A Multisite 2-Year Follow Up of Psychopathology Prevalence, Predictors, and Correlates Among Adolescents Who Did or Did Not Undergo Weight Loss Surgery

Mental health from 5 years before to 10 years after bariatric surgery in adolescents with severe obesity: a Swedish nationwide cohort study with matched population controls

BACKGROUND

The long-term effects of bariatric surgery on the mental health of adolescents with severe obesity remain uncertain. We aimed to describe the prevalence of psychiatric health-care visits and filled prescription psychiatric drugs among adolescents with severe obesity undergoing bariatric surgery in the 5 years preceding surgery and throughout the first 10 years after surgery, and to draw comparisons with matched adolescents in the general population.

METHODS

Adolescents with severe obesity and who underwent bariatric surgery were identified through the Scandinavian Obesity Surgery Registry. We included adolescents who had bariatric surgery between 2007 and 2017 and were younger than 21 years at time of surgery. Each adolescent patient was matched with ten adolescents from the general population by age, sex, and county of residence. Specialist psychiatric care and filled psychiatric prescriptions were retrieved from nationwide data registers.

FINDINGS

1554 adolescents (<21 years) with severe obesity underwent bariatric surgery between 2007 and 2017, 1169 (75%) of whom were female. At time of surgery, the mean age was 19·0 years [SD 1·0], and the mean BMI was 43·7 kg/m2 (SD 5·5). 15 540 adolescents from the general population were matched with adolescents in the surgery group. 5 years before the matched index date, 95 (6·2%) of 1535 surgery patients and 370 (2·5%) of 14 643 matched adolescents had a psychiatric health-care visit (prevalence difference 3·7%; 95% CI 2·4-4·9), whereas 127 (9·8%) of 1295 surgery patients and 445 (3·6%) of 12 211 matched adolescents filled a psychiatric drug prescription (prevalence difference 6·2%; 95% CI 4·5-7·8). The year before the matched index date, 208 (13·4%) of 1551 surgery patients and 844 (5·5%) of 15 308 matched adolescents had a psychiatric health-care visit (prevalence difference 7·9%; 95% CI 6·2-9·6), whereas 319 (20·6%) of 1551 surgery patients and 1306 (8·5%) of 15 308 matched adolescents filled a psychiatric drug prescription (prevalence difference 12·0%; 10·0-14·1). The prevalence difference in psychiatric health-care visits peaked 9 years after the matched index date (12·0%; 95% CI 9·0-14·9), when 119 (17·6%) of 675 surgery patients and 377 (5·7%) of 6669 matched adolescents had a psychiatric health-care visit. The prevalence difference in filled psychiatric drug prescription was highest 10 years after the matched index date (20·4%; 15·9-24·9), when 171 (36·5%) of 469 surgery patients and 739 (16·0%) of 4607 matched adolescents filled a psychiatric drug prescription. The year before the matched index date, 19 (1·2%) of 1551 surgery patients and 155 (1·0%) of 15304 matched adolescents had a health-care visit associated with a substance use disorder diagnosis (mean difference 0·2%, 95% CI -0·4 to 0·8). 10 years after the matched index date, the prevalence difference had increased to 4·3% (95% CI 2·3-6·4), when 24 (5·1%) of 467 surgery patients and 37 (0·8%) of 4582 matched adolescents had a health-care visit associated with a substance use disorder diagnosis.

INTERPRETATION

Psychiatric diagnoses and psychiatric drug prescriptions were more common among adolescents with severe obesity who would later undergo bariatric surgery than among matched adolescents from the general population. Both groups showed an increase in prevalence in psychiatric diagnoses and psychiatric drug prescriptions leading up to the time of surgery, but the rate of increase in the prevalence was higher among adolescents with severe obesity than among matched adolescents. With the exception of health-care visits for substance use disorders, these prevalence trajectories continued in the 10 years of follow-up. Realistic expectations regarding mental health outcomes should be set preoperatively.

FUNDING

Swedish Research Council, Swedish Research Council for Health, Working Life and Welfare.

Two-Year Study on the Impact of Sleeve Gastrectomy on Depressive and Anxiety Symptoms in Adolescents and Young Adults with Moderate to Severe Obesity

PURPOSE

Sleeve gastrectomy (SG), the most commonly performed weight loss surgery in adolescents and young adults with moderate to severe obesity, is highly effective for weight loss. Current literature regarding depressive and anxiety symptomatology following SG in youth is sparse and conflicting. We evaluated changes in depressive and anxiety symptoms in adolescents and young adults with moderate to severe obesity 2 years following SG compared with non-surgical controls (NS) followed for a similar duration.

MATERIALS AND METHODS

Forty-six youth 13-25 years old with moderate-severe obesity (33 female) were followed for 2 years; 21 underwent SG, and 25 were NS. Subjects underwent anthropometric measurements and completed self-report questionnaires. Beck Depression Inventory-II (BDI-II) was used to assess depressive symptoms and the State-Trait Anxiety Inventory (STAI)-X2 for anxiety symptoms.

