP. Impact of gastric bypass operation on
survival: a population-based analysis. J Am Coll Surg.
2004;199:543.
6. Livingston EH, Arterburn D, Schifftner TL, et al. National surgical
quality improvement Pprogram analysis of bariatric operations:
modifiable risk factors contribute to bariatric surgical adverse
Outcomes. J Am Coll Surg. 2006;203(5):625–633.
7. Lautz DB, Jackson TD, Clancy KA, et al. Bariatric operations in
veterans affairs and selected university medical centers. J Am
Coll Surg. 2007;204:1261–1272.
8. DeMaria EJ, Murr M, Byrne TK, et al. Validation of the obesity
surgery mortality risk score in a multicenter study proves it
stratifies mortality risk in patients undergoing gastric bypass for
morbid obesity. Ann Surg. 2007;246(4):578–582.
9. Chan JM, Rimm EB, Colditz GA, et al. Obesity, fat distribution
and weight gain as risk factors for clinical diabetes in men.
Diabetes Care. 1994;17:961–969.
10. Colditz GA, Willett WC, Rotnitzky A, Manson JE.. Weight gain as
a risk factor for clinical diabetes mellitus in woman. Ann Intern
Med. 1995;122:481–486.
11. Mechanick JI, Kushner RF, Sugerman HJ, et al. American
Association of Clinical Endocrinologists, The Obesity Society, and
American Society for Metabolic & Bariatric Surgery Medical
guidelines for clinical practice for the perioperative nutritional,
metabolic, and nonsurgical support of the bariatric surgery
patient. Endocr Pract. 2008;14 Suppl 1:1–83.
12. Wing RR, Koeske R, Epstein LH, et al. Long-term effects of
modest weight loss in type II diabetic patients. Arch Intern Med.
1987;147(10):1749–1753.
13. Kershaw EE, Flier JS. Adipose tissue as an endocrine organ. J
Clin Endocrinol Metab. 2004;89(6):2548–2556.
14. Watson K. Surgical risk in patients with metabolic syndrome:
Focus on lipids and hypertension. Curr Cardiol Rep.
2006;8(6):433–438.
15. Neter JE, Stam BE, Kok FJ, et al. Influence of weight reduction
in blood pressure: a metal-analysis of randomized controlled
trials. Hypertension. 2003;42:878–884.
16. Aucott L, Poobalan A, Smith WC, et al. Effects of weight loss in
overweight/obese individuals and long-term hypertension
outcomes: A systemic review. Hypertension. 2005;45:1035–1041.
17. Appel LJ, Sacks FM, Carey VJ, et al. Effects of protein,
monounsaturated fat, and carbohydrate intake on blood pressure
and serum lipids: results of the OmniHeart randomized trial.
JAMA. 2005;294:2455–2464.
18. Flum DR, Belle SH, King WC, et al. The Longitudinal Assessment
of Bariatric Surgery (LABS) Consortium. Perioperative safety in
the longitudinal assessment of bariatric surgery. N Engl J Med.
2009;361:445–454.
19. Flancbaum L, Belsley S. Factors affecting morbidity and mortality
of Roux en-Y gastric bypass for clinically severe obesity: an
analysis of 1,000 consecutive open cases by a single surgeon. J
Gastrointest Surg. 2007;11:500–507.
20. Chung SA, Yuan H, Chung F. A systemic review of obstructive
sleep apnea and its implications for anesthesiologists. Anesth
Analg. 2008;107:1543–1563.
21. Romero-Corral A, Caples SM, Lopez-Jimenez F, Somers VK.
Interactions between obesity and obstructive sleep apnea:
Implications for treatment. Chest. 2010;137(3):711–719.
22. DeMaria EJ, Portenier D, Wolfe L. Obesity surgery mortality risk
score: proposal for clinically useful score to predict mortality risk
in patients undergoing gastric bypass. Surg Obes Relat Dis.
2007;3:34–40.
23. Still CD, Benotti P, Wood GC, et al. Outcomes of preoperative
weight loss in high-risk patients undergoing gastric bypass
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surgery. Arch Surg. 2007;142(10):994–998.
24. Solomon H, Liu GY, Alami R, et al. Benefits to patients choosing
preoperative weight loss in gastric bypass surgery: New results of
a randomized trial. J Am Coll Surg. 2009;208:241–245.
25. Fris RJ. Preoperative low energy diet diminishes liver size. Obes
Surg. 14;1165–1170.
26. Colles SL, Dixon JB, Marks P, et al. Preoperative weight loss with
a very-low-energy diet: quantitation of changes in liver and
abdominal fat by serial imaging. Am J Clin Nutr.
2006;84(2):304–311.
27. Rockson CL. Pre-operative weight loss and intraoperative
outcomes. Obes Surg. 2005;15:1396–1402.
28. Benotti PN, Still CD, Wood GC, et al. Preoperative weight loss
before bariatric surgery. Arch Surg. 2009;144(12):1150–1155.
