Analysis of changes in protein intake following laparoscopic sleeve gastrectomy and its influencing factors

Analysis of changes in protein intake following laparoscopic sleeve gastrectomy and its influencing factors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Analysis of changes in protein intake following laparoscopic sleeve gastrectomy and its influencing factors Huiling Zhao, Lulu Wu, Xiaoman Zhang, Xiaojiao Zhang, Dan Zhang, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4598227/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Feb, 2025 Read the published version in Obesity Surgery → Version 1 posted 9 You are reading this latest preprint version Abstract Objective: Little is known about factors associated with protein intake post-laparoscopic sleeve gastrectomy especially in Chinese weight loss patients over six months. This project aimed to identify possible factors to improve protein intake, and investigate protein supplement usage to reduce complications such as malnutrition. Methods: A prospective observational study was conducted on 120 eligible patients at a tertiary hospital, who completed study measures at baseline, 3 months post-surgery (M3), and 6 months post-surgery (M6). Univariate and multivariate Linear regressions were utilized to analyze factors related to protein intake. Results: At M6, most patients did not meet the recommended post-LSG protein intake of ≥60 g/day. The three macronutrients for all patients were significant differences in dietary and protein supplement sources between M3 and M6. The EBBS score decreased from M3 to M6, while the chewing cycle and food tolerance scores increased postoperatively. multi-factor linear regression was found that eight independent variables, including gender, age, daily vitamin intake at M6, and total EBBS score at M6, were influencing factors on daily protein intake at M6. Conclusions: Findings shed new light on factors that may account for deficiency protein intake, which have implications for guiding effective interventions targeting this behavior. Laparoscopic sleeve gastrectomy protein intake food tolerance dietary behavior compliance weight loss effect Figures Figure 1 Figure 2 Figure 3 Highlights Patients with insufficient protein intake in the short term after LSG have poor long-term weight loss. The study identified rice, noodles, and red meat as the most common intolerances food among patients Postoperative individuals receive long-term care and increase EBBS scores to achieve sustainable weight loss results in the long term. Findings have clear implications for intervention targets among programs designed to address deficiency protein intake 1. Introduction The primary objective of bariatric surgery (BS) is to achieve substantial and sustainable weight loss, particularly in reducing adipose tissue [1] . However, not all patients undergoing surgery achieve the desired weight loss outcomes. In fact, some patients may mistakenly believe that surgery alone is sufficient for weight loss, neglecting the importance of healthy nutritional guidance and lifestyle modifications like physical exercise [2] . Thus, adherence to dietary behavior recommendations post-bariatric surgery is crucial in determining medical outcomes. Previous studies [3] have indicated that nutritional management plays a crucial role in preventing malnutrition and gastrointestinal complications, as well as reducing the risk of weight regain in morbidly obese patients. The American Society of Bariatric and Metabolic Surgery (ASMBS) guidelines suggest a daily protein intake of 60–80 g after bariatric surgery or 1.1–1.5 g/kg of ideal body weight [4] . Studies [5] have shown that sufficient protein consumption in the initial 6 months post-surgery is vital to prevent loss of fat-free body weight. Protein intake can enhance satiety, reduce muscle breakdown, meet metabolic requirements, and enhance overall nutritional status [6] . Therefore, ensuring a sufficient daily protein intake in the early stages following bariatric surgery is particularly important for long-term weight loss and overall health. Laparoscopic sleeve gastrectomy (LSG) is the predominant bariatric surgery globally [7] and the most frequently performed procedure in China [8] . Research indicates [5, 9, 10] that LSG is a safe and effective treatment for severe obesity, resulting in a reduction of excess body weight ranging from 33–90%. This surgery, which restricts gastric capacity and the secretion of certain substances, such as hydrochloric acid and ghrelin [11, 12] , limits food intake and impacts digestion, potentially leading to food intolerances. Some patients may experience altered taste and smell, contributing to an aversion to certain foods [13] . Food intolerance manifests as symptoms like nausea, vomiting, dysphagia, and dumping syndrome, prompting patients to avoid specific foods. Several international studies [6, 14, 15] have highlighted that high-protein foods, especially red meat with high content of protein can easily cause food intolerance, affecting nutrient absorption and potentially causing malnutrition. However, the correlation between postoperative protein intake and weight loss, dietary compliance, and food tolerance post-bariatric surgery remains unclear, particularly within the Chinese population. Hence, this study aims to investigate the association between daily protein intake, dietary compliance, food intolerance, and food intolerance among obese individuals at 3 months (M3) and 6 months (M6) post-LSG. As well as investigate Sources of common nutrient intakes and protein supplement usage during the early postoperative period in Chinese weight loss patients. 2. Research objects and methods. 2.1Research objects This 6-month prospective observational study utilized a convenience sampling method to select 120 patients admitted to a tertiary hospital in Xuzhou between August 2023 and December 2023. The research subjects were chosen from the Department of Metabolic Surgery based on specific inclusion criteria: patients who underwent LSG, aged ≥ 18 years, had no more than 2 missing dental units and no major oral diseases, had not previously undergone LSG or other bariatric surgeries, and willingly signed the informed consent form. Exclusion criteria included patients with serious underlying diseases such as heart, brain, kidney, and gastrointestinal issues, as well as those with significant complications during hospitalization or follow-up, food intolerance before surgery, and individuals unable to effectively communicate due to educational or mental reasons. Approval for this study was obtained from the hospital ethics research committee, and all patients provided informed consent. 2.2Methods 2.2.1Preoperative/postoperative care All patients underwent a thorough preoperative assessment, including medical history collection and clinical examination, such as blood tests, liver and kidney function tests, digestive system ultrasound, and upper gastrointestinal endoscopy. Only patients meeting surgical criteria were admitted for laparoscopic sleeve gastrectomy (LSG) performed by the same surgical team. Postoperatively, patients followed a multimodal bariatric surgery rehabilitation plan, including early fluid tolerance testing, mobilization encouragement, diatrizoate meglumine testing for anastomosis integrity, and Doppler ultrasound of lower limb blood vessels before discharge. Patients were given dietary and lifestyle guidance both before and after surgery, along with oral and written information on postoperative dietary behavior. This included instructions on maintaining a long-term low-calorie, protein- and fiber-rich diet, chewing slowly, and exercise guidance. Patients were gradually transitioned from clear liquids to regular food after surgery. They were also educated on the importance of taking relevant supplements and medications, with compliance monitored during follow-up visits, including supplement and medication use. Postoperative evaluation of patients was conducted through outpatient visits and follow-up via telephone/WeChat. 2.2.2Research tools Anthropometric measurements were conducted using a standardized protocol at baseline, M3, and M6 time points. Weight and height were measured using a digital medical scale. Body Mass Index (BMI) was calculated as weight (kg) divided by height squared (m2). Patients were required to complete a researcher-designed general information questionnaire, which included information on current weight, the presence of symptoms such as hair loss and fatigue, and the use of vitamins and protein supplements. Chewing performance was assessed using color-changing chewing gum [16] . Patients were instructed to chew the gum 60 times at their own pace and were timed, but no guidance was given about the chewing surface. After chewing, patients spat out the gum, and their chewing performance was evaluated on a scale of L1 to L5 based on the color change compared to a standard color chart, a higher grade indicated better chewing performance. The chewing cycle was calculated as the time taken to chew divided by 60. The 24-hour dietary recall questionnaire was used to assess patients' dietary intake effectively. This questionnaire has demonstrated good reliability and validity in previous studies [17, 18] . This study used dietary review questionnaires for three non-consecutive days (two working days and one weekend) to monitor patients' nutritional intake, including protein supplements. A nutritionist on the team analyzed the questionnaire responses to estimate the average daily intake of energy and macronutrients. To minimize memory bias, researchers provided patients with visual aids such as food models and reference charts to assist in estimating portion sizes and food quantities consumed. Parts 1, 3, and 4 of the validated food tolerance questionnaire by Suter et al. [19] were utilized to calculate specific food tolerance scores ranging from 1 to 27, where a higher score indicates better food tolerance. The questionnaire encompasses 1) overall patient satisfaction with food intake [rated from 1 (very poor) to 5 (excellent)]; 3) assessment of tolerance towards eight food types [scored as 0 (cannot eat), 1 (can eat with some difficulty/restrictions), 2 (can eat without difficulty)]; 4) frequency of vomiting/reflux [scored as 0 (daily), 2 (three or more times per week), 4 (twice per week), 6 (never)]. Apart from the eight common food categories, the questionnaire allows open-ended responses for other food intolerances, which are not included in the total score. This questionnaire was developed to standardize the assessment of food tolerance during follow-up post-bariatric surgery. The Eating Behavior after Bariatric Surgery (EBBS) scale, created by Spaggiari et al. [20] in 2020, is specifically designed to measure patients' adherence to dietary and lifestyle recommendations post-bariatric surgery. The EBBS scale consists of 11 items across 4 dimensions: food, drink, behavior, and lifestyle, with each item scored on a 0 to 2-point scale. A higher score indicates better compliance. In 2021, Xu Mengyu et al. [21] translated the scale into Chinese and assessed its reliability and validity. The Chinese version demonstrated a Cronbach's alpha coefficient of 0.895 and test-retest reliability of 0.835. Protein intake and food tolerance were not assessed before M3, as most patients were still in the liquid/soft food stage, consuming limited types of food and not yet at the normal eating stage, making it difficult to comprehensively evaluate protein intake and various food tolerances. 2.2.3 Statistical analysis Statistical analysis was conducted using IBM SPSS Statistics 25 software. Measurement data were assessed for normality and homogeneity of variances. Data following normal distribution were presented as mean ± standard deviation ( x̄ ± s ), while non-normally distributed data were presented as M (P25, P75); categorical data were expressed as composition ratio/rate. The independent sample t-test was used for comparing two groups with normally distributed continuous data, while the non-parametric Mann-Whitney U test was used for non-normally distributed data. Paired samples t-test or Wilcoxon signed-rank test were employed for dependent samples. The chi-square test ( x 2 ) was used for analyzing categorical data. Changes from pre- to post-operative values were calculated by subtracting pre-operative values from post-operative values for all variables. Linear regression was utilized to analyze factors related to protein intake. A significance level of P<0.05 was considered statistically significant. 