RESULTS

Groups did not differ for age (18.4 ± 0.4 vs. 17.8 ± 0.5 years, p = 0.456). The SG group had a higher mean BMI vs. NS (47.5 (42.1, 52.4) vs. 41.6 (37.8, 46.5) kg/m2; p = 0.011). At 2-year follow-up, SG had greater reductions in weight and BMI vs. NS (p < 0.0001). Groups did not differ for changes in BDI-II and STAI scores (BDI-II: - 1.0 (- 6.0, 10.0) in SG vs. - 1.0 (- 6.0, 3.5) in NS, p = 0.37; STAI: 3.1 ± 3.2 in SG vs. - 1.1 ± 1.5 in NS, p = 0.24).

CONCLUSION

No change was found in depressive and anxiety symptomatology following surgery despite marked weight reduction over a 2-year period, underscoring the need to better evaluate psychopathology in youth undergoing SG to develop supportive therapeutic strategies.

CLINICALTRIALS

GOV IDENTIFIER

NCT02557438 https://clinicaltrials.gov/ct2/show/NCT02557438?id=NCT02557438&draw=2&rank=1 ; The study was registered on 23 September 2015.

Five-Year Physical and Psychosocial Outcomes in Obese Adolescents With and Without Metabolic Bariatric Surgery

PURPOSE

Metabolic bariatric surgery (MBS) is increasingly accepted as a treatment for severely obese adolescents. However, its long-term efficacy and safety are not well characterized, particularly in the Eastern Asian population. We aimed to explore the long-term effects of MBS on Chinese adolescents with severe obesity.

METHODS

A total of 44 obese adolescents (≤18 years old) underwent MBS at our institution from May 2011 to May 2017. A matched nonsurgical control group, including 43 patients, was recruited from lifestyle modification programs in the same period. All patients completed assessments at presurgery/baseline and five years after surgery. The data were collected and analyzed using the χ2 test and an independent sample t-test.

RESULTS

Comparing the surgical and control groups revealed that the surgical patients showed significant weight loss and improvement in comorbidities, while the nonsurgical patients showed a trend of weight gain and increased comorbidities (p < .05). Furthermore, the surgical patients had a higher composite physical quality of life (as determined by the Short Form-36 questionnaire). On the other hand, the patients who underwent MBS had a higher risk of malnutrition.

DISCUSSION

Compared with nonsurgical patients, severely obese adolescents who undergo MBS exhibit more effective long-term weight loss, remission of comorbidities, and improved quality of life. Furthermore, more attention should be paid to helping adolescents avoid malnutrition after they undergo MBS.

Long-term Outcomes Following Adolescent Metabolic and Bariatric Surgery

Severe obesity in adolescence negatively impacts upon health and wellbeing. Lifestyle modifications do not usually achieve a sufficient degree or durability of weight loss to mitigate the risk of medical complications. In recent years, metabolic and bariatric surgery (MBS), already a well-established treatment for adults with severe obesity, has emerged as an option in adolescents. Controlled studies in this age group have demonstrated substantial and sustained weight loss, improvements in associated health parameters, and a safety profile surpassing that observed in adult patients. This review aims to present published data on the results of MBS in adolescents with a focus on long-term outcomes. Indications for bariatric surgery and aspects of timing in the young person's life are also presented, along with safety considerations and factors influencing patient selection for surgery. We conclude, predominantly from short- to medium-term outcomes data, that MBS is a safe and valuable therapeutic option for adolescents with severe obesity. Considering the poor health and social wellbeing prognosis in this group, MBS appears to be underutilized. The need for continued research, multiprofessional specialist provision, coherent contemporary clinical guidelines, and routine long-term follow-up in adolescents undergoing MBS is highlighted.

Trajectories of Psychopathology and Dysregulation 2-4 Years following Adolescent Bariatric Surgery

OBJECTIVE

This study examined psychopathology and weight over 4 years following bariatric surgery in adolescents with obesity, as compared to a nonsurgical group. The role of psychological dysregulation in relation to psychopathology in the 2-4 year "maintenance phase" following surgery was also examined.

METHODS

Adolescent participants (122 surgical and 70 nonsurgical) completed height/weight and psychopathology assessments annually for 4 years, with dysregulation assessed at Year 2. Analyses examined the association of "High" and "Low" psychopathology with weight over time using logistic regression. Mediation analyses in the surgical group examined indirect effects of dysregulation on percent weight loss through Year 4 psychopathology.

RESULTS

There were lower odds of "High" internalizing symptoms in the surgical group versus the nonsurgical group from baseline (presurgery) to Year 4 (OR = .39; p < .001; 42.3% "High" internalizing in surgical; 66.7% in nonsurgical) and during the 2-4 year maintenance phase (OR = .35, p < .05; 35.1% "High" internalizing in surgical; 60.8% in nonsurgical). There was a significant mediation effect in the surgical group: higher dysregulation was associated with greater Year 4 internalizing symptoms (β = .41, p < .001) which in turn was associated with less Year 4 percent weight loss (β = -.27, p < .05).