29. Alvarado R, Alami RS, Hsu G, et al. The impact of preoperative
weight loss in patients undergoing laparoscopic Roux-en-Y
gastric bypass. Obes Surg. 2005;15;(9):1282–1286. BMI
Copyright © 2012 MMC BMI Body • Mind • Inspiration—Winter 2012 17
A MEMBERSHIP ORGANIZATIONThe Obesity Action Coalition (OAC) is a membership
organization. We have three levels of membership; one
for individuals and two for organizations and companies
that would like to support the OAC. Individual
membership benefits include the following:
• Official membership card and welcome letter
• A subscription to the OAC’s official publication titled,
Your Weight Matters
• Subscriptions to Obesity Action Alert and OAC
Members Make a Difference e-Newsletters
• Advocacy alerts
• “Bias Busters” alerts
• The ability to lend your voice to the cause of fighting
obesity
Membership in the OAC also qualifies you to purchase
one of our “educational add-ons.” These “educational
add-on” packages allow you to order OAC educational
resources in bulk. There are three different packages
available, based on the number of materials an individual
is interested in ordering. To learn more about OAC
membership, please visit www.obesityaction.org/
membership/overview.php.
EDUCATIONThe OAC offers a wide variety of free educational
resources on obesity, severe obesity, and childhood
obesity, as well as resources on the consequences and
treatments of the disease. One of our most popular
educational resources is our quarterly publication, Your
Weight Matters. This publication is geared toward
individuals affected by obesity and contains a wide
variety of educational and advocacy information. Each
issue features information on a broad range of weight-
related topics and includes features on weight-loss
surgery, obesity-related conditions, childhood obesity,
nutrition, current advocacy news, and much more. To
learn more about the OAC’s educational resources, please
visit www.obesityaction.org/educationaltools
/brochuresandguides.php.
Other educational materials available include the
following:
• Understanding Obesity brochure series
• Understanding Obesity
• Understanding Severe Obesity
• Understanding Childhood Obesity
• Understanding Obesity Stigma
• Understanding Childhood Obesity poster
• Understanding Obesity poster
• Understanding Excess Weight and Type 2
Diabetes brochure series
• Understanding Excess Weight and its Role in
Type 2 Diabetes
• Understanding Prediabetes and Excess Weight
• Understanding Excess Weight and Type 2
Diabetes
• OAC Insurance Guide: Working with Your
Insurance Provider
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Copyright © 2012 MMC18 BMI Body • Mind • Inspiration—Winter 2012
THE OBESITY
ACTION COALITION:
The Voice of those
Affected by Obesity
by Joe Nadglowski
JOE NADGLOWSKI, President and CEO of the Obesity Action Coalition
The Obesity Action Coalition is a registered 501(c)3 nonprofit organization founded in 2005. The Obesity Action Coalition is the only nonprofit whose sole focus is representing thoseaffected by obesity through education, advocacy, and support.
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Copyright © 2012 MMC BMI Body • Mind • Inspiration—Winter 2012 19
ADVOCACYThe OAC conducts a variety of advocacy efforts
throughout the United States on both the federal andstate level, and encourages individuals to becomeproactive advocates. The primary focus of our advocacyefforts is improving access to obesity treatments. Arecent advocacy victory that the OAC was involved inwas the state of Missouri restoring their bariatric surgerybenefit for state employees in 2012. Several OACmembers testified before the Missouri legislature insupport of this.
Currently, the OAC has been hard at work advocatingfor obesity treatments to be included in the EssentialHealth Benefits (EHB) package for the new state-basedhealth exchange plans under healthcare reform law.Toward the end of 2011, the United States Department ofHealth and Human Services (HHS) held a number ofregional listening sessions across the country to hearfrom local stakeholders about which services should beincluded in the EHB. OAC member advocates spoke ateach of these sessions about the “essential” nature ofobesity treatment and why it is important that HHSinclude these services in the EHB package. To learnmore about the OAC’s advocacy efforts, please visitwww.obesityaction.org/advocacy/overview.php.
SUPPORTThe OAC offers support to those affected by obesity
through everything we do. One of the biggest ways wesupport our members is by representing them in thebattle against weight bias. Recently, the OAC started our“Bias Busters” initiative to bring attention to weight biasand discrimination, as well as to activate our membershipon these issues and ask their help in speaking out against
bias. Weight bias issues addressed so far include thecreation of a petition directed at Facebook concerning“obesity hate” pages that were found on the popularsocial networking site, an Entertainment Tonight
segment where a reality TV star dressed up in a “fatsuit,” as well as targeting stock photography websites,asking them to remove offensive photos of individualsaffected by obesity. To learn more about “Bias Busters”please visitwww.obesityaction.org/gettinginvolved/biasbusters/overview.php.
HOW TO GET INVOLVEDWhether you are personally affected by obesity or just
passionate about the cause, membership in the OAC isone of the easiest ways that you can give back to thefight against obesity. Individual membership in the OACis just $20/year. You can learn more about the OAC atwww.obesityaction.org. BMI
LEARN MORE, GET INVOLVED
For more information on the OAC and how you can get involved, visit the following websites:
GENERAL INFORMATIONwww.obesityaction.org
MEMBERSHIPwww.obesityaction.org/membership/overview.php.
EDUCATIONAL RESOURCESwww.obesityaction.org/educationaltools/brochuresandguides.php.
ADVOCACY EFFORTSwww.obesityaction.org/advocacy/overview.php.
“BIAS BUSTERS”www.obesityaction.org/gettinginvolved/biasbusters/overview.php.
