Bariatric surgery: cost-effectiveness and budget impact

Obesity in adults

Obesity has increased in prevalence worldwide and WHO has declared it a global epidemic. Population-level preventive interventions have been insufficient to slow down this trajectory. Obesity is a complex, heterogeneous, chronic, and progressive disease, which substantially affects health, quality of life, and mortality. Lifestyle and behavioural interventions are key components of obesity management; however, when used alone, they provide substantial and durable response in a minority of people. Bariatric (metabolic) surgery remains the most effective and durable treatment, with proven benefits beyond weight loss, including for cardiovascular and renal health, and decreased rates of obesity-related cancers and mortality. Considerable progress has been made in the development of pharmacological agents that approach the weight loss efficacy of metabolic surgery, and relevant outcome data related to these agents' use are accumulating. However, all treatment approaches to obesity have been vastly underutilised.

Antihypertensive Medication Use Trajectories After Bariatric Surgery: A Matched Cohort Study

BACKGROUND

Metabolic and bariatric surgery (MBS) is the most effective and durable treatment for obesity. We aimed to compare the trajectories of antihypertensive medication (AHM) use among obese individuals treated and not treated with MBS.

METHODS

Adults with a body mass index of ≥35 kg/m2 were identified in the Merative Database (US employer-based claims database). Individuals treated with versus without MBS were matched 1:1 using baseline demographic and clinical characteristics as well as AHM utilization. Monthly AHM use was examined in the 3 years after the index date using generalized estimating equations. Subanalyses investigated rates of AHM discontinuation, AHM initiation, and apparent treatment-resistant hypertension.

RESULTS

The primary cohort included 43 206 adults who underwent MBS matched with 43 206 who did not. Compared with no MBS, those treated with MBS had sustained, markedly lower rates of AHM use (31% versus 15% at 12 months; 32% versus 17% at 36 months). Among patients on AHM at baseline, 42% of patients treated with MBS versus 7% treated medically discontinued AHM use (P<0.01). The risk of apparent treatment-resistant hypertension was 3.41× higher (95% CI, 2.91-4.01; P<0.01) 2 years after the index date in patients who did not undergo MBS. Among those without hypertension treated with MBS versus no MBS, 7% versus 21% required AHM at 2 years.

CONCLUSIONS

MBS is associated with lower rates of AHM use, higher rates of AHM discontinuation, and lower rates of AHM initiation among patients not taking AHM. These findings suggest that MBS is both an effective treatment and a preventative measure for hypertension.

Socio-Demographic and Preoperative Clinical Factors Associated With 5-Year Weight Trajectories After Roux-en-Y Gastric Bypass and Sleeve Gastrectomy

Objective

To determine whether socio-demographic and preoperative clinical factors contribute to the percent total body weight loss (%TBWL) after bariatric surgery (BS).

Background

BS is the most effective long-term treatment for medically complicated obesity. More information is needed about the factors that contribute to postoperative %TBWL in large and ethnically diverse cohorts.

Methods

This retrospective study conducted in the Kaiser Permanente Northern California region included 7698 patients who underwent Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) between January 2009 and March 2015. Trajectory analyses were conducted from 5-year follow-up data to assign patients to "low," "average," or "high" postoperative %TBWL groups. We then evaluated whether age, sex, race/ethnicity, neighborhood deprivation index and preoperative body mass index (BMI)/weight loss, diabetes, hypertension, and sleep apnea contributed to postoperative %TBWL using logistic regression models.

Results

Of 7698 patients (83.2% women), 48.6% underwent a RYGB and 51.4% underwent a SG. Postoperative %TBWL trajectories over 5 years were obtained in 6229 (81%) of 7698 eligible patients. About 27.8% and 29.3% of patients followed the "low" postoperative %TBWL trajectory, for RYGB and SG, respectively. Men, older patients, and Asian, Black, and Hispanic/Latino patients were more likely to be classified in the low postoperative %TBWL group. Patients showing lower postoperative %TBWL had a lower preoperative BMI (but lost less weight before surgery) and were more likely to have preoperative comorbidities.

Conclusions

This study confirms and extends prior findings of the effects of several demographic and preoperative clinical factors on postoperative weight loss. Findings could improve the support of patients to achieve desired surgical outcomes.

The impact of bariatric surgery on hospitalization due to peripheral artery disease and critical limb ischemia: a nationwide analysis

BACKGROUND

Severe obesity could be an independent risk factor for peripheral artery disease (PAD) and critical limb ischemia (CLI). Bariatric surgery reduces cardiac risk factors, decreasing cardiovascular morbidity and mortality in subjects with severe obesity.

OBJECTIVES

We aimed to describe the impact of bariatric surgery on risk of hospitalization due to PAD and CLI.

SETTING

Academic hospital.

METHODS

The National Inpatient Sample data collected from 2010 to 2015 were examined. Patients were classified as treatment and control groups. Treatment was defined as patients with a previous history of bariatric surgery, and control was defined as patients with a body mass index ≥35 without a history of bariatric surgery. The primary outcome was hospitalization due to PAD; secondary outcomes were CLI, revascularization, major amputation, length of hospital stay (LOS), and total cost of hospitalization. Univariate and multivariate analyses were performed to assess the differences between groups.

RESULTS

There were a total of 2,300,845 subjects: 2,004,804 controls and 296,041 treatment patients. Hospitalization rate for PAD was significantly lower compared to the control group (.10% versus .21%, P < .0001), which was confirmed after adjusting for covariables (control versus treatment: odds ratio= 1.20, confidence interval: 1.15-1.47). Subgroup analysis showed patients without a history of bariatric surgery had a higher prevalence of CLI (59.3% versus 52.4%, P < .0219) and a higher mean LOS (6.7 versus 5.7 days, P = .0023) and cost of hospitalization (78.756 versus 72.621$, P = .0089), with no significant differences in other outcomes. After multivariate analysis, only LOS and total costs were significantly different.

CONCLUSIONS

Bariatric surgery may decrease the risk of hospitalization due to PAD, similarly to the LOS and total cost of hospitalization. Prospective studies should be performed to describe this relationship.

Chronic psychiatric diagnoses increase emergency department utilization following bariatric surgery

INTRODUCTION

This study aims to evaluate the impact mental health disorders have on emergency department (ED) utilization following bariatric surgery. We hypothesize that the presence of preexisting psychiatric diagnoses is predictive of increased post-bariatric surgical ED usage as compared to a matched cohort without psychiatric comorbidities.

METHODS AND PROCEDURES

We utilized the Colorado All Payers Claim Database to identify patients undergoing laparoscopic sleeve gastrectomy, gastric band, or gastric bypass, (N = 5393). Patients with preexisting diagnoses of schizophrenia or bipolar disorder (PSY), and no concomitant mental health diagnosis were included (N = 427). Patients without a psychiatric diagnosis (CON) were used for comparison. Propensity score matching in a 1:1 ratio was done matching for age, sex, BMI, procedure type, and comorbidities. Baseline ED utilization was calculated over the year preceding surgery.