CONCLUSIONS

While the surgical group was less likely to experience internalizing symptoms, internalizing psychopathology was related to less percent weight loss in this group. Internalizing symptoms mediated the relationship between dysregulation and percent weight loss in the surgical group. Postoperative mental health follow-up is needed for adolescents into young adulthood.

Laparoscopic sleeve gastrectomy for obesity treatment in adolescents and young adults: a systematic review and meta-analysis

BACKGROUND

The incidence of obesity has been increasing in younger population, posing a significant impact on adolescents' life and health care system worldwide.

METHODS

We critically analyzed the existing literature on the use of laparoscopic sleeve gastrectomy (LSG) for the treatment of obesity. We performed an in-depth evaluation of 37 studies and analyzed the effect of LSG in 2300 patients, aged ≤ 22 years.

RESULTS

Mean body mass index (BMI) loss after LSG was 17.81 kg/m2. Gastroesophageal reflux was the most common complication. Most of the patients showed remission of comorbidities including hypertension, diabetes, and obstructive sleep apnea after LSG.

CONCLUSIONS

These findings suggest that surgical intervention is highly beneficial for reducing BMI in appropriately selected adolescents and young adults suffering from obesity and comorbidities such as life-threatening obstructive sleep apnea.

Ethics of Bariatric Surgery in Adolescence and Its Implications for Clinical Practice

Obesity is increasingly prevalent among adolescents. Clinical and research data support the use of bariatric surgery (BS) as a treatment option for severely obese adolescents, with good results in terms of weight loss, improvement or resolution of comorbidities, and compliance to follow up. Nevertheless, concerns still remain, with significant disparities among countries and ethical concerns mainly raised by performing an irreversible and invasive procedure in adolescence, with potential life-long alterations. In this context, the purpose of this narrative review was to discuss the main current ethical challenges in performing BS in adolescence and to inform appropriate clinical management in the field. The core ethical principles of autonomy, beneficence, nonmaleficence, and justice were revised in terms of patient-centered healthcare through the lens of psychosocial implications. The review concludes with a discussion regarding the potential directives for future research for effective, patient-centered, and ethical management of obesity in the adolescent population.

Psychosocial predictors of problematic eating in young adults who underwent adolescent bariatric surgery

Introduction

This study examined problematic eating and eating-related psychopathology among young adults who underwent adolescent bariatric surgery including concurrent and prospective associations with psychosocial factors and weight change.

Methods

VIEW point is a 6-year follow-up study within a prospective observational study series observing adolescents with severe obesity who had bariatric surgery (n = 139) or who presented to nonsurgical lifestyle modification programs (n = 83). Participants completed height/weight measurements, questionnaires, and diagnostic interviews. Regression analyses compared problematic eating across groups and examined Year 6 correlates (i.e., psychosocial factors and weight change) and baseline predictors (i.e., psychosocial factors) of eating-related psychopathology.

Results

Compared to the nonsurgical group, the surgical group reported lower eating-related psychopathology, objective binge eating, and grazing at Year 6. While chewing/spitting out and vomiting for weight/shape-related reasons were very infrequent for the surgical group, self-induced vomiting for other reasons (e.g., avoid plugging) was more common. For the surgical group, lower self-worth, greater internalizing symptoms, and higher weight-related teasing in adolescence predicted increased eating-related psychopathology in young adulthood. Year 6 eating-related psychopathology was concurrently associated with lower percent weight loss for the surgical group and greater percent weight gain for the nonsurgical group.

Conclusion

Undergoing adolescent bariatric surgery appears to afford benefit for problematic eating and eating-related psychopathology. Current findings suggest that the clinical intervention related to problematic eating and associated psychosocial concerns may be needed for young adults with obesity, regardless of surgical status.

Short-Term Changes in Mental, Physical, and Social Factors After Metabolic Bariatric Surgery in Adolescents: A Nationwide Prospective Cohort Study

Background

Metabolic bariatric surgery (MBS) is an effective treatment for adolescents with severe obesity. However, changes in mental, physical, and social factors, as well as their association with the extent of excess weight loss (%EWL) after MBS, remain controversial.

Methods

We followed 97 adolescents (64% females, aged 17 ± 0.9 years, BMI 46.1 ± 5.9 kg/m2) before and 9 months following MBS in a multi-center, prospective cohort study. Changes in mental, physical, and social factors were assessed by self-reported questionnaires, and associations with %EWL were evaluated after adjustment for potential confounders.

Results

The body mass index (BMI) decreased by 30%, and all physical parameters significantly improved (p ≤ 0.001). Energy level increased by 24%, mood level by 14%, and mental health by 9.5% (p ≤ 0.002). Social parameters were also improved, with a significant decrease in social rejection (p = 0.02), and an increase in participation in after-school social activities (p = 0.008). Mental health improvement was associated with baseline social rejection (r = 0.514, p < 0.001). The improvement in all factors was not related to the extent of %EWL.

Conclusion

Metabolic bariatric surgery MBS in adolescents led to a meaningful decrease in BMI and to an improvement in short-term physical, mental, and social factors that were not related to %EWL. Patients experiencing social rejection may improve their mental health following BS.