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Copyright © 2012 MMC20 BMI Body • Mind • Inspiration—Winter 2012
Knee pain is among the most common of health
concerns in the population, and the subset of
bariatric patients is no exception.1,2 Independently,
in the United States, obesity has prevalence in excess of
33 percent, and a 2006 Centers for Disease Control and
Prevention (CDC) survey of adults reported an 18-
percent incidence of knee pain within the past 30 days.3,4
Bariatric patients have a well-established positive
association with knee osteoarthritis, and it has been
previously noted that body mass index (BMI) in young
adulthood, a time when many patients are now choosing
to pursue bariatric surgical options, may be a good
predictor of subsequent osteoarthritis in later years.5–7
While the etiology of knee pain and treatment
modalities can be wide ranging, this article will focus on
existing medical knowledge of knee pain secondary to
osteoarthritis in the bariatric population, considerations
of the treatment options available for those afflicted with
that diagnosis, and a discussion of the “best questions to
address” in terms of future collaboration between and
treatment options available to primary care physicians,
orthopedic surgeons, and bariatric physicians and
surgeons.
ANATOMYThe knee is a modified hinge joint that experiences
high contact and shear forces during ambulation. There
are three alignments commonly observed in the knee:
neutral, valgus (knock-knee), and varus (bow-legged).8
Existing alignment of the knee can be exacerbated or
altered by degenerative changes, which can significantly
impact force distribution and wear patterns affecting the
three compartments of the knee: medial, lateral, and
patellofemoral. In level walking, the force experienced by
the knee with each step is approximately four times the
total weight of the body, and this increases to
approximately eight times when ambulating down an
incline.9 In effect, the average bariatric patient’s knees
will experience forces comparable to downhill walking at
baseline and much higher forces with additional activity.
The joint is stabilized by four primary ligaments—
anterior cruciate ligament, posterior cruciate ligament,
and medial and lateral collateral ligaments, as well as the
surrounding musculature. Additionally, the knee is
cushioned by synovial fluid and layers of cartilage and
meniscus.
Injury or degeneration of any of these components can
lead to knee pain. A history of prior injury and the
effects of advancing age can lead to degeneration of the
Treatment
Considerations for
Osteoarthritic Knee
Pain in Patients with
Obesity
by James Choi, MD; Jonathan Schaffer, MD, MBA
Dr. Choi, is from the Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston,
Massachusetts. Dr. Schaffer is from the Orthopaedic and Rheumatologic Institute, Cleveland Clinc, Cleveland,
Ohio.
This article discusses treatment modalities for osteoarthritic knee pain in the patient with obesity. Nonoperative options include
physical therapy, orally administered analgesia, and knee injections. Operative intervention options include total knee arthroplasty as
definitive treatment.
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cartilage (osteoarthritis) with an unpredictable
expression of pain and level of functional impairment.
Previous studies have not correlated obesity with
radiographic progression of osteoarthritis. Notably, it has
been observed that obesity can increase the risk of
osteoarthritis progression in those patients with neutral
or valgus (knock-knee) alignment, but varus (bow-
legged) aligned knees did not show the same risk
progression.10,11
EVALUATION AND THERAPY OPTIONS FOR KNEEPAIN
Osteoarthritic pain characteristically worsens with
increased activity, particularly weight bearing, and
improves with rest. Generally, patients report no
systemic symptoms and on physical exam may have
decreased range of motion, crepitus, mild joint effusion,
and palpable osteophytic changes at the knee joint,
though these findings may be more difficult to elucidate
in patients with obesity.12 Pain that continues and
progresses warrants radiographic evaluation with joint
space narrowing representing cartilage degeneration,
characteristic of osteoarthritic changes. Unless there is
suspicion of soft tissue injury, there is generally no need
for further radiographic evaluation by computed
tomography (CT) or magnetic resonance imaging (MRI)
modalities.
Treatment for osteoarthritic knee pain is symptom
based and relies heavily on the patient’s report of
symptoms and functional limitations. There is not a
predictive correlation between a patient’s complaint of
symptoms to radiographic evaluation of osteoarthritis.
The dependence on patient-reported symptoms for
treatment action makes the understanding of pain
reporting especially helpful. The results of the Swedish
obese subjects study13 indicate that patients with a
higher BMI tend to have a higher prevalence of work-
restricting pain (including the knees) than their general
population counterparts. This same study also noted that
postoperative female bariatric patients reported a greater
level of improvement in their symptoms as compared to
their nonoperative peers and that work-restricting knee,
hip, and ankle pain was more responsive than axial
musculoskeletal complaints.13
At present, treatment of osteoarthritic knee pain is
based upon relief of symptoms beginning with
nonoperative options, and treatment modalities generally
do not differ for patients with obesity as compared to
their nonobese counterparts. Pharmacologic therapy is
primarily targeted at analgesia, and periodic use of
analgesics can be effective for intermittent and mild-to-
moderate symptoms. Nonsteroidal anti-inflammatory
drugs (NSAIDS) are often effective for osteoarthritis
pain.14 The use of NSAIDS is complicated in the gastric
bypass patient population due to an increased risk of
adverse gastrointestinal side effects, which include
development of marginal ulcers at the previously created
anastomosis sites. NSAIDs should be used with caution
and possibly with proton pump inhibitor therapy.15 In the
gastric bypass population, there has been little definitive
guidance on the most effective pharmacologic
alternatives given the risks of NSAID use in this patient
subset. Narcotics are generally considered a
pharmacologic last option for advanced osteoarthritis
pain that is refractory to other treatments, and systemic
corticosteroids have not been shown to be effective for
pain relief although localized injections that are
discussed later can be effective for relief of symptoms.14
Physical therapy targeted at the surrounding
musculature, specifically quadriceps strengthening, can
be effective in providing pain relief.16
Among more invasive interventions, knee injections
fall under two categories: corticosteroid and
viscosupplementation. Corticosteroid injections reduce
the inflammatory response within the knee joint and can
provide good relief of variable duration of weeks to
months, but rarely are more than two or three intra-
articular injections to the same joint administered per
year for concern of potentially progressive cartilage
damage.14 Additionally, recent studies have demonstrated
that bupivacaine, a commonly used intra-articular local
anesthetic often combined with a corticosteroid, has a
significantly increased in-vitro toxicity to human
articular chondrocytes when compared to ropivacaine,
and further research on long-term effects should be
followed closely.17 Viscosupplementation of hyaluronates
is intended to counteract the reduction of concentration
and size of hyaluronan, a key component of synovial
fluid, which occurs in osteoarthritis. Clinical trials of
viscosupplementation have yielded highly variable results
ranging from no effect to improvement in symptoms
lasting up to one year.