3. Results Before undergoing surgery, a total of 120 patients underwent general information and chewing performance tests, in addition to completing a 24-hour dietary review questionnaire. However, 7 patients were excluded at M3, with 6 failing to follow up and 1 not completing the questionnaire. The final study cohort comprised 113 patients, with an average age of 32.9 ± 9.4 years (range: 18–57). The average operation time was 101.3 ± 23.8 minutes (range: 64–207), and the average length of stay was 3.7 ± 1.1 hospital days (range: 2–7). The mean preoperative BMI was 40.5 ± 7.5 kg/m2 (range: 31.9–72.5). The characteristics of the study participants at baseline are summarized in Table 1 . Table 1 Characteristics of study participants, grouped according to protein intake goals 3 months and 6 months after surgery All participants M3 M6 N = 113 achieving a protein intake<60g/d achieving a protein intake ≥ 60g/d achieving a protein intake<60g/d achieving a protein intake ≥ 60g/d N = 63 N = 50 N = 66 N = 47 age 32.9 ± 9.4 33.6 ± 10.1 32.1 ± 8.7 31.3 ± 8.7 35.2 ± 10.1 Gender (female) 76(67.2%) 44(69.8%) 32(63.3%) 45(68.2%) 31(65.9%) Days of hospitalization 3.6 ± 1.1 3.9 ± 1.2 3.3 ± 0.8* 3.9 ± 1.2 3.1 ± 0.6* BMI 40.6 ± 7.4 31.7 ± 4.2 32.1 ± 7.4 28.4 ± 3.8 29.4 ± 6.1 TWL% - 22.2 ± 6.2 19.9 ± 4.4* 28.2 ± 6.2 29.2 ± 5.5 TWL% M3−M6 6.8 ± 2.2 8.0 ± 2.9* 6.9 ± 2.4 7.9 ± 2.9* EWL% - 61.1 ± 16.2 58.6 ± 16.4 81.8 ± 20.9 78.8 ± 15.2 EWL% M3−M6 18.9 ± 6.6 22.7 ± 7.5* 20.3 ± 7.6 21.0 ± 6.8 Hair loss - 2(1–2) 1(1–2) 1(1–2) 1(1–1)* Fatigue - 1(1–2) 1(1–1) 1(1–1) 1(1–1) Take vitamins - 3(2–3) 3(2.5-3) 3(1–3) 3(3–3)* Chewing performance 5(4–5) 5(4–5) 5(4–5) 5(4–5) 5(4–5) Chewing cycle (s) 0.62 ± 0.34 0.72 ± 0.12 0.73 ± 0.12 0.79 ± 0.12 0.81 ± 0.13 Energy intake (kcal/d) 2306.7 ± 391.8 559.6 ± 225.5 755.9 ± 253.9* 698.4 ± 141.9 773.7 ± 122.9* EBBS total score - 15.2 ± 1.9 16.2 ± 2.3 14.3 ± 1.9 15.9 ± 1.9* Food tolerance score 25.0 ± 1.9 23.5 ± 2.8 24.4 ± 2.2 24.8 ± 2.3 25.6 ± 1.4 TWL%M3-M6 is the percentage of total weight loss in 3–6 months and EWL%M3-M6 Percentage of excess weight loss in 3–6 months. MU test or independent sample T-test, * indicates that the P value within the group is < 0.05, and there is a statistical difference. 3.1 Weight loss effect and protein intake The study found that most patients did not meet the recommended protein intake of ≥ 60g/day after undergoing LSG at M6 (18.2% of men and 40.9% of women). A significant difference was observed in TWL% between patients with protein intake < 60g/day and those with protein intake ≥ 60g/day from M3 to M6(P = 0.008, P = 0.045). At M6, both groups were in terms of hair loss, vitamin taking vitamins, and EBBS total score, with statistical significance observed (P < 0.05)(Table 1 ). 3.2 Sources of energy and macronutrient intake As expected, energy intake decreased sharply at month M3 post-LSG, but slightly increased by month M6(Table 2 ), with daily carbohydrate and fat intake higher than at M3 while protein intake decreased. Table 2 Changes in patients’ daily energy intake and common nutrients and food tolerance All participants(n = 113) Men(n = 41) Women(n = 72) M3 M6 M3 M6 M3 M6 Energy intake (kcal/d) 648.8 ± 256.3 729.9 ± 138.3* 601.6 ± 233.4 707.2 ± 154.5* 671.8 ± 266.8 740.9 ± 130.4* Carbohydrates (g/d) 55.9 ± 31.9 61.1 ± 22.1* 41.7 ± 17.9 54.4 ± 17.1* 62.9 ± 35.0 ¥ 64.4 ± 23.5 ¥ Proteins (g/d) 57.2 ± 24.1 50.8 ± 16.3* 59.2 ± 25.9 50.4 ± 19.6* 56.2 ± 23.4 51.0 ± 14.7 Fats (g/d) 22.9 ± 14.8 24.0 ± 6.8* 22.3 ± 13.1 24.4 ± 6.9 23.2 ± 15.7 23.8 ± 6.8* hair loss 1(1–2) 1(1–2)* 1(1–2) 1(1–2) 2(1–2) 1(1–2)* fatigue 1(1–1) 1(1–1)* 1(1–1) 1(1–1) 1(1-1.5) 1(1–1)* chewing cycle 0.73 ± 0.12 0.80 ± 0.12* 0.74 ± 0.12 0.81 ± 0.14* 0.72 ± 0.12 0.8 ± 0.12* take vitamins 3(2–3) 3(2–3) 3(1.75-3) 3(2–3) 3(2–3) 3(1–3) Food Tolerance Score 23.9 ± 2.5 25.1 ± 2.0* 24.3 ± 1.6 25.1 ± 1.6* 23.7 ± 2.9 25.1 ± 2.2* Vomiting/reflux Frequency 4.4 ± 1.6 5.4 ± 0.9* 4.6 ± 1.1 5.2 ± 1.0* 4.4 ± 1.8 5.5 ± 1.0* score of food tolerance for 8 categories 15.4 ± 1.3 15.5 ± 1.1* 15.6 ± 0.9 15.7 ± 0.6 15.2 ± 1.5 15.4 ± 2.2 P values are derived from the Wilcox test, paired samples T-test, and MU test. ¥ indicates that there is statistical significance between the two groups of men and women at the same time point, P < 0.05, * indicates that there is statistical significance between the two groups of the same gender at different time points, P < 0.05. Statistical differences (P ≤ 0.002) were observed in the dietary and protein supplement sources of the three macronutrients for all patients between months M3 and M6(Fig. 1 ); In male patients (Fig. 2 ), only carbohydrate intake showed a statistical difference between M3 and M6 (P < 0.001), while in protein supplements, there were statistical differences in all three macronutrients(P = 0.014). Female patients showed statistical differences (P ≤ 0.013) in the intake of the three macronutrients between diet and protein supplements (Fig. 3 ). Overall, there was a significant increase in dietary sources of each nutrient from M3 to M6, while protein supplements showed a significant decrease, resulting in no statistical difference in the three macronutrients overall. Notably, Among the 24 patients who did not take protein supplements at all at the 3-month follow-up, all had a protein intake of less than 60g per day (mean = 29.4 ± 10.6g/day). At the 6-month follow-up, out of the 64 patients who did not take protein supplements, only 6 (9.4%) had a protein intake equal to or greater than 60g per day (mean = 39.9 ± 10.3g/day). 3.3 Food Tolerance Scores and EBBS Scores Over time, from M3 to M6, patients' chewing cycles gradually increased post-surgery (P < 0.001; Table 2 ), and there was a significant improvement in food tolerance score (P < 0.05; Table 2 ), the total score of the 8 food tolerance categories improved compared to before (P = 0.021). The study identified rice [23 people (20.4%) at M3; 22 people (19.5%) at M6], noodles [17 people (15%) at M3; 14 people (12.4%) at M6], and red meat [12 people (10.6%) at M3; 10 people (8.8%) at M6] as the most common intolerances food among patients. During follow-up, 5 patients avoided fish, shrimp, and other fishy-smelling foods due to changes in their sense of smell and taste. The study revealed a decrease in EBBS score from M3 to M6 (P < 0.05; Table 3 ). At M3, men engaged in more weekly physical activities compared to women, with a statistically significant difference; although there was no statistical difference at M6, men still spent more time on physical activities than women (male: female = 1.5:1). Table 3 Changes in The Eating Behavior after Bariatric Surgery (EBBS) scale All participants(n = 113) Men(n = 41) Women(n = 72) M3 M6 M3 M6 M3 M6 EBBS total score 15.7 ± 2.2 14.9 ± 2.1* 16.8 ± 2.1 15.7 ± 2.0* 15.1 ± 1.9 ¥ 14.6 ± 2.0 ¥ How many meals do you eat per day 1(1–2) 1(1–1)* 2(1–2) 1(1–1)* 1(1–2) ¥ 1(1–1)* ¥ How quickly do you consume the main meals? 1(0–1) 1(0–1)* 1(0–1) 1(1–2)* 0(0–1) 1(0–1) ¥ How much water do you drink during the meal? 2(2–2) 2(2–2) 2(2–2) 2(2–2) 2(2–2) 2(2–2) ¥ How many times a week do you eat sweets? (exclude breakfasts) 2(1–2) 1(0–1)* 2(1.75-3) 2(1.75-2)* 2(1–2) ¥ 1(0–1)* ¥ How many times a week do you drink wine or alcohol? 2(2–2) 2(2–2) 2(2–2) 2(1.75-2) 2(2–2) ¥ 2(2–2) ¥ How many times a week do you drink sparkling beverages? 2(2–2) 2(1–2) 2(1–2) 2(1–2) 2(1–2) 2(1–2) How hungry do you feel before meals? 1(0–1) 1(1–1) 1(0.75-2) 1(1–1) 1(0–1) ¥ 1(1–1)* How full do you feel after meals? 2(1–2) 1(1–1)* 2(1–2) 1(1–1)* 2(1–2) 1(1–1)* How is the portion of vegetables you consume during the meal? 1(1–1) 1(1–1)* 1(1–2) 1(1–2) 1(0.5-1) 1(1–1)* How much time do you spend on physical activity? 1(1–2) 1(1–2) 2(1–2) 1.5(1–2) 1(1–2) ¥ 1(1–2) How often do you weigh yourself? 2(2–2) 2(2–2) 2(2–2) 2(2–2) 2(2–2) 2(2–2) P values are derived from the Wilcox test, paired samples T-test, and MU test. ¥ indicates that there is statistical significance between the two groups of men and women at the same time point, P < 0.05, * indicates that there is statistical significance between the two groups of the same gender at different time points, P < 0.05. 3.4 Multivariate analysis of daily protein intake Single-factor analysis of variance indicated that 11 independent variables including gender, age, and being an only child significantly impacted daily protein intake. Following multi-factor linear regression, gender, age, being an only child, educational level, surgery time, hospital days, daily vitamin intake at M6, and EBBS total score at M6 were identified as factors influencing daily protein intake (Table 4 ). Table 4 Multivariate linear regression of daily protein intake at M6 Unstandardized Unstandardized coefficient Standardized coefficient t Significance B Standard Error Beta VIF (constant) -32.727 15.399 -2.125 0.036 Gender 6.184 2.421 0.18 2.555 0.012 1.149 age (years) 0.302 0.126 0.175 2.402 0.018 1.234 Whether she is an only child 13.381 2.413 0.402 5.545 <0.001 1.224 Educational level 4.57 1.289 0.262 3.544 0.001 1.275 Surgery time -0.117 0.048 -0.174 -2.429 0.017 1.19 Days of hospitalization -4.27 1.103 -0.279 -3.871 <0.001 1.206 M6 Chewing cycle -10.341 10.052 -0.078 -1.029 0.306 1.332 M6Vitamins taken/day 5.596 1.362 0.293 4.108 <0.001 1.189 M6 EBBS total score 2.992 0.606 0.378 4.941 <0.001 1.366 R 2 0.570 F 14.754 P <0.001 4. Discussion 4.1 Adequate protein intake contributes to long-term steady-state weight loss After laparoscopic sleeve gastrectomy (LSG), there was a significant difference in total weight loss percentage (TWL%) at 3 months post-surgery between patients consuming ≥ 60g/day of protein and those consuming < 60g/day. but there was no statistical significance in the TWL% of the two groups of patients 6 months after surgery. patients with protein intake of less than 60g/day at M3 experienced greater weight loss initially, the reason may be due to the loss of fat-free body weight [22] , however, in the long term, adequate protein intake led to a more favorable weight loss outcome by promoting higher fat mass loss [1] . As a result, patients with protein intake levels of ≥ 60g/day saw a greater decrease in TWL% six months post-surgery, with no significant difference in weight loss compared to those with lower protein intake levels. Research on the relationship between protein intake and supplements post-LSG is limited, This study highlights that most patients fail to meet their daily protein intake requirements without supplements within six months post-surgery. Patients who do not reach the recommended 60g/day of protein through diet alone may benefit from protein supplementation [5] . Despite medical professionals emphasizing the importance of postoperative protein supplements, patients often overlook the need for adequate protein intake in the short term after bariatric surgery, mistakenly believing they have achieved optimal weight loss results. Previous studies [23, 24] have demonstrated that adequate protein intake post-surgery can support long-term postoperative weight loss, maintain muscle mass, and decrease body fat content. These findings underscore the critical importance of scientific nutritional guidance following bariatric surgery. Therefore, healthcare providers, including clinicians, case managers, and nutritionist teams, must offer sustained and effective supervision and guidance to bariatric patients to ensure proper nutrient intake, minimize adverse events, and sustain positive weight loss outcomes. 