INTRODUCTION

Obesity is currently one of the biggest public health problems in the world. Its projection, according to the World Health Organization, is that in 2025, 2.3 billion adults will be overweight, and more than 700 million will be obese. Being a global epidemic of chronic conditions, a multifactorial etiology whose treatment involves different approaches, the main ones are dietary guidelines, physical activity practice, and, in cases where these measures are not enough, the use of medications and surgical intervention ¹.

Conventional treatment for severe obesity still produces unsatisfactory results since 95% of patients regain their initial weight in up to 2 years. Due to the need for a more effective intervention in the clinical management of severely obese individuals, an indication of surgery is the most effective treatment for obesity control ².

In Brazil, bariatric surgery is among the procedures of high complexity offered by the Unified Health System (SUS), according to the regulation established on April 21, 2001. Its indication must be according to CFM Resolution No. 1,766/05, which designates the following requirements for its accomplishment: being over 18 years of age, presenting a Body Mass Index (BMI) of 40 kg/m² or more or equal to or greater than 35 kg/m² and comorbidities such as diabetes, sleep apnea, hypertension, dyslipidemia, coronary disease, osteoarthritis, and others. In addition, the subject must have undergone conventional methods and have psychological conditions to follow the indications suggested after surgery ².

According to the Brazilian Society of Bariatric and Metabolic Surgery (SBCBM), throughout 2018, 63,969 bariatric surgeries were performed, 49,521 of which for supplementary health (health plans), according to data from the National Supplementary Health Agency (ANS), 11,402 surgeries by the Unified Health System (SUS) and 3,046 private surgeries. The total number of procedures performed in 2018 was 4.38% higher than in 2017, when approximately 61.283 thousand surgeries were performed by SUS and ANS ³.

Although bariatric surgery is an effective clinical strategy for promoting weight loss, reducing comorbidities, and improving quality of life, it is essential to emphasize that it does not promote the cure of obesity but rather its control. Therefore, although the surgical treatment demonstrates satisfactory results, some individuals present postoperative complications related to organic and behavioral problems that damage clinical and nutritional aspects ^4,5.

The Brazilian population has extensive demographic, social, and cultural diversity, which is why population studies that assess the health conditions of the Amazonian peoples and their main conditions allow us to broaden the understanding of the magnitude of diseases, analyze their historical trends, and observe risks of morbidity and mortality in these population groups.

From this perspective, the objective of this study was to analyze the clinical, nutritional, and weight requirements of women undergoing Roux-en-Y gastric bypass according to the time elapsed post-surgery.

PATIENTS AND METHODS

RESULTS

Ninety-three women with a mean age of 41.8 ± 7.6 years, divided into three groups were evaluated according to the postoperative time: group one (G1) up to twenty-four months, group two (G2) of twenty-four months to forty-eight months and group three (G3) over forty-eight months. In the first group, the mean postoperative time was 16.9 ± 7.9 months. In the second group, 33.9 ± 9.2 months, and in the third group, a mean of 75.3 ± 19.1 months.

As described in Table 1, 29% of the patients evaluated reported having a complete secondary level, 24.7% an incomplete upper level, and only 22.6% a complete upper level.

The income classification showed that 17.2% up to one minimum wage 58% had a family income of up to four minimum wages, 18.3% up to seven and 6.5% more than seven minimum wages.

Regarding whether or not to perform nutritional follow-up after surgery, 52.7% said to follow up, and 47.3% did not do nutritional monitoring. Among the groups, the G1 group (25 to 48 months) attended most nutritional consultations, with 42.9% of the patients.

When the groups were compared, the lowest percentage of patients (23.3%) using medication was found in group 2 (25 to 48 months). 98.9% of the patients reported using medications in the preoperative period, with antihypertensives (32.3%) and anxiolytics (24.7%) being the most commonly used medications. In the postoperative period, this index decreased to 46.2%.

