Management of iron deficiency and anemia after Roux-en-Y gastric bypass surgery: an observational study.

BACKGROUND: Iron deficiency (ID) is common after Roux-en-Y gastric bypass surgery (RYGB). Optimal iron management in this population is unclear. The objective of this study was to assess our management of RYGB patients with ID and anemia. METHODS: Clinic visit records of RYGB patients with ID or anemia from January 1, 2008, to February 1, 2010 were evaluated. Demographic characteristics, postsurgery iron and anemia indices, and prescribed treatments were recorded. Three separate definitions for ID and anemia were used (standard textbook, ASBMS, and recent literature). An intravenous iron protocol was later implemented, and follow-up laboratory values were obtained. RESULTS: A total of 125 with ID or anemia (89% female, 86% Caucasian), mean (SD) age 44.7 (8.6) years, and BMI 47.3 (10.8) kg/m(2) at time of RYGB, were included. Proportion of values meeting criteria for ID or anemia at first follow-up: standard textbook, hemoglobin (Hb, 35%), transferrin saturation (Tsat, 48%), ferritin (28%); ASBMS, ferritin (43%); recent literature, ferritin (58%), serum iron (21%). At mean follow-up of 45.7 (43) months, oral iron (n = 49) or intravenous iron (n = 4) had been prescribed for 53 (42.4%) patients, and 32 (25.6%) patients received multiple blood transfusions. Nine patients received intravenous iron using the new protocol (400-1400 mg), resulting in increases in Hb (1.8 g/dL; P<.05) and ferritin (31.8 ng/mL; P< .002). CONCLUSION: Iron management was inadequate. Hematologic values often were deficient for sustained periods. Initially, few patients received intravenous iron after oral iron failure, many received no iron supplementation, and there was high use of blood transfusions. Subsequently, administration of intravenous iron was beneficial.

Use of Orlistat 60 mg in the management of weight loss before bariatric surgery.

BACKGROUND: Patients undergoing gastric bypass surgery are usually required to lose weight during the preoperative phase of their management. For some individuals, this is difficult to achieve with diet and exercise alone, and the use of weight loss medication may be considered a treatment option. OBJECTIVE: To evaluate the use of orlistat 60 mg taken up to 3 times daily as an adjunct to achieve the 10% preoperative weight loss recommended in this bariatric program prior to gastric bypass surgery. METHODS: The aim was to recruit 50 patients (25 treatment, 25 controls) who were in the preoperative phase of their bariatric program. Patients were referred by their physician. Control subjects were selected from individuals who were eligible but not interested in participating in the study during the same period. All patients received usual care. RESULTS: Nineteen patients (5 males) and 19 age- and sex-matched controls were included. The mean (SD) initial body mass index for the treatment versus control group was, respectively, 49.5 (10.5) versus 47.2 (4.9) kg/m(2) (p = 0.559). At 3 months, the percent excess weight (EW) loss was 2.4 (3.8) (n = 15) versus 5.5 (7.6) (n = 19) (p = 0.111) and the percent total body weight (TBW) loss was 1.2 (1.9) versus 2.9 (4.1) (p = 0.103). At 6 months, the percent EW loss was 3.6 (6.4) (n = 9) versus 10.2 (8.0) (n = 16) (p = 0.036) and the percent TBW loss was 2.0 (3.4) versus 5.4 (4.2) (p = 0.048). CONCLUSIONS: Some patients felt that orlistat was beneficial for weight loss; however, overall, they did not show benefit from its addition to their preoperative weight loss management.

Antidepressant drug therapy does not affect weight loss one year after gastric bypass surgery.

