OBES SURG DOI 10.1007/s11695-014-1299-6
ORIGINAL CONTRIBUTIONS
Handgrip Strength as a Predictor for Post Bariatric Body Composition Mirko Otto & Sandra Kautt & Melanie Kremer & Peter Kienle & Stefan Post & Till Hasenberg
# Springer Science+Business Media New York 2014
Abstract Background After bariatric surgery, the postoperative quality of weight loss is variable. The aim of weight loss treatment is to reduce fat mass while keeping fat free mass, in particular body cell mass (BCM), constant. Detection of low BCM is an important aspect of surgical follow up. Handgrip dynamometry is a rapid and inexpensive test to measure static muscle strength, which is an independent outcome indicator of various medical conditions. The objective of this study is to examine the change in handgrip strength after bariatric surgery and its predictive value for postoperative body composition. Furthermore, this study was carried out at the University Hospital, Germany. Methods Twenty-five patients who underwent a bariatric procedure (laparoskopic Roux-Y gastric bypass n=16 or sleeve resection n=9) were included in this study. Bioelectrical impedance analysis and hand-grip strength were measured preoperatively and repeated every 6 weeks for 4 months. An analysis of variance was performed to observe the changes in these individual parameters. Results Postoperatively, all patients showed a significant decrease in the body mass index and body fat. The extracellular mass, BCM, and the lean mass of the patients remained constant. Handgrip strength showed no significant changes during the postoperative course. Nevertheless, the preoperative hand-grip strength showed a strong positive correlation with the postoperative body composition.
Mirko Otto and Sandra Kautt contributed equally to this publication M. Otto (*) : S. Kautt : M. Kremer : P. Kienle : S. Post : T. Hasenberg Department of Surgery, UMM, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68135 Mannheim, Germany e-mail: [email protected]
Conclusions This study showed no changes in the static muscle force after bariatric surgery. The preoperative handgrip strength was strongly correlated with postoperative body composition and may be used to identify patients who need more attention before surgery and in the early postoperative phase. Keywords Handgrip . Bariatric surgery . Body composition
Introduction The prevalence of obesity is increasing worldwide [1]. It is known that severe obesity is related with disease like diabetes, arterial hypertension, dyslipoproteinemia, sleep apnea, and numerous other serious illnesses including cancer [2]. The mentioned negative effects of obesity make a strong case for its treatment. For morbidly obese patients, bariatric surgery is currently the only proven effective therapy [3]. Bariatric surgery leads to a rapid and long-lasting reduction of weight and to a decrease of mortality and morbidity [4]. It achieves an excess weight loss of 54 % at 10 or more years after gastric bypass as well as an improvement of the comorbidities [4, 5]. Independent of the bariatric procedure, it is internationally considered that the postoperative follow-up is a necessity to avoid weight regain and increase patient safety. But what follow-up should include is unclear. Obviously, it is important to reduce body fat while preserving the lean body mass (LBM). In particular, the body cell mass, which is part of the LBM should remain unchanged after bariatric surgery to maintain metabolic and physical capacities of patients stable. Madan showed that bariatric surgery can achieve a constant body cell mass even with large fat loss [6]. However, the data from Zalesin demonstrate that greater weight losses can result in a distinct reduction of lean body mass [7]. He concludes that interventions to improve retention of LBM are needed after
OBES SURG
Roux-Y gastric bypass to prevent excessive losses of muscle tissue. Accordingly, this problem does not affect all patients. Already known predictors for postoperative loss of LBM is the extent of caloric restriction, exercise and the type of bariatric surgery [8]. Ciangura shows that the rate of change in weight, fat mass, and lean body mass is maximal during the first 3 months following Roux-Y gastric bypass [9]. Therefore, it is important to control body composition in addition to the weight loss the first months after bariatric surgery, since this can lead to a change in postoperative treatment like adaption of protein supplemention or increase physical activity. A routine measurement of body composition is not part of the postoperative follow-up in many bariatric centers, and it is controversial which method is suitable and feasible. Beside complex and routinely seldom used procedures, such as dual-energy X-ray absorptiometry (DXA) and the hydrodensitometry, the bioelectrical impedance analysis (BIA) is a common and frequently used tool for the determination of body composition after bariatric operations. During weight loss, BIA has shown