Adeela Jehan  ( Department of Environmental Design Health & Nutritional Sciences, Allama Iqbal Open University(AIOU), Islamabad, Pakistan. )
Zaheer Ahmed  ( Department of Environmental, Nutritional and Health Sciences, Allama Iqbal Open University, Islamabad, Pakistan. )
Seemin Kashif  ( Department of Environmental Design Health and Nutritional Sciences, Allama Iqbal Open University, Islamabad, Pakistan, )
Saba Liaqat  ( Department of Environmental Design Health & Nutritional Sciences, Allama Iqbal Open University(AIOU), Islamabad, Pakistan. )
Humayun Mohmand  ( Hair Transplant Institute, LACHIRUGIE Center, Islamabad, Pakistan. )
Asma Afreen  ( Department of Environmental Design Health and Nutritional Sciences, Allama Iqbal Open University, Islamabad, Pakistan. )

Objective: To observe the effects of dietary counselling on weight management after liposuction.

 

Method: The case-control study was conducted at the La Chirurgie Cosmetic Surgery Centre and Hair Transplant Institute, F-8/3, Islamabad, Pakistan, from January to July 2018, and comprised adults (100) of either gender undergoing liposuction and/or abdominoplasty who were followed for three months in the postoperative period. The subjects were divided into dietary-counselled group A, which received diet plans, and control group B, which followed up without any dietary advice. Lipid profile was done at baseline and three months post-liposuction. Data was analysed using SPSS 20.

 

Results: Of the 100 subjects enrolled, 83(83%) completed the study; 43(51.8%) in group A and 40(48.2%) in group B. Overall, there were 19(22.9%) males, 64(77.1%) females, and 55(66.3%) were aged <40 years, while 28(33.7%) were aged ≥40 years. Intra-group improvement was significant for total cholesterol, low-density lipoprotein, and triglycerides for both the groups (p<0.05). The change for very low-density lipoprotein in group B was not significant (p>0.05). Change in high-density lipoprotein was for the better in group A, while it decreased in group B and the change in both cases was significant (p<0.05). Inter-group differences were not significant (p>0.05) except for total cholesterol (p<0.05).

 

Conclusion: Liposuction alone resulted in the improvement of lipid profile, while dietary intervention resulted in better values with respect to very low-density lipoprotein and high-density lipoprotein.

 

Keywords: Liposuction, Diet, Dietary Counselling, Cholesterol, HDL, LDL, Triglycerides. (JPMA 72: 245; 2022

 

DOI: https://doi.org/10.47391/JPMA.4707

 

Submission completion date: 01-10-2021 - Acceptance date: 08-09-2022

 

Introduction

 

The prevalence of obesity doubled between 1980 and 2014 globally.¹ It is a strong risk factor for cardiovascular disease (CVD) and Type 2 Diabetes Mellitus (T2DM).² Diabesity is a modern epidemic term that was first described in 1970.³ This epidemic condition best describes a pathophysio-logical relation between obesity and diabetes.^4,5 It is associated with diabetes, lipid accumulation in adipose tissue, as well as increased free fatty acids (FFA) in blood circulation.⁶ It also causes insulin resistance (IR), which, in turn seems to be the main cause of the progression of metabolic dyslipidaemia.⁷ Dyslipidaemia is one of the cardio-metabolic risk factors and is characterised by high levels of triglycerides (TG) and total cholesterol (TC), low levels of high-density lipoprotein (HDL), and accumulation of low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL).⁸ According to the report of Cholesterol Education Programme, the diagnosing criteria for cardio-metabolic risk factors are: TG 150mg/dl, TC <200mg/dl desirable and >240mg/dl gigh, LDL <100mg/dl desirable, >160mg/dl high, HDL for men <40mg/dl, for women <50mg/dl), and VLDL >30mg/dl high.⁹

Obesity is managed through weight management programmes.¹⁰ In adults, weight management involves dietary advice, exercise, sometimes pharmacotherapy, and perhaps bariatric surgery.^11-13 Liposuction is a cosmetic procedure designed to remove superficial and deep deposits of subcutaneous fat, and is most commonly used as an adjunct to other aesthetic procedures and improves their outcome.¹⁴ Most patients are, however, interested only in changing their appearance rather than their behaviour and, hence, undergo liposuction alone. Large-volume liposuction was found to improve dyslipidaemia,¹⁵ while low-volume liposuction failed to show any effect on lipid profile.¹⁶

The current study was planned to compare the effect of liposuction alone and of liposuction with dietary counselling on lipid profile.

