Obesity Surgery (2019) 29:3833–3841 https://doi.org/10.1007/s11695-019-04057-2 ORIGINAL CONTRIBUTIONS Prospective Longitudinal Trends in Body Composition and Clinical Outcomes 3 Years Following Sleeve Gastrectomy Shiri Sherf-Dagan1,2,3 & Shira Zelber-Sagi1,4 & Assaf Buch5,6 & Nir Bar1,2 & Muriel Webb1 & Nasser Sakran7,8,9 & Asnat Raziel7 & David Goitein2,7,10 & Andrei Keidar11 & Oren Shibolet1,2 Published online: 11 July 2019 # Springer Science+Business Media, LLC, part of Springer Nature 2019 Abstract Background and Aims Longitudinal assessment of body composition following bariatric surgery allows monitoring of health status. Our aim was to elucidate trends of anthropometric and clinical outcomes 3 years following sleeve gastrectomy (SG). Methods A prospective cohort study of 60 patients who underwent SG. Anthropometrics including body composition analysis measured by multi-frequency bioelectrical impedance analysis, blood tests, liver fat content measured by abdominal ultrasound and habitual physical activity were evaluated at baseline and at 6 (M6), 12 (M12), and 36 (M36) months post-surgery. Results Sixty patients (55% women, age 44.7 ± 8.7 years) who completed the entire follow-up were included. Fat mass (FM) was reducedsignificantly1yearpost-surgery(55.8±11.3to26.7±8.3kg;P < 0.001) and then increased between 1 and 3 years post- operatively, but remained below baseline level (26.7 ± 8.3 to 33.1 ± 11.1 kg; P < 0.001). Fat free mass (FFM) decreased significantly during the first 6 months (64.7 ± 14.3 to 56.9 ± 11.8 kg; P < 0.001), slightly decreased between M6 and M12 and then reached a plateau through M36. Weight loss “failure” (< 50% excess weight loss) was noticed in 5.0% and 28.3% of patients at M12 and M36, respectively. Markers of lipid and glucose metabolism changed thereafter in parallel to the changes observed in FM, with the exception of HDL-C, which increased continuingly from M6 throughout the whole period analyzed (45.0 ± 10.2 to 59.5 ± 15.4 mg/ dl; P < 0.001) and HbA1c which continued to decrease between M12 and M36 (5.5 ± 0.4 to 5.3 ± 0.4%; P <0.001).Therewere marked within-person variations in trends of anthropometric and clinical parameters during the 3-year follow-up. Conclusions Weight regain primarily attributed to FM with no further decrease in FFM occurs between 1 and 3 years post-SG. FM increase at mid-term may underlie the recurrence of metabolic risk factors and can govern clinical interventions. Keywords Bariatric surgery . Clinical parameters . Excess weight loss . Fat mass . Fat free mass Abbreviations CRP C-reactive protein BIA Bioelectrical impedance analysis DEXA Dual X-ray absorptiometry BMI Body mass index EWL Excess weight loss * Shiri Sherf-Dagan Nasser Sakran [email protected] [email protected] Shira Zelber-Sagi Asnat Raziel [email protected] [email protected] David Goitein Assaf Buch [email protected] [email protected] Andrei Keidar [email protected] Nir Bar [email protected] Oren Shibolet [email protected] Muriel Webb [email protected] Extended author information available on the last page of the article 3834 OBES SURG (2019) 29:3833–3841 FFM Fat free mass Materials and Methods FM Fat mass HbA1C Hemoglobin A1c Subjects This prospective cohort study was part of a random- HRI Hepato-renal index ized clinical trial (RCT) of a 6-month treatment period with HDL-C High-density lipoprotein cholesterol probiotic vs. placebo and a 6-month follow-up of 100 nonal- HOMA Homeostasis model assessment coholic fatty liver disease (NAFLD) patients who underwent IBW Ideal body weight SG surgery from February 2014 to January 2015 at the Tel- IR Insulin resistance Aviv Assuta Medical Center [31]. Inclusion criteria were those LDL-C Low-density lipoprotein cholesterol of the primary RCT: age between 18 and 65 years old, body NAFLD Nonalcoholic fatty liver disease mass index (BMI) > 40 kg/m2 or BMI > 35 kg/m2 with co- RCT Randomized clinical trial morbidities, approval of the Assuta Medical Center committee RYGB Roux-en-Y gastric bypass to undergo BS, and ultrasound (US) diagnosed NAFLD. The RMR Resting metabolic rate major exclusion criteria included infection with hepatotrophic SG Sleeve gastrectomy viruses, fatty liver suspected to be secondary to hepatotoxic TC Total cholesterol drugs, excessive alcohol consumption, use of antibiotics or WC Waist circumference probiotics in the last 3 months, and previous BS. Diabetic patients who were treated with anti-diabetic medications, oth- er than exclusive treatment with Metformin at a stable dose for at least 6 months, were also excluded [31]. Patients were invited to attend an additional follow-up visit 3.3 ± 0.2 years (range 3.0–3.7) (defined as “36M”)following Introduction the surgery and were excluded if they underwent conversion surgery or were presently pregnant. Data of the original RCT Sleeve gastrectomy (SG) has become the most commonly combined treatment groups