|Year : 2017 | Volume
| Issue : 3 | Page : 239-245
How far is sleeve gastrectomy more effective than diet regimen in treating obesity-associated hyperlipidemia
Nader M Milad1, Ahmed H Khalil1, Sherif M Mokhtar1, Marian M Daoud2
1 Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
2 National Research Centre, Cairo, Egypt
|Date of Submission||09-Jan-2017|
|Date of Acceptance||04-Feb-2017|
|Date of Web Publication||27-Jul-2017|
Ahmed H Khalil
Department of General Surgery, Faculty of Medicine, Cairo University, Cairo, 25 EL Falah St. Al Mo, 11562
Source of Support: None, Conflict of Interest: None
The global epidemic of obesity is one of the major health issues in the 21st century that influences many aspects of public health, including psychosocial and socioeconomic aspects. Hyperlipidemia is one of the health hazards associated with morbid obesity.
Patients and methods
This was a prospective study conducted in Kasr Al-Aini University Hospital (sleeve gastrectomy group) and the National Nutrition Institute (diet group) during the period from June 2015 till December 2015 with a follow-up of 12 months till December 2016 for both groups. One hundred patients were included in the study and were equally divided into two groups: group A (sleeve gastrectomy group) and group B (diet group).
The objective of this study was to compare the effects of laparoscopic sleeve gastrectomy (LSG) and a dietary regimen on hyperlipidemia in morbidly obese patients.
LSG significantly decreased total cholesterol in 70% of cases and triglycerides in 78% of cases; however, diet caused a decrease of total cholesterol in 30% of cases and triglycerides in 54% of case. Low-density lipoprotein was not significantly changed in both groups.
LSG is more effective than diet programs in treating obesity-associated hyperlipidemia due to more significant and sustained excess body weight loss.
Keywords: diet, hyperlipidemia, morbid obesity, sleeve gastrectomy
|How to cite this article:|
Milad NM, Khalil AH, Mokhtar SM, Daoud MM. How far is sleeve gastrectomy more effective than diet regimen in treating obesity-associated hyperlipidemia. Egypt J Surg 2017;36:239-45
|How to cite this URL:|
Milad NM, Khalil AH, Mokhtar SM, Daoud MM. How far is sleeve gastrectomy more effective than diet regimen in treating obesity-associated hyperlipidemia. Egypt J Surg [serial online] 2017 [cited 2017 Oct 18];36:239-45. Available from: http://www.ejs.eg.net/text.asp?2017/36/3/239/211704
| Introduction|| |
Obesity is now considered to be the second leading cause of preventable death after cigarette smoking . It is associated with multiple comorbidities including type II diabetes mellitus, hyperlipidemia, obstructive sleep apnea, cardiovascular diseases, kidney diseases, gall bladder stones, gastroesophageal reflux disease, osteoarthritis, psychological disorders, metabolic syndrome, and obesity-related cancers . Hyperlipidemia is defined as elevated levels of any or all lipids and/or lipoproteins in the blood . It is a potent risk factor for cardiovascular diseases. Control of hyperlipidemia can be achieved by dietary fat control, regular exercise, and oral medications. Sleeve gastrectomy leads to long-term weight loss and improvement or resolution of its associated comorbidities such as diabetes mellitus, hypertension, and hyperlipidemia . The aim of this work was to compare the effects of laparoscopic sleeve gastrectomy (LSG) and dietary regimen on hyperlipidemia in morbidly obese patients.
| Patients and methods|| |
This was a prospective study conducted in Kasr Al-Aini University Hospital (sleeve gastrectomy group) and the National Nutrition Institute (diet group) during the period from June 2015 till December 2015, with a follow-up of 12 months till December 2016 for both groups. One hundred patients were included in the study and were equally divided into two groups: group A (sleeve gastrectomy group) and group B (diet group after exclusion of drop out cases).
Inclusion criteria included patients having BMI of at least 35 kg/m2 and hyperlipidemia.
Exclusion criteria included the following:
- Endocrinal causes of obesity (hypothyroidism and Cushing disease).
- Uncontrolled psychiatric disorders.
- Patients receiving treatment for hyperlipidemia to study the effect of only a single variable (sleeve or diet regimen) on hyperlipidemia.
All patients were subjected to proper history taking and complete physical examination. Preoperative investigations for group A included the following: complete blood count, coagulation profile, liver function tests, kidney function tests, fasting blood sugar, and the lipid profile including total cholesterol (TC), triglycerides (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL). The thyroid profile was determined to exclude hypothyroidism. Chest radiograph as well as pulmonary function tests were performed to detect associated chest disorders. An abdominal ultrasound was performed to detect gall bladder stones. Cardiological assessment was done by ECG and echocardiography.