Obesity in children and adolescents: epidemiology, causes, assessment, and management

This Review describes current knowledge on the epidemiology and causes of child and adolescent obesity, considerations for assessment, and current management approaches. Before the COVID-19 pandemic, obesity prevalence in children and adolescents had plateaued in many high-income countries despite levels of severe obesity having increased. However, in low-income and middle-income countries, obesity prevalence had risen. During the pandemic, weight gain among children and adolescents has increased in several jurisdictions. Obesity is associated with cardiometabolic and psychosocial comorbidity as well as premature adult mortality. The development and perpetuation of obesity is largely explained by a bio-socioecological framework, whereby biological predisposition, socioeconomic, and environmental factors interact together to promote deposition and proliferation of adipose tissue. First-line treatment approaches include family-based behavioural obesity interventions addressing diet, physical activity, sedentary behaviours, and sleep quality, underpinned by behaviour change strategies. Evidence for intensive dietary approaches, pharmacotherapy, and metabolic and bariatric surgery as supplemental therapies are emerging; however, access to these therapies is scarce in most jurisdictions. Research is still needed to inform the personalisation of treatment approaches of obesity in children and adolescents and their translation to clinical practice.

Unhealthy Eating, Psychopathology, and Nonalcoholic Fatty Liver Disease in Youth Presenting for Bariatric Surgery

OBJECTIVES

Little is known about the behavioral and psychosocial correlates of pediatric nonalcoholic fatty liver disease (NAFLD). Given diet contributes to the development and persistence of NAFLD, we examined (1) the prevalence of unhealthy eating behaviors (UEB), (2) whether these varied by NAFLD or nonalcoholic steatohepatitis (NASH) presence, and explored (3) the association of psychopathology with NAFLD.

METHODS

Before metabolic and bariatric surgery (MBS), adolescents (N = 159; Mage = 16.4; MBMI = 53.7 kg/m2, 73% girls, 62.3% white) self-reported presence/absence of 10 UEB (Questionnaire on Eating and Weight Patterns-Revised, Night Eating Questionnaire, Look AHEAD). NAFLD and NASH presence was assessed by intraoperative liver biopsy. Height/weight, blood pressure, and blood specimens were obtained. A medical comorbidity index was created (prediabetes/diabetes, dyslipidemia, elevated blood pressure). Psychopathology was assessed in a subgroup completing the Youth Self-Report (N = 98).

RESULTS

Binge eating disorder symptomatology was associated with higher odds of NAFLD whereas frequent eating out was associated with lower odds of NAFLD. Among those with NAFLD frequent eating out was associated with higher odds of NASH while nocturnal eating was associated with lower odds of NASH. Separate models identified internalizing psychopathology as associated with higher odds of NAFLD after controlling for demographics, number of UEB, and medical comorbidities.

CONCLUSIONS

Results suggest potential phenotypical differences between adolescents presenting for MBS with/without NAFLD, with implications for behavioral/psychosocial targets for screening and intervention. Replication should occur in a sample with greater gender and ethnic diversity to improve generalizability. Understanding differences in the context of surgical weight loss and comorbidity resolution is indicated.

A systematic review of binge eating, loss of control eating, and weight loss in children and adolescents

OBJECTIVE

This review synthesizes literature on changes in binge eating (BE) and loss of control eating (LOC) following weight loss and the association between BE/LOC and weight loss in children and adolescents.

METHODS

A systematic literature search was conducted in PubMed, Scopus, and PsycInfo. Eligible studies included all peer-reviewed journal articles of primary research that assessed BE/LOC and weight change following a weight-loss intervention in individuals under 18 years of age.

RESULTS

The 29 articles included studies on behavioral therapy, pharmacotherapy, and surgical interventions. Of the 14 studies that assessed the relationship between weight loss and BE/LOC at baseline, 4 showed that higher baseline BE/LOC was associated with less weight loss, whereas 10 showed no significant association. BE/LOC behaviors significantly decreased following weight-loss interventions in 20 of 21 studies. A greater decrease in BE/LOC was associated with improved weight loss in 4 of 9 studies that assessed this change.

CONCLUSIONS

Weight-loss interventions are associated with improved BE/LOC in youth with obesity. The persistence of BE/LOC symptoms may be associated with less weight loss. These results can aid in guiding future treatment for youth with BE/LOC seeking weight-loss treatment.