 

Subjects and Methods

 

The case-control study was conducted at the La Chirurgie Cosmetic Surgery Centre and Hair Transplant Institute, F-8/3, Islamabad, Pakistan, from January to July 2018 after approval from the ethics review committee of Allama Iqbal Open University, Islamabad. The sample size was calculated using the formula:¹⁷

                                Sample size= Z (1 a/2) ² * p (1-p) /d²

Where:

Z (1 a/2) = standard normal variate (at 5% type 1 error (p<0.05) 1.96)

p = expected proportion of the effect on lipid profile which was kept at 23%;¹⁸ and d = absolute error or precision.

The sample was collected using simple random sampling technique after getting approval from Institutional Review Board (IRB). Those included were adults of either gender undergoing liposuction and/or abdominoplasty who were followed up for three months postoperatively. The subjects were divided into dietary-counselled group A, which received diet plans, and control group B, which followed up without any dietary advice. Informed written consent was taken at the time of enrolment, but quite a few individuals left the study because participation was voluntary for the entire duration of the study. There were various reasons for the dropouts, including the fact that most of the individuals had political or social backgrounds and did not want to risk the procedure going public. Most of them were rude and uncooperative, as they were from elite background. Shortage of time on the part of the potential subjects was another reason.

Group A subjects were followed up after they were given diet plans to follow, while group B was followed up without any dietary advice. Lipid profile of both the groups was done at baseline, and then three months post-liposuction.

Data was analysed using SPSS 20. Paired-sample t-tests and independent-sample t-test, as appropriate, were done. Level of significance was kept at p<0.05.

 

Results

 

Of the 100 subjects enrolled, 83(83%) completed the study (Figure); 43(51.8%) in group A and 40(48.2%) in group B. Overall, there were 19(22.9%) males, 64(77.1%) females, and 55(66.3%) were aged <40 years, while 28(33.7%) were aged ≥40 years (Table 1).

Intra-group improvement was significant for TC, LDL, and TG for both the groups (p<0.05). The change for VLDL in group B was not significant (p>0.05). Change in HDL was for the better in group A, while it decreased in group B and the change in both cases was significant (p<0.05). Inter-group differences were not significant (p>0.05) except for TC (Table 2).

 

 

Discussion

 

In the present study, energy intake in both intervention and control groups before the surgery was very high. As part of the dietary advice given to the counselled group, customised diet plans were generated according to each individual’s required calories in the form of macronutrients (fats; carbohydrates; proteins). Mean protein energy intake per day was set at 15% of total energy intake per day, mean energy intake through fats was set at 20% per day, and mean energy intake through carbohydrates was set at 65% per day of total energy intake. The control group was not given such dietary advice. When baseline and post-intervention values of lipid profile of both the groups were compared, significant changes in lipid profile were found within the groups. In the counselled group, TC, LDL, VLDL and TG levels fell significantly, and HDL levels increased. The result was consistent with earlier studies.^19-21

In the control group, TC, HDL, LDL and TG levels fell significantly three months after liposuction, but VLDL level did not fall significantly in this group. This result was consistent with studies showing lowering of levels of lipid profile following liposuction alone.^15,22,23 As no statistically significant difference was found in inter-group comparisons, liposuction alone had a positive impact on lipid profile with or without dietary intervention, but the intervention could increase HDL, the ‘good cholesterol’.

In bariatric surgery procedures, anatomical changes lead to decrease in appetite and change in meal patterns, probably due to pain, or dumping syndrome. Bariatric surgery has been shown to change the rewarding properties of food which may lead to changes in food preference, and, hence, results in decrease in overall caloric intake.²⁴ But liposuction patients might return to their pre-surgery fat mass over one year after surgery. Only 20% of those who undergo liposuction for weight-loss are able to maintain their weight. The reason is probably a significant decrease in energy stores which stimulates a physiological drive to attain the previous fat mass. Subjects report an increase in appetite, and food palatability within a few days of the surgery. This increase in subjective hunger persists for more than a year even after dietary interventions, and their satiety hormones are found to be depressed and hunger hormones are increased. Those subjects are able to maintain a lower body weight who lose a larger initial fat mass, have a lower food addiction score, have greater physical activity level, and healthier dietary habits.²⁵ It has also been observed in human and mouse models that the new adipose tissue, developed after fat-reduction procedures, accumulates as visceral fat, and acts as cardiometabolic risk. Patients are not usually counselled on these potential long-term results of weight-regain after these procedures.²⁶ Many people go for liposuction for weight-loss, although it is just a cosmetic procedure, and is most commonly used as an adjunct to other aesthetic procedures.¹⁴ Most patients are still interested only in change of appearance and do not go for change in their lifestyle behaviour. Dyslipidaemia associated with obesity⁸ can be managed by diet control as well as liposuction, both of which seem to affect lipid profile. Dietary counselling, however, seems to pronounce the effect of liposuction. It can also have long-lasting effects on lipid profile. On the other hand, liposuction might affect dyslipidaemia, but the effect might be reversed if lifestyle changes, including diet and physical activity, are not made.