The aims of preoperative assessment were to detect and control associated comorbidities. Moreover, preoperative psychiatric and anesthetic consultations were conducted and an informed consent about the expected complications was signed. Patients were instructed to follow a carbohydrate-free and fat-free diet regimen for 2 weeks before surgery.
LSG was performed by mobilization of the greater curvature of the stomach proximal to the gastroesophageal junction and distally 6 cm proximal to the pylorus ([Figure 1]). An orogastric 40-Fr bougie was passed till the first part of the duodenum. A 60-mm endoscopic gastrointestinal anastomosis stapler was used to divide the stomach along the line with the bougie creating a gastric tube about 20–25% of the original stomach ([Figure 2] and [Figure 3]).
|Figure 2 The endoscopic gastrointestinal anastomosis stapler dividing the stomach.|
Click here to view
In addition to the routine postoperative follow-up, the patients were instructed to receive the appropriate diet regimen in the form of sugar-free oral fluids for the first 3 weeks, and then sugar-free and fat-free semisolids were added, starting the fourth week. From the seventh week, they were allowed to have fat-free and carbohydrate-free steered food. Regular exercise (three times weekly-1 h each time) was strictly advised.
Patients in this group were subjected to a specific diet regimen at the outpatient clinic of the National Nutrition Institute in Cairo. This regimen was about 1800–2000 calories for male patients and 1400–1600 calories for female patients. The diet regimen consisted of 55% carbohydrates, especially the complex form, 25% proteins, especially plant-based proteins, and 20% fats. Less than 7% of the fat percentage is derived from saturated fats, and the rest was mainly monounsaturated fatty acids. Dietary cholesterol did not exceed 200 mg daily. Other therapeutic lifestyle changes included an increase in dietary fiber intake (>8 g/day), omega-3 supplementation, and cessation of smoking. Regular physical exercise (three times weekly − 1 h each time) was encouraged.
Assessment of the lipid profile for both groups was performed at the start of the study as well as at 3, 6, and 12 months. The term hyperlipidemia refers to elevated lipid levels in the body including high cholesterol (total, LDL, and low HDL) and high TG levels.
Results are expressed as numbers (%). Comparison between categorical data was performed using χ2-test. The statistical package for social science computer programs (version 19, Windows) (IBM Inc., Chicago, Illinois, USA) was used for data analysis. P value less than or equal to 0.05 was considered significant.
| Results|| |
One hundred morbidly obese patients were included in this prospective study and were equally divided into two groups: group A (sleeve gastrectomy group) and group B (low-carbohydrate and low-fat diet group). [Table 1] shows the demographic data of the patients in both groups.
At the start of the study, in the sleeve group, 45 (90%) patients had hypercholesterolemia, which was the same as that in the diet group. After 3 months in the sleeve group, hypercholesterolemia improved in 15 (30%) patients, whereas in the diet group, it improved in five (10%) patients. Six months after surgery, 35 (70%) patients had a normal serum cholesterol level (60% resolution), whereas 17 (34%) patients had a normal serum cholesterol level in the diet group (resolution in 24%) within the same period. Sleeve gastrectomy caused complete resolution in 70% of patients with hypercholesterolemia 12 months after surgery, whereas the diet regimen corrected hypercholesterolemia in 30% of patients after the same period. [Table 2] shows the changes in the serum cholesterol level in both groups.
|Table 2 Serum total cholesterol level at different time intervals in both groups|
Click here to view
LSG significantly normalized serum TG in 24, 58, and 78% of patients after 3, 6, and 12 months, respectively, whereas the diet regimen improved TG in 10, 30, and 54% of patients within the same period. [Table 3] illustrates the changes in serum TG levels in both groups.
|Table 3 Serum triglyceride level at different time intervals in both groups|
Click here to view
At the start of the study, in the sleeve group, 47 (94%) patients had low serum HDL. Sleeve gastrectomy caused improvement in 37 (74%) patients after 1 year. However, in the diet group, improvement occurred in 31 (62%) patients during the same period. [Table 4] shows changes in serum levels of HDL in both groups.
|Table 4 Serum high-density lipoprotein level at different time intervals in both groups|
Click here to view
Unfortunately, sleeve gastrectomy did not lower the serum level of LDL significantly after 1 year. Improvement occurred in 8% of the cases only and this was twice that in the diet group. [Table 5] shows changes in serum levels of LDL in both groups.