Only 35.5% of the patients reported doing some physical activity before surgery, which was the most performed: walking (22.6%) and bodybuilding (8.6%). The frequency of physical activity reported by the majority (21.5%) was 3 to 4 times per week. The number of patients who practiced physical activity decreased to 33.3% in the postoperative period. The types of exercise most performed by them were walking (20.4%) and bodybuilding (8.6%). Most patients (19.4%) reported having physical activity 3 to 4 times a week.

Regarding alcohol consumption, 61.3% reported not consuming. However, 27.9% reported consuming eventually, and 10.8% weekly.

Eighty-seven percent of the patients said they were not smokers, and 13% said they were former smokers.

Regarding using nutritional supplements in the postoperative period, 59.13% of the patients reported taking supplementation, and 40.86% reported not using any supplement. Comparing the groups, the G1 group (25 to 48 months) used the most supplementation (52.7%).

Table 2 shows the participants’ anthropometric variables (weight, height, percentage of fat mass, fat mass, and lean mass).

Regarding the anthropometric evaluation, the mean preoperative BMI was 47.2±4.9 kg/m². Ninety-eight percent of the patients were classified as grade III (IMC>40kg/m²), and 2% were classified as grade II obesity. In the postoperative period, the mean BMI was 31.1±4.0 kg/m², the mean of group one being 31.10±4.8 kg/m², group two 31.1±3.1 kg/m2, and group three of 31.1±3.6 kg/m².

The mean percentage of excess weight loss was 66.1±15.4%, and the following means were found in the groups: G1 65.64±18.1%, G2 67.22±11.6 and G3 66,19±14.6%. Satisfactory results were achieved by 88.1% of the patients who presented PEP≥50%. There was no significant difference between groups (p=0.05).

Table 3 contains the results obtained in the 24-hour recall for mean daily caloric intake, macronutrients, and micronutrients.

Concerning nutrient intake, the dietary survey (R24hs) pointed to the average daily energy consumption of 1262.75±424.11 kcal. There was no difference in energy consumption between the groups evaluated (p>0.05).

The distribution of the macronutrient percentage indicated a mean intake of 59.25±8.33% for carbohydrates, 24.26±6.90% for lipids, and 17.12±6.68% for proteins. There was no significant difference between the groups regarding the intake of macro and micronutrients (p>0.05).

Although the macronutrient intake was not significant between the groups, the mean protein intake was lower in group 01 (16.09±6.23), and that of lipid showed a slight increase over time.

Regarding the regularity of meal times, 69.89% of the patients reported not eating regularly. Only 30.10% stated that they had regular meals. Regarding the number of meals performed daily, most participants had a proper fractionation of their meals; 63.4% stated they had 3 to 4 meals/day, while only 18.3% reported doing 1 to 2 meals/day.

The evaluation of water consumption showed that 74.2% of the patients consumed 1 to 2 liters of water/per day, 19.4% above 2 liters, and 6.5% up to 1 liter of water/per day.

73.3% of the patients reported food intolerances. The most mentioned foods were tapioca (59.1%), açaí (49.5%), rice (43%), fried foods (37.6%), and milk. Food intolerances were not reduced according to the postoperative time (p>0.05).

Sixty-seven percent of the patients presented weight reacquisition, with a mean reacquisition of 14.6±10.8 kg. Among the patients who presented weight reacquisition, 27.4% were from G1 (2 to 24 months), 21%

from G2 (25 to 48 months), and 51.6% from G3 (above 48 months). It was observed that the reacquisition of weight was proportional to the postoperative time (p<0.001).

Of the several factors analyzed that could influence weight reactivity (age, preoperative BMI, percentage of excess weight loss, basal metabolic rate, and caloric intake), none had a significant influence on postoperative weight reactivity (p˃0.05) (Table 4).

Ninety-nine percent of the patients presented at least one obesity-related disease in the preoperative period. After the surgical procedure, this index decreased to 36.7%, showing a significant reduction in the presence of all comorbidities (p=0.01), as shown in Fig. 1.

