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P. K. H. Walton60
14 Conclusion
Registries have the capacity to describe real-world data about patient populations,
their characteristics along with patterns of practice and outcomes. These data help
to inform a wide group of stakeholders as to the value of bariatric and metabolic
surgery and enable surgeons to benchmark their performance against national and
international standards. Starting a registry is not a trivial exercise as it is not only
logistically complex but prone to failure unless all the necessary building blocks
are in place. It is hoped that this chapter will encourage and guide both those that
are about to embark on starting their own national registry or those who are determined to see an existing registry flourish.
The process of turning data into information to improve outcomes is ultimately
to the benefit of patients who can be better informed about the risks and benefits of
different procedures.
References
1. Al Sabah S, Walton P, Kinsman R. First Kuwait National Bariatric Surgery Database Report:
April 2019. ISBN 978–0–9929942–9–7
2. Canadian Task Force on the Periodic Health Examination (3 November 1979). “Task
Force Report: The periodic health examination". Can Med Assoc J. 121 (9): 1193–1254.
PMC 1704686. PMID 115569.
3. Ramos A, Kow L, Brown W, Welbourn R, Kinsman R, Walton P. The 5th IFSO Global
Registry Report September 2019. ISBN 978-1-9160207-3-3
4. Hedenbro JL, Naslund E, Boman L, et al. Formation of the Scandinavian obesity surgery reg-
istry SOReg. Obesity Surgery. 2015;25(10):1893–900.
5. Welbourn R, Small P, Finlay I, Walton P, Sareela A, Somers S, Mahawar K, Kinsman R. The
United Kingdom National Bariatric Surgery Registry Second Registry Report: November
2014. ISBN 978-0-9568154-8-4
6. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016
on the protection of natural persons with regard to the processing of personal data and on
the free movement of such data, and repealing Directive 95/46/EC (General Data Protection
Regulation) (Text with EEA relevance) OJ L 119, 4.5.2016, p. 1–88 (BG, ES, CS, DA, DE,
ET, EL, EN, FR, GA, HR, IT, LV, LT, HU, MT, NL, PL, PT, RO, SK, SL, FI, SV) ELI:
https://data.europa. eu/eli/reg/2016/679/oj
7. Rogers, Everett (16 August 2003). Diffusion of Innovations, 5th Edition. Simon and
Schuster. ISBN 978-0-7432-5823-4
8. Welbourn R, Fiennes A, Kinsman R, Walton P. The United Kingdom National Bariatric
Surgery Registry First Registry Report: February 2011. ISBN 1-903968-27-5
9. Surgeon Specific Outcome Reports for NHS Bariatric Surgery updated April 2019. https://
nbsr.e-dendrite.com
10. Landsberger HA. Hawthorne Revisited: management and the worker, its critics, and develop-
ments in human relations in industry. Ithaca: Cornell University; 1958.
11. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016
on the protection of natural persons with regard to the processing of personal data and on
the free movement of such data, and repealing Directive 95/46/EC (General Data Protection
Regulation) (Text with EEA relevance)
Sleeve Gastrectomy Registries
12. Regulation (EU) 2016/679 of the European Parliament and of the Council of 27 April 2016
on the protection of natural persons with regard to the processing of personal data and on
the free movement of such data, and repealing Directive 95/46/EC (General Data Protection
Regulation) (Text with EEA relevance)
61
Weight Loss: Diet Options
Khawla F. Ali
1 Introduction
The cornerstone therapy for obesity treatment is lifestyle modification. Adaption
of a healthy lifestyle is founded by healthy dietary options, behavioral training
and an increase in physical activity. In this chapter, we discuss the healthy dietary options available for weight loss, emphasizing on the behaviors that form the
backbone of most dietary programs.
2 Principles in Dietary Therapies
Numerous dietary programs currently exist that are targeted to assist with the
weight loss journey. A shared theme in most of these programs is the need for
creating a caloric deficit that results in a negative energy balance [1]. A general
approach to creating such a deficit is to reduce caloric intake by 500 kcal/day, or
to restrict it by approximately 30% of total daily caloric need. The latter roughly
translates to 1200–1500 kcal/day for women and 1500–1800 kcal/day for men [1].
The choice of a specific dietary program depends on several factors: degree of
obesity, existence of comorbidities such as diabetes mellitus and patient preference. It is important to emphasize that no diet out there has been shown to consistently produce superior weight-loss results when compared to other diets. However,
a strong predictive factor of success with any dietary program is patient adherence.