Update on Metabolic Bariatric Surgery for Morbidly Obese Adolescents

Despite worldwide public attention and intense medical efforts, the prevalence of severe morbid obesity in children and adolescents is still rising. Similar to adults, excess adipose tissue triggers multiple immunological and metabolic pathways leading to serious co-morbidities such as impaired glucose tolerance or even type 2 diabetes (T2D), dyslipidemia, arterial hypertension, non-alcoholic fatty liver disease, and hyperuricemia. The management of severe childhood obesity requires a life-long multidisciplinary approach with a combination of lifestyle changes, nutrition, and medications. Standardized life-style intervention programs remain the first-line treatment for morbid obese children and adolescents, but unfortunately reveal limited long-term success. In such cases, metabolic bariatric surgery (MBS) has evolved from being a controversial issue to being included in distinct recommendations. According to the American Society for Metabolic and Bariatric Surgery (ASMBS) Pediatric Committee, indications for bariatric surgery in adolescence must follow very strict criteria. Adolescents with class II obesity (BMI > 120% of the 95th percentile) and a diagnosed co-morbidity or with class III obesity (BMI ≥ 140% of the 95th percentile) should be considered for MBS. These interventions represent high-risk operations, and adolescents should be treated in specialized, multidisciplinary high-volume obesity centers with long-term follow-up programs. The Roux-en-Y gastric bypass (RYGB) remains the gold standard of all malabsorptive procedures. Laparoscopic sleeve gastrectomy (LSG), which the authors pioneered as a stand-alone procedure in morbidly obese adolescents in 2008, has become the most commonly performed operation in morbidly obese adolescents at present. Recent literature proves that MBS is safe and effective in morbidly obese adolescents. Mid-term data have revealed significant improvement or even resolution of major co-morbidities. Thus, MBS for the treatment of morbidly obese adolescents has evolved from being a controversial issue to being included in distinct recommendations by several medical societies as a therapeutic strategy to reduce severe co-morbidities potentially causing end-organ damage in adulthood.

Depression, anxiety, and suicidal ideation in young adults 5 years after undergoing bariatric surgery as adolescents

PURPOSE

Metabolic and bariatric surgery (MBS) is increasingly used in adolescents. The aim was to explore symptoms of depression and anxiety in young adults over 5 years' follow-up after undergoing MBS.

METHODS

Beck Depression Inventory-2 and the Beck Anxiety Inventory were used to assess symptoms of depression and anxiety in 62 patients 1, 2, and 5 years after having Roux-en-Y gastric bypass at 13-18 years of age. Mental health, eating-related problems, and weight outcomes were tested for association with suicidal ideation at the 5-year follow-up.

RESULTS

At the 5-year follow-up, the mean score for depression was 11.4 (± 12.4), indicating minimal symptoms of depression. The mean score for anxiety was 12.82 (± 11.50), indicating mild anxiety symptoms. Still, several participants reported moderate or severe symptoms of depression (26%) and anxiety (32%). Women reported more symptoms than men (P = 0.03 and 0.04). No significant changes were found in self-reported symptoms of depression and anxiety between the 1-year and the 5-year follow-up (P = 0.367 and 0.934). Suicidal ideation was reported by 16% at the 5-year follow-up. Participants reporting suicidal ideation had lost significantly less excess weight than participants without suicidal ideation (P = 0.009).

CONCLUSION

Five years after adolescent MBS, a substantial minority still struggles with mental health issues, and women are more burdened than men. Our results indicate an association between less optimal weight loss and suicidal ideation 5 years after MBS. The findings emphasize the importance of offering long-term follow-up and mental health treatment several years after MBS.

LEVEL OF EVIDENCE

Level III, cohort study.

CLINICAL TRIAL REGISTRATION

The study is registered with ClinicalTrials.gov (NCT00289705). First posted February 10, 2006.

Psychopathology and Adolescent Bariatric Surgery: A Topical Review to Support Psychologists in Assessment and Treatment Considerations

The rising rates of severe obesity among adolescents in the United States indicate a dire need for more intensive weight management strategies. While current evidence suggests that bariatric surgery is a safe and efficacious intervention for adolescents, the linkages with psychopathology before and after surgery are not well understood. Psychologists are an integral part of the interdisciplinary surgery team and play an important role in preparing youth for bariatric surgery as well as supporting adolescents post-surgery. The present manuscript reviews the literature on psychopathology in the context of adolescent bariatric surgery, discusses consideration of psychopathology as a contraindication for surgery, and provides recommendations on how psychologist members of the bariatric surgery team may balance attention to motivation and adherence to medical recommendations with assessment and treatment of psychopathology. Finally, the importance of continued research to confirm clinical consensus regarding decision-making and expansion of psychological resources within adolescent bariatric surgery programs are discussed.

Cigarette Use and Adolescent Metabolic and Bariatric Surgery

OBJECTIVE

This study aimed to track conventional cigarette smoking behaviors and associated correlates in adolescents with severe obesity who did or did not undergo metabolic and bariatric surgery to 4 years after surgery/baseline.

METHODS

Utilizing a prospective controlled design, surgical (n = 153; mean BMI = 52) and nonsurgical (n = 70; mean BMI = 47) groups that completed assessments before surgery/at baseline and at Years 2 and 4 post surgery (Year 4: n = 117 surgical [mean BMI = 38]; n = 56 nonsurgical [mean BMI = 48]) were compared. Separate logistic regression models tested correlates of Year 4 current smoking.