to be a reliable method, as it reaches comparable values to DXA [10–12]. Although some publications demonstrate that the accuracy of measuring total body water is limited in obese patients, individual follow-ups are certainly possible [13]. Physical fitness is a key factor in the vicious circle of obesity and physical inactivity. Pietilainen shows that physically inactive lifestyle triggers weight gain independent of genetic effects [14]. Besides functional and aerobic capacity, in particular, muscle strength is an essential component of physical fitness [15].The avoidance of distinctive muscle atrophy after bariatric surgery is an essential part of postoperative care and one reason using BIA to follow up bariatric patients. Although there is no simple tool describing physical fitness, the handgrip test, which measures static muscle strength, has shown good predictive power for some diseases. For example, in dialysis patients, it has been shown that handgrip strength not only is a marker of lean body muscle mass but also provides important prognostic information independent of other covariates [16]. A low handgrip is also in patients with COPD associated with an increased mortality [17]. The measurement of handgrip strength was originally developed as a functional examination in hand surgery after trauma or surgery. Due to its simple application and low cost, it is now an established procedure for the evaluation of malnutrition and its successful treatment in patients [18]. However, health and physical activity also play a role in handgrip strength [19, 20]. Because handgrip strength is a known independent predictor of the outcome in COPD and hemodialysis patients [16,
17, 21] and physical fitness plays a decisive role in the genesis of obesity, we aimed to determine whether handgrip strength can serve as a predictor for the postoperative body composition after bariatric surgery.
Materials and Methods Subjects Twenty-five patients who underwent Roux-y gastric bypass n=16 or sleeve resection n=9 at the University Hospital were consecutively included in this prospective study over a period of 4 months. We lost five patients to follow up the entire period of this time-demanding study due to a lack of compliance. These patients showed no differences of the baseline values compared to the other participants. At each visit, every 6 weeks, measurements of bioelectrical impedance analysis and handgrip strength were obtained. The study was approved by the Medical Ethics Committee. All patients were provided written informed consent about their participation in this study. We included all patients who agreed with intended bariatric surgery, a body mass index between 35 and 60 kg/m2, a body weight under 200 kg and an age of 18 years. Patients with inadequate compliance were excluded. Bioelectrical Impedance Analysis All patients were required to rest for 30 min, after which, the bioelectrical impedance analysis (BIA) was performed by applying four silver electrodes, with two detecting electrodes placed at the ulnar aspect of the right wrist and the right medial malleolus. After connecting the electrodes to the multiple frequency BIA instrument (BIA 2000, Data Input, Frankfurt, Germany), the measurements were recorded in real-time by a computer. The calculations for body cell mass (BCM), extracellular mass (ECM), ECM/BCM, lean body mass, phase angle, fat and total body weight were conducted with the Body Comp V8.5 software (Medical, Kirchlengern, Germany). Static Muscle Strength The handgrip strength was first measured on the dominant hand and then on the nondominant hand using a Jamar hand dynamometer (Sammons Preston Inc., IL, USA). For this investigation, the patient sat in a comfortable sitting position, with the forearm in a neutral position and the elbow at a 90° angled position. The patients were asked to squeeze the dynamometer with the dominant hand with maximum strength. After a break of approximately 30 s, the measurement was repeated. Altogether, the
OBES SURG
measurement was performed three times with each hand. The mean of the three efforts was calculated and used for this study. This procedure corresponds to other studies [21, 22]. Normal values were derived from Norman et al [17, 18]: 41.2 kg (38.0 to 44.4 kg) for the dominant hand and 39.2 kg (35.9 to 42.6 kg) for the nondominant hand in males, and 26.7 kg (24.9 to 28.5 kg) for the dominant hand and 25.1 kg (23.2 kg to 27.1 kg) for the nondominant hand in females. Because the obese patients included in the study by Norman had muscle strengths similar to those in the normal population, we used the mean values given above for comparison. Statistical Analysis The statistical analysis was performed using the software JMP® 9.0 (SAS Institute, Cary, NC, USA). An analysis of variance was performed. For pairwise mean comparisons, the significance levels were adjusted using the Scheffé method. To test the linear relationship of the data, the Pearson correlation coefficient was determined. A p value of