K. F. Ali (*)
Department of Medicine, Royal College of Surgeons in Ireland-Medical University of
Bahrain, Muharraq, Bahrain
e-mail: khawlafouad@hotmail.com
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_8
63
K. F. Ali64
The programs that have shown to have the best weight-loss outcomes are those
with the highest scores for patient adherence [2].
Most dietary programs produce mild-to-moderate weight loss of 5–15%.
Additionally, most dietary interventions will reach their maximum efficacy
6-months post-initiation, with some patients re-gaining some or most of the
weight in the months to follow. Therefore, it is essential for medical practitioners to discuss such figures with patients to ensure that their perceived weight
goals and expectations align with the expected outcomes. It is also important to
emphasize that weight loss and maintenance of as little as 5–7% still bears significant impact on health and wellbeing, and can lead to substantial improvements
in medical comorbidities. The benefits of 5–7% weight loss were demonstrated
in several landmark clinical trials. The Diabetes Prevention Program (DPP) is a
good example. In the multicenter DPP trial, intensive lifestyle interventions aimed
at weight loss of 7% showed significant reduction in the risk of progression from
impaired glucose tolerance to diabetes by 58% [3]. Additionally, the landmark
Look AHEAD study (Action for Health in Diabetes) for patients with type 2 diabetes mellitus and body mass index (BMI) >25 kg/m2, showed that modest weight
loss can lead to significant improvements in many comorbidities, such as, diabetes
mellitus, sleep apnea, urinary incontinence, depression, physical function, mobility and overall quality of life [4, 5].
Several key principles should be emphasized in any dietary program. Increasing
intake of fiber-rich foods such as fruits, vegetables, legumes and minimally processed whole grains is essential. Patients should also be advised to limit any
processed or refined carbohydrates and meats, in addition to food items high
in sodium and trans fats. The following are simple tips that can be provided to
patients for improving their health and eating behaviors, regardless of whether a
specific dietary program is being prescribed or not:
1. The plate method: patients should be encouraged to limit their plate size to a
9-inch plate. Half of the plate should contain non-starchy vegetables, such as
lettuce, spinach, arugula, etc. A quarter of the plate should contain lean meats
such as chicken, turkey or fish, and a quarter should contain whole grains such
as brown rice, brown bread, etc.
2. Avoid sugar-sweetened beverages such as sodas, creamers, syrups and juices.
Instead, patients should rely on water as a healthy liquid alternative.
3. Replace white carbohydrate options with whole grain ones. For instance,
replace white bread with whole grain bread, replace white pasta with whole
grain pasta, etc.
4. Avoid high-calorie, high-sugar snacks, such as cookies, chocolate and cakes.
Instead, replace these with healthier snacks such as nuts, Greek yogurt and
fruits.
Finally, dietary programs should always be combined with physical activity, particularly resistance anerobic training, for maximum preservations of muscle mass
during the weight loss period.
Weight Loss: Diet Options
65
3 Diet Options for Weight Loss
Several dietary interventions exist. Here, we outline a few of the most commonly
prescribed diets in clinical practice.
• The Mediterranean Diet
The Mediterranean diet is typically rich in fruits, vegetables, nuts and whole grain
sources of carbohydrate. The primary source of fat in this diet comes from the
monounsaturated fatty acids of olive oil. Lean meat, such as chicken and fish are
the primary sources of protein, with red meats being consumed as little as possible. Additionally, dairy sources should be low-fat or fat-free. The diet also allows
low-to-moderate wine consumption.
The Mediterranean diet has been shown to have significant health benefits. In
the large Primary Prevention of Cardiovascular Disease with a Mediterranean Diet
Study (PREDIMED), the Mediterranean diet was associated with a 30% relative
risk reduction in primary cardiovascular events, and a 40% relative risk reduction in the incidence of stroke [6]. Additionally, several observational studies have
found a negative association between the Mediterranean diet and the incidence of
cancers, such as colorectal, prostate and esophageal cancers [7].
The Mediterranean diet has also been shown to have significant impact on
glycaemic measures in subjects with diabetes mellitus. In a recent meta-analysis
examining its effects on type 2 diabetes patients, the Mediterranean diet resulted
in significant reductions in haemoglobin A1c (HbA1c), fasting plasma glucose
and fasting insulin levels compared to controls. Additionally, there were improvements in lipid profiles seen as reductions in total cholesterol and triglycerides, and
increase in high-density lipoprotein (HDL) [8].