RESULTS

More than half of participants (surgical: 55%; nonsurgical: 60%) had ever smoked a cigarette, with current smoking increasing with time. Groups did not differ in Year 4 current smoking (surgical: 23%; nonsurgical: 33%), with ≈ 50% meeting criteria for "heavy" smoking (≥ half pack/day) and ≈ 40% smoking their first cigarette before ninth grade. Factors associated with higher odds of Year 4 current smoking included dysregulation (P < 0.001), internalizing symptoms (P = 0.01), alcohol use (P = 0.04), caregiver smoking (P < 0.001), friend smoking (P = 0.001), and perceiving low harm (P = 0.02), plus greater percent weight loss (P = 0.03) in the surgical group.

CONCLUSIONS

Smoking is a clinical health challenge for adolescents and young adults with severe obesity, including those who have undergone metabolic and bariatric surgery. Upstream identification, monitoring, and intervention to prevent smoking uptake and escalation in youth with obesity across settings should be prioritized.

Psychological Outcomes and Predictors of Weight Loss in Adolescents With Severe Obesity Following a Reversible Endoscopic Bariatric Procedure

Introduction: Adolescent and children obesity is a growing concern worldwide. Bariatric surgery is used as an effective treatment for adolescents with obesity and provides physical and mental health benefits. Application of alternative, minimally invasive, safe, and reversible endoscopic procedures, such as the Duodenojejunal bypass liner (DJBL), has been recently suggested as an effective treatment for adolescents with obesity. We explored specific psychological outcomes of adolescents with obesity during a year of follow-up after undergoing a reversible endoscopic bariatric procedure, and a year after removal. We were also interested in identifying psychological factors that could predict successful weight loss after the procedure. Methods: Nineteen adolescent with severe obesity undergoing DJBL procedure were psychologically assessed in an open-label, prospective clinical trial (NTC0218393), at the implantation of device and at the removal of device after 12 months. Control group of 26 adolescents with severe obesity were recruited from the same outpatient clinic undergoing only conservative treatment. In addition, adolescents from the intervention group were followed for 12 months after the removal of the device. The Youth Self Report (YSR) was used to assess adolescents' emotional and behavioural problems; The Multidimensional Body-Self Relations Questionnaire (MBSRQ) to assess body image and The Eating Disorder Examination Questionnaire (EDE-Q) to assess attitudes and behaviours related to eating disorder. Results: Significant improvements in somatic complain (F = 12.478, p = 0.001), emotional and behavioural problems (F = 7.169, p = 0.011) and food restraining (F = 9.605, p = 0.004) were found in the intervention group at device removal compared to the control group. Moreover, at the time of device removal compared to baseline, improvements in several psychological outcomes were found (F = 32.178 p = 0.000 for emotional and behavioural problems). Adolescents also became more satisfied with their appearance (F = 6.789, p = 0.019). Majority of observed changes remained stable at the next follow up a year after the device removal. Significant predictors of successful weight loss at device removal were fewer overeating episodes (B = 0.147, p = 0.022) and lower body satisfaction (B = 0.932, p = 0.013). Discussion: Following a reversible bariatric procedure, improvements of psychological (emotional and behavioural) factors were found in adolescents with severe obesity. Psychological predictors of successful weight loss were identified, showing the greatest importance of eating behaviour and body satisfaction in successful weight loss.

Psychosocial Outcomes Following Adolescent Metabolic and Bariatric Surgery: a Systematic Review and Meta-Analysis

BACKGROUND

Metabolic and bariatric surgery is an effective strategy to curb the natural history of obesity progression and improve psychosocial status in the short term for adolescents with severe obesity. The medium- and long-term psychosocial impact of bariatric surgery in this population is not established.

METHODS

We searched MEDLINE (Ovid), EMBASE, Web of Science, PsycInfo, and the Cochrane Libraries through October 2017 for reports of weight loss surgery (roux-en-Y gastric bypass, sleeve gastrectomy, and adjustable gastric banding) on adolescents with severe obesity (age ≤ 21 years) having ≥ 6 months of follow-up. The primary outcome for inclusion in systematic review was use of a validated quality of life (QoL) or other psychosocial instrument at baseline and postoperatively. We used standardized mean difference (SMD) and random-effects modeling to provide summary estimates across different instruments.

RESULTS

We reviewed 5155 studies, of which 20 studies met inclusion criteria for qualitative synthesis. There were 14 studies and 9 unique cohorts encompassing 573 patients which were eligible for meta-analysis regarding postoperative change in QoL. Across surgical procedures, there was significant improvement in QoL of 1.40 SMD (95% confidence interval 0.95 to 1.86; I² = 89%; p < 0.001) at last follow-up (range 9-94 months). Trends in QoL improvement demonstrated the greatest improvement at 12 months; however, significant improvement was sustained at longest follow-up of 60+ months.

CONCLUSIONS

Weight loss surgery is associated with sustained improvement in QoL for adolescents with severe obesity across surgical procedures. Long-term data for psychosocial outcomes reflecting other mental health domains is lacking.