4.2 Good dietary adjustments can enhance food tolerance This study shows that the higher incidence of food intolerance post-LSG, Short-term dietary goals should focus on meeting patients' food tolerance and nutritional requirements. Red meat, particularly pork, is commonly reported as poorly tolerated in the initial year post-surgery [14, 15, 25] . Due to its role as a primary protein source, intolerance to red meat may contribute to nutritional deficiencies observed post-LSG. While previous studies have not highlighted rice intolerance, results of only one previous randomized controlled study [11] showed a significant decrease in rice tolerance of patients observed in the SG group, and the majority of the remaining studies did not mention the high intolerance rate of rice, this study reveals that patients in northern China exhibited notable intolerance to rice, noodles, and red meat six months post-surgery, likely due to their rice and cooked wheaten food diet. Changes in taste and smell post-bariatric surgery, as noted by Zerrweck et al. [26] , could potentially lead to aversions of protein-rich foods, resulting in reduced protein intake. This study also identified a similar situation, though the exact mechanisms behind changes in taste and smell and their impact on nutrient intake remain unclear. The research revealed that the increase in chewing cycles post-surgery could be linked to patients' efforts to minimize food intolerance and gradually adjust to the gastric pouch's size. However, the vast majority of patients still have problems with fast eating speed and inadequate chewing, which may also be one of the reasons for the higher incidence of food intolerance at the 6-month mark in this study. Previous studies [27–29] have demonstrated that patients with inefficient chewing are more prone to food intolerance and experience more severe fullness, nausea, and vomiting symptoms, aligning with the findings of this study. In a study [30] using jelly gummies to examine the association between objective chewing function and metabolic syndrome, people in their 70s with poor chewing function had a significantly higher risk of developing metabolic syndrome, while people in their 50s and 60s had a significantly higher risk of developing metabolic syndrome. No association between the two was found. This study shows that chewing performance has nothing to do with patients' postoperative protein intake and food intolerance. This may be related to the late start of bariatric surgery in China and the elderly obese patients. The lack of attention to bariatric surgery is related to the lack of choice of bariatric surgery. Therefore, the age of the participants in this study is concentrated between 24 and 39 years old. The chewing performance results are all good with little difference. In the future, it can increase the number of elderly people after bariatric surgery. Related studies on patients' chewing performance to supplement the research content. Impaired chewing function is a risk factor for nutritional imbalances and obesity [31] , emphasizing the importance of cultivating effective chewing habits to enhance food tolerance and reduce the risk of malnutrition and sarcopenia. During follow-up, when dealing with food intolerance, selecting nutritionally similar food items as substitutes can be beneficial. By adjusting eating habits, such foods can gradually be reintroduced; patients should be advised to consume protein-rich foods to boost satiety and prevent excessive calorie intake. Additionally, patients are encouraged to cultivate the practice of slow and thorough chewing, spending at least 20 minutes on each meal, thoroughly chewing each bite of food, and cutting food into smaller pieces to aid digestion and lessen the strain on the gastrointestinal system. This study demonstrates that after bariatric surgery, female patients tend to have higher daily carbohydrate intake compared to male patients, likely due to their higher frequency of eating and preference for sweets [32] . Women also express a stronger desire for snacks/sweets during follow-up, While frequently eaten snacks/sweets will provide additional amounts of simple sugars or fats [33] ; Conversely, Men after surgery the duration of exercise is longer than that of women, follow-up more male patients were found to develop the habit of adhering to fitness exercise after surgery, while fewer women, which may be related to men's pursuit of strength and muscle. Tailored follow-up care by case managers and nutritionists focusing on individual dietary behaviors could focus on. For different patients, giving different dietary behavior guidance with different priorities may achieve better postoperative results. Researchers observed a decline in EBBS scores over time, possibly due to patient fatigue in maintaining long-term dietary changes, and generally poor compliance with healthy eating habits among obese individuals [34] . Several studies [35–37] investigated patient compliance with the postoperative diet and lifestyle, and all showed poor compliance, which is consistent with the results of this study. Although the medical team after LSG conducts regular follow-up education, they cannot supervise their living habits for a long time, so how to improve the postoperative dietary behavior compliance of obese patients is the key to ensuring and maintaining the effect of weight loss and reducing complications such as malnutrition. Andrade et al. [38] proposed that following weight loss, it is essential to have a well-trained and experienced multidisciplinary weight loss team in place to conduct a thorough evaluation of the patient, customize treatment plans for patients, improve communication strategies, promote adherence to dietary behaviors, and optimize the treatment effect. The authors recommend that postoperative individuals follow nutritional guidelines, receive long-term dietary care, and change unhealthy lifestyle behaviors to achieve sustainable weight loss results in the long term. 4.4 limitations This study has some limitations. Firstly, dietary intake was assessed using a 3-day 24-hour dietary recall questionnaire instead of a 7-day food diary to estimate daily protein intake. However, previous research has indicated that a 7-day food diary may lead to false positives due to participant fatigue, while using a 3-day recall may enhance overall participation, though there may still result in dietary recall bias [39] . Therefore, there may be an under-excessive calculation of protein and energy intake in this study. Secondly, laboratory indicators were not collected from patients to assess malnutrition. Thirdly, this study simultaneously explores the relationship between protein intake sources, food tolerance, and postoperative compliance after LSG. Longer follow-up is necessary to fully understand the relationship between these factors until weight loss stabilizes or rebounds. 4.5 conclusion A significant number of patients fail to meet the recommended protein intake target within six months after LSG, this study underscores the importance of sufficient protein intake post-LSG and supports the current recommendation of a daily protein intake of at least 60 g. Impaired food tolerance is a common issue post-bariatric surgery, highlighting the need for lifelong follow-up, medical monitoring, targeted care, and guidance by a professional bariatric team to ensure postoperative patients receive targeted care and guidance to improve dietary compliance and prevent complications such as malnutrition. Declarations F UNDING DECLARATION This project received no funding. DATA AVAILABILITY STATEMENT The datasets generated and analyzed during the current study are not publicly available due privacy and ethical reasons, but are available from the corresponding author on reasonable request. PATIENT CONSENT STATEMENT Informed consent was not required for the quantitative data analysis, and it was implied through voluntary participation in the interviews. Verbal consent to audio-record the interviews was gained at the start of each interview. CONFLICT OF INTEREST STATEMENT The authors declare that they have no conflict of interest. ETHICAL RESPONSIBILITIES OF AUTHORS The manuscript has not been published previously (partly or in full)；A single study is not split up into several parts to increase the quantity of submissions and submitted to various journals or to one journal over time；No data have been fabricated or manipulated (including images) ；No data, text, or theories by others are presented as if they were the authors own. 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Tolerance to Specific Foods After Laparoscopic Sleeve Gastrectomy[J]. Obesity Surgery, 2020,30(10):3891-3897. Ali M, El Chaar M, Ghiassi S, et al. American Society for Metabolic and Bariatric Surgery updated position statement on sleeve gastrectomy as a bariatric procedure.[Z]. 2017: 13, 1652-1657. 大中华减重与代谢手术数据库研究者团队. 大中华减重与代谢手术数据库2022年度报告[J]. 中国实用外科杂志, 2023,43(5):540-551. Kowalewski P K, Olszewski R, Walędziak M S, et al. Long-Term Outcomes of Laparoscopic Sleeve Gastrectomy-a Single-Center, Retrospective Study.[J]. OBES SURG, 2018,28(1):130-134. Mocian F, Coroş M. Laparoscopic sleeve gastrectomy as a primary bariatric procedure: postoperative outcomes.[J]. Med Pharm Rep, 2021,94(2):208-213. Kvehaugen A S, Farup P G. Changes in gastrointestinal symptoms and food tolerance 6 months following weight loss surgery: associations with dietary changes, weight loss and the surgical procedure.[J]. BMC Obes, 2018,5(null):29. van Beek A P, Emous M, Laville M, et al. Dumping syndrome after esophageal, gastric or bariatric surgery: pathophysiology, diagnosis, and management[J]. Obesity Reviews, 2017,18(1):68-85. Vidal J, Corcelles R, Jiménez A, et al. Metabolic and Bariatric Surgery for Obesity.[Z]. 2017: 152, 1780-1790. Cano-Valderrama O, Sánchez-Pernaute A, Rubio-Herrera M A, et al. Long-Term Food Tolerance After Bariatric Surgery: Comparison of Three Different Surgical Techniques.[J]. OBES SURG, 2017,27(11):2868-2872. Lee J H, Park J H, Kim S M. Comparison of Dietary Quality and Surgical Satisfaction Between Patients With Suboptimal and Optimal Weight Loss After Sleeve Gastrectomy Using Food Tolerance Score and Bariatric Analysis and Reporting Outcome System Questionnaires.[J]. null, 2022,11(2):54-62. Tarkowska A, Katzer L, Ahlers M O. Assessment of masticatory performance by means of a color-changeable chewing gum.[Z]. 2017: 61, 9-19. Castellanos-Gutiérrez A, Rodríguez-Ramírez S, Bromage S, et al. Performance of the Global Diet Quality Score with Nutrition and Health Outcomes in Mexico with 24-h Recall and FFQ Data.[Z]. 2021: 151, 143S-151S. Julián-Almárcegui C, Bel-Serrat S, Kersting M, et al. Comparison of different approaches to calculate nutrient intakes based upon 24-h recall data derived from a multicenter study in European adolescents.[Z]. 2016: 55, 537-545. Suter M, Calmes J, Paroz A, et al. A New Questionnaire for Quick Assessment of Food Tolerance after Bariatric Surgery[J]. Obesity Surgery, 2007,17(1):2-8. Spaggiari G, Santi D, Budriesi G, et al. Eating Behavior after Bariatric Surgery (EBBS) Questionnaire: a New Validated Tool to Quantify the Patients' Compliance to Post-Bariatric Dietary and Lifestyle Suggestions.[J]. OBES SURG, 2020,30(10):3831-3838. 徐梦瑜, 白晓温, 梁晓宇, 等. 减重术后患者饮食行为依从性量表的汉化及信效度检验 [J]. 护理学杂志, 2021,36(16):81-83. Gasmi A, Bjørklund G, Mujawdiya P K, et al. Dietary supplements and bariatric surgery.[Z]. 2023: 63, 7477-7488. Kanerva N, Larsson I, Peltonen M, et al. Changes in total energy intake and macronutrient composition after bariatric surgery predict long-term weight outcome: findings from the Swedish Obese Subjects (SOS) study.[J]. AM J CLIN NUTR, 2017,106(1):136-145. Constansia R, Hentzen J, Hogenbirk R, et al. Actual postoperative protein and calorie intake in patients undergoing major open abdominal cancer surgery: A prospective, observational cohort study.[Z]. 2022: 37, 183-191. Barstad L H, Johnson L K, Borgeraas H, et al. Changes in dietary intake, food tolerance, hedonic hunger, binge eating problems, and gastrointestinal symptoms after sleeve gastrectomy compared with after gastric bypass; 1-year results from the Oseberg study-a randomized controlled trial.[Z]. 2023: 117, 586-598. Zerrweck C, Zurita L, Álvarez G, et al. Taste and Olfactory Changes Following Laparoscopic Gastric Bypass and Sleeve Gastrectomy.[J]. OBES SURG, 2016,26(6):1296-1302. de A G C, Aprigio L, de Godoy E P, et al. Food Tolerance and Eating Behavior After Roux-en-Y Gastric Bypass Surgery[J]. Obes Surg, 2018,28(6):1540-1545. Rossi D C, Soares A N, Silva K R S, et al. Improvement in Food Intolerance Resulting from Roux-En-Y Gastric Bypass after Speech Therapy Intervention in Chewing[J]. Obesity Surgery, 2019,29(10):3195-3201. Saito M, Shimazaki Y, Yoshii S, et al. Association of self-rated chewing function and oral health status with metabolic syndrome.[J]. J ORAL SCI, 2023,65(1):29-33. Kikui M, Ono T, Kokubo Y, et al. Relationship between metabolic syndrome and objective masticatory performance in a Japanese general population: The Suita study.[Z]. 2017: 56, 53-57. Fushida S, Kosaka T, Nakai M, et al. Lower Masticatory Performance Is a Risk for the Development of the Metabolic Syndrome: The Suita Study.