Validity of self-reported weights following bariatric surgery

Patients' perspectives on weight recurrence after bariatric surgery: a single-center survey

BACKGROUND

Weight recurrence (WR) affects nearly 20% of patients after bariatric surgery and may decrease its benefits, affecting patients' quality of life negatively. Patient perspectives on WR are not well known.

OBJECTIVES

Assess patient needs, goals, and preferences regarding WR treatment.

SETTING

Single MBSAQIP-accredited academic center, and online recruitment.

METHODS

An 18-item, web-based survey was distributed to adults seeking treatment for WR after a primary bariatric surgery (PBS), in addition to online recruitment, between 2021 and 2023. Survey items included somatometric data, questions about the importance of factors for successful weight loss, procedure decision-making, and treatment expectations.

RESULTS

Fifty-six patients with > 10% increase from their nadir weight were included in the study. Patients had initially undergone Roux-en-Y gastric bypass (62.5%), sleeve gastrectomy (28.6%), adjustable gastric banding (3.6%), or other procedures (5.3%). When assessing their satisfaction with PBS, 57.1% were somewhat/extremely satisfied, 33.9% somewhat/extremely dissatisfied, while 8.9% were ambivalent. Patients considered the expected benefits (for example, weight loss) as the most important factor when choosing a treatment option for WR. Patient goals included "feeling good about myself" (96.4% very/extremely important), "being able to resume activities I could not do before" (91% very/extremely important), and "improved quality of life" and "-life expectancy" (> 90% very/extremely important). Finally, RBS, lifestyle modification with peer support, and anti-obesity medication were ranked as first treatment options for WR by 40%, 38.8%, and 29.8% of the respondents, respectively.

CONCLUSIONS

Patients considered weight loss as the most important factor when choosing treatment modality for WR, with RBS and lifestyle changes being preferred over weight-loss medications. Large prospective randomized trials are needed to counsel this patient population better.

Post-surgical psychiatric symptoms, maladaptive eating patterns, and lifestyle behaviors associated with weight recurrence after bariatric surgery

BACKGROUND

A significant proportion of patients who undergo bariatric surgery experience weight recurrence; however, the most important areas to target to prevent weight recurrence remain unknown.

OBJECTIVES

The purpose was to examine whether psychiatric symptoms, maladaptive eating behaviors, and lifestyle factors were associated with weight recurrence.

SETTING

Single healthcare system.

METHODS

Individuals who underwent bariatric surgery were invited to complete a web-based survey in which they reported their current weight and completed measures of psychiatric symptoms, maladaptive eating behaviors, and lifestyle behaviors. Participants were included if they were at least 2 years postsurgery. Weight recurrence was measured from the 1-year follow-up to the survey date.

RESULTS

Participants (n = 169) were predominantly female and White or Black, with a mean age of 45 years. The rate of significant weight recurrence was 23.1%. Those who underwent sleeve gastrectomy were more likely to experience weight recurrence (odds ratio [OR] = 12.99; P = .01). In bivariate analyses, anxiety and depressive symptoms, emotional eating, loss of control eating, binge eating, and night eating were associated with weight recurrence (P < .05). Those who did not eat mindfully, take 20 minutes to eat, or get adequate sleep were also more likely to have weight recurrence (P < .05). In a multivariate model, only a lack of mindful eating (OR = 4.84; P = .03) and inadequate sleep (OR = 7.30; P = .02) remained statistically significant predictors.

CONCLUSION

Engaging in mindful eating and obtaining adequate sleep may protect against weight recurrence following bariatric surgery. Clinicians may want to screen and monitor these behaviors.

A comparison of virtual and in person delivery of a full meal replacement program for obesity

Objective

Full meal replacement (FMR) Intensive Lifestyle Interventions (ILI) have been used for weight management. However, predictors of efficacy with these programs are less clear. The primary objective was to assess weight loss predictors in a community-based FMR ILI program. A secondary objective was to determine if weight loss was different between virtual and in person ILI.

Methods

This was a retrospective cohort study involving 234 patients who started the program between 1 January 2016 and 3 March 2021. In the 24-week program, patients spent 12 weeks on FMR and then transitioned back to food for the remainder, with weekly follow up with a physician and group sessions with a dietitian. Visits were in person prior to March 2020 and virtual afterward.

Results

Patients' average age was 47.5 years (SD = 12.0) and 73.5% were female. Average weight loss was 14.3% (SD = 6.2%). There was no significant difference in weight loss between virtual and in person programs. Patients on a Glucagon-like Peptide-1 Receptor Agonist prior lost less weight. Other significant associations between groups were baseline Hemoglobin A1C, classes attended, as well as the age since peak weight.

Conclusion

Weight loss from virtual ILI was not significantly different from person ILI. More research is needed to determine how to best stratify care as virtual or in person using FMR programs.

Weight bias internalization and beliefs about the causes of obesity among the Canadian public

BACKGROUND

Explicit weight bias is known as negative attitudes and beliefs toward individuals due to their weight status and can be perpetuated through misconceptions about the causes of obesity. Individuals may also experience weight bias internalization (WBI) when they internalize negative weight-related attitudes and self-stigmatize. There is a paucity of research on the beliefs about the causes of obesity and the prevalence of WBI among public Canadian samples. The aim of this study was to describe these attitudes and beliefs about obesity among a large Canadian sample across the weight spectrum.

METHODS

A Canadian sample of adults (N = 942; 51% Women; mean age group = 45-54 years; mean body mass index [BMI] = 27.3 ± 6.7 kg/m2) completed an online questionnaire. Participants completed the Modified Weight Bias Internalization Scale, the Anti-Fat Attitudes Questionnaire, and the Causes of Obesity Questionnaire.

RESULTS

Mean WBI score within the entire sample was 3.38 ​​ ± 1.58, and females had higher mean scores as compared to males (p < 0.001). Mean scores were also higher among individuals with a BMI of > 30 kg/m2 (4.16 ± 1.52), as compared to individuals with a BMI of 25-30 kg/m2 (3.40 ± 1.50), and those with a BMI of 20-25 kg/m2 or below 18.5 kg/m2 (2.81 ± 1.44) (p < 0.001 for all). Forty four percent of Canadians believed behavioural causes are very or extremely important in causing obesity, 38% for environmental causes, 28% for physiological and 27% for psychosocial causes. Stronger beliefs in behavioural causes were associated with higher levels of explicit weight bias. No BMI differences were reported on the four different subscales of the Causes of Obesity Questionnaire.

CONCLUSIONS

Weight bias internalization is prevalent among Canadians across all body weight statuses, and the public endorses behavioural causes of obesity, namely physical inactivity and overeating, more than its other causes. Findings warrant the reinforcement of efforts aimed at mitigating weight bias by educating the public about the complexity of obesity and by highlighting weight bias as a systemic issue that affects all Canadians living in diverse body weight statuses.

Weight Regain and Ingestive Behavior in Women after Metabolic Surgery

This study investigated associations between maladaptive ingestive behaviors and weight regain in women who underwent metabolic surgery 2-10 years ago. Using a web-based survey, we assessed emotional, external, and restrained eating (Dutch Eating Behavior Questionnaire-DEBQ), food cravings (Food-Craving Inventory-FCI), and other behaviors (e.g., Eating Disorder Examination Questionnaire-EDE-Q; Alcohol Use Disorder Identification Test-Concise-AUDIT-C) in 36 women (42.9 ± 9.5 years old) post-surgery. We found that weight regain was specifically associated with increased frequency of cravings for sweets (r = 0.43), higher global scores in the EDE-Q (r = 0.38), and time elapsed since surgery (r = 0.35; all p's < 0.04). Multiple regression analysis revealed that the association between weight regain and sweet cravings interacted with time after surgery (p = 0.04), with the strongest association observed in women assessed closer to the surgery (i.e., 2.0-2.8 years). The combination of time after surgery and its interaction with sweet cravings accounted for 31% of the individual variations in weight regain (p = 0.005). Notably, among participants who reported alcohol consumption (31 of 36), 55% had an AUDIT-C score indicating hazardous drinking. These findings highlight the relevance of attending to patients' reports of frequent sweet cravings and screening for alcohol use to enhance strategies tailored to prevent weight regain and alcohol-related health problems post-surgery.

Post-surgical cannabis use is associated with weight loss among individuals up to 4 years after bariatric surgery

INTRODUCTION

Although cannabis is known to stimulate appetite, it is not clear whether cannabis use may impact weight loss outcomes following bariatric surgery. Although some work has suggested that pre-surgical cannabis use is not associated with post-surgical weight loss, the role of post-surgical cannabis use has not yet been examined. The purpose of this study was to measure pre- and post-surgical cannabis use and determine whether cannabis use was associated with weight loss outcomes following bariatric surgery.

METHODS

Patients who underwent bariatric surgery over a 4-year period at a single health care system were invited to complete a survey regarding pre- and post-surgical cannabis use and report their current weight. Pre-surgical weight and BMI were extracted from medical records to calculate change in BMI (ΔBMI), percent total weight loss (%TWL), percent excess weight loss (%EWL), whether participants experienced a successful weight loss outcome, and whether participants had weight recurrence.

