Metabolic Impact of Dietary Protein Supplementation in Surgical Weight Loss (MIPS)

July 18, 2017 updated by: Blandine Laferrere, Columbia University

Metabolic Impact of Dietary Protein Supplementation in Surgical Weight Loss II (MIPS II)

The obesity epidemic has grown rapidly in the United States, and is associated with increased morbidity and mortality rates. Bariatric surgery (BS) has emerged as the most effective treatment for severe obesity. Surgical weight loss (WL) is very significant (~40-50kg) during the first 6-12 months after surgery. The adequate amount of dietary protein during the active period of surgical weight loss is not known. Dietary protein affects body weight regulation: satiety, thermogenesis, energy efficiency and body composition. During diet-induced energy-restriction, sustaining protein intake (PI) at the level of requirement (0.8g /kg ideal body weight (IBW)/ day) appears to preserve fat free mass (FFM) during active WL. PI above requirements (1.2g protein/Kg IBW/ day) results in favorable body composition changes, with greater decrease in fat mass and preservation of FFM, but without effecting WL. Dietary PI 0.8g/day has been associated with greater satiety and increased energy expenditure (EE) during calorie restriction. In this randomized prospective study, the investigators will evaluate the effect of PI on nitrogen balance, body composition, EE and satiety in 40 women undergoing either Gastric Bypass or Vertical Sleeve Gastrectomy, assigned to high protein supplementation (PRO-S), high PRO-S (1.2g /kg IBW/day) or standard- based current guidelines -PRO-S (0.8g /kg IBW/day). PRO-S will be supplied for 3 months after surgery. Outcome measures including nitrogen balance, body composition changes and satiety will be assessed at pre-surgery, and at 3, 6 and 12 months post-surgery. These results will help provide evidence-based data on safe and optimal levels of protein supplementation after BS

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

The goal of this proposal is to study the effect of dietary protein supplementation (PRO-S) during surgical weight loss, on nitrogen balance, energy expenditure, body composition of weight loss, and satiety. The overall goal is to provide evidence-based data on optimal levels of protein supplementation after surgical weight loss by gastric bypass (GBP), a restrictive and malabsorptive procedure, or by vertical sleeve gastrectomy (VSG), a purely restrictive procedure.

We propose a prospective randomized controlled trial (RCT), in which, patients undergoing either GBP or VSG will be allocated to standard PRO-S recommendation ("standard care" according to the American Society for Metabolic and Bariatric Surgery Guidelines) or high supplementation. We will compare 4 groups of subjects:

  • Group 1: GBP Standard PRO-S (0.8g protein/kg ideal body weight (IBW)/day
  • Group 2: GBP High PRO-S (1.2g protein/ kg ideal body weight (IBW)/ day)
  • Group 3: VSG Standard PRO-S (0.8g protein/kg ideal body weight (IBW)/day
  • Group 4: VSG High PRO-S (1.2g protein/ kg ideal body weight (IBW)/ day)

AIM#1: Measure total body nitrogen balance (NB) to assess adequacy of levels of protein intake and protein absorption.

AIM#2: Measure the effect PRO-S on lean body mass (LBM), and resting energy expenditure (REE).

AIM#3: Measure the effect of PRO-S on satiety. Hypothesis 3.1: Patients in the High PRO-S group will experience higher levels of perceived satiety compared with patients in the standard PRO-S group.

AIM #4: Study adherence to protein supplementation. Hypothesis : Adherence will be greater in the Standard PRO-S group.

Background and Significance The obesity epidemic has grown rapidly in the United States, and is associated with increased morbidity and mortality rates. Although preventive measures are needed to solve the obesity epidemic in the long-term, bariatric surgery has become a popular and effective treatment of severe obesity. Obesity and its co-morbidities, including type 2 diabetes (T2DM), have a high health care cost2. The cost is even greater for severe obesity (BMI≥40 kg/m2).

Protein (PRO) malnutrition after bariatric surgery (BS) Bariatric surgery (BS) has emerged as the most effective treatment for severe obesity. Gastric bypass surgery (GBP) results in large weight loss with normalization of metabolic functions, including T2DM remission in ~60-80% of cases. Weight loss is very significant (~40-50kg). The rate of weight loss is rapid during the first year after surgery. Surgical weight loss can be associated with vitamin, mineral, and protein deficiencies. PRO malnutrition, remains the most severe nutritional complication associated with malabsorptive surgical procedures. The prevalence of protein malnutrition after malabsorptive BS procedures varies between 3 to 18% and is associated with the length of the bypassed segment. The US recommended dietary allowance (RDA) for protein is ~50 g/d for healthy normal weight adults. Experts and clinicians recommend ~70 g/d of protein during low-calorie diets or 60 g/day (standard) and 120 g/day (high) in the earlier months after BS. However, there is little evidence-based data to support these recommendations. In spite of the absence of level 1 data on types and amount of protein recommendations, the American Society for Metabolic Surgery and BS's website has 14 links for commercial nutrition supplements14. In this study, we aim to study protein absorption and adequacy of protein intake by nitrogen balance in patients following standard and high PRO-S following BS.

Effects of dietary proteins Dietary PRO-S and amino acids (AA) are important modulators of body weight by affecting various determinants of body weight regulation: satiety, thermogenesis, energy efficiency and body composition. During energy restriction, sustaining protein intake at the level of requirement (0.8g protein/kg ideal body weight (IBW)/ day) appears to be sufficient to induce body weight loss while preserving fat free mass (FFM). Protein intake above requirements (1.2g protein/Kg IBW/ day) results in a greater decrease in fat mass and preservation of FFM, but has no effect on body weight loss.

