Thomas Bøhmer

Vitamin status after bariatric surgery: a randomized study of gastric bypass and duodenal switch

BACKGROUND Bariatric surgery is widely performed to induce weight loss. OBJECTIVE The objective was to examine changes in vitamin status after 2 bariatric surgical techniques. DESIGN A randomized controlled trial was conducted in 2 Scandinavian hospitals. The subjects were 60 superobese patients [body mass index (BMI; in kg/m(2)): 50-60]. The surgical interventions were either laparoscopic Roux-en-Y gastric bypass or laparoscopic biliopancreatic diversion with duodenal switch. All patients received multivitamins, iron, calcium, and vitamin D supplements. Gastric bypass patients also received a vitamin B-12 substitute. The patients were examined before surgery and 6 wk, 6 mo, and 1 y after surgery. RESULTS Of 60 surgically treated patients, 59 completed the follow-up. After surgery, duodenal switch patients had lower mean vitamin A and 25-hydroxyvitamin D concentrations and a steeper decline in thiamine concentrations than did the gastric bypass patients. Other vitamins (riboflavin, vitamin B-6, vitamin C, and vitamin E adjusted for serum lipids) did not change differently in the surgical groups, and concentrations were either stable or increased. Furthermore, duodenal switch patients had lower hemoglobin and total cholesterol concentrations and a lower BMI (mean reduction: 41% compared with 30%) than did gastric bypass patients 1 y after surgery. Additional dietary supplement use was more frequent among duodenal switch patients (55%) than among gastric bypass patients (26%). CONCLUSIONS Compared with gastric bypass, duodenal switch may be associated with a greater risk of vitamin A and D deficiencies in the first year after surgery and of thiamine deficiency in the initial months after surgery. Patients who undergo these 2 surgical interventions may require different monitoring and supplementation regimens in the first year after surgery. This trial was registered at ClinicalTrials.gov as NCT00327912.

CARNITINE DEFICIENCY INDUCED DURING INTERMITTENT HÆMODIALYSIS FOR RENAL FAILURE

Carnitine concentration was measured in plasma, muscle, and dialysate before and after haemodialysis in patients with renal failure and in plasma and muscle of healthy controls. In eight of the nine patients carnitine concentration in muscle after haemodialysis was only 10% of the concentration in controls. Plasma-carnitine varied in patients before dialysis and in all of them was reduced by dialysis. The loss of carnitine into the dialysate (190--2100 mumol/treatment) greatly exceeded the normal loss in urine for most of patients, and was only partly compensated for. In some patients normal or high plasma-carnitine and low concentrations in muscle indicated that the carnitine-concentrating mechanisms in the muscle cell had failed. The reduction in carnitine will interfere seriously with normal cellular functions and this may help to explain the clinical syndrome of cardiomyopathy and cardiac failure which has been observed in some patients treated for a long time with intermittent haemodialysis.

Low Serum Calcidiol Concentration in Older Adults with Reduced Muscular Function

OBJECTIVE: To examine the association between muscular function and the serum concentrations of 25‐hydroxyvitamin D (calcidiol) and 1,25‐dihydroxyvitamin D (calcitriol).

Carnitine levels in human serum in health and disease

Abstract The level of carnitine in serum was examined in a control group and in different patient groups. A radiometric assay of carnitine with carnitine acetyltransferase and radioactively labeled acetyl-CoA was used. By the addition of dithionitrobenzoic acid (DTNB) to the incubation mixture to trap the CoASH released, the formation of radioactive acetylcarnitine was proportional to the carnitine concentration over a wide range. Carnitine was extracted from plasma after ethanol addition and the recovery of [ Me - 3 H] carnitine added to serum was 102%. The serum level of carnitine was reduced in patients with myotonia congenita, Crohns disease in some patients with malabsorption and in cases of anorexia nervosa. During hemodialysis the carnitine concentration was reduced to 25% of the value occurring before dialysis. Normal levels of carnitine were found in ulcerative colitis patients, most patients with malabsorption, in liver cirrhosis, in right-sided heart failure with liver stasis, in juvenile and adult onset diabetes, and in cardiomyopathies. Two patients with progressive cardiac failure with icterus and oliguria showed an eight-fold increase in serum carnitine levels.

