Energy intake and food habits between weight maintainers and regainers, five years after Roux-en-Y gastric bypass.
Obesity has become a global public health crisis. In Canada, 25%-30% of adults aged 18 years or older are now considered obese (BMI [greater than or equal to] 30 kg/[m.sup.2]), and 2.7% of adults are severely obese (BMI [greater than or equal to] 40 kg/[m.sup.2]) [1,2]. The prevalence of severe obesity has increased exponentially over the past 2 decades, which has major implications for the Canadian healthcare system [3, 4]. Roux-en-Y gastric bypass (RYGB) has emerged as the most efficacious treatment for severe obesity when compared with lifestyle or medication alone . This procedure results in clinically meaningful weight loss in the year following surgery. However, research suggests for some patients weight regain may begin as early as 2 years post-surgery . It is not clear if energy intake, food habits, or other factors may be contributing to weight gain in this subset of patients. More insight is needed into the mechanisms of weight regain in this medically complex population.
The primary aim of this study was to compare the differences in dietary intake (caloric and macronutrient) between individuals who have maintained weight loss (maintainers) to those who have regained their lost weight (regainers) on average 12 years after RYGB. Secondary aims were to examine behaviours/habits (i.e., follow-up compliance and vitamin supplementation adherence) between weight regainers and maintainers.
Sixty-one individuals who had RYGB between 1995 and 2008 at the Royal Victoria Hospital in Montreal, Quebec, Canada, were recruited for this study. Further detail on the inclusion and exclusion criteria for this study has been previously published . This study was approved by the McGill University Department of Medicine Institutional Review Board. Participants were contacted by telephone, the study was explained in detail, and those who agreed to participate were asked to complete a 3-day food record (at least 2 weekdays and 1 weekend day of recording)  along with a questionnaire that explored patterns of vitamin supplementation and amount of contact with dietitians or other healthcare professionals. The 3-day food record, questionnaire, and consent form were mailed to all participants along with an addressed and postage-paid return envelope.
Height (m) and weight (kg) were measured using a wall-mounted stadiometer and a bariatric digital platform scale (SECA [TM] Medical Scales and Measuring Devices, U.S.), respectively. Percentage of total body weight loss was calculated by dividing weight loss (pre-operative weight (recorded in a hospital chart before surgery) minus current weight (measured in the lab)) by pre-operative weight and multiplying by 100, as previously described . Participants were classified as maintainers if they exhibited a minimum 38% of total body weight loss and maintained it, as previously described . Participants were classified as regainers if they achieved 30% or less of their total body weight loss, as previously described . Anthropometric measurements were taken 1 year prior to completion of the 3-day food record and questionnaire, as participants of this study were a subsample of a larger long-term post-RYGB follow-up research study. All participants were self-reported as weight stable during this time period.
Food Processor [R] SQL-ESHA Canadian database version 10.8.0 was used to estimate energy intake, macronutrient content, and alcohol intake (ESHA Research, Salem, OR, USA).
Statistical analyses were performed with SPSS version 22 (IBM Corp. [C], Armonk, NY). Continuous variables were analyzed using analyses of covariance (ANCOVA) controlling for age and sex. Differences between categorical variables were analyzed using [chi square], and [alpha] was set at a minimum of 0.05. Data are presented as mean [+ or -] SD.
Sixty-one participants agreed to take part in this study during the initial telephone contact, however only 27 of those individuals completed the protocol (consent form, questionnaire, and food record). From the 34 individuals who did not complete the study, 3 decided to terminate their participation in the study and 31 never responded to the mailed package despite 3 follow-up calls. The 27 individuals who completed questionnaires had surgery on average 12.15 [+ or -] 3.7 years prior to the study and were 89% female. Participants' characteristics separated by maintainers (n = 10) and regainers (n = 17) are displayed in Table 1. At the time of testing, participants weighed 86.0 [+ or -] 20.1 kg with a BMI of 33.8 [+ or -]8.1 kg/[m.sup.2]. Total weight loss was 34.7 [+ or -] 14.0%. Maintainers lost 44.4 [+ or -] 5.4% of their weight since surgery compared with regainers who lost 18.2 [+ or -] 6.3%.
Energy, macronutrient, and alcohol intake
Food-record analysis revealed that all participants reported consuming 1705 [+ or -] 573 kcal/d. After adjusting for sex and age, there was no difference in total calories reportedly consumed per day between regainers and maintainers (F[1, 23] = 4.076, P = 0.071) (Table 2). On average, participants reported consuming 81.0 [+ or -] 32.3 g of protein; however, 37% of participants were consuming on average 51.0 [+ or -] 7.8 g of protein daily, which is lower than the recommended minimum of 60 g/day for optimal post-RYGB surgery care, with no difference in percentage of participants consuming [less than or equal to]60 g/day between maintainers (41%) and regainers (30%), [chi square](1, N = 10) = 0.34, P = 0.206  (Table 2).