|Table 5 Serum low-density lipoprotein level at different time intervals in both groups|
Click here to view
In the sleeve group, we did not experience weight loss failure and the excess body weight loss (EBWL) ranged from 60 to 80%, whereas in the diet group, EBWL ranged from 30 to 45% after 1 year.
| Discussion|| |
The global epidemic of obesity is one of the major health issues in the 21st century, which influences many aspects of public health including psychosocial and socioeconomic aspects. According to the latest report of the WHO, in 2011, people with BMI of more than 30 kg/m2 reached up to10% of the world population. It is worth noting that the percentage of people with morbid obesity has almost doubled during the last 30 years . In Egypt, 30.3% of the adult population is considered to be obese according to the latest figures .
Unfortunately, obesity has a variety of adverse health consequences associated with a high rate of death, such as type 2 diabetes mellitus, hyperlipidemia, hypertension, metabolic syndrome obstructive sleep apnea, certain types of cancer, gall bladder stones, steatohepatitis, gastroesophageal reflux, arthritis, polycystic ovary syndrome, psychological instability, and infertility .
The term hyperlipidemia refers to the elevated lipid levels in the body including high cholesterol (total, LDL, and low HDL) and high TG levels . Common causes of hyperlipidemia include cholesterol-rich food, overweight, alcohol abuse, diabetes, stress, and lack of exercise . Hyperlipidemia is a potent risk factor for developing atherosclerosis, hypertension, cardiovascular strokes, gall bladder stones, hepatosteatosis, and a variety of cardiac diseases . High cholesterol levels is a modifiable risk factor causing 4.4 million deaths annually ,.
Hyperlipidemia can be controlled by weight loss, decreasing dietary fat, regular exercise, and medications. These modalities of treatment decrease TC, LDL, and TG as well as increase the serum level of HDL cholesterol .
Currently, medications from five major classes of drugs have been reported to treat people with detrimental lipid levels, which include statins, nicotinic acid derivatives, fibric acid derivatives, bile acid-binding resins, and cholesterol absorption inhibitors . Side effects of these medications include anorexia, nausea, vomiting, headache and dizziness, flushing, constipation, and joint pain .
LSG, or longitudinal/vertical gastrectomy, has recently gained popularity and acceptance as a single effective procedure for the treatment of morbid obesity and resolution or significant improvement of obesity-associated comorbidities including hyperlipidemia. It is an example of restrictive bariatric surgery. The procedure is relatively safe with low morbidity and mortality sleeve gastrectomy works by the standard principle of restriction and the removal of the anorexigenic cells that produce the hormone ghrelin, in the fundus of the stomach .
Complications of sleeve gastrectomy include hemorrhage, gastric leakage, gastroesophageal reflux disease, gall bladder stones, nutritional deficiency, weight loss failure, deep venous thrombosis, gastric obstruction, chest complications, abdominal collection, visceral injury, and port-site hernia .
Different types of diet programs are available for the treatment of obesity and its associated comorbidities. The most commonly used diet regimens are low-carbohydrate diet, low-fat diet, high-protein diet or a combination of these regimens. A single or a combined regimen can be applied. The term ‘low-carbohydrate diet’ is generally applied to diets that restrict carbohydrates to less than 20% of the caloric intake . It is used to treat morbid obesity and control obesity-associated health hazards mainly metabolic syndrome . Low-carbohydrate diet appears to be at least as effective as low-fat diet in inducing weight loss for up to 1 year . Carbohydrate restriction may help prevent obesity and type 2 diabetes mellitus as well as atherosclerosis . A low-fat diet restricts fat and often also saturated fat and cholesterol. It is intended to reduce diseases such as heart disease and obesity . Lowering fat intake from 35–40% of the total calories to 15–20% of total calories has been shown to decrease total and LDL cholesterol .
Hady et al.  conducted their study including 130 patients who underwent LSG with a follow-up period for 1 year. They achieved a decrease in LDL cholesterol (20% of cases), TG (95% of cases), and TC (40% of cases) as well as an increase in HDL cholesterol (65% of cases). However, short-term results (before the third month after surgery) were not satisfying. The results obtained indicate that bariatric surgery may effectively control obesity-associated hyperlipidemia .
Schauer and Ikramuddin  conducted a study including 20 morbidly obese patients with hyperlipidemia, and concluded that 1 year after LSG, there was a significant increase of HDL cholesterol levels (72% of cases), with a significant decrease in TG (90% of cases), and LDL remained unchanged.