The Prevalence of Undiagnosed Protein‐Calorie Undernutrition in a Population of Hospitalized Elderly Patients

Objective: To determine the extent to which patients with objective signs of malnutrition had been diagnosed as such by physicians and the diagnosis documented in the medical record.

Propionylcarnitine. Physiological variations in vivo.

Abstract 1. 1. Propionylcarnitine has been identified as a relatively important carnitine derivative in liver and kidney in male rats. 2. 2. In the liver of fed rats the ratio of propionylcarnitine/free carnitine + propionylcarnitine was 22% and in the kidney 4%. Fasting reduced this ratio to 1% in both liver and kidney. In the other organs the ratio was 1% or less in both normally fed and fasted rats. 3. 3. Feeding corn oil to rats previously given a diet rich in carbohydrate reduced the level of propionylcarnitine in the liver to fasting values within 4 h. 4. 4. The changes in the propionylcarnitine level in the liver are exactly opposite to those in the long-chain acylcarnitines. 5. 5. The results are discussed in relation to the regulatory mechanisms in mitochondrial metabolism.

The relative amounts of long-chain acylcarnitine, acetylcarnitine, and free carnitine in organs of rats in different nutritional states and with alloxan diabetes

Abstract 1. 1. The relative amounts of free carnitine, acetylcarnitine, and long-chain acylcarnitines have been investigated in the heart, liver and kidney of male rats during different nutritional states and with alloxan diabetes. 2. 2. The relative proportion of long-chain acylcarnitines to free carnitine increases during fat-feeding, diabetes and fasting, and decreases when glucose is given again. 3. 3. The level of long-chain acylcarnitines changes in the same direction as the level of long-chain acyl-CoAs which is known to alter in these conditions. 4. 4. In the kidney the relative proportion of acetylcarnitine to free carnitine increases during fat-feeding, diabetes and fasting, and decreases when glucose is again consumed. These changes are in accord with the changes known to occur with acetyl-CoA in similar conditions. In the liver and the heart the changes in acetylcarnitine were not significant. 5. 5. The method described seems to be convenient for studying the level of activated fatty acids in the tissues.

Carnitine uptake into human heart cells in culture.

The uptake of radiolabeled carnitine and butyrobetaine has been studied in human heart cells (CCL 27). The uptake of carinitine is 3-10-fold higher in heart cells than in fibroblasts (pmol - mug DNA-1). The uptake of carnitine increases with temperature coefficient KT of 1.6 in the interval 10-20 degrees C and with a negligible uptake at 4 and 10 degrees C. The uptake of carnitine follows Michaelis-Menten kinetics with a KM of 4.8 +/- 2.2 muM and V = 8.7 +/- 3.2 pmol - mug DNA-1 - H-1. Carnitine uptake is suppressed 90% by NaF (24MM). Butyrobetaine is taken up into heart cells to the same extent as carnitine with a KM of 5.7-17.3 muM and V = 8.7-9.3 pmol - mug DNA-1 - h-1. Butyrobetaine inhibits competitively the uptake of carnitine and carnitine inhibits the uptake of butyrobetaine to the same extent. No conversion of radiolabeled butyrobetaine to carnitine, or carnitine to methyl choline was observed intra- or extracellulary during incubation. These data are compatible with a selective transport mechanism for carnitine which is also responsible for the uptake of butyrobetaine.