[J]. Front Cardiovasc Med, 2021,8(null):752667. Wawrzyniak A, Krotki M. Environmental Factors Determining Body Mass Index (BMI) within 9 Months of Therapy Post Bariatric Surgery-Sleeve Gastrectomy (SG).[J]. Nutrients, 2022,14(24):null. Njike V Y, Smith T M, Shuval O, et al. Snack Food, Satiety, and Weight.[Z]. 2016: 7, 866-878. Herrera-Espiñeira C, de Pascual Y Medina A M, López-Morales M, et al. Differences in Dietary Habits, Physical Exercise, and Quality of Life between Patients with Obesity and Overweight.[J]. Healthcare (Basel), 2021,9(7):null. Sherf Dagan S, Keidar A, Raziel A, et al. Do Bariatric Patients Follow Dietary and Lifestyle Recommendations during the First Postoperative Year?[J]. OBES SURG, 2017,27(9):2258-2271. Mahawar K K, Clare K, O'Kane M, et al. Patient Perspectives on Adherence with Micronutrient Supplementation After Bariatric Surgery.[J]. OBES SURG, 2019,29(5):1551-1556. Yanos B R, Saules K K, Schuh L M, et al. Predictors of Lowest Weight and Long-Term Weight Regain Among Roux-en-Y Gastric Bypass Patients.[J]. OBES SURG, 2015,25(8):1364-1370. Andrade L, Chiote I, Santos-Cruz A, et al. Protein Intake, Adherence to Vitamin-Mineral Supplementation, and Dumping Syndrome in Patients Undergoing One Anastomosis Gastric Bypass.[J]. OBES SURG, 2021,31(8):3557-3564. Biltoft-Jensen A, Matthiessen J, Rasmussen L B, et al. Validation of the Danish 7-day pre-coded food diary among adults: energy intake v. energy expenditure and recording length.[Z]. 2009: 102, 1838-1846. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2025 Read the published version in Obesity Surgery → Version 1 posted Editorial decision: Revision requested 25 Aug, 2024 Reviews received at journal 20 Aug, 2024 Reviews received at journal 19 Aug, 2024 Reviewers agreed at journal 10 Aug, 2024 Reviewers agreed at journal 09 Aug, 2024 Reviewers invited by journal 07 Aug, 2024 Editor assigned by journal 02 Jul, 2024 Submission checks completed at journal 19 Jun, 2024 First submitted to journal 18 Jun, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4598227","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":321804211,"identity":"8e08683c-6d8c-4832-a5f1-e9099eda0ac9","order_by":0,"name":"Huiling Zhao","email":"","orcid":"","institution":"Xuzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Huiling","middleName":"","lastName":"Zhao","suffix":""},{"id":321804212,"identity":"a4908dad-0224-4429-8792-8978a71509b0","order_by":1,"name":"Lulu Wu","email":"","orcid":"","institution":"Xuzhou Medical 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University","correspondingAuthor":false,"prefix":"","firstName":"Dan","middleName":"","lastName":"Zhang","suffix":""},{"id":321804216,"identity":"95325f71-b3af-47fe-97ed-0b1c5b0be278","order_by":5,"name":"Yuping Liu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYBACNvaG9B8fKiTs5PmbDxCnhY/nwAPJGWcskg1nHEsgTouchOMDad62CsaGAzkGRDpMgjnBgAdIMjac+XjjDYOdnG4DIS3SbQkJEjwSfOzMvZst5zAkG5sdIKRF5kzCAQMJkC1nt0nzMBxI3EZQi0T+x4YEAwmQX54RqyUhmeFAAlgLG5FaeA6kAZVLgALZ2HKOARF+kW9vSGP++68OFJUPb7ypsJMjqAUFSPAQGTXIWkjVMQpGwSgYBSMCAADEzkFVB5L+hwAAAABJRU5ErkJggg==","orcid":"","institution":"Affiliated Hospital of Xuzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Yuping","middleName":"","lastName":"Liu","suffix":""}],"badges":[],"createdAt":"2024-06-18 07:51:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4598227/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4598227/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11695-025-07739-2","type":"published","date":"2025-02-11T15:57:03+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":60171322,"identity":"43488369-3eb6-45c7-b140-7adad686ac4d","added_by":"auto","created_at":"2024-07-12 15:09:55","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":98278,"visible":true,"origin":"","legend":"\u003cp\u003eSources of three constant elements for all patients\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4598227/v1/46246fab495ab4b2f24ed606.jpg"},{"id":60171324,"identity":"7d0f52c9-e5ad-4be7-a0ac-482cb5a243d7","added_by":"auto","created_at":"2024-07-12 15:09:55","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":98791,"visible":true,"origin":"","legend":"\u003cp\u003eSources of three macro elements for male patients\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4598227/v1/a7c386e1b2cb7eb4b91065ed.jpg"},{"id":60171323,"identity":"f8912758-2307-4231-a91d-93bf1464d2d1","added_by":"auto","created_at":"2024-07-12 15:09:55","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":104899,"visible":true,"origin":"","legend":"\u003cp\u003eSources of three macro elements for female patients\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4598227/v1/1610d1b3b921e8598c50d12a.jpg"},{"id":76487544,"identity":"94d66fbd-abee-4b68-8222-1d8e45933b30","added_by":"auto","created_at":"2025-02-17 16:08:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1331257,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4598227/v1/b749869f-c83a-4789-b623-70e47378ea30.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Analysis of changes in protein intake following laparoscopic sleeve gastrectomy and its influencing factors","fulltext":[{"header":"Highlights","content":"\u003cul\u003e\n \u003cli\u003ePatients with insufficient protein intake in the short term after LSG have poor long-term weight loss.\u003c/li\u003e\n \u003cli\u003eThe study identified rice, noodles, and red meat as the most common intolerances food among patients\u003c/li\u003e\n \u003cli\u003ePostoperative individuals receive long-term care and increase EBBS scores to achieve sustainable weight loss results in the long term.\u003c/li\u003e\n \u003cli\u003eFindings have clear implications for intervention targets among programs designed to address deficiency protein intake \u003c/li\u003e\n\u003c/ul\u003e"},{"header":"1. Introduction","content":"\u003cp\u003eThe primary objective of bariatric surgery (BS) is to achieve substantial and sustainable weight loss, particularly in reducing adipose tissue \u003csup\u003e[1]\u003c/sup\u003e. However, not all patients undergoing surgery achieve the desired weight loss outcomes. In fact, some patients may mistakenly believe that surgery alone is sufficient for weight loss, neglecting the importance of healthy nutritional guidance and lifestyle modifications like physical exercise \u003csup\u003e[2]\u003c/sup\u003e. Thus, adherence to dietary behavior recommendations post-bariatric surgery is crucial in determining medical outcomes.\u003c/p\u003e \u003cp\u003ePrevious studies\u003csup\u003e[3]\u003c/sup\u003e have indicated that nutritional management plays a crucial role in preventing malnutrition and gastrointestinal complications, as well as reducing the risk of weight regain in morbidly obese patients. The American Society of Bariatric and Metabolic Surgery (ASMBS) guidelines suggest a daily protein intake of 60\u0026ndash;80 g after bariatric surgery or 1.1\u0026ndash;1.5 g/kg of ideal body weight\u003csup\u003e[4]\u003c/sup\u003e. Studies \u003csup\u003e[5]\u003c/sup\u003ehave shown that sufficient protein consumption in the initial 6 months post-surgery is vital to prevent loss of fat-free body weight. Protein intake can enhance satiety, reduce muscle breakdown, meet metabolic requirements, and enhance overall nutritional status\u003csup\u003e[6]\u003c/sup\u003e. Therefore, ensuring a sufficient daily protein intake in the early stages following bariatric surgery is particularly important for long-term weight loss and overall health.\u003c/p\u003e \u003cp\u003eLaparoscopic sleeve gastrectomy (LSG) is the predominant bariatric surgery globally\u003csup\u003e[7]\u003c/sup\u003e and the most frequently performed procedure in China\u003csup\u003e[8]\u003c/sup\u003e. Research indicates\u003csup\u003e[5, 9, 10]\u003c/sup\u003e that LSG is a safe and effective treatment for severe obesity, resulting in a reduction of excess body weight ranging from 33\u0026ndash;90%. This surgery, which restricts gastric capacity and the secretion of certain substances, such as hydrochloric acid and ghrelin\u003csup\u003e[11, 12]\u003c/sup\u003e, limits food intake and impacts digestion, potentially leading to food intolerances. Some patients may experience altered taste and smell, contributing to an aversion to certain foods \u003csup\u003e[13]\u003c/sup\u003e. Food intolerance manifests as symptoms like nausea, vomiting, dysphagia, and dumping syndrome, prompting patients to avoid specific foods. Several international studies\u003csup\u003e[6, 14, 15]\u003c/sup\u003e have highlighted that high-protein foods, especially red meat with high content of protein can easily cause food intolerance, affecting nutrient absorption and potentially causing malnutrition.\u003c/p\u003e \u003cp\u003eHowever, the correlation between postoperative protein intake and weight loss, dietary compliance, and food tolerance post-bariatric surgery remains unclear, particularly within the Chinese population.\u003c/p\u003e \u003cp\u003eHence, this study aims to investigate the association between daily protein intake, dietary compliance, food intolerance, and food intolerance among obese individuals at 3 months (M3) and 6 months (M6) post-LSG. As well as investigate Sources of common nutrient intakes and protein supplement usage during the early postoperative period in Chinese weight loss patients.\u003c/p\u003e"},{"header":"2. Research objects and methods.","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003e2.1Research objects\u003c/h2\u003e\n\u003cp\u003eThis 6-month prospective observational study utilized a convenience sampling method to select 120 patients admitted to a tertiary hospital in Xuzhou between August 2023 and December 2023. The research subjects were chosen from the Department of Metabolic Surgery based on specific inclusion criteria: patients who underwent LSG, aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years, had no more than 2 missing dental units and no major oral diseases, had not previously undergone LSG or other bariatric surgeries, and willingly signed the informed consent form. Exclusion criteria included patients with serious underlying diseases such as heart, brain, kidney, and gastrointestinal issues, as well as those with significant complications during hospitalization or follow-up, food intolerance before surgery, and individuals unable to effectively communicate due to educational or mental reasons. Approval for this study was obtained from the hospital ethics research committee, and all patients provided informed consent.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n\u003ch2\u003e2.2Methods\u003c/h2\u003e\n\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\n\u003ch2\u003e2.2.1Preoperative/postoperative care\u003c/h2\u003e\n\u003cp\u003eAll patients underwent a thorough preoperative assessment, including medical history collection and clinical examination, such as blood tests, liver and kidney function tests, digestive system ultrasound, and upper gastrointestinal endoscopy. Only patients meeting surgical criteria were admitted for laparoscopic sleeve gastrectomy (LSG) performed by the same surgical team. Postoperatively, patients followed a multimodal bariatric surgery rehabilitation plan, including early fluid tolerance testing, mobilization encouragement, diatrizoate meglumine testing for anastomosis integrity, and Doppler ultrasound of lower limb blood vessels before discharge.\u003c/p\u003e\n\u003cp\u003ePatients were given dietary and lifestyle guidance both before and after surgery, along with oral and written information on postoperative dietary behavior. This included instructions on maintaining a long-term low-calorie, protein- and fiber-rich diet, chewing slowly, and exercise guidance. Patients were gradually transitioned from clear liquids to regular food after surgery. They were also educated on the importance of taking relevant supplements and medications, with compliance monitored during follow-up visits, including supplement and medication use. Postoperative evaluation of patients was conducted through outpatient visits and follow-up via telephone/WeChat.