ORIGINAL CONTRIBUTIONS
Handgrip Strength as a Predictor for Post Bariatric Body Composition Mirko Otto & Sandra Kautt & Melanie Kremer & Peter Kienle & Stefan Post & Till Hasenberg
# Springer Science+Business Media New York 2014
Abstract Background After bariatric surgery, the postoperative quality of weight loss is variable. The aim of weight loss treatment is to reduce fat mass while keeping fat free mass, in particular body cell mass (BCM), constant. Detection of low BCM is an important aspect of surgical follow up. Handgrip dynamometry is a rapid and inexpensive test to measure static muscle strength, which is an independent outcome indicator of various medical conditions. The objective of this study is to examine the change in handgrip strength after bariatric surgery and its predictive value for postoperative body composition. Furthermore, this study was carried out at the University Hospital, Germany. Methods Twenty-five patients who underwent a bariatric procedure (laparoskopic Roux-Y gastric bypass n=16 or sleeve resection n=9) were included in this study. Bioelectrical impedance analysis and hand-grip strength were measured preoperatively and repeated every 6 weeks for 4 months. An analysis of variance was performed to observe the changes in these individual parameters. Results Postoperatively, all patients showed a significant decrease in the body mass index and body fat. The extracellular mass, BCM, and the lean mass of the patients remained constant. Handgrip strength showed no significant changes during the postoperative course. Nevertheless, the preoperative hand-grip strength showed a strong positive correlation with the postoperative body composition.
Mirko Otto and Sandra Kautt contributed equally to this publication M. Otto (*) : S. Kautt : M. Kremer : P. Kienle : S. Post : T. Hasenberg Department of Surgery, UMM, Universitätsmedizin Mannheim, Theodor-Kutzer-Ufer 1-3, 68135 Mannheim, Germany e-mail: [email protected]
Conclusions This study showed no changes in the static muscle force after bariatric surgery. The preoperative handgrip strength was strongly correlated with postoperative body composition and may be used to identify patients who need more attention before surgery and in the early postoperative phase. Keywords Handgrip . Bariatric surgery . Body composition
Introduction The prevalence of obesity is increasing worldwide [1]. It is known that severe obesity is related with disease like diabetes, arterial hypertension, dyslipoproteinemia, sleep apnea, and numerous other serious illnesses including cancer [2]. The mentioned negative effects of obesity make a strong case for its treatment. For morbidly obese patients, bariatric surgery is currently the only proven effective therapy [3]. Bariatric surgery leads to a rapid and long-lasting reduction of weight and to a decrease of mortality and morbidity [4]. It achieves an excess weight loss of 54 % at 10 or more years after gastric bypass as well as an improvement of the comorbidities [4, 5]. Independent of the bariatric procedure, it is internationally considered that the postoperative follow-up is a necessity to avoid weight regain and increase patient safety. But what follow-up should include is unclear. Obviously, it is important to reduce body fat while preserving the lean body mass (LBM). In particular, the body cell mass, which is part of the LBM should remain unchanged after bariatric surgery to maintain metabolic and physical capacities of patients stable. Madan showed that bariatric surgery can achieve a constant body cell mass even with large fat loss [6]. However, the data from Zalesin demonstrate that greater weight losses can result in a distinct reduction of lean body mass [7]. He concludes that interventions to improve retention of LBM are needed after
OBES SURG
Roux-Y gastric bypass to prevent excessive losses of muscle tissue. Accordingly, this problem does not affect all patients. Already known predictors for postoperative loss of LBM is the extent of caloric restriction, exercise and the type of bariatric surgery [8]. Ciangura shows that the rate of change in weight, fat mass, and lean body mass is maximal during the first 3 months following Roux-Y gastric bypass [9]. Therefore, it is important to control body composition in addition to the weight loss the first months after bariatric surgery, since this can lead to a change in postoperative treatment like adaption of protein supplemention or increase physical activity. A routine measurement of body composition is not part of the postoperative follow-up in many bariatric centers, and it is controversial which method is suitable and feasible. Beside complex and routinely seldom used procedures, such as dual-energy X-ray absorptiometry (DXA) and the hydrodensitometry, the bioelectrical impedance analysis (BIA) is a common and frequently used tool for the determination of body composition after bariatric operations. During weight loss, BIA has shown to be a reliable