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Risk of unhealthy alcohol use increased after bariatric surgery

JAMA Network Open
Reuters Health - 24/12/2020 - After bariatric surgery, a person's risk of developing unhealthy drinking patterns is increased, regardless of whether or not they were unhealthy drinkers before having weight-loss surgery, new research in U.S. veterans shows.

Risks were slightly higher for patients who underwent Roux-en-Y gastric bypass (RYGB) compared to those who had laparoscopic sleeve gastrectomy (LSG), Dr. Matthew L. Maciejewski of the Durham VA Medical Center, in North Carolina, and colleagues report.

"From these findings, we estimate that for every 21 patients who undergo an RYGB and every 29 who undergo an LSG, on average 1 from each group will develop unhealthy alcohol use," they conclude in JAMA Network Open.

Some research has suggested an increased risk of unhealthy alcohol use after bariatric surgery, but these studies only looked at RYGB and included predominantly women, the authors note.

They looked at 1,684 patients who underwent LSG and 924 who had RYGB in the U.S. Department of Veterans Affairs (VA) health system from 2008 to 2016. About three-quarters were male.

Since 2004, VA outpatients have been required to undergo annual screening with the Alcohol Use Disorders Identification Test (AUDIT-C). Thresholds for unhealthy alcohol use are an AUDIT-C score of at least three for women and of at least four for men.

At baseline, 92% had negative screens for unhealthy alcohol use, while 215 had unhealthy alcohol use. Roughly two-thirds of patients in each group underwent LSG, and the rest had open or laparoscopic RYGB.

The authors matched 1,539 surgical patients with no unhealthy alcohol use at baseline who underwent LSG to 14,555 similar controls who did not have weight loss surgery, and 854 RYGB patients without unhealthy alcohol use to 8,038 controls.

At five and eight years of follow-up, adjusted mean AUDIT-C scores were significantly higher for patients who underwent LSG than control patients, with differences of 0.21 and 0.23, respectively.

AUDIT-C scores were also significantly higher at three (0.13-point difference), five (0.28) and eight (0.32) years of follow-up for patients who had RYGB.

At eight years, 7.9% of LSG patients had unhealthy alcohol use, versus 4.5% of control patients. Among RYGB patients, 9.2% had unhealthy alcohol use at eight-year follow up, compared to 4.4% of controls.

For the patients who had unhealthy alcohol use at baseline, those who had RYGB had a higher prevalence of unhealthy alcohol use than controls.

While the study didn't look at why unhealthy alcohol use increased, there are several possible contributing factors, said senior author Dr. Katharine A. Bradley of Kaiser Permanente Washington Health Research Institute, in Seattle.

"What we know is that the level of alcohol that reaches the brain is what determines changes in the reward pathways that lead to alcohol use disorder," she told Reuters Health in a Zoom call. "We had a theoretical reason to think that just one drink could be like a binge" after bariatric surgery.

At Kaiser, Dr. Bradley said, "we recommend to patients that they not drink after surgery." She added, "It's really a matter of personalized education . . . it's really about them understanding that they can't drink the way they used to."

Dr. Maciejewski, also on the call, said, "There should be follow-up and education for patients to at least track if unhealthy alcohol use is something that is going on with them in the years after surgery."

He and his colleagues plan to look at use of other substances and mental-health conditions in people who have bariatric surgery. "What we really want to understand next is how these issues interact and how they change in concert after surgery."

Dr. Anne C. Fernandez of Michigan Medicine at the University of Michigan, in Ann Arbor, wrote a commentary accompanying the study.

It's unclear if bariatric surgery "causes" unhealthy drinking, she noted in an email to Reuters Health.

"Whether causal or correlational, the advice to physicians is the same: patients should be screened for alcohol-related risks prior to surgery and all patients should be counseled about the risks of developing unhealthy alcohol use after surgery," she said. "In addition, physicians (such as primary-care doctors) should monitor patient's alcohol use annually following bariatric surgery, as it may take years before unhealthy use develops."

Dr. Fernandez concluded: "My research finds surgery is a pivotal moment in many people's lives when they may make lifestyle changes they normally would be unwilling to make. Surgery can be a time when patients may choose to stop or reduce alcohol use for the short or long term. If properly counseled, bariatric surgery could provide an opportunity to intentionally and consciously reduce alcohol use for health reasons, which could reduce their risks following bariatric surgery."

SOURCE: https://bit.ly/3rnT3e7 and https://bit.ly/2KMbxnH JAMA Network Open, online December 21, 2020.

By Anne Harding

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