Baseline characteristics of participants in the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study

Adipositas Care and Health Therapy (ACHT) after Bariatric-Metabolic Surgery: A Prospective, Non-Randomized Intervention Study

INTRODUCTION

Almost 25% of German adults have obesity and numbers are rising, making it an important health issue. Bariatric-metabolic surgery reduces body weight and complications for persons with obesity, but therapeutic success requires long-term postoperative care. Since no German standards for follow-up by family physicians exist, follow-up is provided by surgical obesity centers, but they are reaching their limits. The ACHT study, funded by the German Innovation Fund, is designed to establish and evaluate the follow-up program, with local physicians following patients supported remotely by obesity centers.

METHODS

ACHT is a multicenter, prospective, non-randomized control group study. The 18-month ACHT follow-up program is a digitally supported, structured, cross-sectoral, and close-to-home program to improve success after bariatric-metabolic surgery. Four groups are compared: intervention group 1 starts the program immediately (3 weeks) after Roux-en-Y gastric bypass or sleeve gastrectomy (months 1-18 postoperatively), intervention group 2 begins the program 18 months after surgery (months 19-36 postoperatively). Intervention groups are compared to respective control groups that had surgery 18 and 36 months previously. In total, 250 patients, enrolled in the intervention groups, are compared with 360 patients in the control groups, who only receive standard care.

RESULTS

The primary endpoint to compare intervention and control groups is the adapted King's score, a composite tool evaluating physical, psychological, socioeconomic, and functional health status. Secondary endpoints include changes in care structures and care processes for the intervention groups. Multivariate regression analyses adjusting for confounders (including the type of surgery) are used to compare intervention and control groups and evaluate determinants in longitudinal analyses. The effect of the intervention on healthcare costs will be evaluated based on health insurance billing data of patients who had bariatric-metabolic surgery in the 3 years prior to the start of the study and of patients who undergo bariatric-metabolic surgery during the study period.

CONCLUSIONS

ACHT will be the one of the first evaluated structured, close-to-home follow-up programs for bariatric surgery in Germany. It will evaluate the effectiveness of the implemented program regarding improvements in health status, mental health, quality of life, and the feasibility of such a program outside of specialized obesity centers.

Updates in metabolic bariatric endoscopy

Obesity and its associated comorbid conditions have been increasing globally. Endoscopic bariatric and metabolic therapies (EBMTs) were initially designed to replicate bariatric surgery physiology for those who are not or choose not to be surgical candidates. Now, newer procedures target the complicated pathophysiology underlying obesity and its comorbidities. EBMT has been categorized based on its therapeutic target (stomach or small intestine), but innovations have expanded to include extraintestinal organs including the pancreas. Gastric EBMTs, namely space-occupying balloons, gastroplasty with suturing or plication, and aspiration therapy, are primarily used for weight loss. Small bowel EBMTs are designed to cause malabsorption, epithelial endocrine remodeling, and other changes to intestinal physiology to ultimately improve the metabolic comorbidities of obesity rather than induce weight loss alone. These include duodenal mucosal resurfacing, endoluminal bypass sleeves, and incisionless anastomosis systems. Extraluminal or pancreatic EBMT is aimed to restore the production of normal pancreatic proteins that are involved in the progression of type 2 diabetes. This review discusses the current and new technologies of metabolic bariatric endoscopy, their pros and cons, and areas for future research.

Baseline Psychosocial, Environmental, Health, and Behavioral Correlates of 1- and 3-Year Weight Loss After Bariatric Surgery

PURPOSE

Weight loss surgery is an effective, long-term treatment for severe obesity but individual response to surgery varies widely. The purpose of this study was to test a comprehensive theoretical model of factors that may be correlated with the greatest surgical weight loss at 1-3 years following surgery. Such a model would help determine what predictive factors to measure when patients are preparing for surgery that may ensure the best weight outcomes.