Wong et al.  studied the lipid profile of 37 patients who underwent LSG. The follow-up period was 9 months. They reported a significant improvement in parameters of lipid profile after LSG. However, compared with our results, they reported improvement not only in HDL (60% of cases), TG (75% of cases), and TC (20% of cases) but also in LDL cholesterol (20% of cases) .
Razak et al.  reported that a short period after LSG (6 months − 33 patient), there is a decrease in TC cholesterol (55% of cases), TG (90% of cases), and HDL (30% of cases), but LDL also unchanged.
In 2011, Marek Bužga and colleagues summarized that 6 months after LSG, 33 patients showed an increase in HDL cholesterol levels (40% of cases) and a reduction in TG level (85% of cases), whereas LDL and TC remained unchanged .
Boza et al.  followed the lipid profile of 50 patients after LSG for 1 year, and concluded that there was a significant decrease in TG cholesterol levels (100% of cases), with a significant decrease in TC (70% of cases), whereas LDL and HDL remained unchanged .
In our study, 50 patients underwent LSG and their lipid profile was followed for 1 year. Sleeve gastrectomy significantly decreased TC (70% of cases), TG (78% of cases), and LDL (8% of cases). HDL increased in 74% of cases. [Table 6] summarizes the changes in lipid profile after LSG in our study as well as others.
|Table 6 Lipid profile changes after laparoscopic sleeve gastrectomy in different studies|
Click here to view
Low-fat diets had the most favorable effects on TC and LDL cholesterol levels, whereas low-carbohydrate diets had the most favorable effects on TG and HDL cholesterol levels .
Shai et al.  found that the total-to-HDL cholesterol ratio was reduced by 20% in participants after a low-carbohydrate diet compared with a 12% reduction in those following a low-fat diet; this was a statistically significant difference.
In 2012, Hu and colleagues compared lowcarbohydrate diets with low-fat diets, and found that participants on low-carbohydrate diets had greater increases in HDL cholesterol (63%) and greater decreases in TG (95%), but experienced less reduction in total (22%) and LDL (12%) cholesterol compared with those on low-fat diets .
Exercise plus a low-saturated fat diet reduced LDL cholesterol levels by 7–15% and TG levels by 4–18%, while increasing HDL cholesterol levels by 5–14%. Exercise plus nutritional supplements reduced LDL cholesterol levels by 8–30% and TG levels by 12–39%, while increasing HDL cholesterol levels by 2–8%. Therefore, combining diet and exercise interventions appears to be additive or at least synergistic .
In our study, 50 patients followed low-carbohydrate and low-fat diet programs for 1 year, which caused a decrease in TC (30% of cases), TG (54% of cases), and LDL (4% of cases). HDL cholesterol increased in 62% of cases. [Table 7] summarizes changes in the lipid profile in the diet group in our study as well as others.
| Conclusion|| |
LSG is an effective and reliable solution for morbid obesity as well as its associated comorbidities including hyperlipidemia. LSG is more effective than diet programs at achieving such goals due to significant and sustained EBWL. LSG significantly improved TC and TG, whereas LDL was not significantly changed in both groups, emphasizing the importance of prophylaxis against cardiovascular risks.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Schirmer BD, Schauer PR, Flum DR, Ellsmere J, Jones DB. Bariatric surgery training: getting your ticket punched. J Gastrointest Surg 2007; 11:807–812.
Flegal KM, Graubard BI, Williamson DF, Gail MH. Cause-specific excess deaths associated with underweight, overweight, and obesity. JAMA 2007; 298:2028–2037.
Sarac I, Backhouse K, Shojaee-Moradie F, Stolinski M, Robertson MD, Bell JD et al.
Gender differences in VLDL1 and VLDL2 triglyceride kinetics and fatty acid kinetics in obese postmenopausal women and obese men. J Clin Endocrinol Metab 2012; 97: 2475–2481.
Sarkhosh K, Birch DW, Shi X, Gill RS, Karmali S. The impact of sleeve gastrectomy on hypertension: a systematic review. Obes Surg 2012; 22:832–837.
Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ et al.
National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet 2011; 377:557–567.
Martorell R, Khan LK, Hughes ML, Grummer-Strawn LM. Obesity in women from developing countries. Eur J Clin Nutr 2000; 54:247–252.
Guh DP, Zhang W, Bansback N, Amarsi Z, Birmingham CL, Anis AH. The incidence of co-morbidities related to obesity and overweight: a systematic review and meta-analysis. BMC Public Health 2009; 9:88.