Physicians should also be aware of patient-directed
therapies as well. In the context of osteoarthritis, this
primarily consists of the nutritional supplements
glucosamine and chondroitin, and National Institute of
Health-sponsored research studies to date have not
shown significant efficacy in symptom relief.14,18
The end-stage therapy for osteoarthritic knee pain is
In effect, the average bariatric patient’s knees will experience forces comparable to
downhill walking at baseline and much higher forces with additional activity.
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surgical intervention, including arthroscopy, osteotomy,
partial knee arthroplasty, and total knee arthroplasty.19
Should this be required, total knee arthroplasty is the
definitive treatment. Other operative modalities that can
potentially be offered include a partial knee arthroplasty,
including patello-femoral arthroplasty for patients with
specifically isolated compartment osteoarthritis. Knee
arthroplasty is generally regarded as a highly successful
procedure with predictably good outcomes. Historically,
orthopedic surgery has been somewhat reticent to
embrace operative treatment for patients with high BMIs.
This is perhaps no better exemplified than by the
decision of the East Suffolk (UK) health board to
prioritize lower extremity arthroplasty for those patients
that are not overweight or obese. The two most cited
reasons for not proceeding with arthroplasty in the obese
patient set are a high rate of perioperative complications
(e.g., wound healing and infections) and concern for the
longevity and efficacy of the implant. Winiarsky et al20
showed a significantly increased postoperative infection
rate (26% vs. 2%) for patients with morbid obesity
undergoing a total knee arthroplasty. A review article by
Gillespie and Porteous21 showed a trend of increasing
complication rates with increasing BMI though no
definitive cutoff could be determined. A study by Amin
et al23 in 2006 showed that arthroplasty patients with
BMIs greater than 40kg/m2 had clinical outcome scores
significantly lower than the control group and a higher
rate of revision and perioperative complications. Amin et
al recommended that patients lose weight and maintain
that weight loss prior to arthroplasty and should be
counseled about the potential for inferior results without
weight loss.22 In 2000, Parvizi et al24 reported seeing
excellent hip and knee arthroplasty results in patients
who were postoperative from bariatric procedures with a
mean BMI change from 49kg/m2 to 29kg/m2.
DISCUSSION/CONCLUSIONSAlthough the connection between these two
morbidities is strong, the course of treatment is not well
defined. From the orthopedist’s perspective, a high BMI
may be viewed as potentially exclusionary from surgical
treatment of osteoarthritis, at least until the patient
achieves some degree of stable and sustained weight
loss. Looking from the bariatric surgeon’s perspective,
bariatric procedures have not historically promoted any
efficacy in improving musculoskeletal concerns to the
extent that has been the case for improving
cardiovascular and endocrine morbidities. In the
literature today, there is a paucity of publications
addressing the long-term outcomes of joint arthroplasty
in the context of osteopenia that is generated by the
malabsorptive state created by a gastric bypass
procedure. This leads us to a number of questions as to
the appropriate path of care for the patient with obesity
and progressive knee osteoarthritis.
1. For patients meeting criteria for both bariatric surgery
and knee arthroplasty, which procedure should be
performed first?
2. How do we best minimize the exposure of patients to
perioperative risk?
3. Can we better understand the outcomes of post-
bariatric procedure patients as compared to their
general population and conservatively treated obese
controls?
4. What is the appropriate timing of procedures? Should
there be absolute BMI cutoffs?
5. What are the cost benefits and comparisons as well as
quality of life considerations regarding bariatric and
arthroplasty procedures?
Some points for future consideration include the
following: 1) understanding noncongruence in age of the
typical bariatric versus arthroplasty patient; 2)
determining whether or not primary care physicians and
orthopedists who have patients with BMIs of greater than
35 presenting to their clinic with knee pain should
consider referring those patients for evaluation by a
bariatric clinic; and 3) determining when a “suboptimal”
arthroplasty procedure is in the best interest of the
patient. Bariatric patients tend to present at a younger
age than the typical arthroplasty candidate. The
youngest bariatric patients would generally not be
considered for arthroplasty; however, patients
progressing into their 40s to 50s may be a potential
subset for future outcomes studies. If weight loss
through invasive restrictive procedures or nonoperative
There is evidence that correlation exists between obesity and progression of knee
pain.5–7 In the patient population with BMI in excess of 40, research indicates that
these patients tend to have suboptimal postoperative arthroplasty results and a higher
incidence of perioperative complications than their knee pain control peers. A gray
area exists for patients with BMIs between 30 and 40 with a noted increasing trend to
suboptimal results and higher complication rates but no definitive cutoff mark.