Short- and long-term safety and efficacy of bariatric surgery for severely obese adolescents: a narrative review

The selection criteria, safety, and efficacy of bariatric surgery are well established in adults but are less well defined for severely obese adolescents. The number of severely obese adolescents who could benefit from weight loss surgery is increasing, although referral rates have plateaued. Surgical options for these adolescents are controversial and raise several questions. Recent studies, including the prospective Teen-Longitudinal Assessment of Bariatric Surgery Study and the Adolescent Morbid Obesity Surgery Study, help answer these questions. Early bariatric surgical intervention improves body mass index but, more importantly, improves cardiovascular and metabolic co-morbidities of severe obesity. A review of the medical, psychosocial, and economic risks and benefits of bariatric surgery in severely obese adolescents is a step toward improving the management of a challenging and increasing population. We describe the current knowledge of eligibility criteria, preoperative evaluation, surgical options, outcomes, and referral barriers of adolescents for bariatric surgery.

Physical and Psychological Effects of Bariatric Surgery on Obese Adolescents: A Review

The worldwide obesity crisis is not isolated to adults; rather, obesity in adolescents has reached epidemic levels as well. Bariatric surgery continues to be one of the most effective treatments for obesity, both in adults and adolescents, with new evidence continually emerging; however, research surrounding outcomes of these procedures in younger patients is limited in comparison with data available for adults. Further, it is important to examine psychological aspects of obesity in adolescents, as well as effects of surgery on mental health endpoints. Conditions such as anxiety, depression, anger, and disruptive behavior show increased prevalence among obese adolescents, but minimal research exists to examine changes in such conditions following bariatric surgery. Additionally, there is growing evidence of a bidirectional relationship between sleep (quality; disorders) and the development of obesity, and the effects of this relationship are particularly pronounced in the vulnerable adolescent population. This review aims to compile and discuss the results of literature within the last 5 years with regard to overall efficacy of bariatric surgery specifically in adolescent patients in terms of weight and body mass index (BMI) reduction, hormonal changes, and co-morbidity resolution, as well as data surrounding sleep and psychological outcomes. Race, ethnicity, and socioeconomic status were also examined. From this review, we conclude that current research supports bariatric surgery in adolescents as an effective method of treatment for obesity and related co-morbidities; however, minimal long-term data exists to adequately assess efficacy and trends into adulthood. These areas are ripe for future study.

Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery

BACKGROUND

Extant literature warns of elevated suicide risks in adults postbariatric surgery, making understanding risks for adolescent patients imperative.

OBJECTIVES

To examine prevalence and predictors/correlates of suicidal thoughts and behaviors (STBs) in adolescents with severe obesity who did/did not undergo bariatric surgery from presurgery/baseline to 4 years postsurgery.

SETTING

Five academic medical centers.

METHODS

Using a prospective observational design, surgical adolescents (n = 153; 79% female, 65% white, mean [M]_age = 17 yr, M_{body mass index[BMI]} = 52 kg/m²) and nonsurgical comparators (n = 70; 80% female, 54% white, M_age = 16 yr, M_BMI = 47 kg/m²) completed psychometrically sound assessments at presurgery/baseline and postsurgery years 2 and 4 (year 4: n = 117 surgical [M_BMI = 38 kg/m²], n = 56 nonsurgical [M_BMI = 48 kg/m²]).

RESULTS

For the surgical group, rates of STBs were low (year 2 [1.3%-4.6%]; year 4 [2.6%-7.9%], similar to national base rates. Groups did not differ on a year 4 postsurgical STBs (post-STBs) composite (post-STBs: ideation/plan/attempt; n = 18 surgical [16%], n = 10 nonsurgical [18%]; odds ratio = .95, P = .90). For the surgical group, predictors/correlates identified within the broader suicide literature (e.g., psychopathology [P < .01], victimization [P < .05], dysregulation [P < .001], drug use [P < .05], and knowing an attemptor/completer [P < .001]) were significantly associated with post-STBs. Surgery-specific factors (e.g., percent weight loss, weight satisfaction) were nonsignificant. Of those reporting a lifetime attempt history at year 4, only a minority (4/13 surgical, 3/9 nonsurgical) reported a first attempt during the study period. Of 3 decedents (2 surgical, 1 nonsurgical), none were confirmed suicides.

CONCLUSIONS

The present study indicates that undergoing bariatric surgery in adolescence does not heighten (or lower) risk of STB engagement across the initial 4 years after surgery. Suicide risks present before surgery persisted, and also newly emerged in a subgroup with poorer psychosocial health.

Change, predictors and correlates of weight- and health-related quality of life in adolescents 2-years following bariatric surgery

Background/Objectives:

Weight-related quality of life (WRQOL) and generic health-related quality of life (HRQOL) have been identified as important patient reported outcomes for obesity treatment and outcome research. This study evaluated patterns of WRQOL and HRQOL outcomes for adolescents at 24-months post-bariatric surgery relative to a non-surgical comparator sample of youth with severe obesity, and examined potential weight-based (e.g., BMI, weight dissatisfaction) and psychosocial predictors and correlates of these outcomes.