• Intermittent Fasting
Intermittent fasting refers to cyclic short periods of feeding followed by prolonged
periods of fasting. An increased volume of literature supports the beneficial effects
of intermittent fasting on disease modification and aging [9]. Additionally, recent
studies have shown its beneficial effects on insulin resistance and glycemic control
[10]. It has been theorized that the beneficial effects of intermittent fasting are not
only due to its effects on weight reduction. Rather, it is thought to be due to adaptive cellular responses to fasting states. During prolonged periods of fasting, cells
activate pathways that combat oxidative and metabolic stress, aiding in the process
of cellular damage repair and reducing inflammation [9].
Several variations of intermittent fasting exist. Alternate-day fasting and daily
time-restricted feeding are the most widely adapted variations. In the former, fasting is done on specific days of the week (one or more), when calories are reduced
to less than 25% of the daily caloric requirements. The second form of intermittent fasting restricts caloric intake to certain hours of the day, typically ranging
between 8 and 10 hours.
K. F. Ali66
• Low-Carb and Very Low-Carb Diets
With the rise of diabetes mellitus prevalence worldwide, more specialists are advocating for low-carb and very-low carb diets as means of improving both glycemic
measures and weight. Several short-term studies have demonstrated the efficacy of
such diets on glycemic control, lipid profiles and weight in those with obesity and/
or type 2 diabetes mellitus [11, 12].
Low-carbohydrate diets are usually composed of 60–130 g of carbohydrates
per day. Very-low carbohydrate diets on the other hand, are usually composed
of no more than 50 g of carbohydrates per day. The reduction in carbohydrate
intake to less than 50 g per day typically depletes glycogen stores, and thus leads
to the breakdown of fatty acids for the generation of ketone bodies and energy
production. In both diets, the initial weight loss can be rapid, but is usually due
to glycogen breakdown and water losses rather than true fat loss. The long-term
superiority of low-carb and very-low carb diets versus other diets for weight loss
has not been demonstrated [13]. Additionally, with lower carbohydrate intake,
there is a higher likelihood for occurrence of adverse events, particularly with the
very low-carb diets, such as constipation, headaches, generalized weakness and
muscle cramps [14].
• Very-Low Calorie Diets
Very-low calorie diets (VLCD) refer to diets that provide less than 800 kcal per
day. VLCD are effective at inducing rapid weight loss on the short-term. However,
long-term outcomes of VLCD have not been demonstrated to be more superior
compared to the more conventional diets. For instance, in a meta-analysis comparing the conventional low-calorie diets to VLCD, the short-term weight reduction was more pronounced in the VLCD (16% vs. 10% of initial body weight,
for VLCD and conventional low-calorie diets, respectively). However, weight
loss beyond one year did not differ (6.3% vs. 5%, for VLCD and conventional
low-calorie diets, respectively) [15].
4 The Weight-Maintenance Diet
A major challenge post-weight loss via dietary methods is the maintenance of
the weight loss achieved. The bodyweight is theorized to be set at a defined set
point programmed at the level of the hypothalamus. Any attempt at lowering bodyweight via dieting and/or exercise would be met by internal resistance, in efforts
to bring the body back to its original set point, no matter how pathological and
disease-provoking this point may be. Resistance is typically seen in the form of
increases in hunger signals such as ghrelin hormone, decreases in satiety signals
such as glucagon-like peptide-1 and peptide YY, and decreases in basal metabolic
rate [16].
Weight Loss: Diet Options
67
Attempts at combatting weight regain have been investigated by several groups.
Recent research has suggested a critical role of macronutrient composition on
weight regain in the weight maintenance period. Diets composed of high-protein
and low-glycemic index foods have been shown to be superior at maintaining
weight loss, compared to low-protein and high-glycemic index diets [17].
5 Summary
Several dietary therapies exist. No single diet has been shown to be more superior
or linked to more weight loss success. Rather, adherence is the key to weight loss
success in any dietary program.
References
1. Garvey WT, Mechanick JI, Brett EM, et al. American association of clinical endocrinologists
and american college of endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. Endocr Pract. 2016;22(Suppl 3):1.
2. 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;293:43.
3. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 dia-
betes with lifestyle intervention or metformin. N Engl J Med. 2002;346:393.
4. Look AHEAD Research Group, Pi-Sunyer X, Blackburn G, et al. Reduction in weight and
cardiovascular disease risk factors in individuals with type 2 diabetes: one-year results of the
look AHEAD trial. Diabetes Care 2007; 30:1374.
5. Look AHEAD Research Group, Wing RR, Bolin P, et al. Cardiovascular effects of intensive
lifestyle intervention in type 2 diabetes. N Engl J Med 2013; 369:145.