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methods can improve symptoms and delay the need for a
primary orthopedic procedure, it may be worthwhile to
further investigate outcomes of each population group as
well as gain a better understanding of the pain response
and symptom reporting as compared to current weight
for bariatric patients. It may also be worthwhile to
consider the appropriateness of arthroplasty in specific
high BMI patients. Amin et al23 demonstrated a
significant difference in Knee Society Scores between
patients with obesity and control patients; however, an
additional consideration may be that the arthroplasty
patient with obesity may not need to generate the same
quantitative score to experience an improvement in
function and decrease in pain. Is it acceptable to expect
less than standard results from the surgeon’s perspective
as long as the patient is aware of the increased risks and
diminished benefits when compared to patients with
lower BMIs?
There is evidence that correlation exists between
obesity and progression of knee pain.5–7 In the patient
population with BMI in excess of 40, research indicates
that these patients tend to have suboptimal
postoperative arthroplasty results and a higher incidence
of perioperative complications than their knee pain
control peers. A gray area exists for patients with BMIs
between 30 and 40 with a noted increasing trend to
suboptimal results and higher complication rates but no
definitive cutoff mark. In limited studies, patients who
require knee arthroplasty after bariatric surgery have
done well, and long-term follow up of those patients will
yield useful information. Presently, it may be worthwhile
to consider a referral to a bariatric surgeon by a primary
care physician or orthopedic surgeon for patients with
obesity presenting with knee pain. After undergoing
bariatric surgery, these patients may see improvement in
the common comorbidities of high BMI patients as well
as improvement in their osteoarthritic knee pain
symptoms. This also generates the potential for delaying
the need for any orthopedic surgical intervention and
reducing the likelihood of perioperative complications
and need for revision surgery should there be a need for
arthroplasty in the future. Further study of outcomes of
bariatric patients with osteoarthritic knee pain would be
helpful to further delineate appropriate treatment
protocols in the future.
REFERENCES
1. Lawrence RC, Felson DT, Helmick CG, et al. Estimates of
the prevalence of arthritis and other rheumatic conditions
in the United States. Part II. Arthritis Rheum.
2008;58(1):26–35.
2. Grotle M, Hagen KB, Natvig B, et al. Obesity and
osteoarthritis in knee, hip and/or hand: An
epidemiological study in the general population with 10
years follow-up. BMC Musculoskelet Disord. 2008;9:132.
3. United States Obesity Trends.
http://www.cdc.gov/obesity/data/trends.html. Accessed
October, 28, 2009.
4. Adults Reporting Joint Pain or Stiffness in the Past 30
Days, 2006. http://www.cdc.gov/Features/dsJointPain/.
Accessed October 28, 2009.
5. Stürmer T, Günther KP, Brenner H. Obesity, overweight
and patterns of osteoarthritis: the Ulm Osteoarthritis
Study. J Clin Epidemiol. 2000;53(3):307–313.
6. Felson DT, Zhang Y, Hannan MT, et al. Risk factors for
incident radiographic knee osteoarthritis in the elderly:
the Framingham Study. Arthritis Rheum.
1997;40(4):728–733.
7. Gelber AC, Hochberg MC, Mead LA, et al. Body mass
index in young men and the risk of subsequent knee and
hip osteoarthritis. Am J Med. 1999;107(6):632–633.
8. Hoppenfeld S. Physical Examination of the Spine and
Extremities. Prentice Hall, Upper Saddle River, NJ, 1976.
9. Kuster MS, Wood GA, Stachowiak GW, Gächter A. Joint
load considerations in knee replacement. J Bone Joint
Surg BR. 1997;79(1):109–113.
10. Felson DT, Goggins J, Niu J, et al. The effect of body
weight on progression of knee osteoarthritis is dependent
on alignment. Arthritis Rheum. 2004;50(12):3904–3909.
11. Niu J, Zhang YQ, Torner J, et al. Is obesity a risk factor
for progressive radiographic knee osteoarthritis?
Arthritis Rheum. 2009;61:329–335.
12. Evaluation of Patients Presenting with Knee Pain.
http://www.aafp.org/afp/20030901/917.html. Accessed
October 28, 2009.
13. Peltonen M, Lindroos AK, Torgerson JS. Musculoskeletal
pain in the obese: a comparison with a general population
and long-term changes after conventional and surgical
obesity treatment. Pain. 2003;104:549–557.
14. Klippel JH et al. Primer on Rheumatic Diseases, edition
12. Arthritis Foundation 2001: 295–296.
15. Wilson JA, Romagnuolo J, Byrne TK, et al. Predictors of
endoscopic findings after Roux-en-Y Gastric Bypass. Am
J Gastroenterol. 2006;101(10):2194–2199.