RESULTS

Among all participants (N = 759), 10.7% and 14.5% engaged in pre- and post-surgical cannabis use, respectively. Pre-surgical cannabis use was not associated with any weight loss outcomes (p > 0.05). Any post-surgical cannabis use was associated with lower %EWL (p = 0.04) and greater likelihood of weight recurrence (p = 0.04). Weekly cannabis use was associated with lower %EWL (p = 0.003), lower %TWL (p = 0.04), and a lower likelihood of having a successful weight loss outcome (p = 0.02).

CONCLUSIONS

Although pre-surgical cannabis use may not predict weight loss outcomes, post-surgical cannabis was associated with poorer weight loss outcomes. Frequent use (i.e., weekly) may be especially problematic. Providers should consider screening patients for cannabis use and educate them about the potential impact of postoperative cannabis use on weight loss following bariatric surgery.

Childhood Maltreatment in Patients Undergoing Bariatric Surgery: Implications for Weight Loss, Depression and Eating Behavior

We aimed to explore the relationships between childhood maltreatment and changes in weight, depressive symptoms and eating behavior post-bariatric surgery (BS). Participants (n = 111, 85% females) were evaluated pre-surgery, and at 6 months (6 M) and 12 months (12 M) post-BS. History of maltreatment was assessed at baseline (Childhood Trauma Questionnaire), and depressive symptoms (Beck Depression Inventory-II) and eating behavior (Dutch Eating Behavior Questionnaire) were assessed at all time points. Participants' mean age and median BMI were 45.1 ± 11.7 years and 46.7 (IQR 42.4-51.9) kg/m², respectively. Histories of emotional (EA), physical (PA) and sexual abuse (SA) and emotional (EN) and physical (PN) neglect were reported by 47.7%, 25.2%, 39.6%, 51.4% and 40.5%, respectively, with 78.4% reporting at least one form of maltreatment. Changes in weight and depressive symptoms were not different between patients with vs. without a history of maltreatment. However, those with vs. without SA demonstrated limited changes in emotional eating (EE) at 12 M, while those without showed improvements. Conversely, patients with vs. without EN showed greater improvements in external eating (ExE) at 6 M, but differences were no longer observed by 12 M. Results indicate that histories of SA and EN are associated with changes in eating behaviors post-BS and have implications for assessment, monitoring and potential intervention development.

Evaluating agreement between clinic- and patient-reported outcomes for weight and co-morbidities at 1 year after bariatric surgery

BACKGROUND

Development of patient-reported outcomes (PROs) to include traditionally clinic-reported data has the potential to decrease the data-collection burden for patients and clinicians and increase follow-up rates. However, replacing clinic report by patient report requires that the data reasonably agree.

OBJECTIVE

To assess agreement between PROs and clinical registry data at 1 year after bariatric surgery.

SETTING

Not-for-profit organization, bariatric surgery data registry, PROs platform.

METHODS

Patient- and clinic-reported 1-year postoperative weight and co-morbidities were compared for matched PROs and registry records. The co-morbidities evaluated were diabetes, sleep apnea, hypertension, gastroesophageal reflux disease, and hyperlipidemia. Weight difference in pounds and nominal groupings (binary, 4-level) for co-morbidities were assessed for agreement between data sources using descriptive statistics, Bland-Altman plots, multiple regression, and kappa coefficients. Sensitivity analyses and follow-up by response method were examined.

RESULTS

Among 1130 patients with both 1-year PROs and registry weights, 95% of patient-reported weights were within 13 lb of the registry-recorded weight, and patients underreported their weight by ∼2 lb, on average. Percent agreement and kappa coefficients were highest for diabetes (n = 999; binary: 94%, κ = .72; 4-level: 86%, κ = .71) and lowest for gastroesophageal reflux disease (n = 1032; binary: 75%, κ = .40; 4-level: 57%, κ = .35). Of patients eligible for both PROs and registry 1-year follow-up, 21% had PROs only.

CONCLUSIONS

One-year patient- and clinic-reported weights and disease status for patients with diabetes and hypertension showed high agreement. The degree of bias from patient report was low. Patient report is a viable alternative to clinic report for certain objective measurements and may increase follow-up.

Effects of Lifestyle and Educational Bridging Programs before Bariatric Surgery on Postoperative Weight Loss: A Systematic Review and Meta-Analysis

OBJECTIVE

To fulfill the requirements for bariatric surgery, patients often need to participate in mandatory preoperative lifestyle interventions. Currently, the efficacy of multi-month preoperative lifestyle intervention programs on body mass index (BMI) reduction from the start of the program (T0) through the immediate preoperative time point (T1) to 1 year post-surgery (T2) and how the amount of preoperative BMI reduction affects postoperative outcome (T1 to T2) is unclear. The aim of this meta-analysis was to analyze the effects of preoperative lifestyle interventions on BMI 1 year post-surgery.

METHOD

A systematic literature search was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Randomized controlled trials that implemented preoperative lifestyle interventions lasting 1-8 months before bariatric surgery were included. The BMI of the intervention group was compared with that of a control group before participation in the preoperative lifestyle interventions (T0), after completion of the program before surgery (T1), and 1 year post-surgery (T2). Finally, the impact of successful BMI reduction at T1 on BMI at T2 was analyzed.

RESULTS

N = 345 patients derived from 4 studies undergoing preoperative lifestyle interventions reduced their BMI at T1 by 1.5 units compared to the control group (95% CI: -2.73, -0.28). One year post-surgery, both groups had lost comparable BMI points. The influence of reduced BMI at T1 on weight status at T2 is unclear due to the lack of available studies. Other endpoints and subgroup analyses were rarely examined.

CONCLUSIONS

Preoperative lifestyle interventions reduce BMI before bariatric surgery more effectively than usual care. These differences are not detectable 1 year post-surgery. Although a short-term energy reduction period before surgery is clearly important to minimize surgery risks, it is currently unclear whether, and if so, under what circumstances, participation in a preoperative lifestyle intervention is beneficial.

Five-year attrition, active enrollment, and predictors of level of participation in the Longitudinal Assessment of Bariatric Surgery (LABS-2) study

BACKGROUND

Reporting high-quality bariatric surgery outcomes depends on participant attrition and level of study participation among enrolled participants.

OBJECTIVES

Our aims are to report participant attrition, active enrollment, and level of participation, and to evaluate pre-surgery sociodemographic, physical health, and psychosocial factors as predictors of attrition and level of participation through 5 years.

SETTING

The Longitudinal Assessment of Bariatric Surgery-2 study which enrolled 2458 adults undergoing a first bariatric surgical procedure at 1 of 6 US cites from 2006 through 2009.

METHODS

In-person research assessments were conducted pre-surgery and annually for five years. Extensive retention strategies including offering remote assessments (telephone, email, mail, or a combination) were fully implemented in 2009. Among living participants, including those inactivated, annual follow-up assessments were categorized as in-person, remote or missed through 5 years.

RESULTS

By year 5, 1.7% of participants had died and 3.2% had withdrawn or were inactivated by the study staff; thus, attrition was 4.9% (n = 121). Controlling for site and calendar year, missed assessments increased from 14.7%-21.8% between years 1 and 2 and then stayed relatively stable (20.8%-19.6%) for years 3-5. Younger age, male sex, White race, lower body mass index, smoking, illicit drug use, and higher weight loss expectations preoperatively were independently associated with a higher likelihood of a missed versus in-person assessment across follow-up.

CONCLUSION

The LABS-2 participant attrition was low. The percentage of missed assessments did not increase after year 2, perhaps due to implementation of a comprehensive retention plan. Predictors of missed assessments highlight subgroups to target for focused retention efforts.

Pain is adversely related to weight loss maintenance following bariatric surgery

BACKGROUND

Pain and obesity are frequently co-morbid health conditions; thus, it is unsurprising that pain is commonly experienced by individuals seeking bariatric surgery. While pain is generally reduced in the short-term after surgery, there is also variability in pain outcomes and less is known about how unresolved or recurring pain may relate to long-term weight loss and weight loss maintenance.

OBJECTIVES

This study evaluated trajectories of pain scores through 7 years following bariatric surgery and whether higher pain levels related to poorer weight loss and greater weight regain.

SETTING

Data were collected from 3 university hospitals, 1 private not-for-profit research institute, and 1 community hospital.

METHODS

Self-report measures of pain and weight change data were utilized for 1702 adults seeking Roux-en-Y gastric bypass surgery from the Longitudinal Assessment for Bariatric Surgery (LABS) cohort. A series of linear mixed models examined trajectories of pain scores and the concurrent predictive relationship between pain and weight outcomes from pre-surgery through 7 years post-surgery.

RESULTS

Overall bodily-, hip-, and knee-pain improved through 2 years, deteriorated from 2-5 years, and then slightly improved from 5-7 years following surgery (P < .001). Greater pain was concurrently associated with less weight loss and greater weight regain over time (P ≤ .006).