RESULTS

A total of 240 patients with bipolar disorder or schizophrenia were identified. After matching, baseline ED utilization was 62% higher in the PSY group (ED visits per person per month (EDVPP) of 0.17 (95%CI 0.16-0.18) in the PSY group compared to 0.10 (95%CI 0.09-0.12) in the CON group). ED utilization increased dramatically in the month following surgery for both PSY and CON groups (EDVPP 0.58 (95%CI 0.52-0.65) vs 0.34 (95%CI 0.28-0.41)), but visits returned to baseline for the CON but not PSY patients by three months after surgery (11% vs 60% above baseline, respectively). In the PSY group, ED utilization remained elevated at 18% above baseline for two years post-surgery (EDVPP 0.20 (95%CI 0.19-0.22).

CONCLUSIONS

Bariatric patients with schizophrenia or bipolar disorder have higher baseline ED usage compared to a matched cohort. ED usage increases post-operatively in all patients but to a greater extent in patients with these diagnoses. Such patients would benefit from intensive outpatient follow-up to limit ED visits.

A review on the beneficial effects of bariatric surgery in the management of obesity

INTRODUCTION

Obesity is a chronic disease with a complex interplay of multiple factors such as genetic, metabolic, behavioral, and environmental factors. The management of obesity includes; lifestyle modification, psychological therapy, pharmacological therapy, and bariatric surgery. To date, bariatric surgery is the most effective treatment for obesity by offering a long-term reduction in weight, remission of obesity-related complications, and improving quality of life. However, bariatric surgery is not equally effective in all patients. Thus, if we can predict who would benefit most, it will improve the risk versus benefit ratio of having surgery.

AREAS COVERED

In this narrative review, we explore the question on who will benefit the most from bariatric surgery by examining the recent evidence in the literature. In addition, we investigate the predisposing predictors of bariatric surgery response. Finally, we offer the best strategies in the clinic to explain the potential benefits of bariatric surgery to patients.

EXPERT OPINION

Bariatric surgery is an effective obesity management approach. Despite its efficacy, considerable variation of individual response exists. Thus, it is important to recognize patients that will benefit most, but at present very few predictors are available which can be clinically useful.

Appetite Changes in Weight Regain and Weight Maintenance After Roux-en-Y Gastric Bypass

PURPOSE

Roux-en-Y gastric bypass (RYGB) surgery produces significant weight loss. However, a number of patients experience weight regain years after surgery. Factors driving weight regain after surgical interventions are currently being explored. Our objective was to investigate appetite-related measures associated with weight regain after RYGB surgery.

MATERIALS AND METHODS

Using a cross-sectional design, 29 participants (49.6 ± 9.1 years of age; current BMI 32.4 ± 4.7 kg/m², 43.6 ± 8.9 months post-RYGB) were stratified into tertiles according to weight regain per month after nadir (weight maintenance (WM), n = 9; low weight regain (LWR), n = 10; and high weight regain (HWR), n = 10). The average weight regain was, by design, significantly different between the groups (WM = 2.2 ± 2.5 kg; LWR = 10.0 ± 3.4 kg; HWR = 14.9 ± 6.3 kg regained, p < 0.05). Appetite (visual analog scales), olfactory performance ("sniffin sticks"), eating behaviors (Three Factor Eating Questionnaire), food reward (Leeds Food Preference Questionnaire), and appetite-related hormones (ghrelin, PYY, GLP-1 and leptin) were measured fasting and in response to a standardized test meal.

RESULTS

Dietary restraint was significantly higher than clinical cutoffs in WM and LWR (p < 0.05). As expected, significant time effects were noted for ghrelin, PYY, and GLP-1, but there were no group differences.

CONCLUSION

The results suggest that appetite-related outcomes are similar across individuals who have maintained weight loss and experienced regain following RYGB.

Analysis of the impact of bariatric surgery on medium-term pharmacological expenditure

INTRODUCTION

Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery.

MATERIAL AND METHODS

Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2 years after surgery.

RESULTS

400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type 2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507 euros per month (P < 0.001).

CONCLUSIONS

In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term.

Patients eligible and referred for bariatric surgery in southeastern Ontario: Retrospective cohort study

OBJECTIVE

To evaluate the proportion of eligible individuals, within one health region in Ontario, who were referred for publicly funded medical and surgical weight-loss interventions (MSWLI).

DESIGN

A retrospective cohort study that used primary care data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) and referral data from the Ontario Bariatric Network (OBN).

SETTING

Primary care practices within southeastern Ontario that contribute data to CPCSSN.

PARTICIPANTS

Patients with class II (body mass index [BMI] 35.0 to 39.9 kg/m²) or III (BMI ≥ 40 kg/m²) obesity who were eligible for referral to the OBN for MSWLI.

MAIN OUTCOME MEASURES

Primary care data about patients within the CPCSSN database were linked to referral records within the OBN database using 3 indirect identifiers to determine the proportion of patients with class II and III obesity who were referred to the OBN for MSWLI. An adjusted multivariate logistic regression model was used to determine the most significant predictors of referral.

RESULTS

Of the 87 276 patients within one health region in Ontario, 15 526 (17.8%) patients had class II or III obesity and were eligible for referral for MSWLI. Only 966 out of those 15 526 (6.2%) patients were actually referred for MSWLI. In the multivariate regression analysis, BMI had the strongest association with referral in terms of adjusted odds ratio (AOR), varying from 2.50 (95% CI 2.04 to 3.06) for a BMI of 40.0 to 44.9 kg/m², to 5.15 (95% CI 4.21 to 6.30) for a BMI of 50.0 kg/m² or greater. Referral was more likely for female than male patients (AOR = 2.18; 95% CI 1.86 to 2.57), those living rurally than for urban dwellers (AOR = 1.39; 95% CI 1.20 to 1.60), and those aged 30 to 39 (AOR = 1.61; 95% CI 1.24 to 2.09) and 40 to 49 (AOR = 1.53; 95% CI 1.18 to 1.98) compared with other age groups.

CONCLUSION

Within one health region in Ontario, the referral rate of patients with class II and III obesity for MSWLI was low. Our findings highlight the need for further research to understand and address the barriers to referral of patients with class II and III obesity for MSWLI.

Effect of bariatric surgery on employment status-a 7 years controlled nationwide registry study

BACKGROUND

Severe obesity is associated with a reduced ability to work. Bariatric surgery is the most effective method to achieve a sustained weight loss. Previous studies have reported conflicting results regarding the effect of bariatric surgery on employment status. To address this, we investigated the effect of bariatric surgery on employment status in the Danish population.

METHODS

In this nationwide study, we identified 5450 subjects who underwent bariatric surgery and 10 900 control subjects matched for age, sex and municipality. From accessible registries, we extracted data regarding employment, absenteeism, sick leave and pension. Using a multistate model, we compared time in occupational states and transitions between these states to determine the effect of bariatric surgery on employment status.