16. Fransen M, Crosbie J, Edmonds J. Physical therapy is
effective for patients with osteoarthritis of the knee: a
randomized controlled clinical trial. J Rheumatol.
2001;28(1):156–164.
17. Piper SL, Kim HT. Comparison of ropivacaine and
bupivacaine toxicity in human articular chondrocytes. J
Bone Joint Surg Am. 2008;90:986–991.
18. Clegg DO, Reda DJ, Harris CL, et al. Glucosamine,
chondroitin sulfate, and the two in combination for
painful knee osteoarthritis. N Engl J Med.
2006;354(8):795–808.
19. Gidwani S, Fairbank A. The orthopaedic approach to
managing osteoarthritis of the knee. BMJ.
2004;329(7476):1220–1224.
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20 Winiarsky R, Barth P, Lotke P. Total knee arthroplasty in
morbidly obese patients. J Bone Joint Surg Am.
1998;80:1770–1774.
21. Mantilla CB, Horlocker TT, Schroeder DR, et al. Risk
factors for clinically relevant pulmonary embolism and
deep venous thrombosis in patients undergoing primary
hip or knee arthroplasty. Anesthesiology.
2003;99(3):552–560; discussion 5A.
22. Gillespie GN, Porteous AJ. Obesity and knee arthroplasty.
Knee. 2007; 14:81–86.
23. Amin AK, Clayton RA, Patton JT, et al. Total knee
replacements in morbidly obese patients. J Bone Joint
Surg Br. 2006;88(10): 1321–1326.
24. Parvizi J, Trousdale RT, Sarr MG. Total joint arthroplasty
in patients surgically treated for morbid obesity. J
Arthroplasty. 2000;15(8):1003–1008. BMI
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Morbid obesity is a refractory disease related to diets
and medication.1 Bariatric surgery is seen as the only
effective treatment in such cases.2,3 Currently, surgical
treatment of obesity is divided into the following two groups:
1) restrictive surgical procedures and 2) mixed surgical
procedures, with the restrictive factor described as having
more or less of a disabsorptive component. Malnutrition is a
risk associated with all bariatric procedures, and hair loss is a
frequent complaint that may be associated with nutritional
factors, such as lower caloric intake and/or lower absorption of
important nutrients for the maintenance and growth of hair.4
Hair loss can seriously impact the lives of individuals and
may lead to anxiety, low self-esteem, psychosocial problems,
and depression. As a consequence, hair loss can be a stress
factor for this population.5,6 The aim of this article is to provide
a comprehensive review of the literature on hair loss in
patients undergoing bariatric surgery and provide clinicians
with a description of the causes and recommended treatments.
LITERATURE SEARCHA broad review of the Medline and Pubmed databases for
articles published between the years 1983 and 2009 was
conducted, selecting articles related to humans. The key
words used in the electronic search included the following:
hair loss, bariatric surgery, alopecia, nutritional deficiencies,
biotin, zinc, iron, vitamin B12, and essential fatty acids.
A total of 41 articles were found, of which 30 were selected.
Among these, 15 were reviews, four compilations of guidelines,
eight original articles, two clinical case studies, and one
statement of the original article. Articles that addressed other
causes of hair loss, outside of the area of nutrition, were
excluded. Besides scientific articles, 10 chapters from books
and one monograph were also examined.
CAUSES AND TREATMENTS OF HAIR LOSSThe most likely causes of hair loss were found to be related
to age, sex, disease, and genetic factors. It is therefore
important to gather history of each patient who presents with
hair loss regarding any current illness, recent illnesses, auto-
immune diseases, family history of hair loss, food intake,
medications, and the use of cosmetics harmful to the hair.5
Hair follicles have two stages: the anagen (hair growth)
stage and the telogen (inactive) phase. All hairs begin their
cycle in the anagen phase, grow for a period of time and move
into the telogen phase, which lasts about 100 to 120 days.
Then the hair falls out. This process, if accelerated, is called
telogen effluvium and is the cause of hair loss in bariatric
patients.7
The causes for telogen effluvium are drugs, surgery, fever,
childbirth, diseases related to the thyroid, such as hyper- and
Hair Loss Among
Weight Loss
Surgery Patients
by Silvia Leite Faria, MS; Orlando Pereira Faria, MD;
Renato Diniz Lins, MD; and Heloisa Rodrigues de
Gouvea
Ms. Faria is a nutritionist from Gastrocirurgia de Brasília, Brasília, Brazil and is also in private
practice; Dr. Pereira Faria is a chief surgeon, Gastrocirurgia de Brasília, Brasília, Brazil; Dr. Lins is a
medical doctor from Gastrocirurgia de Brasília, Brasília; and Ms. Rodrigues de Gouvêa is a
nutritionist and trainee from Gastrocirurgia de Brasília, Brasília, Brazil.
Bariatric surgery may lead to nutritional deficiencies due to reduced food intake, the scope of the surgery itself, rapid weight
loss, inadequate absorption of nutrients, and the lack of adherence to supplement programs. This article provides an extensive
review of current literature relating to hair loss in bariatric patients. A description of current methods of treatments is included.