CONCLUSION

Pain is evident in the long-term following bariatric surgery and associated with suboptimal weight outcomes. More research is needed to identify mechanisms underlying this relationship, which may ultimately help develop appropriate pain assessment and treatment strategies to ensure optimal post-surgery outcomes.

Psychological Functioning and Health Behaviors Associated with Weight Loss Patterns up to 13.7 Years After Weight Loss Surgery

Weight loss surgery produces dramatic health improvements immediately after surgery, including rapid declines in diabetes. However, less is known about its long-term effects. 124 St. Vincent Bariatric Center patients completed questionnaires on weight and psychological functioning a mean of 7.7 and 13.7 years post-surgery (T1 and T2, respectively). Because mean weight data may mask differing weight trajectories, participants were categorized based on weight over time. Most participants underwent Roux-En-Y gastric bypass (90.3%) and were Caucasian (96%), female (81.5%), and married (69.1%). Mean age at T2 was 64; mean %EWL was 64.9%. Most patients fit into one of three weight change patterns, reaching weight nadir, and regaining by T1 and then, by T2, experiencing (1) Weight Loss (n = 36), (2) Weight Maintenance (n = 37), or (3) Continued Weight Gain (n = 39). Groups differed significantly on body satisfaction, weighing frequency, and conscientiousness, with Weight Gainers significantly lower than other groups on conscientiousness and body satisfaction, and Weight Losers reporting higher frequency of weighing than Maintainers. Bariatric patients can maintain substantial weight loss and positive psychological functioning for many years post-surgery, although weight regain is associated with less body satisfaction. Conscientiousness may signify medical adherence, whereas frequent weighing may be a behavior that promotes ongoing weight loss.

Examining Weight Bias and Loss-of-Control Eating among Individuals Seeking Bariatric Surgery

OBJECTIVE

Externalized weight bias (EWB), directed towards others, and internalized weight bias (IWB), directed towards the self, are thought to exacerbate obesity and disordered eating and may be important factors to assess and understand among individuals seeking bariatric surgery. This study examined clinical correlates (pre-surgical BMI, depressive symptoms, weight self-efficacy, and shape/weight overvaluation) of both EWB and IWB among individuals presenting for bariatric surgery with and without regular loss-of-control eating (LOC eating).

METHODS

A total of 316 adults presenting for bariatric surgery completed established self-report measures to assess EWB, IWB, depressive symptoms, weight self-efficacy, and core symptoms of disordered eating including LOC eating and overvaluation of shape/weight.

RESULTS

IWB and EWB were not associated with pre-surgical BMI, age, or sex, but were both significantly higher among White than non-White participants. Adjusting for race, IWB and EWB were significantly associated with greater eating disorder psychopathology and depressive symptoms and with less weight-related self-efficacy. Participants who endorsed regular LOC eating (53.5% of the sample) endorsed significantly lower weight self-efficacy and higher IWB, EWB, depressive symptoms, and overvaluation of shape/weight.

CONCLUSIONS

Findings suggest that regular LOC eating is common among individuals seeking bariatric surgery and associated with a range of heightened eating disorder and psychosocial concerns including both IWB and EWB. Future research exploring the longitudinal significance of the relationship between these two forms of weight bias and LOC eating is indicated.

Factors associated with completion of patient surveys 1 year after bariatric surgery

BACKGROUND

Patient-reported outcomes (PRO) obtained from follow-up survey data are essential to understanding the longitudinal effects of bariatric surgery. However, capturing data among patients who are well beyond the recovery period of surgery remains a challenge, and little is known about what factors may influence follow-up rates for PRO.

OBJECTIVES

To assess the effect of hospital practices and surgical outcomes on patient survey completion rates at 1 year after bariatric surgery.

SETTING

Prospective, statewide, bariatric-specific clinical registry.

METHODS

Patients at hospitals participating in the Michigan Bariatric Surgery Collaborative are surveyed annually to obtain information on weight loss, medication use, satisfaction, body image, and quality of life following bariatric surgery. Hospital program coordinators were surveyed in June 2017 about their practices for ensuring survey completion among their patients. Hospitals were ranked based on 1-year patient survey completion rates between 2011 and 2015. Multivariable regression analyses were used to identify associations between hospital practices, as well as 30-day outcomes, on hospital survey completion rankings.

RESULTS

Overall, patient survey completion rates at 1 year improved from 2011 (33.9% ± 14.5%) to 2015 (51.0% ± 13.0%), although there was wide variability between hospitals (21.1% versus 77.3% in 2015). Hospitals in the bottom quartile for survey completion rates had higher adjusted rates of 30-day severe complications (2.6% versus 1.7%, respectively; P = .0481), readmissions (5.0% versus 3.9%, respectively; P = .0157), and reoperations (1.5% versus .7%, respectively; P = .0216) than those in the top quartile. While most hospital practices did not significantly impact survey completion at 1 year, physically handing out surveys during clinic visits was independently associated with higher completion rates (odds ratio, 13.60; 95% confidence interval, 1.99-93.03; P =.0078).

CONCLUSIONS

Hospitals vary considerably in completion rates of patient surveys at 1 year after bariatric surgery, and lower rates were associated with hospitals that had higher complication rates. Hospitals with the highest completion rates were more likely to physically hand surveys to patients during clinic visits. Given the value of PRO on longitudinal outcomes of bariatric surgery, improving data collection across multiple hospital systems is imperative.

Associations of Pregnancy After Bariatric Surgery with Long-Term Weight Trajectories and Birth Weight: LABS-2 Study

OBJECTIVE

This study aimed to examine whether pregnancy following bariatric surgery affects long-term maternal weight change and offspring birth weight.

METHODS

Using data from the Longitudinal Assessment of Bariatric Surgery (LABS)-2 study, linear regression was used to evaluate percent change in total body weight over a 5-year follow-up period among reproductive-aged women who underwent Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding as well as evaluate the association of bariatric procedure type and offspring birth weight.

RESULTS

Of 727 women with preoperative age of 36.1 (6.3) years (mean [SD]) and BMI of 46.9 (7.0) kg/m² , 80 (11%) reported at least one pregnancy. After adjusting for covariates, percent change in total body weight was not significantly different between women who became pregnant and those who did not during a 5-year follow-up period (β = 2.02; 95% CI: -1.03 to 5.07; P = 0.19). Additionally, mean birth weight was not significantly different between mothers who underwent Roux-en-Y gastric bypass versus laparoscopic adjustable gastric banding (P = 0.99).

CONCLUSIONS

Postoperative pregnancy did not diminish long-term weight loss in women in the LABS-2 study. The finding of comparable weight loss is relevant for providers counseling women of reproductive age on weight-loss expectations and family planning following bariatric surgery.

The Influence of Health Literacy and Health Numeracy on Weight Loss Outcomes Following Bariatric Surgery

BACKGROUND

Although cognitive functioning and health literacy are related to weight loss 1year following bariatric surgery, the influence of health numeracy (i.e., health-related mathematical abilities) is unknown. In addition, further research is needed to examine the impact of all these factors on longer-term weight loss outcomes to determine if they influence the ability to maintain weight loss.

SETTING

Single bariatric center.

METHODS

Patients (N = 567) who underwent bariatric surgery from 2014-2017 completed a brief survey including current weight. Retrospective chart reviews were conducted to gather information from the presurgical evaluation including weight, body mass index (BMI), health literacy, health numeracy and score on a cognitive screener.

RESULTS

Among participants in the weight loss period (< 2 years postsurgery), health literacy, health numeracy and cognitive functioning were not related to change in BMI (ΔBMI), percent total weight loss (%TWL) or percent excess weight loss (%EWL). However, for participants in the weight maintenance period (2-4 years postsurgery), higher health literacy scores were related to greater change in ΔBMI, and higher health numeracy scores were related to greater ΔBMI, %TWL, and %EWL.

DISCUSSION

Although health literacy and health numeracy did not predict weight loss outcomes for those in the initial weight loss period, they were related to weight outcomes for participants in the weight maintenance period. This suggests that health literacy and health numeracy may play a role in facilitating longer-term weight maintenance among patients who undergo bariatric surgery. Clinicians conducting presurgical psychosocial evaluations should consider routinely screening for health literacy and health numeracy.

Associations between Physical Activity and Changes in Weight Across 7 Years following ROUX-en-Y Gastric Bypass Surgery: A Multicenter Prospective Cohort Study

OBJECTIVE

To examine associations of objectively-measured physical activity (PA) with changes in weight after Roux-en-Y gastric bypass (RYGB) over 7 years.

BACKGROUND

The contribution of free-living PA to surgery-induced weight loss and subsequent weight regain is not well understood.

METHODS

Participants of a multi-center prospective cohort study of bariatric surgery were followed annually ≥7 years. Of 807 participants who underwent RYGB and were given an activity monitor, 649 (80%) had sufficient data for this report (78% female; median age 47 years; median body mass index 46 kg/m). Mean daily steps, hours/day in sedentary behavior (SB) and minutes/week in moderate-to-vigorous physical activity (MVPA) were determined at each assessment. Mixed models tested associations between PA measures and weight outcomes, controlling for sociodemographics, health status and eating behaviors.