BACKGROUND: Preliminary data suggest that patients with actively treated depression should expect the same outcomes after surgery. The objective of this study was to compare weight loss 12 months after gastric bypass surgery in patients taking antidepressants before surgery (AD) versus those who were not (non-AD). METHODS: IRB approval was obtained. All patients gave informed consent prior to participating in the study. Medication and weight loss histories were retrospectively reviewed in adult patients who were followed at 12 months post-surgery. RESULTS: 145 of 364 patients were taking antidepressants at baseline. There was no significant difference in weight loss between the AD and non-AD groups at 12 months (p > 0.05). CONCLUSIONS: Taking antidepressant medication prior to gastric bypass surgery did not affect weight loss outcomes at 12 months.

Specialty residency training in medical nutrition education: history and proposal for improvement.

Nutrition education among residents in training is at a critical juncture. There is a general lack of a unified curriculum, a lack of nutrition physician mentors, and a failure to properly train physicians about nutrition. In surveys, residents in training have acknowledged their minimal nutrition education. Published data and training experiences suggest the importance of creating physician mentors in nutrition who are embedded in residency training programs. The development of recurrent short-term nutrition credentialing courses and online nutrition tool kits is also thought to be important in future residency training.

Proposal for medical school nutrition education: topics and recommendations.

The mission of increasing the number of physician nutrition experts requires focused nutrition education directed at medical students across the 4-year curriculum and into postgraduate training. Courses should be horizontally and vertically integrated, bridging the basic sciences and clinical medicine. It is anticipated that the Liaison Committee on Medical Education and Association of American Medical Colleges will require competency in nutrition with emphasis on preventive and therapeutic applications. Barriers to implementation of nutrition courses can be overcome by using innovative teaching in association with cooperative course directors. Analysis of prior governmental efforts, through the Nutrition Academic Award, provides a basis for targeting fundamental knowledge and creative methods for achieving educational goals. Recommendations for short-term and long-term ideas for increasing the number of adequate physician nutrition experts are offered.

Board certification and credentialing in nutrition.

Board certification and credentialing in nutrition for physicians are problematic issues. Many board examinations are offered, but have few candidates and poor recognition. This discussion focuses on the feasibility of establishing a single board examination body. Some key considerations were identified to improve credentialing and examination in nutrition for physicians. Increasing the number of nutrition physicians and improving recognition of their credentials should ultimately translate to better patient health and safety. Consolidation of board examinations may be in the best interest of physician nutritionists.

Preoperative weight loss as a predictor of long-term success following Roux-en-Y gastric bypass.

BACKGROUND: All patients undergoing gastric bypass surgery at this institution are recommended to achieve a goal of 10% total body weight (TBW) loss prior to surgery. The objective of this study was to determine whether preoperative TBW correlated with 3- and 4-year weight loss outcome. METHODS: This study was conducted prospectively at a large teaching hospital. All adult patients with 3- and 4-year follow-up data since the start of the study in 1998 to September 2007 were included. All data are expressed as mean +/- SD. Pairwise correlation and ordinary least squares regression analysis was used to determine the strength of association between preoperative TBW loss and weight loss at 3 and 4 years. RESULTS: One hundred fifty patients (120 females), age 45.3 +/- 8.9 years, were included. Their body mass indexes (BMIs), preoperatively and after 3 years, were 52.2 +/- 9.8 and 35.4 +/- 8.2 kg/m(2), respectively. There was a significant correlation between preoperative and 3-year TBW lost (9.5 +/- 6.8% vs 31.9 +/- 11.7%, r = 0.302, p = 0.0002) and between excess body weight (EBW) lost preoperatively and after 3 years (16.1 +/- 11.3% vs 55.1 +/- 20.2%, r = 0.225, p = 0.006). Ninety five patients had follow-up data available at 4 years. Their mean preoperative BMI was 52.6 +/- 9.7 kg/m(2) and decreased to 37.5 +/- 9.0 kg/m(2). The TBW loss prior to and after surgery (10.0 +/- 6.5% vs 29.4 +/- 11.5%) was significantly correlated (r = 0.247, p = 0.015). The EBW loss preoperatively and after 4 years correlated positively (17.1 +/- 11.1% vs 50.8 +/- 19.8%, r = 0.205, p = 0.046). CONCLUSION: There is a significant correlation between weight loss attained preoperatively and sustained weight loss at 3 and 4 years.