MATERIALS AND METHODS

The Bariatric Experience Long Term (BELONG) study collected self-reported and medical record-based baseline information as correlates of 1- and 3-year % total weight loss (TWL) in n = 1341 patients. Multiple linear regression was used to determine the associations between 120 baseline variables and %TWL.

RESULTS

Participants were 43.4 ± 11.3 years old, Hispanic or Black (52%; n = 699), women (86%; n = 1149), and partnered (72%; n = 965) and had annual incomes of ≥ $51,000 (60%; n = 803). A total of 1006 (75%) had 3-year follow-up weight. Regression models accounted for 10.1% of the variance in %TWL at 1-year and 13.6% at 3 years. Only bariatric operation accounted for a clinically meaningful difference (~ 5%) in %TWL at 1-year. At 3 years after surgery, only bariatric operation, Black race, and BMI ≥ 50 kg/m2 were associated with clinically meaningful differences in %TWL.

CONCLUSIONS

Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment.

Using patient-reported outcome measures to assess the effectiveness of social media networking programs for people living with overweight and obesity to adopt a healthier lifestyle

Introduction

Overweight, obesity, and their associated health complications have become a major public health issue. Online approaches have been rarely attempted to address the problem. The aim of this study was to evaluate the effectiveness of using social media networking for people living with overweight and obesity to adopt a healthier lifestyle with a three-month multidisciplinary healthcare program. Effectiveness was assessed through questionnaires on patient-related outcome measures (PROMs).

Materials and methods

Two non-profit associations designed the program delivered to people living with overweight and obesity in a closed group via Facebook, the popular social network. The three-month program had three main axes, namely nutrition, psychology, and physical activity. Anthropomorphic data and sociodemographic profiles were collected. Quality of life (QoL) was assessed at the beginning and at the end of the intervention using PROM questionnaires for six different domains, i.e., body image, eating behavior, physical, sexual, social, and psychological functioning.

Results

Six hundred and twenty persons participated in the program; 567 persons consented for the study, and 145 completed the questionnaires entirely. QoL was significantly improved in five out of six domains, i.e., body image, eating behavior, as well as physical, sexual, and psychological functioning. The improvement was valid regardless of age, gender, initial body mass index, person with or without children, educational level (primary versus secondary versus high school), and occupation (employment compared to unemployment or any kind of social assistance). In multivariate analysis, living as a couple was an independent factor correlated to a positive progression in four domains, i.e., body image, eating behavior, as well as physical, and psychological functioning.

Conclusion

This study showed that an online lifestyle intervention might be a promising way of improving the quality of life of people living with overweight or obesity.

Health change awareness and its association with weight loss following bariatric surgery

OBJECTIVE

Patients' ability to judge health change over time has important clinical implications for treatment, but is understudied in longitudinal contexts with meaningful health change. We assess patients' awareness of health change for 5 years following bariatric surgery, and its association with weight loss.

METHOD

Participants were part of the Longitudinal Assessment of Bariatric Surgery (N = 2,027). Perceived health change for each year was assessed by comparing it to self-reports of health on the SF-36 health survey. Participants were categorized as concordant when perceived and actual self-reported health change corresponded, and as discordant when they did not correspond.

RESULTS

Year-to-year concordance between perceived and actual self-reported health change occurred less than 50% of the time. Discordance between perceived and actual health was associated with weight loss following surgery. Discordant-positive participants who perceived their health change as more positive than was warranted lost more weight post-surgery and thus had lower body mass index scores than concordant participants. Conversely, discordant-negative participants who perceived their health as worse than what was warranted lost less weight post-surgery and thus had higher body mass index scores.

CONCLUSIONS

These results suggest that recollection of past health is generally poor and can be biased by salient factors during recall. Clinicians are advised to use caution when retrospective judgments of health are utilized. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Maternal and Neonatal Outcomes of Pregnancy within 7 years after Roux-Y Gastric Bypass or Sleeve Gastrectomy Surgery

PURPOSE

Few studies examine whether maternal and neonatal outcomes differ by time from metabolic and bariatric surgery (MBS) to conception. We describe maternal and neonatal outcomes among women with pregnancy after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) overall and by whether conception occurred during the period when pregnancy is not recommended (< 18 months postoperative) versus later.