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hypothyroidism, rapid weight loss, anorexia, low proteinintake, iron and zinc deficiency, and toxicity of heavy metals.4–6
In bariatric surgery, telogen effluvium may be associated withpatients who are nonadherent to the supplement program orwho have had rapid weight loss, difficulty in feedingthemselves, or have poor dietary habits (e.g., foodintolerances, especially with protein sources).4
Hair loss after bariatric surgery often occurs between thethird and sixth month after surgery and can last 6 to 12months or more. In the first six months, this framework can bereversed without intervention, although there is no consensuson treatment for these cases.8 After six months postsurgery,nutritional causes are involved in hair loss.4 In both cases,there is no harm to the follicle, so the hair can grow back.9
The nutrients possibly related to hair loss are protein, iron,zinc, essential fatty acids, vitamin B12, and biotin.
Protein. Protein-energy deficiency is associated withincreased hair loss.4,5 A protein deficiency can manifest itselfthrough the reduction of hepatic proteins including albumin,loss of muscle mass, asthenia (weakness), and alopecia.10
Among the factors contributing to protein deficiency arethe following: insufficient chewing, since food needs to bebetter digested in order to compensate for the mechanicalbarrier imposed by the weight loss surgery (WLS);10 reductionof the availability of pepsin, renin, and hydrochloric acid due tothe isolation of the distal stomach, thus limiting proteindigestion;11 anorexia; frequent episodes of vomiting; diarrhea;food intolerances; depression; fear of weight regain; abuse ofalcohol or drugs; and socioeconomic status. Thus, all patientsafter surgery are at risk of developing protein deficiency inconnection with restrictive and disabsorptive procedures.10
Patients who undergo Roux-en-Y gastric bypass (RYGB)usually have a low-calorie diet of 500 to 800kcal per day.Despite a calorie-protein increase during the first year, suchintakes remain at insufficient levels.11
According to Marcason,12 the minimum recommendedprotein intake for bariatric patients is 60g per day, withemphasis on proteins of high biological value (HBV).12,13
However, in general, the recommended intake is 80g of proteinfor women and 100g for men per day or 1.5g/kg idealweight.11,14 In cases of more disabsorptive surgery, such asbiliopancreatic diversion (BPD), there is a raisedmalabsorption of protein. It is therefore recommended thatpatients intake at least 90g of protein.15
It is believed that a reduction in the availability of proteincan cause thinning of the hair, difficulty in the normal hairgrowth process, and diffuse alopecia.16 In relation to essentialamino acids, their deficiency can affect growth anddifferentiation of hair, since they compose 27 percent of the
protein content of hair.16
Among all essential amino acids, a deficiency of L-lysine, inparticular, can contribute to hair loss while “full body suppliesof L-lysine” improve hair growth after periods of decline andimprove the levels of iron in the body. Its bioavailable form isprimarily found in fish, meat and eggs and a decrease inconsumption of these foods may cause a negative balance ofthis amino acid affecting hair growt.17 Thus, a supplementationof 1.5–2g of L-lysine is recommended.4
Iron. Iron is the micronutrient most related to hair loss. Itsdeficiency, in cases without anemia, was related to hair loss forthe first time in the early 60s.18
In WLS, specifically RYGB, a decreased intake of foods richin iron occur. Decreased absorption also occurs, since ironabsorption is more efficient in the duodenum and adjacentparts of the jejunum, which are isolated in RYGB. Concomitantwith this is a decrease in the reduction process of iron to itsmost bioavailable form, due to lower production ofhydrochloric acid.10
For women, iron deficiency is more prevalent among thosewho are in a fertile age, and serum ferritin levels below 40Ìgare strongly associated with hair loss.4,10,19 Kantor et al20 relatedlow concentrations of serum ferritin and hemoglobin with hairloss. Researchers have observed in cases of telogen effluviumthat a significant number of people respond well when treatedwith iron. In a study by Rushton et al,21 researchers correlatedlow serum ferritin with hair loss among women treatment forsix months with daily supplementation of 72mg of iron, and
The nutrients possibly related to hair loss
are protein, iron, zinc, essential fatty
acids, vitamin B12, and biotin.
TABLE 1. Recommended supplements for specific
micronutrient deficiencies
NUTRIENT RECOMMENDATION
ProteinWomen: 80g/daya
Men: 100g/daya
Biotin 2,5 mg/day
Flaxseed oil 2 capsules/day
Multivitamin/Multimineral 200% DRIb
Vitamin B12(crystalline form)
350–500Ìg /day
Iron (ferrous fumarate orgluconate)c 320mg
320mg
Elemental iron 65mg
aWith adequate amounts of L–lysine: 1.5 to 2g/daybDietary Reference Intake (Daily Value)cWomen in their fertile age
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1.5g of L-lysine decreased the percentage of hairs in thetelogen phase as well as the hair loss in 39 percent andincreased levels of serum ferritin.
Iron supplementation recommended for patients with hairloss is 320mg of ferrous fumarate or gluconate or 65mg ofelemental iron twice a day, with a volume of approximately 25percent ingested being absorbed.18,22 Parenteral infusion mustbe prescribed for bariatric patients who are refractory to ironsupplementation or have anemia related to iron deficiency orhemoglobin serum levels below 11g/dL.23
Biotin. A biotin deficiency can cause depigmentation ofhair and diffuse alopecia, since this vitamin plays an importantrole in the development of the hair follicles.16,24 It is believedthat supplementation or topical use of biotin can prevent hairloss and accelerate growth after a period of decline.4
Such biotin deficiency related to hair loss was initiallyobserved in patients undergoing total parenteral nutrition(TPN) without prolonged biotin. After starting theirsupplementation of biotin, patients undergoing TPN improvedrapidly in terms of hair loss.9
In 2001, Bruginsky25 evaluated 118 patients and found that17 percent of women reported alopecia due to surgery. Also,these women presented with inadequate intake of severalnutrients, such as folic acid, retinol, fiber, vitamin C, and biotin.In a period of 30 days, the growth of hair in 100 percent ofcases was observed after supplementation of 100mcg of biotinand other nutrients, such as folic acid, inositol, choline, Bcomplex, that are known to boost the action of biotin.