Bruzzi P, Predieri B, Patianna VD, Salvini A, Rossi R, Modena MG et al.
Longitudinal evaluation of endothelial function in children and adolescents with type 1 diabetes mellitus: a long term follow up study. Pediatr Int 2013; 56:188–195.
Rohilla A, Dagar N, Rohilla S, Dahiya A, Kushnoor A. Hyperlipidemia − a deadly pathological condition. Int J Curr Pharm Res 2012; 4:15–18.
Grauvogel J, Grauvogel TD, Gebhard MM, Werner J. Combined effects of chronic and acute ethanol on pancreatic injury and microcirculation. Pancreas 2012; 41:1.
Koh KK, Sakuma I, Quon MJ. Differential metabolic effects of distinct statins, Atherosclerosis 2011; 215:1–8.
Saurav A, Kaushik M, Mohiuddin SM. Fenofibric acid for hyperlipidemia. Expert Opin Pharmacother 2012; 13:717–722.
Frezza EE. Laparoscopic vertical sleeve gastrectomy for morbid obesity. The future procedure of choice? Surg Today 2007; 37:275–281.
Phinney SD. Ketogenic diets and physical performance. Nutr Metab (Lond) 2004; 1:2.
Taubes G. The science of obesity: what do we really know about what makes us fat? An essay by Gary Taubes. BMJ 2013; 1050:1–5.
Samaha FF, Iqbal N, Seshadri P, Chicano KL, Daily DA, McGrory J et al.
A low-carbohydrate as compared with a low-fat diet in severe obesity. N Engl J Med 2003; 348: 2074–2081.
Kopp W. The atherogenic potential of dietary carbohydrate. Prev Med (Baltim) 2006; 42:336–342.
Pirozzo S, Summerbell C, Cameron C, Glasziou P. Advice on low-fat diets for obesity. Cochrane Database Syst Rev 2002; CD003640.
Schwingshackl L, Hoffmann G. Comparison of effects of long-term low-fat vs high-fat diets on blood lipid levels in overweight or obese patients: a systematic review and meta-analysis. J Acad Nutr Diet 2013; 113:1640–1661.
Hady HR, Dadan J, Gołaszewski P, Safiejko K. Impact of laparoscopic sleeve gastrectomy on body mass index, ghrelin, insulin and lipid levels in 100 obese patients. Wideochir Inne Tech Maloinwazyjne 2012; 7:251–259.
Schauer PR, Ikramuddin S. Laparoscopic surgery for morbid obesity. Surg Clin North Am 2001; 81:1145–1179.
Wong ATY, Chan DC, Armstrong J, Watts GF. Effect of laparoscopic sleeve gastrectomy on elevated C-reactive protein and atherogenic dyslipidemia in morbidly obese patients. Clin Biochem 2011; 44:342–344.
Razak ZA, Mukhtar RS, Fadhel MA, Turki KM. Impact of sustained weight loss achieved through gastric gastric sleeve surgery with circulating level of obestatin hormone in Iraqi obese subjects. IOSR J Dent Med Sci 2014; 1:54–60.
Bužga M, Holéczy P, Svagera Z, Svorc P Jr, Zavadilová V. Effects of sleeve gastrectomy on parameters of lipid and glucose metabolism in obese women - 6 months after operation. Wideochir InneTech Maloinwazyjne 2013; 8:22–28.
Boza C, Daroch D, Barros D, León F, Funke R, Crovari F. Long-term outcomes of laparoscopic sleeve gastrectomy as a primary bariatric procedure. Surg Obes Relat Dis 2014; 10:1129–1133.
Nordmann AJ, Nordmann A, Briel M, Keller U, Yancy WS Jr, Brehm BJ 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; 166:285–293.
Shai I, Schwarzfuchs D, Henkin Y, Shahar DR, Witkow S, Greenberg I et al.
Dietary Intervention Randomized Controlled Trial (DIRECT) Group. Weight loss with a low-carbohydrate, mediterranean, or low-fat diet. N Engl J Med 2008; 359:229–241.
Hu T, Mills KT, Yao L, Demanelis K, Eloustaz M, Yancy WS et al.
Effects of low-carbohydrate diets versus low-fat diets on metabolic risk factors: a meta-analysis of randomized controlled clinical trials. Am J Epidemiol 2012; 176(Suppl 7): S44–S54.
Varady KA, Jones PJH. Combination diet and exercise interventions for the treatment of dyslipidemia: an effective preliminary strategy to lower cholesterol levels? J Nutr 2005; 135: 1829–1835.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]