The lifestyle challenge program: a multidisciplinary approach to weight management.

BACKGROUND: The increasing prevalence of overweight and obesity in the US has received widespread attention and is highlighted in recent government-issued health priorities. While there are many weight loss programs in different settings, few include pharmacist involvement in spite of pharmacists' recognized easy accessibility to the public. OBJECTIVE: To provide insight into a successful, collaborative, multidisciplinary approach to weight management and to encourage pharmacists and other healthcare professionals to adopt a similar approach to patient management. METHODS: Adult patients >18 years of age were recruited from an outpatient university-based setting to participate in a weight management program. The principles of the program included diet, exercise, and behavior modification. The program was conducted through weekly one-hour group sessions held over a 20-week period. Faculty involved in the program included an attending physician specializing in nutrition, a pharmacist, and a behavioral psychologist. All data are expressed as mean +/- SD unless otherwise specified. RESULTS: Ninety participants (74 female, mean age 48 +/- 10 y) entered the program between April 2001 and April 2004. Participants had multiple obesity-related comorbid diseases. The weight of completers (n = 59) decreased from 100.9 +/- 20 kg at baseline to 97.3 +/- 19.5 kg at 10 weeks and 95.9 +/- 20 kg at 20 weeks. Thirty-nine patients completed both baseline and final assessments, which showed improvement in health-related quality of life, binge-eating behavior, and depressive symptoms (p < 0.05). CONCLUSIONS: This program is a successful multidisciplinary model for the management of overweight and obese patients in an outpatient-based hospital setting.

Medication associated with weight gain may influence outcome in a weight management program.

BACKGROUND: Weight gain is a commonly overlooked adverse effect of some medications that potentially confounds weight loss efforts in individuals who are overweight and obese. OBJECTIVE: To determine the frequency of use of drugs associated with weight gain by participants and the effect on outcome in a weight management program. METHODS: Adult patients > 18 years of age were recruited from an outpatient, university-based setting to participate in a 20-week structured weight management program. RESULTS: Ninety patients (74 women) were recruited (mean [+/- SD] age 48 +/- 10 y, mean body mass index 37 +/- 6 kg/m2). Patients had multiple diseases including type 2 diabetes mellitus (n = 23), hypertension (n = 48), depression (n = 18), and dyslipidemia (n = 9). The median number of drugs per patient was 4.0 (range 0-15). The median number of drugs associated with weight gain was zero (range 0-3). Forty-three (48%) patients were taking at least one of these agents, including beta-blockers (n = 18), selective serotonin-reuptake inhibitors (n = 18), sulfonylureas (n = 7), insulin (n = 9), and thiazolidinediones (n = 6). Seven patients completed < or = 6 weeks of the program and were excluded from further analysis, and 83 patients completed 10 weeks. Of these 83 patients, 39 had lost < or = 2% of their initial weight; 23 (59%) of those 39 were taking drugs associated with weight gain. Fifty-nine patients completed the full 20 weeks. The mean overall weight loss of completers was 4.8 +/- 5.0% (range-5.9 [gain] to 17.1% [loss]) at 20 weeks. CONCLUSIONS: Patients taking WGDs weighed more at baseline and were less likely to lose weight in this program. Attention should be given when prescribing such medications to obese patients, as this may negatively influence their weight management.

Medication use patterns after gastric bypass surgery for weight management.