Nitrogen balance (NB) study The NB method is classically used to determine adequate protein intakes and to measure whole body protein balance in response to nutritional interventions. Prolonged negative nitrogen balance should not be sustained for long periods due its negative impact on overall health.

Risk of decreased lean body mass (LBM) and resting energy expenditure (REE) with surgical weight loss BS results in large weight losses (30-50kg), with both fat mass (FML) and LBM losses. Our previous observational studies aiming to evaluate the relationship between protein intake and loss of LBM following BS have shown that protein intake > 60g/ day is associated with better maintenance of LBM after BS. LBM is the main determinant of REE, explaining 75% of the REE variance with REE being the largest component of 24-h energy expenditure (EE). Reduced EE may trigger weight regain in this population. High PRO-S diets may also benefit this population by increasing EE while preventing LBM loss. Increased EE from dietary protein is attributed to an enhanced thermic effect (23-30%) compared to carbohydrates (5-10%) or lipids (2-3%).

Dietary protein intake and satiety High-protein intake increases satiety despite energy restriction. Proposed mechanisms are as follows: a ketogenic state, relatively elevated plasma amino acid (AA) levels, and anorexigenic hormone concentrations feedback on the central nervous system to prolong the duration before one feels hunger for the next meal (satiety) such as, Peptide YY, Glucagon-Like Peptide -1 and cholecystokinin produced in response to peripheral and central detection of amino acid, and decreased levels of the orexigenic hormone ghrelin.

Protein supplementation and adherence Low protein intake after BS has been reported. PRO-S has always been recommended after BS but its feasibility has not been well addressed in any RCT. We will study adherence to PRO-S. Increasing adherence with dietary recommendation is challenging, but may represent a key strategy to improve the clinical nutritional treatment and outcomes after BS.

Study Type

Interventional

Enrollment (Actual)

6

Phase

  • Not Applicable

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years to 65 years (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

Female

Description

Inclusion Criteria:

  1. Women scheduled to undergo either GBP or VSG.
  2. Ethnicity/gender: People of all race/ethnicity are eligible to participate, so that the study will reflect a diverse population.
  3. Non diabetic or diet controlled diabetic with no medication

Exclusion Criteria:

  1. Individuals who have a clinical history strongly suggestive of type 1 diabetes mellitus or T2DM will be excluded.
  2. Nitrogen retention disease such as renal or hepatic disease.
  3. Known malabsorption syndrome.
  4. Any other condition which, in the opinion of the investigators, may make the candidate unsuitable for participation in this study.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Treatment
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Active Comparator: GBP-SPS
GBP Standard PRO-S (0.8g protein/kg ideal body weigh/day)
Dietary supplement: GBP-SPS
Protein powder supplementation will be given to participants to add to regular foods during the dietary intervention phase until reach protein objectives based on randomization and during 12 weeks after Bariatric Surgery.
Experimental: GBP-HPS
GBP High PRO-S (1.2g protein/ kg ideal body weight/ day)
Dietary supplement: GBP-HPS
Protein powder supplementation will be given to participants to add to regular foods during the dietary intervention phase until reach protein objectives based on randomization and during 12 weeks after Bariatric Surgery.
Active Comparator: VSG-SPS
VSG Standard PRO-S (0.8g protein/kg ideal body weigh/ day)
Dietary supplement: VSG-SPS
Protein powder supplementation will be given to participants to add to regular foods during the dietary intervention phase until reach protein objectives based on randomization and during 12 weeks after Bariatric Surgery.
Experimental: VSG-HPS
VSG High PRO-S (1.2g protein/ kg ideal body weight/ day)
Dietary supplement: VSG-HPS
Protein powder supplementation will be given to participants to add to regular foods during the dietary intervention phase until reach protein objectives based on randomization and during 12 weeks after Bariatric Surgery.

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Change in Nitrogen balance (NB)
Time Frame: Change from baseline of NB at 3 months after surgery
During inpatient stay. Nitrogen intake and output will be accurately monitored
Change from baseline of NB at 3 months after surgery
Change in Nitrogen balance (NB)
Time Frame: Change form 3 month to 12 months
During inpatient stay. Nitrogen intake and output will be accurately monitored
Change form 3 month to 12 months
Change in Nitrogen Balance
Time Frame: Change from baselina to 12 months
During inpatient stay. Nitrogen intake and output will be accurately monitored
Change from baselina to 12 months

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Composite outcome measure consisting of Lean body mass (LBM), and resting energy expenditure (REE).
Time Frame: 0, 3 and 12 months after surgery
LBM (Kg) will be analyzed by Bod Pod and Total Body Water technique REE will be determined by indirect calorimetry
0, 3 and 12 months after surgery
Satiety scores
Time Frame: 0, 3 and 12 months
Hormonals levels and perceived satiety scores will be evaluated
0, 3 and 12 months
Adherence score to protein supplementation.
Time Frame: 0, 3 and 12 months
Score of Adherence will be obtained
0, 3 and 12 months

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Columbia University

Investigators

  • Principal Investigator: Xavier Pi-Sunyer, MD, Columbia University

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Helpful Links

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start (Actual)

November 1, 2014

Primary Completion (Actual)

February 1, 2016

Study Completion (Actual)

February 1, 2016

Study Registration Dates

First Submitted

October 10, 2014

First Submitted That Met QC Criteria

October 16, 2014

First Posted (Estimate)

October 21, 2014

Study Record Updates

Last Update Posted (Actual)

July 19, 2017

Last Update Submitted That Met QC Criteria

July 18, 2017

Last Verified

July 1, 2017

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • AAAN6105

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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