One must consider that the daily 1 to 2mg of biotin mayprovide clinical support to cases of hair loss not responding toother types of treatment.17 Daily consumption of 2.5mg wasestablished as a safe limit of intake of biotin, the no observedadverse effects level (NOAEL).24
Zinc. Zinc has several functions and is an important factorfor growth and development of hair. Its uptake can be assistedby the presence of glucose and amino acids in the intestinaltract and its deficiency can cause growth retardation, diarrhea,alopecia, skin lesions, and loss of appetite, among othersproblems.26,27
In cases of hair loss, a supplementation of 15mg/day of zincchelate is recommended.28 The upper level is 40mg of zinc; asupplementation of 50mg over long periods can lead to copperdeficiency.10
Essential fatty acids. Some studies have observeddeficiency of essential fatty acids (linoleic and linolenic acids)
in patients after RYGB and adjustable gastric banding (AGB)since these procedures alter the digestion of lipids and, as aconsequence, the uptake of essencial fatty acids.10,15,29 Inrelation to BPD and duodenal switch (DS), only 28 percent ofingested fat is absorbed.29
In patients with biotin deficiency, levels of linoleic acidlower than normal were observed. In cases of functionaldeficiency of biotin (due to lack of carboxylase) associated tohair loss, supplementation with polyunsaturated fatty acidsmay reduce this symptom, suggesting that hair loss can becaused by impairment of elongation of polyunsaturated fattyacids as a result of reduced activity of acetyl-CoAcarboxylase.24
For patients post-RYGB, flaxseed oil (15mL) isrecommended.15 The recommended dose of linolenic acid is 0.5to 1.0 percent of energy intake and linoleic acid is from 3 to 5percent. These amounts can be reached with two capsules of1g of linseed oil and two tablespoons of extra virgin olive oil.22
Vitamin B12. It is known that the human body has storesof vitamin B12, on average, for 3 to 5 years dependent on one’sdaily intake. However, since patients undergoing RYGB havelower production of hydrochloric acid and of the intrinsicfactor, both of which are needed for its absorption in theterminal ileum, there may be deficiency of vitamin B12 if thesupplementation is not adequate. Thus, RYGB patients havedigestion, release, and absorption difficulties of vitamin B12.10
Brolin et al30 observed deficiency of vitamin B12 in patientssix months after bariatric surgery, becoming more commonafter one year.10 Deficiency in B12 may alter the pigmentationof hair. This alteration can be reversed with B12supplementation.16 The supplementation of vitamin B12 mustbe at least 350 to 500Ìg/day orally in its crystalline for, butpatients may need a monthly intramuscular supplement of1000Ìg.10,22
RECOMMENDATIONSPatients who present with hair loss six months postsurgery
should follow the following recommendation daily: intake 80gof protein for women and 100g for men (with sufficientamounts of L-lysine, 1.5 to 2g/day), add 15 mL of flaxseed oil,2.5g of biotin, one or two multivitamin capsules with minerals(thus providing 200 percent of DRIs), 350 to 500Ìg/day of B12in its crystalline form, and 320mg of ferrous fumarate orgluconate or 65mg of elemental iron twice daily. (Table 1) Thesupplementation of zinc recommended in this article is already
Patients undergoing WLS may have hair loss after surgery due to the lower intake and
inadequate absorption of protein, iron, biotin, zinc, vitamin B 12, and essential fatty
acids. These patients need an adequate supplementation in order to prevent
complications from evolving.
present in sufficient doses in multivitamins that contain
minerals.
CONCLUSION
Patients undergoing WLS may have hair loss after surgery
due to the lower intake and inadequate absorption of protein,
iron, biotin, zinc, vitamin B 12, and essential fatty acids. These
patients need an adequate supplementation in order to
prevent complications from evolving. Further randomized
studies on hair loss in bariatric patients are needed in order to
know, with accuracy, the adequate levels of supplementation
of these nutrients to be administered.
REFERENCES
1. Buchwald H, Avidor Y, Braundwald E, et al. Batritric surgery: a
systematic review and meta-analysis. JAMA.
2004;292(14):1724–37.
2. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes,
and cardiovascular risk factors 10 years after bariatric surgery.
N Engl J Med. 2004;351:2683–2693.
3. Folli F, Pontiroli AE, Schwesinger WH. Metabolic aspects of
bariatric surgery. Med Clin N Am. 2007;91:393–414.
4. Jacques J. Micronutrition for the Weight Loss Surgery
Patient. Edgemont, PA: Matrix Medical Communications;
2006:146–147.
5. Beattie PE. The patient with hair loss. Practioner.
2003;247(1643):128–134.
6. Williamson D, Gonzalez M, Finlay AY. The effect of hair loss on
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