BACKGROUND: Bariatric surgery, commonly gastric bypass, is an effective intervention in achieving sustained weight loss in patients with a body mass index (BMI) >40 kg/m(2). Currently, there are few data in the literature describing medication use after bariatric surgery. OBJECTIVE: To document the change in medication use patterns over a 2-year period in patients who had gastric bypass surgery. METHODS: Institutional review board approval was obtained for this ongoing, prospective longitudinal study. Adults (>18 y) scheduled for gastric bypass surgery were recruited. Clinical and demographic data, including age, gender, weight, height, BMI, number of obesity-related comorbidities, and number of medications and nutritional supplements, were obtained by medical chart review. RESULTS: One hundred fourteen patients (87 females) were recruited. The mean +/- SD age was 45 +/- 9 years. Patients had multiple obesity-related comorbid diseases for which they were receiving medication. Drug therapy for diabetes and hypertension was significantly reduced (p < 0.05). All patients were required to take additional nutritional supplements and medications associated with surgery postoperatively. CONCLUSIONS: Bariatric surgery has a positive benefit in terms of reduction intake of medication associated with obesity-related comorbid disease. However, there is limited reduction in the overall number of drugs and supplements being consumed by the patient, especially during the first year postoperatively.

Binge status and quality of life after gastric bypass surgery: a one-year study.

OBJECTIVE: This study evaluated gastric bypass surgery outcomes according to presurgical binge eating severity. RESEARCH METHODS AND PROCEDURES: Adult patients completed assessment questionnaires including the Short Form-36, Gormally Binge Eating Scale (BES), and Beck Depression Inventory (BDI) before and 12 months after surgery. RESULTS: One hundred nine patients (18 men, 91 women) were recruited. Based on their baseline BES scores, patients were non- [n = 52 (48%)], moderate [n = 31 (28%)], or severe [n = 26 (24%)] binge eaters. Although the percentage of excess weight loss was greatest after 12 months in the severe binge eaters, the difference among groups was not significant. Severe binge eaters had higher baseline BDI scores than either non- or moderate binge eaters (p = 0.001). After surgery, BDI scores declined significantly in all groups from the baseline scores but remained higher postoperatively in the severe binge eaters (p = 0.018). BES scores declined significantly (p = 0.000) after surgery within all groups. There was no difference in the Short Form-36 physical component summary scores at baseline among groups. Mental component summary scores were significantly lower in the severe binge eaters (p = 0.001). After surgery, there was no difference among groups in either physical or mental component summary scores. DISCUSSION: In conclusion, data from the present study suggest that patients have similar outcomes in terms of improved depression scores, binge eating behavior, and health-related quality of life regardless of their binge eating severity before surgery. Patients with the most severe binge eating behavior before surgery showed the most improvement when assessed 12 months after surgery.

Pharmacist intervention enhances adherence to orlistat therapy.

BACKGROUND: Pharmacists, especially those in community practice, should increase their level of intervention in dealing with the nationwide epidemic of obesity since they interact with large numbers of the public on a regular basis. We hypothesized that patients who receive medication for weight loss may have an improved therapeutic outcome if they received additional support from their community pharmacist. OBJECTIVE: To evaluate the impact of pharmacist support on patient persistence with orlistat. METHODS: Pharmacists were trained in basic obesity management skills. Patients who were prescribed orlistat and attending an outpatient nutrition program were invited to participate in the study. All patients agreed to receive pharmaceutical care. Those who lived where the service was available were assigned to the intervention (I) group and those who did not were assigned to the control (C) group. All patients received usual care provided by the outpatient clinic. RESULTS: Thirty patients, 15 in the I group and 15 in the C group, were recruited. Both groups were predominantly women (87%) with a mean +/- SD age of 43.8 +/- 9.7 years. Patients in the I group had significantly greater persistence with orlistat therapy as assessed by duration of therapy (p = 0.006) and number of patients completing the 26-week study (7 I, 2 C; p = 0.046). There was no significant difference in percent of weight loss between groups (p > 0.05). CONCLUSIONS: In this pilot study, patients receiving pharmaceutical care took orlistat longer than the controls and had improved outcome with orlistat therapy.