MATERIALS AND METHODS

A prospective cohort study enrolled 135 US adult women (median age, 30 years, body mass index [BMI], 47.2 kg/m2) who underwent RYGB or SG (2006-2009) and subsequently reported ≥ 1 pregnancy within 7 years. Participants self-reported pregnancy-related information annually. Differences in prevalence of maternal and neonatal outcomes by postoperative conception timeframe (< 18 versus ≥ 18 months) were assessed.

RESULTS

Thirty-one women reported ≥ 2 postoperative pregnancies. At time of postoperative conception (median 26 [IQR:22-52] months postoperative) median BMI was 31 (IQR:27-36) kg/m2. Excessive gestational weight gain (55%), cesarean section (42%) and preterm labor or rupture of membranes (40%) were the most common maternal outcomes. Forty percent of neonates had a composite outcome of still birth (1%), preterm birth (26%), small for gestational age (11%), or neonatal intensive care unit admission (8%). Prevalence of outcomes did not statistically significantly differ by timeframe.

CONCLUSION

In US women who conceived ≤ 7 years following RYGB or SG, 40% of neonates had the composite neonatal outcome. The prevalence of maternal and neonatal outcomes post-MBS were not statistically significant by conception timeframe.

The Prevalence of Depression and Anxiety in Post-bariatric Surgery Patients at King Khalid University Hospital, Riyadh

Background Obesity negatively impacts mental and physical health and is a leading cause of disease worldwide. Obesity affects 33% of Saudi adults, with 10% being morbidly obese (body mass index, BMI >40 kg/m²). This study explored the association between bariatric surgery (BS) and a predisposition or exacerbation of depressive and anxiety symptoms. Material and methods A cross-sectional study of patients who underwent bariatric surgery at the King Khalid University Hospital in Riyadh, Saudi Arabia, was conducted between February 2016 and December 2021. The patients were contacted by phone to complete a self-administered questionnaire on demographic information, chronic medical diseases, psychiatric diseases, body mass index, and type of bariatric surgery. In addition, they completed the patient health questionnaire-9 (PHQ-9) and general anxiety disorder-7 (GAD-7) questionnaire to screen for patients' depression and anxiety symptoms. Results The findings of the 367 BS patients showed that 20.7% of the patients were considered to have mild anxiety, 11.2% had moderate anxiety, and 8.7% had high anxiety levels. However, regarding depression, 46.9% had extremely low levels of depression, followed by mild depression in 29.4% and moderate depression in 11.2%. Furthermore, another 8.2% of BS patients had moderately high depression levels, and 4.4% had severe depression. The anxiety and depression levels of the patients in this study did not show any statistically significant changes postoperatively in the short, medium, or long term. On the other hand, almost all of the patients 97% who underwent bariatric surgery were satisfied with the outcome of their surgery. Conclusion Few BS patients had high symptoms of depression and anxiety. We recommend pre- and postoperative psychiatric assessment for all bariatric surgery patients as surgical protocol.

Associations Between Physical Activity and Changes in Depressive Symptoms and Health-related Quality of Life Across 7 Years After Roux-en-Y Gastric Bypass Surgery: A Multicenter Prospective Cohort Study

OBJECTIVE

To examine associations of objectively-measured free-living physical activity (PA) with changes in depressive symptoms and mental and physical health-related quality of life (HRQoL) over 7 years after Roux-en-Y gastric bypass surgery (RYGB).

BACKGROUND

The contributions of PA to improvements in mental and physical health after RYGB, independent of weight loss, are unclear.