RESULTS

Across follow-up, mean pre- to post-surgery changes in PA were small, and mean post-surgery PA level was below PA recommendations for health (e.g., 101 MVPA min/week 7 years post-surgery versus the ≥150 MVPA min/week recommendation). There was a dose-response association between more steps, less SB and more MVPA with greater weight loss. Steps and SB, but not MVPA, were also associated with weight regain. For example, participants in the highest versus lowest steps quartile lost 2.9% (95%CI, 1.8-4.1) more of their pre-surgery weight and regained 5.4% (95%CI, 2.4-8.3) less of their maximum weight lost across follow-up.

CONCLUSION

Despite only small increases in objectively-measured PA level after RYGB, PA level was independently associated with weight outcomes of bariatric surgery throughout 7 years of follow-up.

REPRINTS

Reprints will not be available from the authors.

Reported nutrient intake over 7 years after Roux-en-Y gastric bypass in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) psychosocial study

BACKGROUND

Bariatric surgery is the most effective therapy for severe obesity. It reduces gastric capacity and may modify regulation of appetite, satiety, insulin, and other physiologic processes, resulting in weight loss.

OBJECTIVE

Long-term data on postsurgical nutrient intake are lacking.

SETTING

The Longitudinal Assessment of Bariatric Surgery-3 psychosocial study.

METHODS

Reported dietary intake was assessed in a subset of participants (n = 72) of the Longitudinal Assessment of Bariatric Surgery-3 psychosocial study who underwent Roux-en-Y gastric bypass surgery. Two 24-hour diet recalls at presurgery and annual assessments over 7 years were obtained. Reported diets were evaluated for energy, macro- and micronutrient intake, and assessed for adequacy by comparison to the dietary reference intakes.

RESULTS

After surgery, reported intake of total energy, and all macronutrients were significantly reduced. At least a quarter of participants reported protein intake below the recommended dietary allowance. Over half of participants reported intake of several vitamins (C, D, A, E, thiamin, folate) and minerals (zinc, calcium) below recommended levels over 7 years. Compared with presurgery, reported energy intake was reduced over 7 years. This study was registered at ClinicalTrials.gov as NCT02495142.

CONCLUSIONS

The reduction in energy resulted in intakes below the dietary reference intakes for many micronutrients among the majority of participants and below the recommended dietary allowance for protein in a substantial subgroup. These data support continued long-term nutrition education, monitoring, and supplementation.

Differences in body mass index based on self-reported versus measured data from women veterans

OBJECTIVE

The objective was to compare differences in body mass index (BMI) calculated with self-reported versus clinically measured pre-conception data from women veterans in California.

METHODS

Veterans Health Administration (VHA) and California state birth certificate data were used to develop a cohort of women who gave birth from 2007-2012 and had VHA data available to calculate BMI (N = 1,326 mothers, 1,473 births). Weighted Kappa statistics assessed concordance between self-reported and measured BMI. A linear mixed-effects model with maximum likelihood estimation, adjusted for mother as a random effect, assessed correlates of differences in BMI.

RESULTS

Mean BMI was in the overweight range based on self-reported (26.2 kg/m2, SD: 5.2) and measured (26.8 kg/m2, SD: 5.2) data. Weighted Kappa statistics indicated good agreement between self-reported and measured BMI (0.73, 95% CI: 0.70, 0.76). Compared to the normal weight group, groups with overweight or obesity were significantly more likely to have lower BMIs when calculated using self-reported versus measured heights and weights, in unadjusted and adjusted models. The finding was pronounced for class 3 obesity, which was associated with a BMI underestimation of 6.4 kg/m2.

CONCLUSIONS

Epidemiologic research that guides the clinical care of pregnant women should account for potential under-estimation of BMI in heavier women, and perform direct measurement where feasible.

The effectiveness of psychosocial interventions to support psychological well-being in post-operative bariatric patients: A systematic review of evidence

BACKGROUND

Bariatric surgery is considered an effective obesity management intervention for individuals with a BMI greater than 40, or 35 with co-morbidities. However, research documents that psychological difficulties prevalent amongst individuals seeking surgery may persist post-operatively. This systematic review aims to assess the evidence to show which psychosocial interventions support psychological well-being post-operatively.

METHODS

The review is registered with Prospero (CRD42018100280), complying with PRISMA guidelines. The research protocol included grey literature and database searches of psychosocial interventions for post-operative bariatric patients, between November 2017 and September 2019. The primary outcome was psychological well-being; secondary outcomes included weight loss maintenance and quality of life (QoL). The primary reviewer screened titles and extracted data. Study quality was assessed independently by two reviewers, using the Effective Public Health Practice Project criteria. Due to heterogeneity across studies, narrative synthesis was considered suitable for data analysis.

RESULTS

Ten studies met inclusion criteria. Psychosocial intervention content was delivered in a variety of ways (e.g., clinic, internet-based). Overall, participants (N = 382, Mage = 46.4) receiving psychosocial interventions post bariatric surgery, demonstrated improvements in psychological well-being and weight loss maintenance, compared to baseline measures and/or controls. The strength of evidence is currently limited by the small number of studies found and study quality, limiting the power to detect clinically meaningful changes; findings should therefore be considered preliminary.

CONCLUSION

Preliminary findings suggest that interdisciplinary interventions including acceptance-based approaches, psychoeducation, nutrition and lifestyle modification, delivered 1-year post-operative, are promising. Further scientific enquiry is warranted with well-designed studies and long-term follow-ups.

Association between weight loss and serum biomarkers with risk of incident cancer in the Longitudinal Assessment of Bariatric Surgery cohort

BACKGROUND

Bariatric surgery reduces cancer risk in populations with obesity. It is unclear if weight loss alone or metabolic changes related to bariatric surgery cause this effect.

OBJECTIVE

We evaluated the relationship between surgical weight loss and serum biomarker changes with incident cancer in a bariatric surgery cohort.

SETTING

Ten U.S. clinical facilities.

METHODS

The Longitudinal Assessment of Bariatric Surgery 2 (LABS-2) is a prospective multicenter cohort (n = 2458, 79% female, mean age = 46). We evaluated weight and serum biomarkers, measured preoperatively and 1 year postoperatively, as predictors for incident cancer. Associations were determined using Cox proportional hazards models adjusting for weight loss, age, sex, education, and smoking history.

RESULTS

Over 8759 person-years of follow-up, 82 patients reported new cancer diagnosis (936 per 100,000 person-years, 95% confidence interval [CI]: 749-1156). Cancer risk was decreased by approximately 50% in participants with 20% to 34.9% total weight loss (TWL) compared with <20% TWL (hazard ratio [HR] = .49, 95%CI: .29-.83). Reduced cancer risk was observed with percent decrease from baseline for glucose (per 10%, HR = .94, 95%CI: .90-.99), proinsulin (per 20%, HR = .95, 95%CI: .93-.98), insulin (per 30%, HR = .97, 95%CI: .96-.99), and leptin (per 20%, HR = .81, 95%CI: .68-.97), and per 15% percent increase in ghrelin (HR = .94, 95%CI: .29-.83).

CONCLUSIONS

After bariatric surgery, cancer risk is reduced >50% when weight loss exceeds 20% TWL compared with patients with <20% TWL. Weight loss alone may not explain the observed risk reduction, as improvements in diabetes, leptin, and ghrelin were associated with decreased cancer risk.

Weight regain after bariatric surgery: a systematic literature review and comparison across studies using a large reference sample

Published estimates of weight regain (WR) after bariatric surgery vary greatly. Understanding the sources of variability in the literature and clarifying the magnitude of WR after Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) are critical for informing expectations and planning interventions. A literature search through January 2019 yielded 15 English-language studies that reported WR in at least 30 participants, not selected based on weight loss or WR, at least 3 years after primary RYGB (n = 11) or SG (n = 5). Median follow-up was 5.0 (range, 3.2-10.0) years. Median sample size was 62 (range, 33-464). Samples represented a median of 54.3% (range, 10.7%-100%) of eligible participants. Nadir weight was determined by serial research assessments (n = 1), medical records (n = 7), participant recall (n = 4), or an undisclosed method (n = 4). Three continuous and 8 binary WR measures (the latter, based on various thresholds for clinically meaningful WR) were reported. To enable comparison across studies, the percentage difference in WR in each study versus a reference sample (n = 1433 RYGB), matched on time since surgery and WR measure, was calculated. Median WR in the reference sample increased from 8.2 (25th-75th percentile: 0-19.5) to 23.8 (25th-75th percentile: 9.0-33.9) percent of maximum weight lost, 3 to 6 years post RYGB surgery. Studies of RYGB versus SG, with larger versus smaller samples, with higher versus lower participation rates, that determined nadir weight via participant recall versus medical records, and reported continuous versus binary WR measures tended to have WR values closer to the reference sample and each other. Variation in WR estimates was explained by heterogeneity in WR measures, timing of assessment, surgical procedure, and study design characteristics. The best estimate of WR after RYGB likely comes from the large reference sample. WR after SG versus RYGB appears higher. However, additional high-quality studies with uniform reporting of WR by surgical procedure are needed.