FINDINGS

Before surgery, cases had an absolute risk increase (95% CI)(ARI (CI)) and a relative risk (RR (CI)) of being in full-time employment of -0.12 (-0.14 to -0.10) and 0.84 (0.82 to 0.86) and were more often unemployed or in a subsidised job than the background population. Taking into account the employment status before surgery, the bariatric surgery group increased their probability of being in full-time employment 1-3 years after bariatric surgery. However, this positive effect was not present with a longer duration of follow-up. Being male, above 50 years of age, or employed as a craftsman or office worker were associated with a sustained positive effect of being in full-time employment (ARI (CI) and RR (CI) 0.05 (0.04 to 0.05) and 1.05 (1.04 to 1.06), 0.06 (0.06 to 0.07) and 1.08 (1.07 to 1.09) and 0.05 (0.05 to 0.06) and 1.05 (1.05 to 1.06), respectively).

INTERPRETATION

Compared with a matched control group, those undergoing bariatric surgery did not improve their employment status in the long term. Certain subgroups had a more sustained positive effect.

Analysis of the impact of bariatric surgery on medium-term pharmacological expenditure

INTRODUCTION

Obesity and associated diseases represent an important health and economic problem since pharmacological treatment for many of these pathologies needs lifelong subsidies. Theoretically, bariatric and metabolic surgery decreases the medication requirements of patients for these diseases but may result in other types of pharmacological needs. This study aims to demonstrate whether there is a real decrease in pharmacological expenditure after bariatric surgery.

MATERIAL AND METHODS

Retrospective cross-sectional analysis of patients who were treated in our centre between 2012 and 2016, comparing different associated comorbidities and pharmacological expenses one month before and 2years after surgery.

RESULTS

400 patients were operated. The results were presented, showing the differences between the resolution of the different comorbidities and the pharmacological savings generated for each of the surgical techniques studied. The most cost-effective comorbidity in the study was type2 diabetes mellitus (DM2). The surgical technique with the best results was metabolic bypass, presenting a cost difference after surgery of 507euros per month (P<.001).

CONCLUSIONS

In a 2-year follow-up after bariatric surgery, a decreased prevalence of obesity-related diseases and associated pharmacological expenditure was observed, showing the efficiency of this intervention over the medium term.

Lithium toxicity with prolonged neurologic sequelae following sleeve gastrectomy: A case report and review of literature

RATIONALE

Lithium is the first-line medication for bipolar disorder, given a narrow therapeutic window of 0.8 to 1.2 mEq/L. Change of lithium pharmacokinetics following bariatric surgery may lead to lithium toxicity, which is particularly concerned.

PATIENT CONCERNS

We presented a 39-year-old man with morbid obesity and bipolar affective disorder for 20 years, who was treated with lithium. He developed serious lithium toxicity following sleeve gastrectomy and prolonged neurologic sequelae.

DIAGNOSES

He suffered from persistent watery diarrhea, general weakness, and then drowsy consciousness. Lithium level was checked immediately to be 3.42 mEq/L and lithium toxicity was diagnosed.

INTERVENTIONS

After 3 courses of hemodialysis, his serum lithium level subsequently declined to 0.63 mEq/L, while his consciousness returned normal. Lithium was replaced by lamotrigine.

OUTCOMES

The patient was discharged thirty-five days after admission, while his serum lithium declined to 0.06 mEq/L. Neurologic sequelae were noted by muscle weakness and pain sensation in both feet. The nerve conduction test revealed sensorimotor polyneuropathy with conduction block. He was advised to keep a passive range of motion exercise.

LESSONS

Although the consensus guideline remains lacking, our report reviewed cases of relevance in the literature and highlighted the awareness of the potential risk of lithium toxicity following bariatric surgery. We suggest close monitoring of the lithium levels and perhaps a dosage adjustment for the postoperative period.

Laparoscopic Sleeve Gastrectomy Affects Coagulation System of Obese Patients

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is nowadays the most popular bariatric procedure for obesity. However, whether LSG increases the risk of thrombosis remains unclear. The aim of this study was to investigate potential effects of LSG on coagulation system.

METHODS

Fifty-five obese patients underwent LSG between 2016 and 2018. The LSG was performed with pneumoperitoneum pressure maintained at 13 mmHg. Venous blood specimens were collected from each patient before surgery, at the end of pneumoperitoneum (i.e., 0 h after surgery), and at 24 h after surgery to determine prothrombin time (PT), activated partial thromboplastin time (APTT), fibrinogen (FIB), platelet count (PLT), D-dimer (D-D), red blood cell count (RBC), hematocrit (HCT), plateletcrit (PCT), cholesterol (CHOL), triglyceride (TRIG), and serum calcium (Ca). All patients were examined on the veins of the lower limbs by color Duplex sonography (CDS) before surgery and at 24 h after surgery, respectively.

RESULTS

All patients successfully underwent LSG. No severe surgery-related complications were observed during 1-month follow-up after operation. Preoperative BMI was 43.6 ± 8.3 kg/m². The levels of coagulation factors were within the normal range before surgery, except a relatively higher PLT. The PT and D-D were increased at 0 h and 24 h after surgery (P < 0.05), whereas APTT was decreased (P < 0.05). The postoperative FIB remained similar to the preoperative one (P > 0.05). The CDS identified no thrombus in the veins of the lower limbs, either before surgery or at 24 h after surgery.

CONCLUSIONS

LSG may cause postoperative hypercoagulability of patients with obesity.

Impact of self-efficacy on risk aversion in the context of surgical weight loss decision scenarios

Obesity is prevalent among a third of US adults and a leading indicator for many chronic diseases. Self-efficacy is important for non-surgical weight loss interventions, but there is less information about the role of self-efficacy in the candidacy phase when there are discussions of side effects and decisions for uptake. This study conducted an experiment set within an online survey assessing risk aversion towards bariatric surgery as a weight loss intervention. The survey asked about hypothetical weight loss scenarios for bariatric surgery among a national probability-based sample of US adults aged 18 years and older. Participants answered their willingness to achieve different weight loss amounts within the context of bariatric surgery in varying risk scenarios. The analysis utilized a repeated-measures linear mixed model. A three-way interaction demonstrated that participants were more willing to take risks under ideal weight loss conditions even with the risk of death, particularly when considering self-efficacy (𝛽 = 1.20, P = .05). Margin projections showed that those with lower self-efficacy were more likely to take risks overall. This trend was significant for those with a body mass index of 30 and above in scenarios presenting one's ideal weight as the outcome of bariatric surgery. Adding a measure of self-efficacy within patient assessments could identify those eligible patients who are most likely to adopt bariatric surgery, particularly among those who may have negative post-surgical outcomes due to low self-efficacy levels. Addressing self-efficacy by way of providing support resources in tandem with candidacy consultations may enhance quality of life and post-surgical outcomes.

Cost-effectiveness of an educational healthcare circuit for bariatric surgery in France

OBJECTIVES

An educational healthcare circuit (EHC) is proposed with the objective of preventing weight recovery of patients after bariatric surgery through education and lifestyle change. The objective of this study was to measure the viability of the EHC (shared medical appointments [SMAs] combined with bariatric surgery) through cost-effectiveness analysis. The EHC presented in this study is innovative because it offers a multidisciplinary approach based on medical, psychological and dietetic expertise to combat obesity. The strategy is to give the patient a diagnosis and then a personalised follow-up.