METHODS

Adults undergoing RYGB in a US multi-center cohort study wore an activity monitor and completed the Beck depression inventory (BDI) and 36-Item Short Form Health Survey (SF-36) annually ≤7 years (N = 646; 78% female, median age 47 years, median body mass index 46kg/m 2 ). Linear mixed models estimated associations of quartiles of steps, sedentary behavior (SB), and moderate-to-vigorous intensity physical activity (MVPA), respectively, with pre-to-post-surgery changes in the BDI and SF-36 mental component summary and physical component summary scores, respectively, over 1-7 years post-surgery, with adjustment for sex, age, race, pre-surgerybody mass index, the respective pre-surgery score, treatment for depression (time-varying) and pre-to-post-surgery weight change (time-varying).

RESULTS

There were dose-response associations between steps, SB (inverse) and MVPA quartiles, respectively, with improvements in each score. Across follow-up, mean improvements in the BDI, Mental Component Summary and physical component summary scores, were 1.9 [95% confidence interval (CI), 1.0-2.8], 3.1 (95% CI, 1.5-4.7), and 4.0 (95% CI, 2.7-5.4) points higher, respectively, in the highest versus lowest steps quartile.

CONCLUSION

Among adults who underwent RYGB, multiple objective PA measures were associated with decreases in depressive symptoms and improvements in mental and physical HRQoL throughout 7 years, independent of weight loss, indicating PA is a modifiable behavior to augment outcomes.

Risk factors for preterm birth in pregnancies following bariatric surgery: an analysis of the Longitudinal Assessment of Bariatric Surgery-2

BACKGROUND

Bariatric surgery has been shown to increase the risk for preterm birth in a subsequent pregnancy. Determining factors that contribute to this heightened risk will inform the development of targeted interventions to improve birth outcomes postbariatric surgery.

OBJECTIVES

This study aimed to identify risk factors of preterm birth in pregnancies following bariatric surgery. Factors being considered were preoperative medical conditions and behaviors (e.g., obesity-associated co-morbidities, gastrointestinal symptoms, substance use), antenatal factors (e.g., prepregnancy body mass index, gestational weight gain), and surgery-specific factors (e.g., surgery type, surgery-to-conception interval).

SETTING

Bariatric surgery centers in the United States.

METHODS

This is a retrospective analysis of the Longitudinal Assessment of Bariatric Surgery-2. Participants were women who reported at least 1 singleton live birth during the 7-year postoperative period. Logistic regressions were used to identify risk factors of preterm birth, adjusting for covariates such as maternal age, race, and ethnicity.

RESULTS

Participants (n = 97) were mostly White (84.5%) and non-Hispanic (88.7%). At the time of surgery, the mean age was 29.4 ± 4.6 years, and the mean body mass index was 47.6 ± 6.3 kg/m2. The prevalence of preterm birth was 13.4%. Preoperative gastrointestinal symptoms significantly increased (odds ratio: 1.12; 95% confidence interval: 1.00-1.26), while unexpectedly, excessive versus adequate gestational weight gain (odds ratio: .12; 95% confidence interval: .02-1.00) decreased the odds of preterm birth following bariatric surgery.

CONCLUSIONS

This analysis identified potential risk and protective factors of preterm birth among pregnancies postbariatric surgery. However, given the small sample size, findings should be regarded as hypothesis-generating and merit further study.

Desire to lose weight was associated with the adoption of weight control strategies but not healthier lifestyle behaviours among post-bariatric surgery patients: NHANES 2013-2018