Subjects/Methods:

Multi-site data from 139 adolescents undergoing bariatric surgery (M_age=16.9; 79.9% female, 66.2% White; M_{Body Mass Index [BMI]=} 51.5kg/m²) and 83 comparators (M_age=16.1; 81.9 % female, 54.2% White; M_BMI= 46.9kg/m²) were collected at pre-surgery/baseline, 6-, 12-, and 24-months post-surgery/baseline with high participation rates across time points (>85%). Self-reports with standardized measures of WRQOL/HRQOL as well as predictors/covariates (e.g., weight dissatisfaction, social support, peer victimization, family dysfunction, loss of control eating, self-worth, and internalizing symptoms) were obtained. Growth curve models using structural equation modeling examined WRQOL/HRQOL over time and linear regressions examined predictors and correlates of WRQOL/HRQOL outcomes.

Results:

Significant improvement in WRQOL and Physical HRQOL, particularly in the first post-operative year with a leveling off subsequently, was found for the surgical group relative to comparators, but with no significant Mental HRQOL change. At 24 months, the surgical group had signficantly greater WRQOL/HRQOL across most subscales. Within the surgical group at 24 months, weight-based variables were signficantly associated with WRQOL and Physical HRQOL, but not Mental HRQOL. Mental HRQOL was associated with greater internalizing symptoms and loss of control eating.

Conclusions:

For adolescents undergoing bariatric surgery, most clinically meaningful changes in WRQOL and Physical HRQOL occurred early post-operatively, with weight-based variables as the primary drivers of 24-month levels. In contrast, expectations for Mental HRQOL improvement following surgery should be tempered, with 24-month levels significantly associated with psychosocial rather than weight-based correlates.

Sexual behaviors, risks, and sexual health outcomes for adolescent females following bariatric surgery

BACKGROUND

Adolescents females with severe obesity are less likely to be sexually active, but those who are sexually active engage in risky sexual behaviors.

OBJECTIVES

To examine patterns and predictors of sexual risk behaviors, contraception practices, and sexual health outcomes in female adolescents with severe obesity who did or did not undergo bariatric surgery across 4 years.

SETTING

Five academic medical centers.

METHODS

Using a prospective observational controlled design, female adolescents undergoing bariatric surgery (n = 111; M_age = 16.95 ± 1.44 yr; body mass index: M_BMI = 50.99 ± 8.42; 63.1% white) and nonsurgical comparators (n = 68; M_age = 16.18 ± 1.36 yr; M_BMI = 46.47 ± 5.83; 55.9% white) completed the Sexual Activities and Attitudes Questionnaire at presurgery/baseline and 24- and 48-month follow-up, with 83 surgical females (M_BMI = 39.27 ± 10.08) and 49 nonsurgical females (M_BMI = 48.56 ± 9.84) participating at 48 months.

RESULTS

Most experienced sexual debut during the 4-year study period, with a greater increase in behaviors conferring risk for sexually transmitted infections (STIs) for surgical females (P = .03). Half (50% surgical, 44.2% nonsurgical, P = .48) reported partner condom use at last sexual intercourse. The proportion of participants who had ever contracted an STI was similar (18.7% surgical, 14.3% nonsurgical). Surgical patients were more likely to report a pregnancy (25.3% surgical, 8.2% nonsurgical, P = .02) and live birth (16 births in 15 surgical, 1 nonsurgical), with 50% of offspring in the surgical cohort born to teen mothers (age ≤19 yr).

CONCLUSIONS

Bariatric care guidelines and practices for adolescent females must emphasize the risks and consequences of teen or unintended pregnancies, sexual decision-making, dual protection, and STI prevention strategies to optimize health and well-being for the long term.

Energy Management for Personalized Weight Reduction (EMPOWER) Program: Three-Year Outcome Data

BACKGROUND

The current consensus guidelines for management of pediatric obesity recommend clinic-based, family-centered, multi-disciplinary interventions. It is well reported that these programs often only lead to modest improvements in BMI status. The individual factors that differentiate which patient's BMI status will improve vs. worsen remains understudied. A retrospective cohort study was conducted to evaluate the outcomes of EMPOWER clinic and identify the participant specific characteristics that predicted BMI status improvement in this population.

METHODS

Youth who completed at least 6 visits in EMPOWER were included. Paired t-test was utilized to evaluate the mean change in zBMI, modified BMIz and %BMI_p95 from baseline to 6^th visit, and multivariate mixed effect models were utilized to analyze effect of baseline characteristics on change in BMI status.

RESULTS

92 participants were included in the analysis, 87% with severe obesity and 66% Hispanic. At the 6^th visit, there was a significant reduction in zBMI (-0.09 SD, p <0.001) and modified BMIz (-0.0003 SD, p = 0.04) with a small reduction in %BMI_p95 (-1.15 %, p = 0.20). Lower BMI status (p < 0.001) and absence of a comorbidity (p < 0.05) at baseline were predictors of BMI status improvement whereas age, gender, ethnicity, family history of obesity and insurance status were not significant predictors.

CONCLUSIONS

Given that implementation of the current guidelines for management of obesity in pediatrics only results in modest BMI status reduction, further investigation is required to understand how the determinants of obesity-related health outcomes can guide development of more innovative, effective interventions for this high risk population.