are presented, since no difference performed bariatric surgery (BS) worldwide in recent years, between them was observed for the measurements discussed but data on long-term outcomes are still limited [1–3]. Recent here. Medical history and demographic details were obtained studies have shown a wide variation in the amount of weight from the patients’ medical records. Baseline (M0) and follow- loss and weight regain following SG [2, 4–6]. Outcomes post- up evaluations at 6 (M6), 12 (M12), and 36 months (M36) BS are usually reported using metrics such as percent excess were performed at the Tel-Aviv Medical Center. weight loss (%EWL) [4]. It was suggested that body compo- sition measurement is more accurate in assessing the quality Anthropometric Measurements Weight and height were mea- of weight loss [7], has a close relationship with metabolism sured on a digital medical scale, BMI was calculated, and [8], and should become a routine part of the clinical evaluation waist circumference (WC) was measured twice at the level pre- and post-surgery [7]. of the umbilicus. EWL percentage and percentage of total Changes in body composition post-BS such as a sustained weight loss were calculated as recommended [32]. Cut-off loss of body fat mass (FM) are frequently associated with an points for FM percent were used for defining overweight inevitable loss of fat free mass (FFM) [9]. FFM loss may (20.0–24.9% for men and 30.0–34.9% for women) and obe- contribute to an undesirable disturbance in resting metabolic sity (≥ 25.0% for men and ≥ 35.0% for women) as frequently rate (RMR), weight maintenance, metabolic impairment, used in the literature [27, 33, 34]. Patients with EWL < 50% at functional loss, sarcopenia, and frailty development [9–11]. M12 were considered as primarily poor weight-loss re- Presently, no definition for “standard” FFM or FM loss post- sponders and patients with EWL ≥ 50% at M12, but EWL < BS exists [12] and the longevity and time course of these 50% at M36, were considered as secondarily poor weight-loss changes are unclear [10]. There is emerging data on body responders [35]. composition changes following different types of bariatric Patients were measured for body composition using multi- procedures [10, 13–25]. However, only limited studies follow- frequency bioelectrical impedance analysis (BIA) ed BS patients for more than 2 years [26–29], when weight (Inbody220®, InBody Co., Ltd.). All patients were evaluated recidivism might begin [4, 30] or correlated these changes to after an overnight fast of 12 h and according to the manufac- other metabolic parameters [27] or functionality [28]. turer’sstandardspecifications. Tracking of body composition through longer postoperative BIA is a simple, low-cost, and non-invasive procedure used period may yield clinically relevant information to better iden- for the evaluation of body composition [29]. Multiple- tify and treat patients by lifestyle and medical care [27]. Thus, frequencies BIA instruments determine body composition by our aim was to evaluate trends of body composition and clin- applying electrical current across a range of frequencies to ical outcomes 3 years following SG. obtain fluid volumes [36]. OBES SURG (2019) 29:3833–3841 3835 Fatty Liver by US All US (Preirius Scanner Hitachi Medical to 22.8 kg weight regain), with 43.3% of participants Corporation, Tokyo, Japan) were performed by the same ra- regaining ≥ 5 kg. The percentages of primarily poor weight diologist. Hepato-renal index (HRI) score, a validated index loss and secondarily poor weight loss were 5.0% and 23.3% at highly correlated with fat content, was calculated [37]. M12 and M36, respectively. Mean FM decreased significantly 1 year following the surgery (55.8 ± 11.3 to 26.7 ± 8.3 kg; Biochemical Tests All blood tests were drawn following a 12-h P < 0.001) and then increased between 1 and 3 years post- fast and included lipids profile, glucose, hemoglobin A1C operatively, but remained below baseline level (26.7 ± 8.3 to (HbA1c), insulin, and C-reactive protein (CRP). 33.1 ± 11.1 kg; P <0.001). The homeostasis model assessment of insulin resistance FFM decreased significantly during the first 6 months (HOMA-IR) was calculated [38]. (64.7 ± 14.3 to 56.9 ± 11.8 kg; P < 0.001), slightly decreased Normal values of blood tests were defined according to the between M6 and M12 and then reached a plateau through recommended outcome reporting standards [32]. M36 (Table 1). Significant correlations were found between FFM and hours spent per week in physical activity at M0 (r = Physical Activity Assessment Weekly minutes spent per week 0.384; P =0.002)andM12(r =0.274;P = 0.034), but not at in performing physical activity were calculated by the multi- M6 and M36. plication of the number of training sessions per week with the Variability in anthropometric parameters between patients duration of exercise in minutes [39].