6. Estruch R, Ros E, Salas-Salvadó J, et al. Primary prevention of cardiovascular disease with a
Mediterranean diet [retracted in: N Engl J Med. 2018 Jun 21;378(25):2441–2442]. N Engl J
Med. 2013;368(14):1279–1290.
7. Schwingshackl L, Hoffmann G. Adherence to mediterranean diet and risk of can-
cer: a systematic review and meta-analysis of observational studies. Int J Cancer.
2014;135(8):1884–97.
8. Huo R, Du T, Xu Y, et al. Effects of Mediterranean-style diet on glycemic control, weight
loss and cardiovascular risk factors among type 2 diabetes individuals: a meta-analysis. Eur J
Clin Nutr. 2015;69(11):1200–8.
9. de Cabo R, Mattson MP. Effects of intermittent fasting on health, aging, and disease. N Engl
J Med. 2019;381(26):2541–51.
10. Horne BD, Muhlestein JB, Anderson JL. Health effects of intermittent fasting: hormesis or
harm? A systematic review. Am J Clin Nutr. 2015;102(2):464–70.
11. Boden G, Sargrad K, Homko C, et al. Effect of a low-carbohydrate diet on appetite, blood
glucose levels, and insulin resistance in obese patients with type 2 diabetes. Ann Intern Med.
2005;142:403.
12. Gannon MC, Nuttall FQ. Effect of a high-protein, low-carbohydrate diet on blood glucose
control in people with type 2 diabetes. Diabetes. 2004;53:2375.
13. Nordmann AJ, Nordmann A, Briel M, et al. Effects of low-carbohydrate vs. low-fat diets on
weight loss and cardiovascular risk factors: a meta-analysis of randomized controlled trials.
Arch Intern Med. 2006;166:285.
K. F. Ali68
14. Yancy WS Jr, Olsen MK, Guyton JR, et al. A low-carbohydrate, ketogenic diet versus a
low-fat diet to treat obesity and hyperlipidemia: a randomized, controlled trial. Ann Intern
Med. 2004;140:769.
15. Tsai AG, Wadden TA. The evolution of very-low-calorie diets: an update and meta-analysis.
Obesity (Silver Spring). 2006;14:1283.
16. Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adapta-
tions to weight loss. N Engl J Med. 2011;365:1597.
17. Larsen TM, Dalskov SM, van Baak M, et al. Diets with high or low protein content and gly-
cemic index for weight-loss maintenance. N Engl J Med. 2010;363:2102.
Candidates for Sleeve Gastrectomy
Eligibility Criteria for Sleeve Gastrectomy
Faiz Shariff and Ali Aminian
1 Introduction
Global obesity is rising at an alarming rate, with estimates predicting that by 2030
nearly 1 in 2 adults will have obesity (BMI ≥ 30 kg/m2), and 1 in 4 adults will have
severe obesity (BMI ≥ 35 kg/m2) [1]. It is well studied that obesity increases the risk
of other chronic medical conditions, including type 2 diabetes mellitus, cardiovascular disease, cerebrovascular, chronic kidney disease, nonalcoholic fatty liver disease,
metabolic syndrome, and many cancers. With an increasing number of patients with
severe obesity and related comorbidities, there is an increasing role of bariatric surgery in managing these conditions, especially diabetes. Each year there is an increase
in the number of bariatric procedures performed in the US as per the American
Society for Metabolic and Bariatric Surgery (ASMBS) estimate of bariatric surgery
numbers. The most significant upsurge seen in the number of sleeve gastrectomy
(SG) performed rose from 17.8% of total procedures performed in 2011 to 61.4% of
total procedures performed in 2018 [2, 3]. This increasing popularity of SG over the
past decade has been due to its safety profile, technical ease, and excellent long-term
efficacy. However, a blanket prescription of this procedure should be avoided, and an
effort towards more personalized and evidence-based procedure selection should be
adopted. In this chapter, we will first explore the current indications for metabolic and
bariatric surgery, followed by a criterion that makes SG a better surgical option.
F. Shariff
Department of General Surgery, Wellspan Bariatric Surgery, Wellspan Hospital,
25 Monument Road, York, Pennsylvania, USA
e-mail: fshariff@wellspan.org
A. Aminian (*)
Department of General Surgery, Bariatric and Metabolic Institute, Clevland Clinic,
Clevland, Ohio, USA
e-mail: AMINIAA@ccf.org
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer
Nature Switzerland AG 2021
S. Al-Sabah et al. (eds.), Laparoscopic Sleeve Gastrectomy,
https://doi.org/10.1007/978-3-030-57373-7_9
71