Intake of macronutrients was similar between groups with the exception of carbohydrate intake, which was greater in regainers compared with maintainers, F = 5.065, P < 0.05. Regainers also reported consuming more alcohol compared with maintainers, F = 4.836, P < 0.05. There was no difference in percent of total calories from macronutrients (protein, fat, and carbohydrate) between groups (Table 2).
Contact with dietitian or healthcare professional
Most participants (74%) reported no contact with a Registered Dietitian post-surgery. Moreover, 78% reported being in contact with a healthcare professional only once a year post-surgery. There were no differences between maintainers and regainers with respect to the frequency of contact with dietitians and healthcare professionals.
Twenty-six percent of participants reported never taking vitamin supplements post-surgery. Frequency of vitamin supplementation was not different between maintainers and regainers.
Roux-en-Y gastric bypass may lead to significant weight loss and improvements in health status, but weight regain is a growing problem in this population and more research into all aspects of weight loss maintenance is needed. Non-surgical predictors of long-term successful weight maintenance among individuals formerly living with obesity have been documented. These predictors include high levels of physical activity, a consistent diet across the week and weekend, a diet low in calories and fat, and weight monitoring . Studies of individuals who underwent RYGB 2-4 years earlier suggested that an increase in energy intake and decrease in physical activity may lead to weight regain [15, 16]. Although physical activity and sedentary behaviour have been reported long-term post-surgery , energy intake 10 years after RYGB is less clearly defined in the literature. Therefore, the purpose of this study was to compare energy intake and dietary habits between individuals who have maintained a successful weight-loss over time to those who have regained their weight to better understand what nutritional factors may contribute to this long-term successful weight loss in individuals who have undergone RYGB.
The literature shows that frequent consumption of snacks high in fat and sugar could lead to excessive energy intake from carbohydrates and this behaviour may reduce the ability to maintain weight loss [17, 18], Our study results tend to support this finding as regainers reported consuming more carbohydrates compared with maintainers; however, we did not evaluate intake of snack foods per se.
Regainers reported consuming more alcohol than maintainers. Alcohol is an energy dense substance, second only to fat in its caloric value per gram (6.9 kcal/g) [19, 20]. By consuming larger volumes of alcohol per day, regainers are ingesting high amounts of calories with little to no nutritional value . Although reported consumption of alcohol by regainers (1.32 standard drinks per day) and maintainers (0.19 standard drinks per day) was within the recommended low-risk level (0-2 standard drinks per day) , alcohol metabolism is different post-RYGB allowing individuals a greater peak blood alcohol level and a longer time for the alcohol level to reach "0" . There is a well-documented link between substance abuse and bariatric surgery, which worsens post-surgery . Our data suggest that this additional consumption of alcohol may contribute to regain of excess weight post-surgery.
Over one-third of participants reported not consuming recommended amounts of protein considered optimal for post-RYGB surgical care, which is suggested as a minimum of 60 g per day for life . Similarly, Sarwer et al.  reported the percentage of daily calories from protein was reduced at 92 weeks post-surgery compared with 20 weeks after the surgery. This shows that adherence to the recommended dietary protein intake is diminished with time after RYGB. If protein consumption among individuals who have undergone RYGB is inadequate long-term post-surgery, it can potentially lead to losses in lean body mass, reduced metabolic rate, and possibly substantial weight regain .
Since one-quarter of participants reported never taking vitamin supplements post-surgery, they may be at increased risk for lifetime micronutrient deficiencies resulting from the combined restrictive and mal-absorptive aspects of this surgery, which bypasses areas of the digestive tract for nutrient absorption [25, 26]. Iron, calcium, vitamin B12, and vitamin D deficiencies are common post-RYGB . These deficiencies can lead to severe metabolic consequences such as hepatic disease, renal disease, and renal stones . Risk of nutrition-related post-surgical complications is greatly increased if diet and supplement prescriptions are not adhered to and if there is no frequent nutritional follow-up. Regardless of the type of procedure, bariatric surgery reduces stomach capacity, which can present some risks for long-term diet-related complications [25, 26]. Nevertheless, micronutrient deficiencies can be managed with adequate vitamin supplementation and follow-up with a Registered Dietitian to improve overall nutritional status following RYGB . As regular meetings with a healthcare professional after RYGB can promote better long-term health outcomes for individuals who have undergone RYGB , it is alarming that three-quarters of our study's participants reported never being in contact with a dietitian.