The desire to lose weight is presumably high among patients with severe obesity who have undergone bariatric surgery. The purpose of this study is to examine the associations of desire to lose weight with weight control strategies, depressive symptoms and lifestyle behaviours among post-bariatric surgery patients. Participants were adults who participated in the National Health and Nutrition Examination Survey (2013-2018) and self-identified a history of bariatric surgery. The desire to lose weight, weight control strategies, depressive symptoms, physical activity and sitting time were measured by self-report questionnaires. Dietary information was derived from 24-h dietary recalls. The correlates of the desire to lose weight were examined by logistic or linear regressions with appropriate weighting and variance estimation techniques, adjusting for covariates such as length of time post-surgery. Results showed that at a mean of 7.8 (standard deviation [SD] = 0.5) years post-surgery (N = 142), 88.6% of participants wanted to weigh less. The average total energy intake was 1747 (SD = 72) kcal/day with 36.2% (SD = 0.7%) of the energy from total fat; the median total moderate-intensity physical activity was 88.5 min/week; and the mean sitting time was 796.0 (SD = 47.0) min/day. The desire to lose weight was positively associated with the adoption of healthy weight control strategies (odds ratio 17.4, 95% confidence interval 3.5-87.0, p < .01). No other significant associations were observed. Findings highlight the need for studies to improve patients' lifestyle behaviours post-surgery (e.g., reduce fat intake, increase physical activity) and examine the correlates of desire to lose weight in larger samples.

Cohort profile: The Bariatric Experience Long Term (BELONG): a long-term prospective study to understand the psychosocial, environmental, health and behavioural predictors of weight loss and regain in patients who have bariatric surgery

PURPOSE

The Bariatric Experience Long Term (BELONG) prospective study cohort was created to address limitations in the literature regarding the relationship between surgical weight loss and psychosocial, health, behaviour and environmental factors. The BELONG cohort is unique because it contains 70% gastric sleeve and 64% patients with non-white race/ethnicity and was developed with strong stakeholder engagement including patients and providers.

PARTICIPANTS

The BELONG cohort study included 1975 patients preparing to have bariatric surgery who completed a baseline survey in a large integrated health system in Southern California. Patients were primarily women (84%), either black or Hispanic (59%), with a body mass index (BMI) of 45.1±7.4 kg/m², age 43.3±11.5 years old, and 32% had at least one comorbidity.

FINDINGS TO DATE

A total of 5552 patients were approached before surgery between February 2016 and May 2017, and 1975 (42%) completed a baseline survey. A total of 1203 (73%) patients completed the year 1 and 1033 (74%) patients completed the year 3 postoperative survey. Of these survey respondents, 1341 at baseline, 999 at year 1, and 951 at year 3 were included in the analyses of all survey and weight outcome data. A total of 803 (60% of eligible patients) had survey data for all time points. Data collected were self-reported constructs to support the proposed theoretical model. Height, weight and BMI were abstracted from the electronic medical record to obtain the main outcomes of the study: weight loss and regain.

FUTURE PLANS

We will collect self-reported constructs and obtain height, weight and BMI from the electronic medical record 5 years after bariatric surgery between April 2022 and January 2023. We will also collect patient experiences using focus groups of 8-12 patients each throughout 2022.

The prototype of a preference-based index of weight-related quality of life: demonstrating the possibilities

PURPOSE

Evidence for comparative and cost-effectiveness of weight-loss interventions is lacking as there are no obesity-specific measures fit for this purpose. This study aimed to estimate the extent to which a prototype of a brief, multi-dimensional obesity-specific Preference-Based Index of Weight-Related Quality of Life (PBI-WRQL) could fill this gap.

METHODS

Longitudinal data from a Canadian bariatric cohort was used. Forty-eight items from the IWQoL-Lite, EQ-5D-3L, and SF-12V2 were mapped onto the WHO ICF domains, and one item was chosen for the dimension based on fit to the Rasch model. Individuals' health ratings (0-100) were regressed on each dimension, and the regression coefficients for the response options were used as weights to generate a total score. Generalized estimation equations were used to compare measure parameters across groups and levels of converging constructs.

RESULTS

Pre-surgery data were available on 201 people (Women: 82%; BMI: 48.8 ± 6.7 kg/m²; age: 43 ± 9.0 years) and on 125 (62%) at 6 months post-bariatric surgery. Seven dimensions with three response options formed the PB-WRQL prototype: Mobility/Physical Function, Pain, Depression, Participation, Energy, Peripheral Edema, and Dyspnea. The prototype showed substantial change (mean + 40) with bariatric surgery, higher than the EQ-5D (mean + 11.5). The prototype showed the strongest relationship with BMI at baseline (t = - 3.68) and was the most sensitive to change in BMI (t = - 3.42).