Available literature did not show any specific study in relation to dietary counselling following liposuction and its effect on lipid profile. Although dietary advice has been proved to affect the lipid profile^27-29 and, large-volume liposuction is found to improve dyslipidaemia,¹⁵ no study has been done previously to observe combined the effect of both diet and liposuction on serum lipids. Although high-volume liposuction affect lipid profile,^27,28 low-volume liposuction does not seem to affect lipid profile.^16,30 The current study showed significant effects of liposuction alone and of dietary counselling following liposuction on lipid profile.

The current study has added to the knowledge regarding positive and comparative effects of dietary counselling in liposuction patients. The current study’s limitations include a short span of only 3 months. Dietary counselling could have further affected the lipid profile in a positive way, and a regain of fat mass and change of lipid profile could have been observed in the control group if the study was extended over a year or so.

 

Conclusion

 

Liposuction alone resulted in improvement in serum cholesterol, LDL and TG levels, but liposuction along with dietary counselling resulted in the fall in VLDL, and increase in the HDL.

 

Acknowledgement: We are grateful to all the study participants for cooperation.

 

Disclaimer: One of the co-authors was also a member of the ethics review board which approved the study.

 

Conflict of Interest: None.

 

Source of Funding: None.

 

References

 

 

1.      World Health Organization (WHO). Obesity and overweight. News release. The WHO Media Center. [Online] 2016 [Cited 2018 October 15]. Available from URL: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

2.      Xiao C, Dash S, Morgantini C, Hegele RA, Lewis GF. Pharmacological Targeting of the Atherogenic Dyslipidemia Complex: The Next Frontier in CVD Prevention Beyond Lowering LDL Cholesterol. Diabetes 2016;65:1767-78. doi: 10.2337/db16-0046.

3.      Sims EA, Danforth E Jr, Horton ES, Bray GA, Glennon JA, Salans LB. Endocrine and metabolic effects of experimental obesity in man. Recent Prog Horm Res 1973;29:457-96. doi: 10.1016/b978-0-12-571129-6.50016-6.

4.      Pappachan JM, Fernandez CJ, Chacko EC. Diabesity and antidiabetic drugs. Mol Aspects Med 2019;66:3-12. doi: 10.1016/j.mam.2018. 10.004.

5.      Kalra S. Diabesity. J Pak Med Assoc 2013;63:532-4.

6.      Engin AB. What Is Lipotoxicity? Adv Exp Med Biol 2017;960:197-220. doi: 10.1007/978-3-319-48382-5_8.

7.      Vekic J, Zeljkovic A, Stefanovic A, Jelic-Ivanovic Z, Spasojevic-Kalimanovska V. Obesity and dyslipidemia. Metabolism 2019;92:71-81. doi: 10.1016/j.metabol.2018.11.005.

8.      Björnson E, Adiels M, Taskinen MR, Borén J. Kinetics of plasma triglycerides in abdominal obesity. Curr Opin Lipidol 2017;28:11-18. doi: 10.1097/MOL.0000000000000375.

9.      James M, Varghese TP, Sharma R, Chand S. Association Between Metabolic Syndrome and Diabetes Mellitus According to International Diabetic Federation and National Cholesterol Education Program Adult Treatment Panel III Criteria: a Cross-sectional Study. J Diabetes Metab Disord 2020;19:437-43. doi: 10.1007/s40200-020-00523-2.

10.    Mottalib A, Kasetty M, Mar JY, Elseaidy T, Ashrafzadeh S, Hamdy O. Weight Management in Patients with Type 1 Diabetes and Obesity. Curr Diab Rep 2017;17:92. doi: 10.1007/s11892-017-0918-8.

11.    Bray GA, Frühbeck G, Ryan DH, Wilding JP. Management of obesity. Lancet 2016;387:1947-56. doi: 10.1016/S0140-6736(16)00271-3.

12.    Dietz WH, Baur LA, Hall K, Puhl RM, Taveras EM, Uauy R, et al. Management of obesity: improvement of health-care training and systems for prevention and care. Lancet 2015;385:2521-33. doi: 10.1016/S0140-6736(14)61748-7.

13.    Johns DJ, Hartmann-Boyce J, Jebb SA, Aveyard P; Behavioural Weight Management Review Group. Diet or exercise interventions vs combined behavioral weight management programs: a systematic review and meta-analysis of direct comparisons. J Acad Nutr Diet 2014;114:1557-68. doi: 10.1016/j.jand.2014.07.005.