STUDY DESIGN

A mathematical model based on a decision tree (1 year) and a Markov model (10 years) to measure the efficiency and cost of an EHC in comparison with the customary care offered in France were built.

METHODS

The effects of the EHC were observed for the prevalence of type 2 diabetes and the risk of cardiovascular disease. The chosen financial perspective is from the point of view of the French social security system.

RESULTS

The EHC records an incremental cost-effective ratio (ICER) of € 48,315.43 per quality-adjusted life year (QALY) over a 1-year horizon and € 28,283.77 per QALY over 10 years (with discount rate of 8%: € 25,362.85 per QALY).

CONCLUSION

The results suggest that an EHC is more expensive yet more effective than usual care. That is, in the short term, the costs are high, but at 10 years, the treatment is cost-effective, representing a feasible alternative for those patients who qualify for bariatric surgery in France.

Cost-Effectiveness of Bariatric Surgery Compared With Nonsurgical Treatment in People With Obesity and Comorbidity in Colombia

BACKGROUND

The increase in obesity prevalence and its relationship with multiple cardiovascular complications have raised the burden of obesity in the general population. Bariatric surgery has shown to be more effective in reducing weight than the traditional pharmacologic and nonpharmacologic treatments.

OBJECTIVE

To evaluate the cost-effectiveness of this alternative compared with standard treatment in the Colombian context.

METHODS

A Markov single cohort model was used to simulate the incremental cost per quality-adjusted life-year (QALY) gained every year over a base-case 5-year time horizon. The model considers 5 health states: comorbidity, remission, acute myocardial infarction, stroke, and death. Four comorbidity conditions were evaluated separately: diabetes, hypertension, dyslipidemia, and sleep apnea. The model was evaluated from a third-payer perspective. All costs were expressed in 2016 Colombian pesos ($1.00 = 3051 COP). A 5% annual discount rate was applied to both costs and outcomes.

RESULTS

In baseline analysis, bariatric surgery was a cost-effective alternative compared with nonsurgical treatment in the diabetes and hypertension cohort with an incremental cost-effectiveness ratio of $6  194 899 and $43 689 527 per QALY gained, respectively. In the sleep apnea cohort, surgery has greater effectiveness and lower costs, which is why it is a dominant strategy. In the dyslipidemia cohort, bariatric surgery is dominated by the nonsurgical approach.

CONCLUSION

The current study provides evidence that bariatric surgery is a cost-effective alternative among some cohorts in the Colombian setting. For obese patients with sleep apnea or diabetes, bariatric surgery is a recommendable alternative (dominant and cost-effective, respectively) for the Colombian healthcare system.

Portrayal of bariatric surgery in the New Zealand print news media

BACKGROUND

Bariatric surgery has become topical in the media worldwide, influencing wider societal attitudes towards obesity and obesity management. This study aims to explore the media portrayal of bariatric surgery in all print news articles published in New Zealand (NZ) over a decade.

METHODS

An electronic search of two databases (Proquest Australia/NZ Newsstream and Newztext) and two NZ news media websites (Stuff and the NZ Herald) was performed to retrieve print news articles reporting stories, opinion pieces or editorials regarding bariatric surgery published between January 2007 to June 2017. Qualitative thematic analysis was performed on all included articles.

RESULTS

From January 2007 to December 2017, 252 articles related to bariatric surgery were published. Seven major themes emerged centred around barriers to accessing bariatric surgery, deficit attitudes towards obesity and social justice. These views were driven by articles that debated the limited number of publicly funded bariatric procedures offered in NZ. In addition, healthcare professionals used the media as a platform to challenge discriminatory attitudes towards obesity and bariatric surgery.

CONCLUSION

The NZ media is a powerful tool that still bolsters binary perspectives of obesity and bariatric surgery which may work against addressing the obesity epidemic.

A narrative review of bariatric surgery in Indigenous peoples

INTRODUCTION

Indigenous peoples suffer high rates of obesity and obesity-related disease worldwide. Currently, bariatric surgery is the most effective intervention for severe obesity and obesity-related disease. The role bariatric surgery plays in alleviating the obesity burden amongst Indigenous peoples is unknown. We aimed to collate studies investigating bariatric surgery in Indigenous peoples and to provide a simple framework to use in future research surrounding this important issue.

MATERIALS AND METHODS

We conducted a systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that investigated outcomes for Indigenous peoples at any point along the bariatric surgery journey were included.

RESULTS

Six articles were included in this review. Three studies investigated access to bariatric surgery and the remaining three studies investigated short to long-term outcomes following bariatric surgery. A narrative review was performed given study heterogeneity and quality of included studies. Indigenous peoples had lower access to bariatric surgery and in one study had greater weight loss in comparison to non-Indigenous peoples.

CONCLUSION

Despite a paucity of studies, it appears that there is emerging interest in investigating bariatric surgery among Indigenous peoples. We encourage those who seek to investigate this important issue at any point along the bariatric surgery journey, to do so using an equity-based approach.

The effect of sleeve gastrectomy technique on women's sexual function: A prospective study

INTRODUCTION

Obesity may lead to a serious deterioration in general quality of daily life and sexual functionality. Bariatric surgery is the most effective treatment method for obesity and related morbidities so far and it is better than some medical treatment modalities. In this study, we aimed to investigate the effects of bariatric surgery and especially sleeve gastrectomy, which has been currently performed in increasing numbers on female sexual functions and quality of life.

MATERIALS AND METHODS

A total of 53 patients were included to the current study. The participants were selected from eligible individuals who have undergone laparoscopic sleeve gastrectomy operation in our center between April 2014 and March 2015 dates. Age, body weights and body mass indexes (BMIs) of the patients were pre-operatively recorded. The patients have completed the Female Sexual Function Index (FSFI), Beck Depression Scale and SF-36 (Short form-36) forms before and after the surgery. Additionally, post-operative decrease in body weights and mean BMI were recorded.

RESULTS

Following bariatric surgery, sexual functions of the female patients improved and total FSFI scores increased. When FSFI scores were analyzed, it was observed that sexual desire, sexual arousal, lubrication, orgasm and sexual satisfaction increased, while the pain parameter has not changed.

CONCLUSION

Recent literature reveals that unfavorable effects of increasingly prevalent obesity on sexual functions cannot be denied. We think that sleeve gastrectomy can obtain considerable weight loss, improvement in self-esteem, decrease in anxiety, amelioration in sexual functions and general quality of life.

Polygenic risk score for predicting weight loss after bariatric surgery

BACKGROUND

The extent of weight loss among patients undergoing bariatric surgery is highly variable. Herein, we tested the contribution of genetic background to such interindividual variability after biliopancreatic diversion with duodenal switch.