CONCLUSION

This study demonstrates that a brief, 7-dimension index weighted by health impact performed as well as the 31-item IWQoL-Lite and better than the EQ-5D-3L. These findings demonstrate the potential value of the brief PB-WRQL prototype index and support its further development using preference weights to reflect the current generation's needs and concerns.

Validity of dual-energy x-ray absorptiometry for estimation of visceral adipose tissue and visceral adipose tissue change after surgery-induced weight loss in women with severe obesity

OBJECTIVE

Reliable and simple methods to quantify visceral adipose tissue (VAT) and VAT changes are needed. This study investigated the validity of dual-energy x-ray absorptiometry (DXA) compared with magnetic resonance imaging (MRI) for estimating VAT cross sectionally and longitudinally after surgery-induced weight loss in women with severe obesity.

METHODS

Women with obesity (n = 36; mean age 43 [SD 10] years; 89% White) with DXA and MRI before bariatric surgery (T0) at 12 (T12) and 24 months (T24) post surgery were included. CoreScan (GE Healthcare, Chicago, Illinois) estimated VAT from 20% of the distance between the top of the iliac crest and the base of the skull. MRI VAT (total VAT) was measured from the base of the heart to the sacrum/coccyx on a whole-body scan.

RESULTS

Mean DXA VAT was 45% of MRI VAT at T0, 46% at T12, and 68% at T24. DXA underestimated change in MRI VAT between T0 and T12 by 26.1% (0.81 kg, p = 0.03) and by 71.7% (0.43 kg, p < 0.001) between T12 and T24. The relationship between DXA VAT and MRI VAT differed between T12 and T24 (p value for interaction = 0.03).

CONCLUSIONS

CoreScan lacks validity for comparing VAT across individuals or for estimating the size of changes within individuals; however, within the limits of measurement error, it may provide a useful indicator of whether some VAT change has occurred within an individual.

Does the socio-demographic profile of patients limit access to bariatric surgery?

PURPOSE

Surgery remains the only treatment allowing for a significant and sustainable weight loss in case of severe obesity. Patients undergo a specific multidisciplinary preparation and selection before the operation. This study aims to correlate the psychosocial profile with the likelihood of undergoing bariatric surgery in patients enrolled in the preparation program of a Swiss reference center.

METHODS

All patients referred to an obesity center between January 1, 2016, and June 30, 2017, seeking a first bariatric procedure were included. Socio-demographic data, BMI, preoperative psychological and dietary evaluations were collected. Usually, the preoperative process lasts 1 year. Patients who left the preparation or who had not undergone surgery after more than 2 years of follow-up were considered withdrawers. Surgery completion predictors were reviewed with bivariate analysis and socio-demographic clusters established using the K-means method.

RESULTS

Out of a total of 221 patients, 99 (45%) patients had not undergone bariatric surgery 2 years after their first consultation. The patients were divided into four distinct socio-demographic clusters, among which a particularly deprived one. Criteria such as unfavorable psychological (p < 0.001) and dietary (p < 0.001) evaluations, and male gender (p < 0.05) were significantly associated with non-operation, unlike socio-demographic indicators and clusters (p > 0.1).

CONCLUSION

Almost half of the patients starting a bariatric program are not operated on, which is related to an unfavorable psychological or dietary evaluation and to the male gender. This study also demonstrates that a significant share of patients combines several factors of social deprivation, without influencing the likelihood of surgery completion.

LEVEL OF EVIDENCE

Level V: Descriptive study.

Longitudinal Outcomes in Adolescents After Referral for Metabolic and Bariatric Surgery

BACKGROUND

Metabolic and bariatric surgery (MBS) can be a well tolerated and effective treatment option for severe obesity in adolescents. We compared outcomes for adolescents that did and did not proceed to surgery.