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\n\u003ch2\u003e2.2.2Research tools\u003c/h2\u003e\n\u003cp\u003eAnthropometric measurements were conducted using a standardized protocol at baseline, M3, and M6 time points. Weight and height were measured using a digital medical scale. Body Mass Index (BMI) was calculated as weight (kg) divided by height squared (m2). Patients were required to complete a researcher-designed general information questionnaire, which included information on current weight, the presence of symptoms such as hair loss and fatigue, and the use of vitamins and protein supplements.\u003c/p\u003e\n\u003cp\u003eChewing performance was assessed using color-changing chewing gum\u003csup\u003e[16]\u003c/sup\u003e. Patients were instructed to chew the gum 60 times at their own pace and were timed, but no guidance was given about the chewing surface. After chewing, patients spat out the gum, and their chewing performance was evaluated on a scale of L1 to L5 based on the color change compared to a standard color chart, a higher grade indicated better chewing performance. The chewing cycle was calculated as the time taken to chew divided by 60.\u003c/p\u003e\n\u003cp\u003eThe 24-hour dietary recall questionnaire was used to assess patients' dietary intake effectively. This questionnaire has demonstrated good reliability and validity in previous studies\u003csup\u003e[17, 18]\u003c/sup\u003e. This study used dietary review questionnaires for three non-consecutive days (two working days and one weekend) to monitor patients' nutritional intake, including protein supplements. A nutritionist on the team analyzed the questionnaire responses to estimate the average daily intake of energy and macronutrients. To minimize memory bias, researchers provided patients with visual aids such as food models and reference charts to assist in estimating portion sizes and food quantities consumed.\u003c/p\u003e\n\u003cp\u003eParts 1, 3, and 4 of the validated food tolerance questionnaire by Suter et al.\u003csup\u003e[19]\u003c/sup\u003e were utilized to calculate specific food tolerance scores ranging from 1 to 27, where a higher score indicates better food tolerance. The questionnaire encompasses 1) overall patient satisfaction with food intake [rated from 1 (very poor) to 5 (excellent)]; 3) assessment of tolerance towards eight food types [scored as 0 (cannot eat), 1 (can eat with some difficulty/restrictions), 2 (can eat without difficulty)]; 4) frequency of vomiting/reflux [scored as 0 (daily), 2 (three or more times per week), 4 (twice per week), 6 (never)]. Apart from the eight common food categories, the questionnaire allows open-ended responses for other food intolerances, which are not included in the total score. This questionnaire was developed to standardize the assessment of food tolerance during follow-up post-bariatric surgery.\u003c/p\u003e\n\u003cp\u003eThe Eating Behavior after Bariatric Surgery (EBBS) scale, created by Spaggiari et al.\u003csup\u003e[20]\u003c/sup\u003e in 2020, is specifically designed to measure patients' adherence to dietary and lifestyle recommendations post-bariatric surgery. The EBBS scale consists of 11 items across 4 dimensions: food, drink, behavior, and lifestyle, with each item scored on a 0 to 2-point scale. A higher score indicates better compliance. In 2021, Xu Mengyu et al.\u003csup\u003e[21]\u003c/sup\u003e translated the scale into Chinese and assessed its reliability and validity. The Chinese version demonstrated a Cronbach's alpha coefficient of 0.895 and test-retest reliability of 0.835.\u003c/p\u003e\n\u003cp\u003eProtein intake and food tolerance were not assessed before M3, as most patients were still in the liquid/soft food stage, consuming limited types of food and not yet at the normal eating stage, making it difficult to comprehensively evaluate protein intake and various food tolerances.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\n\u003ch2\u003e2.2.3 Statistical analysis\u003c/h2\u003e\n\u003cp\u003eStatistical analysis was conducted using IBM SPSS Statistics 25 software. Measurement data were assessed for normality and homogeneity of variances. Data following normal distribution were presented as mean \u0026plusmn; standard deviation (\u003cem\u003ex̄ \u0026plusmn; s\u003c/em\u003e), while non-normally distributed data were presented as M (P25, P75); categorical data were expressed as composition ratio/rate. The independent sample t-test was used for comparing two groups with normally distributed continuous data, while the non-parametric Mann-Whitney U test was used for non-normally distributed data. Paired samples t-test or Wilcoxon signed-rank test were employed for dependent samples.\u003c/p\u003e\n\u003cp\u003eThe chi-square test (\u003cem\u003ex\u003c/em\u003e\u003csup\u003e2\u003c/sup\u003e) was used for analyzing categorical data. Changes from pre- to post-operative values were calculated by subtracting pre-operative values from post-operative values for all variables. Linear regression was utilized to analyze factors related to protein intake. A significance level of P\u0026lt;0.05 was considered statistically significant.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eBefore undergoing surgery, a total of 120 patients underwent general information and chewing performance tests, in addition to completing a 24-hour dietary review questionnaire. However, 7 patients were excluded at M3, with 6 failing to follow up and 1 not completing the questionnaire. The final study cohort comprised 113 patients, with an average age of 32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4 years (range: 18\u0026ndash;57). The average operation time was 101.3\u0026thinsp;\u0026plusmn;\u0026thinsp;23.8 minutes (range: 64\u0026ndash;207), and the average length of stay was 3.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1 hospital days (range: 2\u0026ndash;7). The mean preoperative BMI was 40.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5 kg/m2 (range: 31.9\u0026ndash;72.5). The characteristics of the study participants at baseline are summarized in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eCharacteristics of study participants, grouped according to protein intake goals 3 months and 6 months after surgery\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eAll participants\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eM3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eM6\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;113\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eachieving a\u003c/p\u003e\n\u003cp\u003eprotein intake\u0026lt;60g/d\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eachieving a protein intake\u0026thinsp;\u0026ge;\u0026thinsp;60g/d\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eachieving a\u003c/p\u003e\n\u003cp\u003eprotein intake\u0026lt;60g/d\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eachieving a protein intake\u0026thinsp;\u0026ge;\u0026thinsp;60g/d\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;63\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;66\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;47\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eage\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33.6\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.3\u0026thinsp;\u0026plusmn;\u0026thinsp;8.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e35.2\u0026thinsp;\u0026plusmn;\u0026thinsp;10.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eGender (female)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e76(67.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44(69.8%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32(63.3%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45(68.2%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31(65.9%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDays of hospitalization\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.3\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e31.7\u0026thinsp;\u0026plusmn;\u0026thinsp;4.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTWL%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19.9\u0026thinsp;\u0026plusmn;\u0026thinsp;4.4*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.5\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTWL%\u003csub\u003eM3\u0026minus;M6\u003c/sub\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEWL%\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.1\u0026thinsp;\u0026plusmn;\u0026thinsp;16.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e58.6\u0026thinsp;\u0026plusmn;\u0026thinsp;16.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e81.8\u0026thinsp;\u0026plusmn;\u0026thinsp;20.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e78.8\u0026thinsp;\u0026plusmn;\u0026thinsp;15.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEWL%\u003csub\u003eM3\u0026minus;M6\u003c/sub\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.9\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.7\u0026thinsp;\u0026plusmn;\u0026thinsp;7.5*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20.3\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHair loss\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFatigue\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTake vitamins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(2\u0026ndash;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(2.5-3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(1\u0026ndash;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(3\u0026ndash;3)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChewing performance\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(4\u0026ndash;5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(4\u0026ndash;5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(4\u0026ndash;5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(4\u0026ndash;5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5(4\u0026ndash;5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eChewing cycle (s)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.62\u0026thinsp;\u0026plusmn;\u0026thinsp;0.34\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.79\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.13\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEnergy intake (kcal/d)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2306.7\u0026thinsp;\u0026plusmn;\u0026thinsp;391.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e559.6\u0026thinsp;\u0026plusmn;\u0026thinsp;225.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e755.9\u0026thinsp;\u0026plusmn;\u0026thinsp;253.9*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e698.4\u0026thinsp;\u0026plusmn;\u0026thinsp;141.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e773.7\u0026thinsp;\u0026plusmn;\u0026thinsp;122.9*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEBBS total score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e-\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.9\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFood tolerance score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003eTWL%M3-M6 is the percentage of total weight loss in 3\u0026ndash;6 months and EWL%M3-M6 Percentage of excess weight loss in 3\u0026ndash;6 months. MU test or independent sample T-test, * indicates that the P value within the group is \u0026lt;\u0026thinsp;0.05, and there is a statistical difference.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\n\u003ch2\u003e3.1 Weight loss effect and protein intake\u003c/h2\u003e\n\u003cp\u003eThe study found that most patients did not meet the recommended protein intake of \u0026ge;\u0026thinsp;60g/day after undergoing LSG at M6 (18.2% of men and 40.9% of women). A significant difference was observed in TWL% between patients with protein intake\u0026thinsp;\u0026lt;\u0026thinsp;60g/day and those with protein intake\u0026thinsp;\u0026ge;\u0026thinsp;60g/day from M3 to M6(P\u0026thinsp;=\u0026thinsp;0.008, P\u0026thinsp;=\u0026thinsp;0.045). At M6, both groups were in terms of hair loss, vitamin taking vitamins, and EBBS total score, with statistical significance observed (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05)(Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\n\u003ch2\u003e3.2 Sources of energy and macronutrient intake\u003c/h2\u003e\n\u003cp\u003eAs expected, energy intake decreased sharply at month M3 post-LSG, but slightly increased by month M6(Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), with daily carbohydrate and fat intake higher than at M3 while protein intake decreased.