METHODS

Percentage of excess body weight loss (%EBWL) was monitored in 865 patients over a period of 48 months after bariatric surgery, and two polygenic risk scores were constructed with 186 and 11 (PRS186 and PRS11) single nucleotide polymorphisms previously associated with body mass index (BMI).

RESULTS

The accuracy of the %EBWL logistic prediction model - including initial BMI, age, sex, and surgery modality, and assessed as the area under the receiver operating characteristics (ROC) curve adjusted for optimism (AUCadj = 0.867) - significantly increased after the inclusion of PRS186 (ΔAUCadj = 0.021; 95% CI of the difference [95% CIdiff] = 0.005-0.038) but not PRS11 (ΔAUCadj= 0.008; 95% CIdiff= -0.003-0.019). The overall fit of the longitudinal linear mixed model for %EBWL showed a significant increase after addition of PRS186 (-2 log-likelihood = 12.3; P = 0.002) and PRS11 (-2 log-likelihood = 9.9; P = 0.007). A significant interaction with postsurgery time was found for PRS186 (β = -0.003; P = 0.008) and PRS11 (β = -0.008; P = 0.03). The inclusion of PRS186 and PRS11 in the model improved the cost-effectiveness of bariatric surgery by reducing the percentage of false negatives from 20.4% to 10.9% and 10.2%, respectively.

CONCLUSION

These results revealed that genetic background has a significant impact on weight loss after biliopancreatic diversion with duodenal switch. Likewise, the improvement in weight loss prediction after addition of polygenic risk scores is cost-effective, suggesting that genetic testing could potentially be used in the presurgical assessment of patients with severe obesity.

FUNDING

Heart and Stroke Foundation of Canada (G-17-0016627) and Canada Research Chair in Genomics Applied to Nutrition and Metabolic Health (no. 950-231-580).

Protocol for a 1-year prospective, longitudinal cohort study of patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy: the BARI-LIFESTYLE observational study

INTRODUCTION

Roux-en-Y gastric bypass and sleeve gastrectomy are the two most common bariatric surgery performed in the UK that result in comparable weight loss and remission of obesity-associated comorbidities. However, there is a paucity of studies examining the impact of these procedures on body composition, physical activity levels, sedentary behaviour, physical function and strength, dietary intake, health-related quality of life and costs.

METHODS AND ANALYSIS

The BARI-LIFESTYLE observational study is a 1-year prospective, longitudinal cohort study within a real-world routine clinical care setting aiming to recruit 100 patients with severe obesity undergoing either primary Roux-en-Y gastric bypass or sleeve gastrectomy from two bariatric centres in London, UK. Participants will be followed up four times during the study period; presurgery baseline (T0) and at 3 (T1), 6 (T2) and 12 months (T3) postsurgery. In addition to the standard follow-up investigations, assessments including dual-energy X-ray absorptiometry scan, bioelectric impedance analysis, 6 min walk test, sit-to-stand test and handgrip test will be undertaken together with completion of questionnaires. Physical activity levels and sedentary behaviour will be assessed using accelerometer, and dietary intake will be recorded using a 3-day food diary. Outcome measures will include body weight, body fat mass, lean muscle mass, bone mineral density, physical activity levels, sedentary behaviour, physical function and strength, dietary intake, health-related quality of life, remission of comorbidities, healthcare resource utilisation and costs.

ETHICS AND DISSEMINATION

This study has been reviewed and given a favourable ethical opinion by London-Dulwich Research Ethics Committee (17/LO/0950). The results will be presented to stakeholder groups locally, nationally and internationally and published in peer-reviewed medical journals. The lay-person summary of the findings will be published on the Centre for Obesity Research, University College London website (http://www.ucl.ac.uk/obesity).

Shunt freedom and clinical resolution of idiopathic intracranial hypertension after bariatric surgery in the pediatric population: report of 3 cases

Idiopathic intracranial hypertension (IIH), formerly known as pseudotumor cerebri, is a disease of elevated intracranial pressure that is thought to develop due to impaired CSF absorption related to elevated venous sinus pressure in the setting of increased intraabdominal and thoracic pressures. Symptoms can be disabling and, if left untreated, can lead to permanent visual loss. Previous treatments directed toward vision preservation include CSF diversion through shunting and optic nerve sheath fenestration. Recently, attention has been turned toward surgical weight loss strategies as an alternative to shunt treatment. The authors present a report of 3 patients with adolescent-onset IIH that was treated at the authors' institution (Duke University) in whom bariatric surgery was pursued successfully. The patients had previously undergone CSF shunting at ages 12, 15, and 23 years. They were shunt dependent for a collective average of 3.3 years prior to bariatriwc surgery. All patients reported "low-pressure" or postural headaches after bariatric surgery that correlated with dramatic reduction in their weight. Two of the 3 patients had their shunts removed and continued to be shunt free 1.5 years later at last follow-up; the third patient remained shunt dependent with the pressure set at 200 mm H₂O. Given the significant complications inherent to multiple shunt revisions, earlier intervention for weight loss, including bariatric surgery, in these patients might have prevented complications and the associated health care burden. The authors recommend a multidisciplinary approach for IIH treatment with early consideration for weight loss interventions in select patients.

Clinical outcomes for the obese hospital inpatient: An observational study

OBJECTIVES

The prevalence of obesity presents a burden for Australian health care. The aim of this study was to determine whether severely obese hospital inpatients have worse outcomes.

METHODS

This is an observational cohort study, using data from all adult patients admitted to hospital for all elective and emergency admissions of patients aged over 18 years to two large Australian urban hospitals. We measured their length of stay, intensive care unit admission rate, intensive care unit length of stay, mortality and readmission rates within 28 days of discharge and compared these outcomes in the severely obese and non-severely obese subjects using t-test or chi-square test as appropriate.

RESULTS

Between February 2008 and February 2012, 120,872 were admitted to hospital 193,800 times; 2701 patients were identified as severely obese (2.23%) and 118,171 patients were non-severely obese. If admitted as an emergency, severely obese patients have worse outcomes and consume more resources than other patients. These outcomes are still worse, but less so, if the obese patient is admitted as an elective patient suggesting that anticipation of any obesity-specific problems can have a beneficial effect.

CONCLUSION

Upon admission or discharge of severely obese hospital inpatients, health care plans should be even more carefully laid than usual to reduce the risk of readmission.

Comparison of Efficacy and Safety of Liraglutide 3.0 mg in Individuals with BMI above and below 35 kg/m²: A Post-hoc Analysis

OBJECTIVE

To investigate whether the efficacy and safety of liraglutide 3.0 mg differed between two subgroups, BMI 27 to <35 and BMI ≥ 35 kg/m², in individuals without and with type 2 diabetes (T2D).

METHODS

A post-hoc analysis of two 56-week, randomized, double-blind, placebo-controlled trials (SCALE Obesity and Prediabetes; SCALE Diabetes). Subgroup differences in treatment effects of liraglutide 3.0 mg were evaluated by testing the interaction between treatment group and baseline BMI subgroup.