Examining emotion-, personality-, and reward-related dispositional tendencies in relation to eating pathology and weight change over seven years in the Longitudinal Assessment of Bariatric Surgery (LABS) study

This study examined dispositional emotion-, personality/temperament-, and reward-related variables in relation to post-surgery eating pathology and weight-change among 107 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB). As part of a prospective cohort study, annual post-surgical assessments were conducted to evaluate eating pathology, using the Eating Disorder Examination-Bariatric Surgery Version, and percent weight change from pre-surgery. Dispositional measures were administered at the 6- or 7-year assessment and included the Affect Intensity Measure, Difficulties in Emotion Regulation Scale, UPPS-P Impulsive Behavior Scale, Adult Temperament Questionnaire-Effortful Control Scale, and Sensitivity to Punishment/Sensitivity to Reward Questionnaire. Results from a series of linear mixed models revealed significant associations of emotion dysregulation, affect intensity, positive and negative urgency, effortful control, and reward sensitivity with eating pathology severity across 7 years; additionally, all but two of the subscales comprising the total scores were also significantly associated. Fewer statistically significant results were found in relation to weight change; emotion dysregulation and affect intensity (along with several subscales) were significantly associated with lower percent weight change (i.e., less weight loss), but of the reward-related and personality/temperament variables, only total effortful control emerged as significant. However, the associations of the other variables with both outcomes were consistently in the expected direction. Associations also appeared consistent across surgical procedures. Taken together, findings suggest that certain dispositional tendencies may relate to less optimal long-term outcomes following bariatric surgery and thus may be useful to assess in pre-surgical or early post-surgical evaluations to inform targeted recommendations.

Bariatric Surgery Among Medicare Subgroups: Short- and Long-Term Outcomes

OBJECTIVE

This study sought to examine weight change, postoperative adverse events, and related outcomes of interest among age-qualified (AQ) and disability-qualified (DQ) Medicare recipients compared with non-Medicare (NM) patients undergoing an initial bariatric procedure.

METHODS

The Longitudinal Assessment of Bariatric Surgery (LABS-2) is an observational cohort study of 2,458 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) bariatric surgery. Weight, percentage body fat, functional status, and comorbidities, as well as postoperative adverse events, were assessed at baseline and annually for 5 years. The 1,943 participants who reported insurance type were categorized into the following groups: AQ, DQ, or NM.

RESULTS

The median preoperative BMI ranged from 45 to 48 kg/m² across groups. For RYGB, 5-year BMI loss was approximately 30% for all groups, and for LAGB, BMI loss was 12% to 15%. Diabetes remission after 5 years was also similar across groups within procedure types (RYGB: 33%-40%; LAGB: 13%-19%). The frequency of adverse events after RYGB ranged from 4.1% for NM participants to 6.7% for DQ participants. After LAGB, there were no adverse events for the AQ group, whereas 3% of DQ participants and 1.8% of NM participants had at least one adverse event.

CONCLUSIONS

Medicare participants experienced substantial BMI loss and diabetes remission, with a frequency of adverse events similar to that of NM participants.

Proximal Roux-en-Y gastric bypass: Addressing the myth of limb length

BACKGROUND

Some studies suggest that changes in weight or metabolic outcomes are affected by the lengths of the gastrointestinal limbs in the Roux-en-Y gastric bypass.

METHODS

Participants (N = 1,770) underwent primary Roux-en-Y gastric bypass and were followed ≤7 years in the Longitudinal Assessment of Bariatric Surgery-2, a multicenter US cohort study. Alimentary limb and biliopancreatic limb lengths were measured according to research protocol; common channel was measured in a subsample (N = 547). Aimentary limb, biliopancreatic limb, and common channel ratio to total small bowel length were calculated.

RESULTS

Median presurgery body mass index was 46 (25th-75th percentile: 43-51) kg/m2. Medians (25th-75th percentiles) for alimentary limb length were 125 cm (100-150), for biliopancreatic limb length were 50 cm (50-60), and common channel length were 410 cm (322-520). Statistics for ratios to the small bowel length were 0.23 (0.18-0.27) for alimentary limb, 0.09 (0.07-0.10) for biliopancreatic limb, and 0.69 (0.63-0.73) for common length. There were no significant associations between alimentary limb, biliopancreatic limb, common channel, alimentary limb ratio, biliopancreatic limb ratio or common channel ratio, and either weight loss or improvement in cardiometabolic outcomes.

CONCLUSION

The common channel length in Roux-en-Y gastric bypass is highly variable between individuals. None of the limb lengths in this study, nor alimentary limb, biliopancreatic limb, or common channel ratios, seem to be related to weight loss or metabolic improvements >7 years.

Seven-Year Weight Trajectories and Health Outcomes in the Longitudinal Assessment of Bariatric Surgery (LABS) Study

Importance

More information is needed about the durability of weight loss and health improvements after bariatric surgical procedures.

Objective

To examine long-term weight change and health status following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB).

Design, Setting, and Participants

The Longitudinal Assessment of Bariatric Surgery (LABS) study is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Adults undergoing bariatric surgical procedures as part of clinical care between 2006 and 2009 were recruited and followed up until January 31, 2015. Participants completed presurgery, 6-month, and annual research assessments for up to 7 years.

Main Outcome and Measures

Percentage of weight change from baseline, diabetes, dyslipidemia, and hypertension, determined by physical measures, laboratory testing, and medication use.

Results

Of 2348 participants, 1738 underwent RYGB (74%) and 610 underwent LAGB (26%). For RYBG, the median age was 45 years (range, 19-75 years), the median body mass index (calculated as weight in kilograms divided by height in meters squared) was 47 (range, 34-81), 1389 participants (80%) were women, and 257 participants (15%) were nonwhite. For LAGB, the median age was 48 years (range, 18-78), the body mass index was 44 (range, 33-87), 465 participants (76%) were women, and 63 participants (10%) were nonwhite. Follow-up weights were obtained in 1300 of 1569 (83%) eligible for a year-7 visit. Seven years following RYGB, mean weight loss was 38.2 kg (95% CI, 36.9-39.5), or 28.4% (95% CI, 27.6-29.2) of baseline weight; between years 3 and 7 mean weight regain was 3.9% (95% CI, 3.4-4.4) of baseline weight. Seven years after LAGB, mean weight loss was 18.8 kg (95% CI, 16.3-21.3) or 14.9% (95% CI, 13.1-16.7), with 1.4% (95% CI, 0.4-2.4) regain. Six distinct weight change trajectory patterns for RYGB and 7 for LAGB were identified. Most participants followed trajectories in which weight regain from 3 to 7 years was small relative to year-3 weight loss, but patterns were variable. Compared with baseline, dyslipidemia prevalence was lower 7 years following both procedures; diabetes and hypertension prevalence were lower following RYGB only. Among those with diabetes at baseline (488 of 1723 with RYGB [28%]; 175 of 604 with LAGB [29%]), the proportion in remission at 1, 3, 5, and 7 years were 71.2% (95% CI, 67.0-75.4), 69.4% (95% CI, 65.0-73.8), 64.6% (95% CI, 60.0-69.2), and 60.2% (95% CI, 54.7-65.6), respectively, for RYGB and 30.7% (95% CI, 22.8-38.7), 29.3% (95% CI, 21.6-37.1), 29.2% (95% CI, 21.0-37.4), and 20.3% (95% CI, 9.7-30.9) for LAGB. The incidence of diabetes at all follow-up assessments was less than 1.5% for RYGB. Bariatric reoperations occurred in 14 RYGB and 160 LAGB participants.

Conclusions and Relevance

Following bariatric surgery, different weight loss patterns were observed, but most participants maintained much of their weight loss with variable fluctuations over the long term. There was some decline in diabetes remission over time, but the incidence of new cases is low following RYGB.

Trial Registration

clinicaltrials.gov Identifier: NCT00465829.

Mortality after bariatric surgery: findings from a 7-year multicenter cohort study

BACKGROUND

Patients having bariatric surgery have lower mortality compared with those with similar body mass index who do not undergo surgery. It is unclear whether mortality post-bariatric surgery is similar to the general population. The benefit of bariatric surgery would be highlighted should people previously at high risk for premature death have comparable, or better, mortality as the general population.

OBJECTIVE

To compare mortality after bariatric surgery to the general U.S. population of the same age, sex, and race.

SETTING

The Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) prospective cohort of 2458 adults who underwent bariatric surgery at 10 U.S. hospitals between 2006 and 2009.

METHODS

Deaths were identified via LABS-2 follow-up and the National Death Index. Standardized mortality ratios (SMR) of post-bariatric surgery mortality observed in LABS-2 versus age-, sex-, race-, and year-adjusted expected mortality in the general U.S. population were calculated and compared with 1, which results when the number of observed and expected deaths are equal.