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eChanges in patients\u0026rsquo; daily energy intake and common nutrients and food tolerance\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAll participants(n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMen(n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWomen(n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eM3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eM6\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eM3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eM6\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eM3\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eM6\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEnergy intake (kcal/d)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e648.8\u0026thinsp;\u0026plusmn;\u0026thinsp;256.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e729.9\u0026thinsp;\u0026plusmn;\u0026thinsp;138.3*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e601.6\u0026thinsp;\u0026plusmn;\u0026thinsp;233.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e707.2\u0026thinsp;\u0026plusmn;\u0026thinsp;154.5*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e671.8\u0026thinsp;\u0026plusmn;\u0026thinsp;266.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e740.9\u0026thinsp;\u0026plusmn;\u0026thinsp;130.4*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eCarbohydrates (g/d)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e55.9\u0026thinsp;\u0026plusmn;\u0026thinsp;31.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61.1\u0026thinsp;\u0026plusmn;\u0026thinsp;22.1*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41.7\u0026thinsp;\u0026plusmn;\u0026thinsp;17.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54.4\u0026thinsp;\u0026plusmn;\u0026thinsp;17.1*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e62.9\u0026thinsp;\u0026plusmn;\u0026thinsp;35.0\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e64.4\u0026thinsp;\u0026plusmn;\u0026thinsp;23.5\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eProteins (g/d)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e57.2\u0026thinsp;\u0026plusmn;\u0026thinsp;24.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.8\u0026thinsp;\u0026plusmn;\u0026thinsp;16.3*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e59.2\u0026thinsp;\u0026plusmn;\u0026thinsp;25.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50.4\u0026thinsp;\u0026plusmn;\u0026thinsp;19.6*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e56.2\u0026thinsp;\u0026plusmn;\u0026thinsp;23.4\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e51.0\u0026thinsp;\u0026plusmn;\u0026thinsp;14.7\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFats (g/d)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;14.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.0\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;13.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.2\u0026thinsp;\u0026plusmn;\u0026thinsp;15.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.8*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003ehair loss\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003efatigue\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1-1.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003echewing cycle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.73\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.80\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.81\u0026thinsp;\u0026plusmn;\u0026thinsp;0.14*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.12*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003etake vitamins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(2\u0026ndash;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(2\u0026ndash;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(1.75-3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(2\u0026ndash;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(2\u0026ndash;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3(1\u0026ndash;3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eFood Tolerance Score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25.1\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eVomiting/reflux Frequency\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.4\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e5.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003escore of food tolerance for 8 categories\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\"\u0026plusmn;\"\u003e\n\u003cp\u003e15.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003eP values are derived from the Wilcox test, paired samples T-test, and MU test. \u0026yen; indicates that there is statistical significance between the two groups of men and women at the same time point, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, * indicates that there is statistical significance between the two groups of the same gender at different time points, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eStatistical differences (P\u0026thinsp;\u0026le;\u0026thinsp;0.002) were observed in the dietary and protein supplement sources of the three macronutrients for all patients between months M3 and M6(Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e); In male patients (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), only carbohydrate intake showed a statistical difference between M3 and M6 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), while in protein supplements, there were statistical differences in all three macronutrients(P\u0026thinsp;=\u0026thinsp;0.014). Female patients showed statistical differences (P\u0026thinsp;\u0026le;\u0026thinsp;0.013) in the intake of the three macronutrients between diet and protein supplements (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). Overall, there was a significant increase in dietary sources of each nutrient from M3 to M6, while protein supplements showed a significant decrease, resulting in no statistical difference in the three macronutrients overall.\u003c/p\u003e\n\u003cp\u003eNotably, Among the 24 patients who did not take protein supplements at all at the 3-month follow-up, all had a protein intake of less than 60g per day (mean\u0026thinsp;=\u0026thinsp;29.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.6g/day). At the 6-month follow-up, out of the 64 patients who did not take protein supplements, only 6 (9.4%) had a protein intake equal to or greater than 60g per day (mean\u0026thinsp;=\u0026thinsp;39.9\u0026thinsp;\u0026plusmn;\u0026thinsp;10.3g/day).\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\n\u003ch2\u003e3.3 Food Tolerance Scores and EBBS Scores\u003c/h2\u003e\n\u003cp\u003eOver time, from M3 to M6, patients' chewing cycles gradually increased post-surgery (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), and there was a significant improvement in food tolerance score (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e), the total score of the 8 food tolerance categories improved compared to before (P\u0026thinsp;=\u0026thinsp;0.021).\u003c/p\u003e\n\u003cp\u003eThe study identified rice [23 people (20.4%) at M3; 22 people (19.5%) at M6], noodles [17 people (15%) at M3; 14 people (12.4%) at M6], and red meat [12 people (10.6%) at M3; 10 people (8.8%) at M6] as the most common intolerances food among patients. During follow-up, 5 patients avoided fish, shrimp, and other fishy-smelling foods due to changes in their sense of smell and taste.\u003c/p\u003e\n\u003cp\u003eThe study revealed a decrease in EBBS score from M3 to M6 (P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e). At M3, men engaged in more weekly physical activities compared to women, with a statistically significant difference; although there was no statistical difference at M6, men still spent more time on physical activities than women (male: female\u0026thinsp;=\u0026thinsp;1.5:1).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eChanges in The Eating Behavior after Bariatric Surgery (EBBS) scale\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eAll participants(n\u0026thinsp;=\u0026thinsp;113)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eMen(n\u0026thinsp;=\u0026thinsp;41)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eWomen(n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM6\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eM6\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eEBBS total score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16.8\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14.6\u0026thinsp;\u0026plusmn;\u0026thinsp;2.0\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow many meals do you eat per day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow quickly do you consume the main meals?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0(0\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow much water do you drink during the meal?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow many times a week do you eat sweets?\u003c/p\u003e\n\u003cp\u003e(exclude breakfasts)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1.75-3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1.75-2)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)*\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow many times a week do you drink wine or alcohol?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1.75-2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow many times a week do you drink sparkling beverages?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow hungry do you feel before meals?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0.75-2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0\u0026ndash;1)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow full do you feel after meals?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow is the portion of vegetables you consume during the meal?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(0.5-1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;1)*\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow much time do you spend on physical activity?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.5(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003csup\u003e\u003cstrong\u003e\u0026yen;\u003c/strong\u003e\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1(1\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eHow often do you weigh yourself?\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2(2\u0026ndash;2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"8\"\u003eP values are derived from the Wilcox test, paired samples T-test, and MU test. \u0026yen; indicates that there is statistical significance between the two groups of men and women at the same time point, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, * indicates that there is statistical significance between the two groups of the same gender at different time points, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\n\u003ch2\u003e3.4 Multivariate analysis of daily protein intake\u003c/h2\u003e\n\u003cp\u003eSingle-factor analysis of variance indicated that 11 independent variables including gender, age, and being an only child significantly impacted daily protein intake. Following multi-factor linear regression, gender, age, being an only child, educational level, surgery time, hospital days, daily vitamin intake at M6, and EBBS total score at M6 were identified as factors influencing daily protein intake (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab4\" style=\"width: 648px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eMultivariate linear regression of daily protein intake at M6 Unstandardized\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003cth style=\"height: 70px; width: 156px;\" rowspan=\"2\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 160px;\" colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eUnstandardized coefficient\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003eStandardized coefficient\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 70px; width: 36px;\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003et\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 70px; width: 74px;\" rowspan=\"2\" align=\"left\"\u003e\n\u003cp\u003eSignificance\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003cth