Fig. 1 Comorbidities associated with obesity before and after operation. 

DISCUSSION

Currently, bariatric surgery is considered the most effective strategy for managing and treating severe obesity. However, several studies show that the surgical procedure does not end treatment, necessitating auxiliary therapies associated with continuously monitoring risk factors by a multiprofessional team ¹³.

In Brazil, the highest prevalence of severe obesity is concentrated in women. The higher prevalence of women undergoing bariatric surgery may be justified by a social issue that involves the beauty pattern, the appreciation of leanness, and the social pressure for weight loss to be greater in this public. In addition, women seek more health services than men ^14-16.

According to information published by the Brazil Agency website, 70% of bariatric surgeries are performed by women¹⁷. Research carried out in different sociocultural contexts has shown that women are the majority of patients who seek a surgical procedure to treat obesity^18,19.

Comparing data from the pre-and postoperative periods of the population evaluated in this study showed improvement in all obesity-related comorbidities. Several studies ^20-22 described the reduction of the presence of comorbidities.

In this study, most patients reported the use of drugs in the preoperative period, and in the postoperative period, there was a significant reduction. Possibly, this result is directly related to the reduction of comorbidities diagnosed before surgery. According to Ceneviva et al.²³, the reduction of comorbidities and the use of medications is proportional to weight reduction in the postoperative period of bariatric surgery. A meta-analysis investigated the impact of surgery on weight and reduction of significant comorbidities in more than 136 studies, totalling 22,094 patients (72.6% women) with a mean age of 39. The results found that the reduction of comorbidities was proportional to the loss of excess weight, similar to that found in this research ²⁴.

A study of 342 patients (261 women and 81 men) who underwent Roux-en-Y gastric bypass showed that, as the mean BMI decreased in a postoperative period of 1,2,5 and 10 years, the associated comorbidities were also reduced in the short, medium, and long term ²⁵.

Regarding the practice of physical activity, we observed in this study that there was a reduction in the postoperative period, which may contribute to the reacquisition of weight. Bariatric surgery, combined with guided physical exercise, potentiates the reduction of comorbidities and contributes to a better quality of life for the patient ²⁶. Although no significant result was found between the association of physical activity practice and weight reactivity in this study, it is known that those who become more active present better weight control postoperatively compared to people who do not exercise physically ²⁷. Weich et al. identified that 30% of the patients who adhered to regular physical activity had better weight control in the postoperative period of bariatric surgery ²⁸.

Regarding using nutritional supplements in the postoperative period, most patients evaluated in this study did not use any supplementation. When comparing the groups, it was observed that group 02 was the least medication user. This result may be related to the non-attendance of these patients in the health unit for nutritional follow-up since it was the group that less frequently attended consultations with nutritionists. Regarding whether or not to attend the nutritional consultation, 49% of the patients stated that they did not attend the consultations. Similar results were described by Magro et al. and Souza JMB ^27,29, evidencing that periodic nutritional monitoring greatly influences dietary habits and adherence to supplementation.

Regarding the anthropometric evaluation, this study did not observe a significant difference in BMI values between the groups evaluated in the postoperative period. This study confirmed that satisfactory results were achieved by 88.17% of the patients (% PEP ≥50%), with similar results ²⁴.

The dietary survey (R24h) indicated an average daily energy consumption of 1262.7 ± 424.1 kcal. There was no significant difference between groups in terms of nutrient intake. A similar result was described by Brolin RE et al.³⁰.

Carbohydrate intake was 57±6.4%, the only macronutrient that presented intakes compatible with current nutritional recommendations. In this study, we found similar results since the percentage of carbohydrate intake was also the only one that showed adequacy of the current daily recommendations ³¹.

Although the macronutrient intake was not significant between the groups, the mean protein intake was lower in group 01 (16.09 ± 6.23), and that of lipids showed a discrete increase over time. The average protein intake in grams was shown to be inadequate since the minimum recommendation is 60 to 70 grams per day. A study showed similar results when citing the average protein intake performed by most patients in the postoperative period ¹³.