RESULTS

LABS-2 median follow-up was 6.6 (interquartile range: 5.9-7.0) years postsurgery. Seventy-six deaths were observed over 15,616 person-years (PY) of observation (4.9 deaths/1000 PY). The rate expected in the general U.S. population with the same age, sex, race, and year distribution was 4.8 deaths per 1000 PY (SMR = 1.02, 95% confidence interval [CI]: .80-1.27). There were no significant differences between observed and expected mortality by surgical procedure. Compared with expected mortality in the general U.S. population, people 35-44 years old at time of surgery had significantly more deaths (SMR = 2.06, 95% CI: 1.22-3.25), while people at least 55 years of age had significantly fewer (SMR = .63, 95% CI: .42-.92). Significantly more deaths than expected occurred in the perioperative period and 5-7 years after surgery.

CONCLUSIONS

Mortality within 7 years of bariatric surgery is comparable to the general U.S. population, which is likely to have better survival than people with severe obesity. However, more deaths than expected were identified 5-7 years after surgery.

Drug- and alcohol-related mortality risk after bariatric surgery: evidence from a 7-year prospective multicenter cohort study

BACKGROUND

It is unclear whether bariatric surgery affects the risk of drug- and alcohol-related mortality.

OBJECTIVES

To compare the observed drug- and alcohol-related mortality rate with age, sex, race, and year-adjusted rates from the general U.S.

POPULATION

SETTING

The Longitudinal Assessment of Bariatric Surgery-2, a prospective cohort study of 2458 adults who underwent bariatric surgery at 10 U.S. hospitals between April 2006 and April 2009.

METHODS

Participants attended presurgery and annual postsurgery assessments for up to 7 years. Drug- and alcohol-related standardized mortality ratios (SMR) comparing the observed post-bariatric surgery mortality rate with the age, sex, race, and year-adjusted expected mortality rate from the general U.S. population, among the entire cohort, and among those who underwent Roux-en-Y gastric bypass (RYGB).

RESULTS

Ten deaths related to drug or alcohol use (6 accidental overdose, 1 intentional overdose, 1 intent unknown overdose, and 2 alcoholic liver disease) occurred across 15,616 person-years of follow-up, all among participants who underwent RYGB (n = 1770). The observed mortality rate was significantly higher than expected for all drug- and alcohol-related causes overall (SMR = 2.10, 95% confidence interval = 1.01-3.86, P = .03) and among participants who underwent RYGB (SMR = 2.90, 95% confidence interval = 1.39-5.33, P = .003). The RYGB SMRs were significant for all overdoses (P = .002) and accidental overdoses (P = .01) and in the same direction but nonsignificant for intentional overdoses, intent unknown overdoses, and alcoholic liver disease (P for all ≥. 05).

CONCLUSIONS

Drug- and alcohol-related mortality is significantly higher than expected in the 7 years after bariatric surgery, specifically after RYGB.

Mental disorders and weight change in a prospective study of bariatric surgery patients: 7 years of follow-up

BACKGROUND

Long-term, longitudinal data are limited on mental disorders after bariatric surgery.

OBJECTIVE

To report mental disorders through 7 years postsurgery and examine their relationship with changes in weight and health-related quality of life.

SETTING

Three U.S. academic medical centers.

METHOD

As a substudy of the Longitudinal Assessment of Bariatric Surgery Consortium, 199 adults completed the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition prior to Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric band. Participants who completed ≥1 follow-up through 7 years postsurgery are included (n = 173; 86.9%). Mixed models were used to examine mental disorders over time, and among the RYGB subgroup (n = 104), their relationship with long-term (≥4 yr) pre- to postsurgery changes in weight and health-related quality of life, measured with the Short Form-36 Health Survey, and with weight regain from nadir.

RESULTS

Compared with presurgery (34.7%), the prevalence of having any mental disorder was significantly lower 4 years (21.3%; P < .01) and 5 years (19.2%; P = .01), but not 7 years (29.1%; P = .27) after RYGB. The most common disorders were not related to long-term weight loss postRYGB. However, independent of weight change, mood and anxiety disorders, both pre- and postRYGB, were significantly related to less improvement in mental (but not physical) health-related quality of life. Having a concurrent mood disorder appeared to be associated with greater weight regain (6.4% of maximum weight lost, 95% confidence interval, -.3 to 13.1), but this was not statistically significant (P = .06).

CONCLUSIONS

Bariatric surgery does not result in consistent long-term reductions in mental disorders. Mood disorders may impact long-term outcomes of bariatric surgery.

Association of Obesity Subtypes in the Longitudinal Assessment of Bariatric Surgery Study and 3-Year Postoperative Weight Change

OBJECTIVE

The study objective was to empirically identify subgroups of patients with obesity and investigate their association with postoperative weight change.

METHODS

A longitudinal analysis of 2,458 adults in the Longitudinal Assessment of Bariatric Surgery (LABS) study was used. Baseline data were used to identify subgroups. The outcome was 3-year weight change after bariatric surgery.

RESULTS

We identified four classes (subtypes) of obesity, which could be characterized as diabetes with low rates of high-density lipoprotein (Class 1), disordered eating (Class 2), mixed (Class 3), and extreme obesity with early onset (Class 4). Approximately 98% of participants in Class 1 had diabetes compared with < 40% in the other classes. There were high rates of binge eating in Class 2, and more than 92% of those in this class reported eating when not hungry. Class 4 was characterized by a higher BMI at baseline. Adults in Class 4 lost an average of 25.0% (males) and 30.3% (females) of their baseline weight over 3 years. In contrast with participants in Class 1, those in Classes 2 and 3 had significantly larger 3-year weight losses than their peers in Class 4.

CONCLUSIONS

Obesity is a heterogeneous disease. Bariatric surgery may be most beneficial for adults with disordered eating.

Eating pathology and associations with long-term changes in weight and quality of life in the longitudinal assessment of bariatric surgery study

OBJECTIVE

This study examines the course of eating pathology and its associations with change in weight and health-related quality of life following bariatric surgery.

METHOD

Participants (N = 184) completed the eating disorder examination-bariatric surgery version (EDE-BSV) and the medical outcomes study 36-Item short form health survey (SF-36) prior to and annually following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) for up to 7 years.

RESULTS

The prevalence of ≥ weekly loss of control (LOC) eating, picking/nibbling, and cravings declined post-RYGB and remained lower through 7 years (LOC: 5.4% at Year-7 vs. 16.2% pre-RYGB, p = .03; picking/nibbling: 7.0% vs. 32.4%, p < .001; and cravings: 19.4% vs. 33.6%, p = .02). The prevalence of picking/nibbling was significantly lower 7 years following LAGB vs. pre-LAGB (29.4% vs 45.8%, p = .049), while cravings (p = .13) and LOC eating (p = .95) were not. EDE-BSV global score and ratings of hunger and enjoyment of eating were lower 7 years following both RYGB and LAGB versus pre-surgery (p's for all <.05). LOC eating following RYGB was associated with less long-term weight loss from surgery (p < .01) and greater weight regain from weight nadir (p < .001). Higher post-surgery EDE-BSV global score was associated with less weight loss/greater regain (both p < .001) and worsening/less improvement from surgery in the SF-36 mental component summary scores (p < .01).

DISCUSSION

Initial improvements in eating pathology following RYGB and LAGB were sustained across 7 years of follow-up. Individuals with eating pathology post-RYGB, reflected by LOC eating and/or higher EDE-BSV global score, may be at risk for suboptimal long-term outcomes.

Comparison of the Performance of Common Measures of Weight Regain After Bariatric Surgery for Association With Clinical Outcomes

IMPORTANCE

Estimates of weight regain following bariatric surgery vary widely.

OBJECTIVE

To describe weight regain after reaching nadir weight following Roux-en-Y gastric bypass (RYGB) surgery and compare weight regain measures for association with outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study of 2458 adults who underwent bariatric surgery at 10 hospitals in 6 US cities between March 2006 and April 2009. Assessments were conducted within 30 days' presurgery, at 6 months' postsurgery, and then annually until January 2015. Of the 1703 participants who underwent RYGB surgery, 1406 (83%) were followed up for 5 years or longer and had 5 or more weight measurements (excluding those who died or underwent surgical reversal).

EXPOSURES

Weight regain assessed by 5 continuous measures (weight in kilograms, body mass index [BMI], percentage of presurgery weight, percentage of nadir weight, and percentage of maximum weight lost) and 8 dichotomous measures (per established thresholds) were compared in relation to clinical outcomes based on statistical significance, magnitude of association, and model fit.

MAIN OUTCOMES AND MEASURES

Progression of diabetes, hyperlipidemia, and hypertension and declines in physical and mental health-related quality of life and satisfaction with surgery.