method, as it reaches comparable values to DXA [10–12]. Although some publications demonstrate that the accuracy of measuring total body water is limited in obese patients, individual follow-ups are certainly possible [13]. Physical fitness is a key factor in the vicious circle of obesity and physical inactivity. Pietilainen shows that physically inactive lifestyle triggers weight gain independent of genetic effects [14]. Besides functional and aerobic capacity, in particular, muscle strength is an essential component of physical fitness [15].The avoidance of distinctive muscle atrophy after bariatric surgery is an essential part of postoperative care and one reason using BIA to follow up bariatric patients. Although there is no simple tool describing physical fitness, the handgrip test, which measures static muscle strength, has shown good predictive power for some diseases. For example, in dialysis patients, it has been shown that handgrip strength not only is a marker of lean body muscle mass but also provides important prognostic information independent of other covariates [16]. A low handgrip is also in patients with COPD associated with an increased mortality [17]. The measurement of handgrip strength was originally developed as a functional examination in hand surgery after trauma or surgery. Due to its simple application and low cost, it is now an established procedure for the evaluation of malnutrition and its successful treatment in patients [18]. However, health and physical activity also play a role in handgrip strength [19, 20]. Because handgrip strength is a known independent predictor of the outcome in COPD and hemodialysis patients [16,
17, 21] and physical fitness plays a decisive role in the genesis of obesity, we aimed to determine whether handgrip strength can serve as a predictor for the postoperative body composition after bariatric surgery.
Materials and Methods Subjects Twenty-five patients who underwent Roux-y gastric bypass n=16 or sleeve resection n=9 at the University Hospital were consecutively included in this prospective study over a period of 4 months. We lost five patients to follow up the entire period of this time-demanding study due to a lack of compliance. These patients showed no differences of the baseline values compared to the other participants. At each visit, every 6 weeks, measurements of bioelectrical impedance analysis and handgrip strength were obtained. The study was approved by the Medical Ethics Committee. All patients were provided written informed consent about their participation in this study. We included all patients who agreed with intended bariatric surgery, a body mass index between 35 and 60 kg/m2, a body weight under 200 kg and an age of 18 years. Patients with inadequate compliance were excluded. Bioelectrical Impedance Analysis All patients were required to rest for 30 min, after which, the bioelectrical impedance analysis (BIA) was performed by applying four silver electrodes, with two detecting electrodes placed at the ulnar aspect of the right wrist and the right medial malleolus. After connecting the electrodes to the multiple frequency BIA instrument (BIA 2000, Data Input, Frankfurt, Germany), the measurements were recorded in real-time by a computer. The calculations for body cell mass (BCM), extracellular mass (ECM), ECM/BCM, lean body mass, phase angle, fat and total body weight were conducted with the Body Comp V8.5 software (Medical, Kirchlengern, Germany). Static Muscle Strength The handgrip strength was first measured on the dominant hand and then on the nondominant hand using a Jamar hand dynamometer (Sammons Preston Inc., IL, USA). For this investigation, the patient sat in a comfortable sitting position, with the forearm in a neutral position and the elbow at a 90° angled position. The patients were asked to squeeze the dynamometer with the dominant hand with maximum strength. After a break of approximately 30 s, the measurement was repeated. Altogether, the
OBES SURG
measurement was performed three times with each hand. The mean of the three efforts was calculated and used for this study. This procedure corresponds to other studies [21, 22]. Normal values were derived from Norman et al [17, 18]: 41.2 kg (38.0 to 44.4 kg) for the dominant hand and 39.2 kg (35.9 to 42.6 kg) for the nondominant hand in males, and 26.7 kg (24.9 to 28.5 kg) for the dominant hand and 25.1 kg (23.2 kg to 27.1 kg) for the nondominant hand in females. Because the obese patients included in the study by Norman had muscle strengths similar to those in the normal population, we used the mean values given above for comparison. Statistical Analysis The statistical analysis was performed using the software JMP® 9.0 (SAS Institute, Cary, NC, USA). An analysis of variance was performed. For pairwise mean comparisons, the significance levels were adjusted using the Scheffé method. To test the linear relationship of the data, the Pearson correlation coefficient was determined. A p value of