style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003eB\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003eStandard Error\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003eBeta\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003eVIF\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003e(constant)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e-32.727\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e15.399\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e-2.125\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e0.036\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eGender\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e6.184\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e2.421\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e0.18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e2.555\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e0.012\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.149\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eage (years)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e0.302\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e0.126\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e0.175\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e2.402\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e0.018\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.234\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eWhether she is an only child\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e13.381\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e2.413\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e0.402\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e5.545\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.224\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eEducational level\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e4.57\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e1.289\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e0.262\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e3.544\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.275\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eSurgery time\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e-0.117\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e0.048\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e-0.174\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e-2.429\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e0.017\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.19\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eDays of hospitalization\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e-4.27\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e1.103\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e-0.279\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e-3.871\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.206\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eM6 Chewing cycle\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e-10.341\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e10.052\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e-0.078\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e-1.029\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e0.306\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.332\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35.8729px;\"\u003e\n\u003ctd style=\"height: 35.8729px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eM6Vitamins taken/day\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35.8729px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e5.596\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35.8729px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e1.362\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35.8729px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e0.293\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35.8729px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e4.108\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35.8729px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35.8729px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.189\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 156px;\" align=\"left\"\u003e\n\u003cp\u003eM6 EBBS total score\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 52.9213px;\" align=\"left\"\u003e\n\u003cp\u003e2.992\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 107.079px;\" align=\"left\"\u003e\n\u003cp\u003e0.606\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 149px;\" align=\"left\"\u003e\n\u003cp\u003e0.378\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 36px;\" align=\"left\"\u003e\n\u003cp\u003e4.941\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 74px;\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 31px;\" align=\"left\"\u003e\n\u003cp\u003e1.366\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 37px;\"\u003e\n\u003ctd style=\"height: 37px; width: 465px;\" colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 37px; width: 141px;\" colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e0.570\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 465px;\" colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eF\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 141px;\" colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e14.754\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 465px;\" colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eP\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 141px;\" colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003c/div\u003e"},{"header":"4. Discussion","content":"\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Adequate protein intake contributes to long-term steady-state weight loss\u003c/h2\u003e \u003cp\u003eAfter laparoscopic sleeve gastrectomy (LSG), there was a significant difference in total weight loss percentage (TWL%) at 3 months post-surgery between patients consuming\u0026thinsp;\u0026ge;\u0026thinsp;60g/day of protein and those consuming\u0026thinsp;\u0026lt;\u0026thinsp;60g/day. but there was no statistical significance in the TWL% of the two groups of patients 6 months after surgery. patients with protein intake of less than 60g/day at M3 experienced greater weight loss initially, the reason may be due to the loss of fat-free body weight\u003csup\u003e[22]\u003c/sup\u003e, however, in the long term, adequate protein intake led to a more favorable weight loss outcome by promoting higher fat mass loss\u003csup\u003e[1]\u003c/sup\u003e. As a result, patients with protein intake levels of \u0026ge;\u0026thinsp;60g/day saw a greater decrease in TWL% six months post-surgery, with no significant difference in weight loss compared to those with lower protein intake levels.\u003c/p\u003e \u003cp\u003eResearch on the relationship between protein intake and supplements post-LSG is limited, This study highlights that most patients fail to meet their daily protein intake requirements without supplements within six months post-surgery. Patients who do not reach the recommended 60g/day of protein through diet alone may benefit from protein supplementation\u003csup\u003e[5]\u003c/sup\u003e. Despite medical professionals emphasizing the importance of postoperative protein supplements, patients often overlook the need for adequate protein intake in the short term after bariatric surgery, mistakenly believing they have achieved optimal weight loss results.\u003c/p\u003e \u003cp\u003ePrevious studies\u003csup\u003e[23, 24]\u003c/sup\u003ehave demonstrated that adequate protein intake post-surgery can support long-term postoperative weight loss, maintain muscle mass, and decrease body fat content. These findings underscore the critical importance of scientific nutritional guidance following bariatric surgery. Therefore, healthcare providers, including clinicians, case managers, and nutritionist teams, must offer sustained and effective supervision and guidance to bariatric patients to ensure proper nutrient intake, minimize adverse events, and sustain positive weight loss outcomes.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Good dietary adjustments can enhance food tolerance\u003c/h2\u003e \u003cp\u003eThis study shows that the higher incidence of food intolerance post-LSG, Short-term dietary goals should focus on meeting patients' food tolerance and nutritional requirements. Red meat, particularly pork, is commonly reported as poorly tolerated in the initial year post-surgery\u003csup\u003e[14, 15, 25]\u003c/sup\u003e. Due to its role as a primary protein source, intolerance to red meat may contribute to nutritional deficiencies observed post-LSG.\u003c/p\u003e \u003cp\u003eWhile previous studies have not highlighted rice intolerance, results of only one previous randomized controlled study\u003csup\u003e[11]\u003c/sup\u003e showed a significant decrease in rice tolerance of patients observed in the SG group, and the majority of the remaining studies did not mention the high intolerance rate of rice, this study reveals that patients in northern China exhibited notable intolerance to rice, noodles, and red meat six months post-surgery, likely due to their rice and cooked wheaten food diet.\u003c/p\u003e \u003cp\u003eChanges in taste and smell post-bariatric surgery, as noted by Zerrweck et al.\u003csup\u003e[26]\u003c/sup\u003e, could potentially lead to aversions of protein-rich foods, resulting in reduced protein intake. This study also identified a similar situation, though the exact mechanisms behind changes in taste and smell and their impact on nutrient intake remain unclear.\u003c/p\u003e \u003cp\u003eThe research revealed that the increase in chewing cycles post-surgery could be linked to patients' efforts to minimize food intolerance and gradually adjust to the gastric pouch's size. However, the vast majority of patients still have problems with fast eating speed and inadequate chewing, which may also be one of the reasons for the higher incidence of food intolerance at the 6-month mark in this study. Previous studies\u003csup\u003e[27\u0026ndash;29]\u003c/sup\u003e have demonstrated that patients with inefficient chewing are more prone to food intolerance and experience more severe fullness, nausea, and vomiting symptoms, aligning with the findings of this study. In a study\u003csup\u003e[30]\u003c/sup\u003eusing jelly gummies to examine the association between objective chewing function and metabolic syndrome, people in their 70s with poor chewing function had a significantly higher risk of developing metabolic syndrome, while people in their 50s and 60s had a significantly higher risk of developing metabolic syndrome. No association between the two was found. This study shows that chewing performance has nothing to do with patients' postoperative protein intake and food intolerance. This may be related to the late start of bariatric surgery in China and the elderly obese patients. The lack of attention to bariatric surgery is related to the lack of choice of bariatric surgery. Therefore, the age of the participants in this study is concentrated between 24 and 39 years old. The chewing performance results are all good with little difference. In the future, it can increase the number of elderly people after bariatric surgery. Related studies on patients' chewing performance to supplement the research content. Impaired chewing function is a risk factor for nutritional imbalances and obesity \u003csup\u003e[31]\u003c/sup\u003e, emphasizing the importance of cultivating effective chewing habits to enhance food tolerance and reduce the risk of malnutrition and sarcopenia.\u003c/p\u003e \u003cp\u003eDuring follow-up, when dealing with food intolerance, selecting nutritionally similar food items as substitutes can be beneficial. By adjusting eating habits, such foods can gradually be reintroduced; patients should be advised to consume protein-rich foods to boost satiety and prevent excessive calorie intake. Additionally, patients are encouraged to cultivate the practice of slow and thorough chewing, spending at least 20 minutes on each meal, thoroughly chewing each bite of food, and cutting food into smaller pieces to aid digestion and lessen the strain on the gastrointestinal system.