RESULTS

Significantly greater weight loss (0-56 weeks) was observed with liraglutide 3.0 mg versus placebo in all patient groups while on treatment. There was no evidence that the weight-lowering effect of liraglutide 3.0 mg differed between BMI subgroups (interaction p > 0.05). Similarly, for most secondary endpoints significantly greater improvements were observed with liraglutide 3.0 mg versus placebo, with no indication treatment effects differing between subgroups. The safety profile of liraglutide 3.0 mg was broadly similar across BMI subgroups.

CONCLUSION

This post-hoc analysis did not indicate any differences in the treatment effects, or safety profile, of liraglutide 3.0 mg for individuals with BMI 27 to <35 or ≥35 kg/m². Liraglutide 3.0 mg can therefore be considered for individuals with a BMI of ≥35 as well as for those with a BMI of 27 to <35 kg/m².

Indications for Revisions Following 630 Consecutive Laparoscopic Sleeve Gastrectomy Cases: Experience in a Single Accredited Center

INTRODUCTION

Bariatric surgery is the only proven and effective long-term treatment for morbid obesity, with laparoscopic sleeve gastrectomy (LSG) being the most commonly performed weight loss procedure in the USA. Despite its safety and efficacy, LSG's association with both de novo and pre-existing gastroesophageal reflux disease (GERD) remains controversial.

METHODS

Therefore, this retrospective study determined the incidence, indications, and outcomes of revisional surgery following LSG in adult patients at our institution from 2010 to 2014. Descriptive outcomes are reported due to the small sample size.

RESULTS

Of the 630 LSGs performed, 481 patients were included in the analysis (mean age and BMI = 46.2 and 44.3, respectively; 79.5 % female; 82.3 % white). A total of 12/481 patients underwent conversion to a different bariatric procedure due to inadequate weight loss, GERD, or both. The 6/12 patients with GERD-related symptoms and failed medical management underwent conversion to Roux-en-Y gastric bypass (RYBG) following preoperative wireless Bravo pH monitoring (Given Imaging) to confirm the diagnosis objectively. The other 6/12 patients with inadequate weight loss received either RYBG or bilio-pancreatic diversion with duodenal switch (BPD/DS) based on personal choice. Overall, 9/12 patients underwent conversion to RYBG, and 3/12 underwent conversion to BPD/DS. Median time from the initial surgery to conversion was 27 months (range 17-41). Median operating room time was 168 min (range 130-268). Median length of stay was 48 h (range 24-72). The follow-up rate at 3 months was 100 % (12/12 patients).

CONCLUSIONS

Our study showed that some patients may present following LSG with refractory GERD or inadequate weight loss, but that conversion to RYBG or BPD/DS may be done safely and effectively.

Emerging drugs for the treatment of obesity

INTRODUCTION

The increasing prevalence of obesity represents a huge threat to public health and the current pharmacological treatment options are limited. Bariatric surgery is by far the most effective treatment for severe obesity, highlighting the urgent need for new and improved drug therapies. Areas covered: Based on the physiological regulation of energy homeostasis, pharmacological strategies to treat obesity are evaluated with focus on drugs in phase 2 and 3 clinical development. The potential impact of these drugs on current treatment standards and the barriers for development are discussed and set in a historical perspective of previous antiobesity medications. Expert opinion: The radical effects of bariatric surgery have extended our understanding of the mechanisms controlling appetite and boosted the search for new drug targets in obesity treatment. Accordingly, several compounds targeting the central nervous system and/or periphery are in pipeline for obesity. These drugs should be evaluated over a wide array of end-points; in particular, long-term safety monitoring is necessary as serious adverse events may appear. Combination therapy targeting more than one pathway controlling energy balance might be necessary to achieve substantial weight loss while minimising side effects.

Costs and outcomes of increasing access to bariatric surgery for obesity: cohort study and cost-effectiveness analysis using electronic health records

Background

Bariatric surgery is known to be an effective treatment for extreme obesity but access to these procedures is currently limited.

Objective

This study aimed to evaluate the costs and outcomes of increasing access to bariatric surgery for severe and morbid obesity.

Design and methods

Primary care electronic health records from the UK Clinical Practice Research Datalink were analysed for 3045 participants who received bariatric surgery and 247,537 general population controls. The cost-effectiveness of bariatric surgery was evaluated in severe and morbid obesity through a probabilistic Markov model populated with empirical data from electronic health records.

Results

In participants who did not undergo bariatric surgery, the probability of participants with morbid obesity attaining normal body weight was 1 in 1290 annually for men and 1 in 677 for women. Costs of health-care utilisation increased with body mass index category but obesity-related physical and psychological comorbidities were the main drivers of health-care costs. In a cohort of 3045 adult obese patients with first bariatric surgery procedures between 2002 and 2014, bariatric surgery procedure rates were greatest among those aged 35–54 years, with a peak of 37 procedures per 100,000 population per year in women and 10 per 100,000 per year in men. During 7 years of follow-up, the incidence of diabetes diagnosis was 28.2 [95% confidence interval (CI) 24.4 to 32.7] per 1000 person-years in controls and 5.7 (95% CI 4.2 to 7.8) per 1000 person-years in bariatric surgery patients (adjusted hazard ratio was 0.20, 95% CI 0.13 to 0.30;p < 0.0001). In 826 obese participants with type 2 diabetes mellitus who received bariatric surgery, the relative rate of diabetes remission, compared with controls, was 5.97 (95% CI 4.86 to 7.33;p < 0.001). There was a slight reduction in depression in the first 3 years following bariatric surgery that was not maintained. Incremental lifetime costs associated with bariatric surgery were £15,258 (95% CI £15,184 to £15,330), including costs associated with bariatric surgical procedures of £9164 per participant. Incremental quality-adjusted life-years (QALYs) were 2.142 (95% CI 2.031 to 2.256) per participant. The estimated cost per QALY gained was £7129 (95% CI £6775 to £7506). Estimates were similar across gender, age and deprivation subgroups.

Limitations

Intervention effects were derived from a randomised trial with generally short follow-up and non-randomised studies of longer duration.

Conclusions

Bariatric surgery is associated with increased immediate and long-term health-care costs but these are exceeded by expected health benefits to obese individuals with reduced onset of new diabetes, remission of existing diabetes and lower mortality. Diverse obese individuals have clear capacity to benefit from bariatric surgery at acceptable cost.

Future work

Future research should evaluate longer-term outcomes of currently used procedures, and ways of delivering these more efficiently and safely.

Funding

The National Institute for Health Research (NIHR) Health Services and Delivery Research programme. Martin C Gulliford and A Toby Prevost were supported by the NIHR Biomedical Research Centre at Guy’s and St Thomas’ Hospitals. Peter Littlejohns was supported by the South London Collaboration for Leadership in Applied Health Research and Care. The funders did not engage in the design, conduct or reporting of the research.

Present status of bariatric surgery in Poland

INTRODUCTION

The first survey of bariatric surgery in Poland was published in 2007. New trends are observed worldwide, and there is a current need to investigate the status of bariatric surgery in Polish institutions. This survey was initiated to gain an overview of Polish bariatric surgery during 2007-2014.