METHODS

A single-center longitudinal study (2015-2020). Patients were identified as LSG if they completed laparoscopic sleeve gastrectomy within 6 months of initial visit and NoLSG if they did not. Chi-square, Fisher exact, nonparametric Kruskal-Wallis tests, and Linear Mixed Models (LMM) were used to compare outcomes over 2 years.

RESULTS

Three hundred fifty-two adolescents were referred with a mean age of 15.6 ± 1.4, 69% girls, 38% Hispanic, and 78% had noncommercial insurance. The median baseline weight was 135 kg and body mass index (BMI) was 48 kg/m2; 42% had a BMI >50. Seventy-nine (22%) underwent LSG whereas 273 (78%) did not complete MBS primarily because of lack of interest. LSG patients had 21% total weight loss and 22% total BMI loss at 24 months whereas NoLSG patients had 4% total weight gain and 3% BMI gain (P < 0.01). Obesity-associated conditions improved in the LSG group (P < 0.01). Follow-up in both groups was poor (≤30% at 24 months). Patients with public insurance and those with BMI from 50 to 59.9 kg/m2 were high performing LSG patients.

CONCLUSIONS

A minority (22%) of adolescents referred for MBS proceeded to surgery, despite its demonstrated efficacy and safety in adolescence. Those that did not undergo surgery continued to gain weight. Further research is needed to understand patient preferences or concerns related to MBS utilization during adolescence.

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

BACKGROUND

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

OBJECTIVES

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

Risks and Rewards of Bariatric Surgery in Advanced Chronic Liver Diseases

The burden of obesity and metabolic syndrome has determined a sharp increase in bariatric surgery (BS) procedures, which lead to marked weight loss, improved metabolic syndrome, reduced cardiovascular risk, and even improvement in nonalcoholic steatohepatitis (NASH). Despite these promising results, BS in patients with chronic liver disease can rarely lead to worsening of liver function, progression to cirrhosis and its complications, and even liver transplantation. On the other hand, since obesity in patients with cirrhosis is a major cofactor for progression to a decompensated stage of the disease and a risk factor for hepatocellular carcinoma, BS has been used to achieve weight loss in this population. In this review, we critically analyze the existing data on outcomes of BS in patients with cirrhosis and the possible mechanisms leading to fibrosis progression and worsening liver function in patients undergoing BS. Finally, we propose a set of measures that could be taken to improve the multidisciplinary management of liver disease in patients undergoing BS, including early recognition of malnutrition and alcohol misuse.

Pain is adversely related to weight loss maintenance following bariatric surgery

BACKGROUND

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

OBJECTIVES

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSION

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

Postbariatric hypoglycemia: symptom patterns and associated risk factors in the Longitudinal Assessment of Bariatric Surgery study

BACKGROUND

Postbariatric hypoglycemia (PBH) can be a devastating complication for which current therapies are often incompletely effective. More information is needed regarding frequency, incidence, and risk factors for PBH.

OBJECTIVES

To examine hypoglycemia symptoms following Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB) and baseline and in-study risk factors.

SETTING

Multicenter, at 10 US hospitals in 6 geographically diverse clinical centers.

METHODS

A prospective, longitudinal cohort study of adults undergoing RYGB or LAGB as part of clinical care between 2006 and 2009 were recruited and followed until January 31, 2015, with baseline and annual postoperative research assessments. We analyzed baseline prevalence and post-operative incidence and frequency of self-reported hypoglycemia symptoms as well as potential preoperative risk factors.