Five-Year Outcomes After Laparoscopic Gastric Bypass and Laparoscopic Duodenal Switch in Patients With Body Mass Index of 50 to 60: A Randomized Clinical Trial

IMPORTANCE There is no consensus as to which bariatric procedure is preferred to reduce weight and improve health in patients with a body mass index higher than 50. OBJECTIVE To compare 5-year outcomes after Roux-en-Y gastric bypass (gastric bypass) and biliopancreatic diversion with duodenal switch (duodenal switch). DESIGN, SETTING, AND PARTICIPANTS Randomized clinical open-label trial at Oslo University Hospital, Oslo, Norway, and Sahlgrenska University Hospital, Gothenburg, Sweden. Participants were recruited between March 17, 2006, and August 20, 2007, and included 60 patients aged 20 to 50 years with a body mass index of 50 to 60. The current study provides the 5-year follow-up analyses by intent to treat, excluding one participant accepted for inclusion who declined being operated on prior to knowing to what group he was randomized. INTERVENTIONS Laparoscopic gastric bypass and laparoscopic duodenal switch. MAIN OUTCOMES AND MEASURES Body mass index and secondary outcomes including anthropometric measures, cardiometabolic risk factors, pulmonary function, vitamin status, gastrointestinal symptoms, health-related quality of life, and adverse events. RESULTS Sixty patients were randomly assigned and operated on with gastric bypass (n = 31) and duodenal switch (n = 29). Fifty-five patients (92%) completed the study. Five years after surgery, the mean reductions in body mass index were 13.6 (95% CI, 11.0-16.1) and 22.1 (95% CI, 19.5-24.7) after gastric bypass and duodenal switch, respectively. The mean between-group difference was 8.5 (95% CI, 4.9-12.2; P < .001). Remission rates of type 2 diabetes mellitus and metabolic syndrome and changes in blood pressure and lung function were similar between groups. Reductions in total cholesterol, low-density lipoprotein cholesterol, triglycerides, and fasting glucose were significantly greater after duodenal switch compared with gastric bypass. Serum concentrations of vitamin A and 25-hydroxyvitamin D were significantly reduced after duodenal switch compared with gastric bypass. Duodenal switch was associated with more gastrointestinal adverse effects. Health-related quality of life was similar between groups. Patients with duodenal switch underwent more surgical procedures related to the initial procedure (13 [44.8%] vs 3 [9.7%] patients; P = .002) and had significantly more hospital admissions compared with patients with gastric bypass. CONCLUSIONS AND RELEVANCE In patients with a body mass index of 50 to 60, duodenal switch resulted in greater weight loss and greater improvements in low-density lipoprotein cholesterol, triglyceride, and glucose levels 5 years after surgery compared with gastric bypass while improvements in health-related quality of life were similar. However, duodenal switch was associated with more surgical, nutritional, and gastrointestinal adverse effects. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00327912.

Conversion of butyrobetaine to carnitine in the rat in vivo

1. 1. The half life of the disappearance of itnravenously injected l-[Me-3H]-butyrobetaine and l-[Me-3H] carnitine from rat plasma was studied. The appearance of [3H] carnitine in liver, plasma, muscle, heart and kidney 0.5 and 2 h after intravenous injection of l-[Me-3H]-butyrobetaine was also investigated in vivo in rats. In addition, the synthesis of carnitine was studied 30 min after injection of l-[Me-3H]-butyrobetaine, in rats which had their livers excluded from the circulation (superior body preparation). 2. 2. 0.5 h after injection of l-[Me-3H]-butyrobetaine, 85% of the radioactivity was recovered in the liver. The plasma, kidney and heart together accounted for 15% of the radioactivity. Of the radioactivity in liver, plasma, kidney, muscle and heart, 80, 67, 43, 25 and 30%, respectively, consisted of carnitine. Butyrobetaine accounted for the remaining radioactivity. 3. 3. 2 h after intravenous injection of l-[Me-3H]-butyrobetaine, there was a reduction of the total radioactivity in the liver an increase in plasma, kidney, heart and muscle compared with values obtained after 0.5 h. All the radioactivity in the liver, plasma and kidney was found to be in carnitine. In heart and muscle, only 72 and 73%, respectively, was present as such while butyrobetaine accounted for the remainder. 4. 4. When the liver was excluded from the circulation, no conversion of butyrobetaine to carnitine was observed in either the liver, plasma, heart or muscle. 5. 5. These results indicate that: (a) the liver is the only organ which converts butyrobetaine to carnitine and (b) carnitine is subsequently rapidly transported to other organs.