AIM

To analyze the number and types of bariatric procedures performed in Polish institutions in 2014 and to perform a trend analysis from 2007 to 2014.

MATERIAL AND METHODS

A questionnaire regarding the numbers and types of bariatric procedures performed between 2007 and 2014 was e-mailed to all members of the Bariatric Society (a branch of the Association of Polish Surgeons) and to 28 surgical departments. Trend analyses from 2007 to 2014 were performed.

RESULTS

Among the surgical departments, 16 (57%) responded. The results showed that 1499 bariatric procedures were performed in Poland in 2014, with 96.4% done laparoscopically. The highest number was from Masovian Voivodeship. The most commonly reported procedures were laparoscopic sleeve gastrectomy (LSG) (60.7%), followed by laparoscopic Roux-en-Y gastric bypass (19.2%), mini gastric bypass (11.1%), and adjustable gastric banding (7.6%). Most significant was the rise in prevalence of LSG from 8.0% to 60.4% of the total bariatric procedures from 2007 to 2014.

CONCLUSIONS

Laparoscopic sleeve gastrectomy is currently the most frequently performed bariatric procedure in Poland. The accuracy of the national survey of procedures would be enhanced if we could create a national registry.

Female Sexual Function Before and After Bariatric Surgery: a Cross-Sectional Study and Review of Literature

Background

The aims of the present study were to compare sexual quality of life and prevalence of female sexual dysfunction (FSD) after surgical weight loss with controls seeking bariatric surgery, and to perform a literature review.

Methods

Female Sexual Function Index (FSFI) and Sexual Quality of Life–Female (SQoL-F) questionnaires were sent within 12–18 months postoperatively via e-mail to 153 women who had undergone weight loss surgery (postoperative group). The control group comprised of 23 women who were asked to complete the questionnaires during their preoperative evaluation (preoperative group). The total FSFI cutoff score for a diagnosis of FSD was ≤ 26.55.

Results

The median (Q1, Q3) FSFI score did not differ significantly between the preoperative (26.9 [24.3, 30.7]) and postoperative groups (26.9 [22.6, 30.0]). There was no difference in the prevalence of FSD between groups. However, median scores in FSFI domains of desire and arousal were significantly higher in the postoperative group. There were no differences in the other FSFI domains. The median SQoL-F was significantly higher in the postoperative group.

Conclusions

The FSFI score did not predict the SQoL-F score. The prevalence of FSD was comparable in the two groups. The higher SQoL-F score in the postoperative group may be the result of an improvement in self-esteem, which in turn leads to greater interest in sex and more intense feelings of desire and arousal.

Cost-Effectiveness of Bariatric Surgery Prior to Total Knee Arthroplasty in the Morbidly Obese: A Computer Model-Based Evaluation

BACKGROUND

Obesity is associated with adverse outcomes and increased costs after total knee arthroplasty. Bariatric surgery is an effective treatment for morbid obesity, but its cost-effectiveness for weight loss prior to total knee arthroplasty is unknown. The purpose of this study was to evaluate the cost-effectiveness of bariatric surgery prior to total knee arthroplasty for patients in whom medical treatment of obesity and knee osteoarthritis had failed.

METHODS

A state-transition Markov model was constructed to compare the cost-utility of two treatment protocols for patients with morbid obesity and end-stage knee osteoarthritis: (1) immediate total knee arthroplasty and (2) bariatric surgery two years prior to the total knee arthroplasty. The probability of transition for each health state and its utility were derived from the literature. Costs, expressed in 2012 United States dollars, were estimated with use of administrative and claims data. Costs and utilities were discounted at 3% annually, and effectiveness was expressed in quality-adjusted life-years (QALYs). The principal outcome measure was the incremental cost-effectiveness ratio (ICER). One-way, two-way, and probabilistic sensitivity analyses were performed, using $100,000 per QALY as the threshold willingness to pay.

RESULTS

Morbidly obese patients undergoing total knee arthroplasty alone had lower QALYs gained than patients who underwent bariatric surgery two years prior to the total knee arthroplasty. The ICER between these two procedures was approximately $13,910 per QALY, well below the threshold willingness to pay. Results were stable across broad value ranges for independent variables. Probabilistic sensitivity analysis found that the median ICER was $14,023 per QALY (95% confidence interval, $4875 to $51,210 per QALY).

CONCLUSIONS

This model supports bariatric surgery prior to total knee arthroplasty as a cost-effective option for improving outcomes in morbidly obese patients with end-stage knee osteoarthritis who are indicated for total knee arthroplasty.

LEVEL OF EVIDENCE

Economic and Decision Analysis Level II. See Instructions for Authors for a complete description of levels of evidence.

Impact of commissioning weight-loss surgery for bariatric patients

Obesity is a major UK public health issue that is increasingly costly to an individual's personal health, the NHS and society. It requires an immediate intervention, as well as a long-term strategy to decrease the rising rates of obesity. NHS England (2013) has published a policy to commission bariatric surgery for carefully selected individuals according to National Institute for Health and Care Excellence (NICE) guidelines (NICE, 2006). This has been shown to be a clinically and cost effective weight-loss treatment option (Picot et al, 2009), but is invasive and expensive compared with non-surgical weight-loss programmes. In addition, there remains inequality in access to bariatric care services across England, thereby preventing potentially eligible patients from getting the treatment they need. Further clarity is required regarding the commissioning responsibilities across the four tiers of the obesity care services. This clarity would help to achieve a more 'joined-up' clinical pathway that is focused at a local level to improve access. However, there is criticism that too much funding is currently being invested in the provision of bariatric surgery when it could be better spent on national roll-out programmes for intensive lifestyle interventions that promote more sustainable weight loss across England.

Fast-track bariatric surgery improves perioperative care and logistics compared to conventional care

BACKGROUND

Due to the increased incidence of morbid obesity, the demand for bariatric surgery is increasing. Therefore, the methods for optimising perioperative care for the improvement of surgical outcome and to increase efficacy are necessary. The aim of this prospective matched cohort study is to objectify the effect of the fast-track surgery (FTS) programme in patients undergoing primary Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) surgery compared to conventional perioperative care (CPC).

METHODS

This study compared the perioperative outcome data of two groups of 75 consecutive morbid obese patients who underwent a primary LRYGB according to international guidelines in the periods January 2011-April 2011 (CPC group) and April 2012-June 2012 (FTS group). The two groups were matched for age and sex. Primary endpoints were surgery and hospitalisation time, while secondary endpoints were intraoperative medication use and complication rates.

RESULTS

Baseline patient characteristics for age, sex, weight and ASA classification were similar (p > 0.05) for CPC and FTS patients. BMI and waist circumference were significantly lower (p < 0.05) in the FTS compared to CPC. The total time from arrival at the operating room to the arrival at the recovery was reduced from 119 to 82 min (p < 0.001). Surgery time was reduced from 80 to 56 min (p < 0.001); mean hospital stay was reduced from 65 to 43 h (p < 0.001). Major complications occurred in 3 versus 4 % in the FTS and CPC, respectively.