RESULTS

Among the 1406 participants who underwent RYGB surgery, the median age was 47 years (25th-75th percentile, 38-55 years) and the median BMI was 46.3 (25th-75th percentile, 42.3-51.8) prior to surgery. Most participants were female (80.3%) and white (85.6%). The median follow-up was 6.6 years (25th-75th percentile, 5.9-7.0 years). The median percentage of maximum weight loss was 37.4% (25th-75th percentile, 31.6%-43.3%) of presurgery weight and occurred a median of 2.0 years after RYGB surgery (25th-75th percentile, 1.0-3.2 years). The rate of weight regain was highest during the first year after reaching nadir weight, but weight regain continued to increase throughout follow-up (range, a median of 9.5% of maximum weight lost [25th-75th percentile, 4.7%-17.2%] to 26.8% of maximum weight lost [25th-75th percentile, 16.7%-41.5%] 1 to 5 years after reaching nadir weight). The percentage of participants who regained weight depended on threshold (eg, 5 years after nadir weight, 43.6% regained ≥5 BMI points; 50.2% regained ≥15% of nadir weight; and 67.3% regained ≥20% of maximum weight lost). Compared with other continuous weight regain measures, the percentage of maximum weight lost had the strongest association and best model fit for all outcomes except hyperlipidemia, which had a slightly stronger association with BMI. Of the dichotomous measures, 20% or greater of maximum weight lost performed better or similarly with most of the outcomes, and was the second best measure for hyperlipidemia (after ≥10 kg of weight) and hypertension (after ≥10% of maximum weight lost).

CONCLUSIONS AND RELEVANCE

Among a large cohort of adults who underwent RYGB surgery, weight regain quantified as percentage of maximum weight lost performed better for association with most clinical outcomes than the alternatives examined. These findings may inform standardizing the measurement of weight regain in studies of bariatric surgery.

The long-term effect of pregnancy on weight loss after sleeve gastrectomy

BACKGROUND

Pregnancy outcomes after bariatric surgery have been addressed extensively; however, the impact of pregnancy on long-term outcomes after bariatric surgery has only been sparsely studied.

OBJECTIVES

We explored the effects of pregnancy on weight loss outcomes after laparoscopic sleeve gastrectomy (LSG).

SETTING

University hospital.

METHODS

A cross-sectional case-control study. Eighty women who became pregnant after LSG were matched by preoperative body mass index, age, and follow-up duration to 80 post-LSG patients who did not conceive after surgery (control group).

RESULTS

The median follow-up duration was 5.2 years for the study group and 5.3 years for the control group (P = .73). For the study group, the median time from surgery to conception was 508 (interquartile range 372-954) days and the median gestational weight gain was 9 (6-12) kg. Comparing the study with the control group, median percentage total weight loss was similar, 31% versus 30% (P = .77); as was percentage excess weight loss (EWL%) 72% versus 71% (P = .77). For the study group, a multivariable analysis showed EWL% at the end of follow-up to be directly correlated with the lowest EWL% achieved before pregnancy (β = .78, P < .0001), and inversely correlated with time lapsed from surgery (β = -.26, P < .0001); yet EWL% was not found to be associated with surgery-to-conception time interval, gestational weight gain, breastfeeding, co-morbidities, smoking, occupational status, physical activity, and dietary habits.

CONCLUSIONS

Pregnancy after LSG does not affect long-term weight results. Coupled with the positive reports of improved pregnancy outcomes after bariatric surgery, these data should reassure women who wish to conceive after surgery.

Avoiding exercise mediates the effects of internalized and experienced weight stigma on physical activity in the years following bariatric surgery

Background

People living with severe obesity report high levels of weight-related stigma. Theoretically, this stigma undermines weight loss efforts. The objective of this study is to test one proposed mechanism to explain why weight loss is so difficult once an individual becomes obese: that weight-related stigma inhibits physical activity via demotivation to exercise.

Methods

The study focused on individuals who had bariatric surgery within the past 5 years (N = 298) and who report a post-surgical body mass index (BMI) ranging from 16 to 70. Exercise avoidance motivation (EAM) and physical activity (PA) were modeled as latent variables using structural equation modeling. Two measures of weight stigma, the Stigmatizing Situations Inventory (SSI) and the Weight Bias Internalization Scale (WBIS) were modified for people with a long history of extreme obesity for use as observed predictors.

Results

Exercise avoidance motivation (EAM) significantly mediated the association between both experienced (SSI) and internalized (WBIS) weight stigma and physical activity (PA) in this population.

Conclusion

Exercise avoidance motivation, influenced by weight stigma, may be a significant factor explaining the positive relationship between higher body weights with lower levels of physical activity.

Insurance status differences in weight loss and regain over 5 years following bariatric surgery

BACKGROUND

The effectiveness of bariatric surgery among Medicaid beneficiaries, a population with a disproportionately high burden of obesity, remains unclear. We sought to determine if weight loss and regain following bariatric surgery differed in Medicaid patients compared to commercial insurance.

SUBJECTS/METHODS

Data from the Longitudinal Assessment of Bariatric Surgery, a ten-site observational cohort of adults undergoing bariatric surgery (2006-2009) were examined for patients who underwent Roux-en-Y Gastric Bypass (RYGB), Laparoscopic Adjustable Band (LAGB), or Sleeve Gastrectomy (SG). Using piecewise spline linear mixed-effect models, weight change over 5 years was modeled as a function of insurance type (Medicaid, N = 190; commercially insured, N = 1448), time, procedure type, and sociodemographic characteristics; additionally, interactions between all time, insurance, and procedure type indicators allowed time- and procedure-specific associations with insurance type. For each time-spline, mean (kg) difference in weight change in commercially insured versus Medicaid patients was calculated.

RESULTS

Medicaid patients had higher mean weight at baseline (138.3 kg vs. 131.2 kg). From 0 to 1 year post-operatively, Medicaid patients lost similar amounts of weight to commercial patients following all procedure types (mean weight Δ difference [95% CI]: RYGB: -0.9 [-3.2, 1.4]; LAGB: -1.5 [-6.7, 3.8]; SG: 5.1 [-4.0, 14.2]). From 1 to 3 years post-operatively Medicaid and commercial patients continued to experience minimal weight loss or began to slowly regain weight (mean weight Δ difference [95% CI]: RYGB: 0.9 [0.0, 2.0]; LAGB: -2.1 [-4.2, 0.1]; SG: 0.7 [-3.0, 4.3]). From 3 to 5 years post-operatively, the rate of regain tended to be faster among commercial patients compared to Medicaid patients (mean weight Δ difference [95% CI]: RYGB: 1.1 [0.1, 2.0]; LAGB: 1.5 [-0.5, 3.5]; SG: 1.0 [-2.5, 4.5]).

CONCLUSIONS

Although Medicaid patients had a higher baseline weight, they achieved similar amounts of weight loss and tended to regain weight at a slower rate than commercial patients.

Extreme under-reporting of body weight by young adults with obesity: relation to social desirability

Objective

The objective of this study was to determine whether there is an association between under‐reporting of body weight and social desirability as is found with self‐reports of energy intake.

Methods

Twenty‐seven lean individuals (mean body mass index ± standard deviation = 21.6 ± 2.0 kg m⁻²) and 26 individuals with obesity (mean body mass index = 35.4 ± 4.8 kg m⁻²) were e‐mailed a questionnaire on which they had to state their body weight and conduct a home food inventory. The next day, research team members went to their homes to weigh the participants, conduct their own food inventory and administer the Marlowe–Crowne scale for social desirability.

Results

Among individuals with obesity, lower social desirability scores were associated with a greater degree of under‐reporting body weight (r = +0.48, p < 0.02). Among lean individuals, the correlation was negative but statistically non‐significant (p = −0.22, p > 0.10). Nine individuals with obesity were extreme under‐reporters (2.27 kg or more), and eight of these had social desirability scores in the bottom half of the Marlowe–Crowne scale (p < 0.01). Six under‐reported on the home food inventory by three or more items.

Conclusions

Individuals with obesity and low social desirability scores are more likely than others to be extreme under‐reporters of body weight, possibly due to a lack of awareness of their own weight.

Psychosocial Predictors of Change in Depressive Symptoms Following Gastric Banding Surgery

OBJECTIVE

The aim of this study is to identify psychosocial variables associated with the relationship between weight loss and change in depressive symptoms following gastric banding surgery.

METHODS

Ninety-nine adults completed self-report questionnaires assessing depressive symptoms and other psychosocial variables (self-esteem, body image dissatisfaction, perceived physical health, and perceived weight-based stigmatisation) prior to gastric-band surgery and monthly for 6-month post-surgery.

RESULTS

Weight, depressive symptoms, and other psychosocial variables improved significantly 1-month post-surgery and remained lower to 6 months. Weight loss from baseline to 1- and 6-months post-surgery significantly correlated with change in depressive symptoms. Body image dissatisfaction and self-esteem accounted for some of the variance in change in depressive symptoms from baseline to 1-month and baseline to 6-months post-surgery.

CONCLUSIONS

Depressive symptoms improved significantly and rapidly after bariatric surgery, and body image dissatisfaction and self-esteem predicted change in depressive symptoms. Interventions targeting body image and self-esteem may improve depressive symptoms for those undergoing weight loss interventions.