14.    Toma T, Harling L, Athanasiou T, Darzi A, Ashrafian H. Does Body Contouring After Bariatric Weight Loss Enhance Quality of Life? A Systematic Review of QOL Studies. Obes Surg 2018;28:3333-41. doi: 10.1007/s11695-018-3323-8.

15.    Sailon AM, Wasserburg JR, Kling RR, Pasick CM, Taub PJ. Influence of Large-Volume Liposuction on Metabolic and Cardiovascular Health: A Systematic Review. Ann Plast Surg 2017;79:623-30. doi: 10.1097/SAP.0000000000001195.

16.    Lubkowska A, Chudecka M. The Effects of Small-Volume Liposuction Surgery of Subcutaneous Adipose Tissue in the Gluteal-Femoral Region on Selected Biochemical Parameters. Int J Environ Res Public Health 2019;16:3298. doi: 10.3390/ijerph16183298.

17.    Charan J, Biswas T. How to calculate sample size for different study designs in medical research? Indian J Psychol Med 2013;35:121-6. doi: 10.4103/0253-7176.116232.

18.    Greenland P, Alpert JS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010 ACCF/AHA guideline for assessment of cardiovascular risk in asymptomatic adults: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines. Circulation 2010;122:e584-636. Doi: 10.1161/CIR. 0b013e3182051b4c.

19.    Singh RK, Chang HW, Yan D, Lee KM, Ucmak D, Wong K, et al. Influence of diet on the gut microbiome and implications for human health. J Transl Med 2017;15:73. doi: 10.1186/s12967-017-1175-y.

20.    Suri S, Kumar V, Kumar S, Goyal A, Tanwar B, Kaur J,et al. DASH Dietary Pattern: A Treatment for Non-communicable Diseases. Curr Hypertens Rev 2020;16:108-14. doi: 10.2174/ 1573402115666191007144608.

21.    Shih CW, Hauser ME, Aronica L, Rigdon J, Gardner CD. Changes in blood lipid concentrations associated with changes in intake of dietary saturated fat in the context of a healthy low-carbohydrate weight-loss diet: a secondary analysis of the Diet Intervention Examining The Factors Interacting with Treatment Success (DIETFITS) trial. Am J Clin Nutr 2019;109:433-41. doi: 10.1093/ajcn/nqy305.

22.    Souilm NA, Shokre ES. Effect of Liposuction on Overweight/ObesePatients’ Eating Concerns, Body Shape Concerns, and Self-esteem. Am J Nurs Res 2018;6: 484-90. doi: 10.12691/ajnr-6-6-16..

23.    Swanson E. Evidence-Based Body Contouring Surgery and VTE Prevention. Cham, Switzerland: Springer International Publishing AG; 2018. Doi: 10.1007/978-3-319-71219-2.

24.    Shah H, Shin AC. Meal patterns after bariatric surgery in mice and rats. Appetite 2020;146:104340. doi: 10.1016/j.appet.2019.104340.

25.     Davis W, Lawrence N. Weight Loss: How Does It Fit in With Liposuction? Dermatol Surg 2020;46:S22-8. doi: 10.1097/DSS.0000000000002225.

26.    Cox SE, Eldik H. Commentary on Weight Loss: How DoesIt Fit in With Liposuction? Dermatol Surg 2020;46:S29-30. doi: 10.1097/DSS.0000000000002331.

27.    Hillesheim E, Ryan MF, Gibney E, Roche HM, Brennan L. Optimisation of a metabotype approach to deliver targeted dietary advice. Nutr Metab 2020;17:e82. doi: 10.1186/s12986-020-00499-z.

28.    Pawlik-Sobecka L, Płaczkowska S, Rorbach-Dolata A, Piwowar A. Exogenous dietary factors as important modulator of human lipid profile.J Pre-Clin Clin Res 2019;13:83–91. doi: 10.26444/jpccr/108704

29.    Zhao H, Song A, Zheng C, Wang M, Song G. Effects of plant protein and animal protein on lipid profile, body weight and body mass index on patients with hypercholesterolemia: a systematic review and meta-analysis. Acta Diabetol 2020;57:1169-80. doi: 10.1007/s00592-020-01534-4.

30.    Pruksapong C, Chamnanchanunt S, Thanachartwet V, Desakorn V, Nakawiro D, Sahassananda D, et al. Association of Body Dysmorphic Disorder with Leptin Levels in Patients with Normal Weight Undergoing Liposuction: A Matched Case Study. Plast Reconstr Surg Glob Open 2019;7:se2482. doi: 10.1097/GOX.0000000000002482