\u003c/p\u003e \u003cp\u003eThis study demonstrates that after bariatric surgery, female patients tend to have higher daily carbohydrate intake compared to male patients, likely due to their higher frequency of eating and preference for sweets\u003csup\u003e[32]\u003c/sup\u003e. Women also express a stronger desire for snacks/sweets during follow-up, While frequently eaten snacks/sweets will provide additional amounts of simple sugars or fats\u003csup\u003e[33]\u003c/sup\u003e; Conversely, Men after surgery the duration of exercise is longer than that of women, follow-up more male patients were found to develop the habit of adhering to fitness exercise after surgery, while fewer women, which may be related to men's pursuit of strength and muscle. Tailored follow-up care by case managers and nutritionists focusing on individual dietary behaviors could focus on. For different patients, giving different dietary behavior guidance with different priorities may achieve better postoperative results.\u003c/p\u003e \u003cp\u003eResearchers observed a decline in EBBS scores over time, possibly due to patient fatigue in maintaining long-term dietary changes, and generally poor compliance with healthy eating habits among obese individuals \u003csup\u003e[34]\u003c/sup\u003e. Several studies \u003csup\u003e[35\u0026ndash;37]\u003c/sup\u003e investigated patient compliance with the postoperative diet and lifestyle, and all showed poor compliance, which is consistent with the results of this study. Although the medical team after LSG conducts regular follow-up education, they cannot supervise their living habits for a long time, so how to improve the postoperative dietary behavior compliance of obese patients is the key to ensuring and maintaining the effect of weight loss and reducing complications such as malnutrition. Andrade et al. \u003csup\u003e[38]\u003c/sup\u003e proposed that following weight loss, it is essential to have a well-trained and experienced multidisciplinary weight loss team in place to conduct a thorough evaluation of the patient, customize treatment plans for patients, improve communication strategies, promote adherence to dietary behaviors, and optimize the treatment effect. The authors recommend that postoperative individuals follow nutritional guidelines, receive long-term dietary care, and change unhealthy lifestyle behaviors to achieve sustainable weight loss results in the long term.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003e4.4 limitations\u003c/h2\u003e \u003cp\u003eThis study has some limitations. Firstly, dietary intake was assessed using a 3-day 24-hour dietary recall questionnaire instead of a 7-day food diary to estimate daily protein intake. However, previous research has indicated that a 7-day food diary may lead to false positives due to participant fatigue, while using a 3-day recall may enhance overall participation, though there may still result in dietary recall bias\u003csup\u003e[39]\u003c/sup\u003e. Therefore, there may be an under-excessive calculation of protein and energy intake in this study. Secondly, laboratory indicators were not collected from patients to assess malnutrition. Thirdly, this study simultaneously explores the relationship between protein intake sources, food tolerance, and postoperative compliance after LSG. Longer follow-up is necessary to fully understand the relationship between these factors until weight loss stabilizes or rebounds.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003e4.5 conclusion\u003c/h2\u003e \u003cp\u003eA significant number of patients fail to meet the recommended protein intake target within six months after LSG, this study underscores the importance of sufficient protein intake post-LSG and supports the current recommendation of a daily protein intake of at least 60 g. Impaired food tolerance is a common issue post-bariatric surgery, highlighting the need for lifelong follow-up, medical monitoring, targeted care, and guidance by a professional bariatric team to ensure postoperative patients receive targeted care and guidance to improve dietary compliance and prevent complications such as malnutrition.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eF\u003c/strong\u003e\u003cstrong\u003eUNDING DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project received no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDATA AVAILABILITY STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are not publicly available due privacy and ethical reasons, but are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePATIENT CONSENT STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was not required for the quantitative data analysis, and it was implied through voluntary participation in the interviews. Verbal consent to audio-record the interviews was gained at the start of each interview.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONFLICT OF INTEREST STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICAL RESPONSIBILITIES OF AUTHORS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe manuscript has not been published previously (partly or in full)；A single study is not split up into several parts to increase the quantity of submissions and submitted to various journals or to one journal over time；No data have been fabricated or manipulated (including images) ；No data, text, or theories by others are presented as if they were the authors own.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eSteenackers N, Gesquiere I, Matthys C. 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OBES SURG, 2017,27(11):2868-2872.\u003c/li\u003e\n\u003cli\u003e Lee J H, Park J H, Kim S M. Comparison of Dietary Quality and Surgical Satisfaction Between Patients With Suboptimal and Optimal Weight Loss After Sleeve Gastrectomy Using Food Tolerance Score and Bariatric Analysis and Reporting Outcome System Questionnaires.[J]. null, 2022,11(2):54-62.\u003c/li\u003e\n\u003cli\u003e Tarkowska A, Katzer L, Ahlers M O. Assessment of masticatory performance by means of a color-changeable chewing gum.[Z]. 2017: 61, 9-19.\u003c/li\u003e\n\u003cli\u003e Castellanos-Guti\u0026eacute;rrez A, Rodr\u0026iacute;guez-Ram\u0026iacute;rez S, Bromage S, et al. Performance of the Global Diet Quality Score with Nutrition and Health Outcomes in Mexico with 24-h Recall and FFQ Data.[Z]. 2021: 151, 143S-151S.\u003c/li\u003e\n\u003cli\u003e Juli\u0026aacute;n-Alm\u0026aacute;rcegui C, Bel-Serrat S, Kersting M, et al. Comparison of different approaches to calculate nutrient intakes based upon 24-h recall data derived from a multicenter study in European adolescents.[Z]. 2016: 55, 537-545.\u003c/li\u003e\n\u003cli\u003e Suter M, Calmes J, Paroz A, et al. A New Questionnaire for Quick Assessment of Food Tolerance after Bariatric Surgery[J]. Obesity Surgery, 2007,17(1):2-8.\u003c/li\u003e\n\u003cli\u003e Spaggiari G, Santi D, Budriesi G, et al. Eating Behavior after Bariatric Surgery (EBBS) Questionnaire: a New Validated Tool to Quantify the Patients' Compliance to Post-Bariatric Dietary and Lifestyle Suggestions.[J]. OBES SURG, 2020,30(10):3831-3838.\u003c/li\u003e\n\u003cli\u003e 徐梦瑜, 白晓温, 梁晓宇, 等. 减重术后患者饮食行为依从性量表的汉化及信效度检验 [J]. 护理学杂志, 2021,36(16):81-83.\u003c/li\u003e\n\u003cli\u003e Gasmi A, Bj\u0026oslash;rklund G, Mujawdiya P K, et al. Dietary supplements and bariatric surgery.[Z]. 2023: 63, 7477-7488.\u003c/li\u003e\n\u003cli\u003e Kanerva N, Larsson I, Peltonen M, et al. 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Lower Masticatory Performance Is a Risk for the Development of the Metabolic Syndrome: The Suita Study.[J]. Front Cardiovasc Med, 2021,8(null):752667.\u003c/li\u003e\n\u003cli\u003e Wawrzyniak A, Krotki M. Environmental Factors Determining Body Mass Index (BMI) within 9 Months of Therapy Post Bariatric Surgery-Sleeve Gastrectomy (SG).[J]. Nutrients, 2022,14(24):null.\u003c/li\u003e\n\u003cli\u003e Njike V Y, Smith T M, Shuval O, et al. Snack Food, Satiety, and Weight.[Z]. 2016: 7, 866-878.\u003c/li\u003e\n\u003cli\u003e Herrera-Espi\u0026ntilde;eira C, de Pascual Y Medina A M, L\u0026oacute;pez-Morales M, et al. Differences in Dietary Habits, Physical Exercise, and Quality of Life between Patients with Obesity and Overweight.[J]. Healthcare (Basel), 2021,9(7):null.\u003c/li\u003e\n\u003cli\u003e Sherf Dagan S, Keidar A, Raziel A, et al. Do Bariatric Patients Follow Dietary and Lifestyle Recommendations during the First Postoperative Year?[J]. 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Validation of the Danish 7-day pre-coded food diary among adults: energy intake v. energy expenditure and recording length.[Z]. 2009: 102, 1838-1846.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Laparoscopic sleeve gastrectomy, protein intake, food tolerance, dietary behavior compliance, weight loss effect","lastPublishedDoi":"10.21203/rs.3.rs-4598227/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4598227/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eLittle is known about factors associated with protein intake post-laparoscopic sleeve gastrectomy especially in Chinese weight loss patients over six months. This project aimed to identify possible factors to improve protein intake, and investigate protein supplement usage to reduce complications such as malnutrition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A prospective observational study was conducted on 120 eligible patients at a tertiary hospital, who completed study measures at baseline, 3 months post-surgery (M3), and 6 months post-surgery (M6). Univariate and multivariate Linear regressions were utilized to analyze factors related to protein intake.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eAt M6, most patients did not meet the recommended post-LSG protein intake of ≥60 g/day. The three macronutrients for all patients were significant differences in dietary and protein supplement sources between M3 and M6. The EBBS score decreased from M3 to M6, while the chewing cycle and food tolerance scores increased postoperatively. multi-factor linear regression was found that eight independent variables, including gender, age, daily vitamin intake at M6, and total EBBS score at M6, were influencing factors on daily protein intake at M6.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e Findings shed new light on factors that may account for deficiency protein intake, which have implications for guiding effective interventions targeting this behavior.\u003c/p\u003e","manuscriptTitle":"Analysis of changes in protein intake following laparoscopic sleeve gastrectomy and its influencing factors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 15:09:50","doi":"10.21203/rs.3.rs-4598227/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-08-25T18:47:57+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-21T02:36:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-19T14:36:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156904615407841022425511234740910604176","date":"2024-08-10T23:16:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136153502752423113096760092139307473469","date":"2024-08-09T12:42:09+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-08-07T20:33:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-07-02T15:10:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-19T10:56:51+00:00","index":"","fulltext":""},{"type":"submitted","content":"Obesity Surgery","date":"2024-06-18T07:47:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"obesity-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"obsu","sideBox":"Learn more about [Obesity Surgery](https://link.springer.com/journal/11695)","snPcode":"11695","submissionUrl":"https://submission.springernature.com/new-submission/11695/3","title":"Obesity Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"7d7c6477-536f-41a6-81eb-dc64cfb830b0","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-17T16:02:58+00:00","versionOfRecord":{"articleIdentity":"rs-4598227","link":"https://doi.org/10.1007/s11695-025-07739-2","journal":{"identity":"obesity-surgery","isVorOnly":false,"title":"Obesity Surgery"},"publishedOn":"2025-02-11 15:57:03","publishedOnDateReadable":"February 11th, 2025"},"versionCreatedAt":"2024-07-12 15:09:50","video":"","vorDoi":"10.1007/s11695-025-07739-2","vorDoiUrl":"https://doi.org/10.1007/s11695-025-07739-2","workflowStages":[]},"version":"v1","identity":"rs-4598227","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4598227","identity":"rs-4598227","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}