Lifetime Self-Harm Behaviors Are Not More Prevalent in Bariatric Surgery Candidates than in Community Controls with Obesity

OBJECTIVE

The study aimed at investigating the lifetime prevalence of 22 self-harm behaviors in bariatric surgery candidates (pre-bariatric surgery group; PSG) compared to community controls with obesity (obese community group; OCG).

METHODS

The Self-Harm Inventory (SHI) was administered to the PSG (n = 139, BMI ≥ 35 kg/m2) and to the OCG (n = 122, BMI ≥ 35 kg/m2).

RESULTS

Group comparison of cumulative SHI scores indicated a trend towards less endorsed SHI items in the PSG compared to the OCG (medianPSG = 1.00, IQRPSG = 2.00, medianOCG = 1.00, IQROCG = 2.25, U = 7.241, p = 0.033, η2 = 0.02). No significant group differences were found with regard to the rate of suicide attempts (12.4% vs. 9.4% for OCG vs. PSG). At least one type of lifetime self-harm behavior was admitted by 51.8% of the PSG and 63.9% of the OCG (χ2(1) = 3.91, p = 0.048). The results of logistic regressions using Firth's bias reduction method with at least one SHI item endorsed as dependent variable, group as categorical predictor (PSG as baseline), and age or BMI or PHQ-4 as continuous control variable indicated that only PHQ-4 had a positive effect on the odds ratio.

CONCLUSION

The results suggest that self-harm (including suicidal attempts) is not more prevalent in bariatric surgery candidates than in community control participants with obesity. Further studies are needed to investigate self-harm in bariatric surgery patients, prior and following surgery, compared to non-operated patients with obesity.

Accuracy of Self-Reported Weight Among Adolescent and Young Adults Following Bariatric Surgery

PURPOSE

This study evaluates accuracy of self-reported weight in adolescent bariatric surgery patients.

MATERIALS AND METHODS

During follow-up visits, participants self-reported weight and had weight measured. The differences between self-reported and measured weights were analyzed from 60 participants.

RESULTS

Participants were 70% (n = 42) female, 72% (n = 43) white, mean age of 20.8 years and a median body mass index of 36.6 kg/m². At an average of 3.5 years following surgery, females underestimated weight (0.5 kg, range: -18.7 to 5.6 kg), while males overestimated (1.1 kg, range: -7.8 to 15.2 kg). Most (80%, n = 48) reported within 5 kg of measured weight. The majority of adolescents who previously underwent bariatric surgery reported reasonably accurate weights, but direction of misreporting varied by gender.

CONCLUSION

Self-reported weights could be utilized when measured values are unavailable without markedly biasing the interpretation of outcomes.

Project HELP: a Remotely Delivered Behavioral Intervention for Weight Regain after Bariatric Surgery

BACKGROUND

Weight regain following bariatric surgery is common and potentially compromises the health benefits initially attained after surgery. Poor compliance to dietary and physical activity prescriptions is believed to be largely responsible for weight regain. Patients may benefit from developing specialized psychological skills necessary to engage in positive health behaviors over the long term. Unfortunately, patients often face challenges to physically returning to the bariatric surgery program for support in developing and maintaining these behaviors. Remotely delivered interventions, in contrast, can be conveniently delivered to the patient and have been found efficacious for a number of health problems, including obesity. To date, they have received little attention with bariatric surgery patients. The study aimed to evaluate a newly developed, remote acceptance-based behavioral intervention for postoperative weight regain.

METHODS

Patients at least 1.5 years out from surgery who experienced postoperative weight regain were recruited to receive the 10-week intervention. Participants were assessed at baseline, mid-treatment, post-treatment, and at 3-month follow-up.

RESULTS

Support for the intervention's feasibility and acceptability was achieved, with 70 % retention among those who started the program and a high mean rating (4.7 out of 5.0) of program satisfaction among study completers. On average, weight regain was reversed with a mean weight loss of 5.1 ± 5.5 % throughout the intervention. This weight loss was maintained at 3-month follow-up. Significant improvements in eating-related and acceptance-based variables also were observed.

CONCLUSIONS

This pilot study provides initial support for the feasibility, acceptability, and preliminary efficacy of a remotely delivered acceptance-based behavioral intervention for postoperative weight regain.

Long-Term Effect of Gastric Bypass and Sleeve Gastrectomy on Severe Obesity: Do Preoperative Weight Loss and Binge Eating Behavior Predict the Outcome of Bariatric Surgery?

BACKGROUND

Few studies have examined weight loss sustainability after sleeve gastrectomy (SG). The purpose of this study was to determine long-term outcome after SG and gastric bypass (GBP) and learn whether preoperative weight loss and binge eating behavior can be used to predict outcome.

MATERIALS AND METHODS

Together, 257 patients (64 % women) were operated, 163 by GBP and 94 by SG. Binge eating was assessed by binge eating scale (BES) and preoperative weight loss was advised to all, including very low-calorie diet for 5 weeks. Postoperative visits took place at 1 and 2 years, and long-term outcome was at median 5 years (range 2.29-6.85). Multivariate linear regression analysis was used to predict outcome at 2-year and long-term control.

RESULTS

Median age was 48 years, weight 141.1 kg, and BMI 48.2 kg/m(2). Preoperative weight loss was median 4.9 % before GBP and 3.8 % before SG, P = 0.04. Total weight loss at year one was 24.1 % in GBP and 23.7 % in SG (P = 0.40), at year two 24.4 and 23.4 % (P = 0.26), and at long-term control 23.0 and 20.2 % (P = 0.006), respectively. Weight was analyzed in 93, 88, and 89 % of those alive, respectively. BES did not predict weight outcome, but larger preoperative weight loss predicted less postoperative weight loss at 2 years.

CONCLUSION

On long term, weight loss was better maintained after GBP compared with SG. Binge eating behavior was not a significant predictor, but larger preoperative weight loss predicted less postoperative weight loss for the next 2 years.

Does Laparoscopic Sleeve Gastrectomy Improve Depression, Stress and Eating Behaviour? A 4-Year Follow-up Study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is a restrictive bariatric surgery procedure and currently the second most performed technique worldwide. Follow-up data on depression, stress and eating behaviour are scarce. The aim of this longitudinal study was to investigate the medium-term effects of LSG on mental health and eating behaviour and their influence on weight loss by using a comprehensive interview-based assessment.

METHODS

Seventy-five individuals, who had undergone LSG at a university hospital, were included in the study. Symptoms of disordered eating were assessed using a structured clinical interview (eating disorder examination) and the Three-Factor Eating Questionnaire with depressive symptoms and stress assessed via the Patient Health Questionnaire.

RESULTS

Mean interval from LSG to follow-up (FU) examination was 48 ± 13.3 months. The total body weight loss was 24.2 ± 12.0 %. Depressive symptom scores improved from pre-operative to FU (9 [IQR 5-14] vs. 6 [IQR 2-10], p = 0.002) as did stress scores (8.7 ± 4.6 vs. 6.3 ± 4.7, p = 0.001). At FU, 11 % of patients reported loss-of-control eating and 39 % grazing, paralleled by increased body mass index, stress and depressive symptoms. Prior to LSG, nine patients fulfilled the diagnostic criteria of binge eating disorder but only one at FU.

CONCLUSIONS

Post-surgical mental health appears to be highly relevant in terms of weight loss maintenance. It is likely that the surgical outcome could be positively influenced if patients at risk of developing mental health issues or eating disorders were identified and monitored in order to offer targeted interventions.

Postoperative Outcomes, Weight Loss Predictors, and Late Gastrointestinal Symptoms Following Laparoscopic Sleeve Gastrectomy

OBJECTIVE

To evaluate the outcomes, weight loss predictors, and gastrointestinal symptoms of patients after laparoscopic sleeve gastrectomy (LSG).

METHODS

The postoperative medical status of the patients was obtained retrospectively using a questionnaire and was compared to existing medical data before the surgery.

RESULTS

We included 201 candidates, 178 patients completed mean of 3 years of follow-up. Mean excess body weight loss (%EWL) was 65.14% ± 15.74 at 6 months, 78.53% ± 20.28 at 12 months, and 74.32% ± 23.92 at 3 years after LSG. Older age (P = 0.018), higher baseline BMI (P = 0.003), and higher number of medications (P < 0.001) were negative predictors for EWL%. Total weekly hours of physical activity was found to be a positive predictor for EWL% (P = 0.008). Remission rates of co-morbidities were 83.5% for dyslipidemia (P < 0.001), 65.8% for hypertension (P < 0.001), 62.1% for type 2 diabetes mellitus (T2DM) (P < 0.001), and 60.7% for gastroesophageal reflux (GERD) (P < 0.001). Late gastrointestinal symptoms were as follows: emesis in 25.9%, constipation in 24.7%, diarrhea in 4.5%, food intolerance in 22.5% and alopecia in 42.7% of the patients.

CONCLUSION

Our study shows LSG as a potential tool in achieving almost 75% of EWL% with significant remission of co-morbidities, along with various late gastrointestinal symptoms.