We acknowledge several limitations in this cohort study. The 3-day food record is a self-reporting tool; therefore, food consumption may have been under- or misreported. However, this tool has been shown to be valid and reliable in other studies . We did not look at physical activity levels of our participants. Physical activity promotes weight control and contributes to successful weight-loss in this population . Lastly, we acknowledge that the small sample may limit interpretation of these findings. However, there are few studies on the long-term nutritional status of individuals who have undergone RYGB and we feel our findings provide unique long-term insight into the dietary habits of this population.
RELEVANCE TO PRACTICE
We identified higher reported intakes of carbohydrate and alcohol in regainers compared with maintainers long-term post-RYGB. Alcohol intake and other alcohol-related issues should be considered in follow-up assessment of individuals with RYGB and in future studies. Other dietary concerns in this population include the potential for inadequate protein intake and not taking prescribed vitamin supplements post-surgery. Hospitals that perform RYGB may benefit from developing effective protocols for patient follow-up that include dietitian services. Dietitians should encourage individuals who have undergone RYGB to participate in continuous nutritional counselling programs long-term post-surgery.
We wish to extend our gratitude to Lisa Kaouk (RD), Dietitian at the Montreal General Hospital at the Bariatric Surgery Clinic, who has provided continual support and professional expertise throughout this research study.
Conflict of interest: The authors declare that they have no competing interests and that there was no financial support for this work.
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RYAN E. R. REID, BSc (a); EKATERINA OPARINA, MSc (b); HUGUES PLOURDE, PhD, RD (b); ROSS E. ANDERSEN, PhD (a)
(a) Department of Kinesiology and Physical Education, Montreal, QC; (b) School of Dietetics and Human Nutrition, McGill University, Montreal, QC
Table 1. Participant characteristics post Roux-en-Y gastric bypass (mean [+ or -] SD). Weight maintenance Regainers Maintainers Characteristic (n = 17) (n = 10) Age (y) 51.1 [+ or -] 9.6 54.4 [+ or -] 7.6 Height (m) 1.59 [+ or -] 0.13 1.61 [+ or -] 0.06 Weight (kg) 95.5 [+ or -] 19.5 80.5 [+ or -] 18.8 BMI (kg/[m.sup.2]) 38.5 [+ or -] 10.4 * 31.1 [+ or -] 6.9 Years post-surgery 11.3 [+ or -] 3.7 12.65 [+ or -] 3.7 Weight lost (%) 18.2 [+ or -] 6.3 ** 44.4 [+ or -] 5.4 Weight maintenance Total Characteristic (n = 27) Age (y) 53.2 [+ or -] 8.3 Height (m) 1.6 [+ or -] 0.09 Weight (kg) 86.0 [+ or -] 20.1 BMI (kg/[m.sup.2]) 33.8 [+ or -] 8.1 Years post-surgery 12.15 [+ or -] 3.7 Weight lost (%) 34.7 [+ or -] 14.0 Note: * p [less than or equal to] 0.05, **p [less than or equal to] 0.01 for comparisons between regainer and maintainer groups. Table 2. Age- and sex-adjusted daily reported dietary intake post Roux-en-Y gastric bypass (mean [+ or -] SD). Weight maintenance status Regainers (n = 17) Maintainers (n = 10) Total calories (kcal) 1985 [+ or -] 639 1541 [+ or -] 476 Protein (g) 81.9 [+ or -] 34.1 80.5 [+ or -] 32.3 Protein (%) 16.81 [+ or -] 6.48 20.64 [+ or -] 5.17 Carbohydrates (g) 222 [+ or -] 84.3 * 162 [+ or -] 67.5 Carbohydrates (%) 43.42 [+ or -] 8.73 42.22 [+ or -] 12.59 Fat (g) 74.9 [+ or -] 40.9 64.8 [+ or -] 35.3 Fat (%) 33.71 [+ or -] 11.22 36.15 [+ or -] 10.67 Alcohol (g) 18.5 [+ or -] 30.9 * 2.6 [+ or -] 6.5 Health Canada Total (n = 27) adult guidelines  Total calories (kcal) 1705 [+ or -] 573 -- Protein (g) 81.0 [+ or -] 32.3 -- Protein (%) 19.21 [+ or -] 5.87 10-13 Carbohydrates (g) 184.8 [+ or -] 78.4 -- Carbohydrates (%) 42.67 [+ or -] 11.15 45-65 Fat (g) 68.6 [+ or -] 37.0 -- Fat (%) 35.24 [+ or -] 10.73 20-35 Alcohol (g) 8.5 [+ or -] 20.5 -- Note: * p [less than or equal to] 0.05, for comparisons between regainer and maintainer groups.
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|Title Annotation:||Perspectives in practice/Perspectives pour la pratique|
|Author:||Reid, Ryan E.R.; Oparina, Ekaterina; Plourde, Hugues; Andersen, Ross E.|
|Publication:||Canadian Journal of Dietetic Practice and Research|
|Date:||Dec 1, 2016|
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