Compared to the DRIs-recommended Daily Intake Means, inadequacy was observed in all micronutrients analyzed: calcium, iron, thiamine, vitamin B₁₂, folate, and zinc. Other studies ^30-32 also reported low vitamin B₁₂, iron, zinc, iron, calcium, and folate intake.

In patients over 18 years of both genders submitted to Roux-en-Y gastric bypass gastroplasty, it was evidenced that 30.83% of subjects had vitamin B₁₂ deficiency, 29.1% had iron deficiency, and 14.1% had calcium deficiency ^30-32.

The majority of patients adequately fractionated their meals. Thirty-five reported similar results, identifying that 62.1% of the individuals evaluated consumed four or five meals daily.

Food intolerances were reported by 73.3% of the patients, similar to that found by other authors ^30-35, who also identified that the foods that caused the most discomfort were rice, sweets, and meat. In this study, the most mentioned foods were tapioca (59.1%), açaí (49.5%), rice (43%), fried foods (37.6%), milk (32.3%), and sweet (31,2%). Foods such as tapioca and açaí have not yet been cited in other studies because they are regional foods.

Regarding weight reacquisition, 67% of the patients regained weight, with a mean reacquisition of 14.6 ± 10.8 kg. ²⁷, finding that 46% of the patients regained weight in two years postoperatively and 63.6% in four years.

In this study, most patients who presented reacquisition were in G3 (above 48 months). Thus, reacquisition was significantly proportional to postoperative time, although no significant relationship was found with income, daily caloric intake, basal metabolic rate, body composition, physical exercise, and nutritional monitoring.

As observed in this study, the literature ^30-35 points out a greater incidence of weight reacquisition after two years of surgery, which is attributed to the longer time elapsed after surgery.

The occurrence of weight relapse, especially in patients with a more extended postoperative period, is associated with worsening comorbidities. There is little data on patients with more than 10 years of postoperative, which increases the concern and the need for more research in the area ³¹.

In the last five years, the scientific literature has pointed out that so far, bariatric surgery is the most effective method to treat obesity and can play an essential role in reducing the direct and indirect costs of obesity treatment ³⁶. The procedure increases fertility rates and improves breastfeeding, providing benefits to infant and maternal health³⁷ However, it pointed out that issues associated with bone mineralization ³⁸, digestive motility ³⁹, and nutritional deficiencies should be carefully observed ⁴⁰.

The results found in this study evidenced that the public that most demanded bariatric surgery in the Western Amazon is the female population.

Among the individuals evaluated, there was a significant reduction in comorbidities associated with obesity and, consequently, a decrease in medication use. The loss of excess weight was satisfactory concerning the surgical procedure adopted (Roux-en-Y gastric bypass), and daily caloric intake, as well as protein, vitamin, and mineral intake, especially in the first two postoperative years, presented inadequacies compared to the current recommended nutrient recommendations.

Most patients did not perform periodic nutritional monitoring, which can demonstrate non-attendance to consultations with other health professionals since the answering service is integrated. In addition, most of the patients did not adequately use nutritional supplementation. The foods with the most significant potential for food intolerances in the region were tapioca, açaí, sweets, and milk.

Regarding weight reacquisition, the higher the postoperative period of the patients, the greater the weight reacquisition was found. This fact did not present significant relevance when compared to variables such as income, physical activity practice, nutritional monitoring, basal metabolic rate and daily energy intake. This result is worrisome and must be investigated in other research, seeking to describe the determining factors for the reality found.

Bariatric surgery significantly reduced comorbidities, medication use, and excess weight loss. However, the adequacy of nutrients and the increasing incidence of weight reactivity in the postoperative period demonstrated that bariatric surgery does not end the treatment of obesity; on the contrary, it is only a step that requires periodic monitoring by health professionals.