CONCLUSIONS

The introduction of a fast-track programme after primary LRYGB improves short-term recovery and may reduces direct hospital-related resources.

Gap Between Evidence and Patient Access: Policy Implications for Bariatric and Metabolic Surgery in the Treatment of Obesity and its Complications

Despite consistently supportive evidence of clinical effectiveness and economic advantages compared with currently available non-surgical obesity treatments, patient access to bariatric and metabolic surgery (BMS) is impeded. To address this gap and better understand the relationship between value and access, the objectives of this study were twofold: (i) identify the multidimensional barriers to adoption of BMS created by clinical guidelines, public policies, and health technology assessments; and, most importantly, (ii) develop recommendations for stakeholders to improve patient access to BMS. Updated public policies focused on treatment and clinical guidelines that reflect the demonstrated advantages of BMS, patient education on safety and effectiveness, updated reimbursement policies, and additional data on long-term BMS effectiveness are needed to improve patient access.

Patterns of brain structural connectivity differentiate normal weight from overweight subjects

Background

Alterations in the hedonic component of ingestive behaviors have been implicated as a possible risk factor in the pathophysiology of overweight and obese individuals. Neuroimaging evidence from individuals with increasing body mass index suggests structural, functional, and neurochemical alterations in the extended reward network and associated networks.

Aim

To apply a multivariate pattern analysis to distinguish normal weight and overweight subjects based on gray and white-matter measurements.

Methods

Structural images (N = 120, overweight N = 63) and diffusion tensor images (DTI) (N = 60, overweight N = 30) were obtained from healthy control subjects. For the total sample the mean age for the overweight group (females = 32, males = 31) was 28.77 years (SD = 9.76) and for the normal weight group (females = 32, males = 25) was 27.13 years (SD = 9.62). Regional segmentation and parcellation of the brain images was performed using Freesurfer. Deterministic tractography was performed to measure the normalized fiber density between regions. A multivariate pattern analysis approach was used to examine whether brain measures can distinguish overweight from normal weight individuals.

Results

1. White-matter classification: The classification algorithm, based on 2 signatures with 17 regional connections, achieved 97% accuracy in discriminating overweight individuals from normal weight individuals. For both brain signatures, greater connectivity as indexed by increased fiber density was observed in overweight compared to normal weight between the reward network regions and regions of the executive control, emotional arousal, and somatosensory networks. In contrast, the opposite pattern (decreased fiber density) was found between ventromedial prefrontal cortex and the anterior insula, and between thalamus and executive control network regions. 2. Gray-matter classification: The classification algorithm, based on 2 signatures with 42 morphological features, achieved 69% accuracy in discriminating overweight from normal weight. In both brain signatures regions of the reward, salience, executive control and emotional arousal networks were associated with lower morphological values in overweight individuals compared to normal weight individuals, while the opposite pattern was seen for regions of the somatosensory network.

Conclusions

1. An increased BMI (i.e., overweight subjects) is associated with distinct changes in gray-matter and fiber density of the brain. 2. Classification algorithms based on white-matter connectivity involving regions of the reward and associated networks can identify specific targets for mechanistic studies and future drug development aimed at abnormal ingestive behavior and in overweight/obesity.

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Multivariate analysis can be used to classify overweight from normal weight individuals.

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Anatomical connectivity achieved 97% accuracy in the classification algorithm.

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Greater connectivity was observed in extended reward and somatosensory regions.

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Morphological gray-matter achieved 69% accuracy in the classification algorithm.

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Lower morphological values were observed in regions of the extended reward network.

Metabolic Mechanisms in Obesity and Type 2 Diabetes: Insights from Bariatric/Metabolic Surgery

Obesity and the related diabetes epidemics represent a real concern worldwide. Bariatric/metabolic surgery emerged in last years as a valuable therapeutic option for obesity and related diseases, including type 2 diabetes mellitus (T2DM). The complicated network of mechanisms involved in obesity and T2DM have not completely defined yet. There is still a debate on which would be the first metabolic defect leading to metabolic deterioration: insulin resistance or hyperinsulinemia? Insight into the metabolic effects of bariatric/metabolic surgery has revealed that, beyond weight loss and food restriction, other mechanisms can be activated by the rearrangements of the gastrointestinal tract, such as the incretinic/anti-incretinic system, changes in bile acid composition and flow, and modifications of gut microbiota; all of them possibly involved in the remission of T2DM. The complete elucidation of these mechanisms will lead to a better understanding of the pathogenesis of this disease. Our aim was to review some of the metabolic mechanisms involved in the development of T2DM in obese patients as well as in the remission of this condition in patients submitted to bariatric/metabolic surgery.

Striatal dopamine homeostasis is altered in mice following Roux-en-Y gastric bypass surgery

Roux-en-Y gastric bypass (RYGB) is an effective treatment for obesity. Importantly, weight loss following RYGB is thought to result in part from changes in brain-mediated regulation of appetite and food intake. Dopamine (DA) within the dorsal striatum plays an important role in feeding behavior; we therefore hypothesized that RYGB alters DA homeostasis in this subcortical region. In the current study, obese RYGB-operated mice consumed significantly less of a high-fat diet, weighed less by the end of the study, and exhibited lower adiposity than obese sham-operated mice. Interestingly, both RYGB and caloric restriction (pair feeding) resulted in elevated DA and reduced norepinephrine (NE) tissue levels compared with ad libitum fed sham animals. Consequently, the ratio of NE to DA, a measure of DA turnover, was significantly reduced in both of these groups. The RYGB mice additionally exhibited a significant increase in phosphorylation of tyrosine hydroxylase at position Ser31, a key regulatory site of DA synthesis. This increase was associated with augmented expression of extracellular-signal-regulated kinases ERK1/2, the kinase targeting Ser31. Additionally, RYGB has been shown in animal models and humans to improve insulin sensitivity and glycemic control. Curiously, we noted a significant increase in the expression of insulin receptor-β in RYGB animals in striatum (a glucosensing brain region) compared to sham ad libitum fed mice. These data demonstrate that RYGB surgery is associated with altered monoamine homeostasis at the level of the dorsal striatum, thus providing a critical foundation for future studies exploring central mechanisms of weight loss in RYGB.

The impact of obesity surgery on musculoskeletal disease

Obesity is an important modifiable risk factor for musculoskeletal disease. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant systematic review of bariatric surgery on musculoskeletal disease symptoms was performed. One thousand nineteen papers were identified, of which 43 were eligible for data synthesis. There were 79 results across 24 studies pertaining to physical capacity, of which 53 (67 %) demonstrated statistically significant post-operative improvement. There were 75 results across 33 studies pertaining to musculoskeletal pain, of which 42 (56 %) demonstrated a statistically significant post-operative improvement. There were 13 results across 6 studies pertaining to arthritis, of which 5 (38 %) demonstrated a statistically significant post-operative improvement. Bariatric surgery significantly improved musculoskeletal disease symptoms in 39 of the 43 studies. These changes were evident in a follow-up of 1 month to 10 years.