RESULTS

In all groups, postoperative prevalence of hypoglycemia symptoms was 38.5%. Symptom prevalence increased postoperatively from 2.8%-36.4% after RYGB in patients without preoperative diabetes (T2D), with similar patterns in prediabetes (4.9%-29.1%). Individuals with T2D had higher baseline hypoglycemia symptoms (28.9%), increasing after RYGB (57.9%). Hypoglycemia symptoms were lower after LAGB, with 39.1% reported hypoglycemia symptoms at only 1 postoperative visit with few (4.0%) having persistent symptoms at 6 or more annual visits. Timing of symptoms was not restricted to the postprandial state. Symptoms of severe hypoglycemia were reported in 2.6-3.6% after RYGB. The dominant risk factor for postoperative symptoms was preoperative symptoms; additionally, baseline selective serotonin (SSRI) and serotonin-norepinephrine (SNRI) reuptake inhibitor use was also associated with increased risk in multivariable analysis. Weight loss and regain were not related to hypoglycemia symptom reporting.

CONCLUSION

Hypoglycemia symptoms increase over time after RYGB, particularly in patients without diabetes. In a small percentage, symptoms can be persistent or severe and require hospitalization. Preoperative hypoglycemia symptoms and SSRI/SNRI use in RYGB patients without diabetes is associated with increased risk of symptoms.

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

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

Emergency department encounters, hospital admissions, course of treatment, and follow-up care for behavioral health concerns in patients after Roux-en-Y gastric bypass surgery

BACKGROUND

The benefits of bariatric surgery are well-established, however, concerns surrounding postoperative psychiatric destabilization and alcohol misuse remain. Research has initiated the process of identifying risks associated with bariatric surgery, although less is known regarding when or why psychiatric hospitalizations occur postoperatively.

OBJECTIVES

The goal of the current study was to examine the incidence of, and contributing factors to, behavioral health-related emergency room (ER) encounters and hospitalization after bariatric surgery.

SETTING

Integrated multispecialty health system with an accredited bariatric surgery program.

METHODS

Retrospective review of patients who underwent Roux-en-Y gastric bypass (RYGB) surgery and had been readmitted to the hospital or presented to the ER after bariatric surgery at least once for a behavioral-health related reason.

RESULTS

Of 1449 patients, 93 had at least 1 psychiatric or substance use-related ER visit/hospitalization post-surgery and were included in the study; 53% had 1 ER/hospital encounter after bariatric surgery; 24% had 2 encounters, 11% had 3-4 encounters, and 10% of patients had ≥5 encounters. Across 267 postbariatric surgery encounters, 42.4% were due to alcohol-related problems. The index presentation for alcohol-related reasons occurred at a mean of 1942 days (approximately 5.3 yr; SD = 1217 d). Patients' index presentation for a psychiatric concern (41.3%) occurred at a mean of 1278 days (3.5 yr; SD = 1056 d) post-surgery.

CONCLUSION

A significant percentage of patients who present to the ER or hospital for behavioral health reasons after RYGB surgery had alcohol-related problems, long after their surgery. Psychologists working with bariatric surgery teams should prioritize ongoing assessment of and education on alcohol misuse in those seeking RYGB and in the long-term postoperative period.

Bariatric surgery and the risk of alcohol-related cirrhosis and alcohol misuse

BACKGROUND & AIMS

Bariatric surgery is common, but alcohol misuse has been reported following these procedures. We aimed to determine if bariatric surgery is associated with increased risk of alcohol-related cirrhosis (AC) and alcohol misuse.

METHODS

Retrospective observational analysis of obese adults with employer-sponsored insurance administrative claims from 2008 to 2016. Subjects with diagnosis codes for bariatric surgery were included. Primary outcome was risk of AC. Secondary outcome was risk of alcohol misuse. Bariatric surgery was divided into before 2008 and after 2008 to account for patients who had a procedure during the study period. Cox proportional hazard regression models using age as the time variable were used with interaction analyses for bariatric surgery and gender.

RESULTS

A total of 194 130 had surgery from 2008 to 2016 while 209 090 patients had bariatric surgery prior to 2008. Age was 44.1 years, 61% women and enrolment was 3.7 years. A total of 4774 (0.07%) had AC. Overall risk of AC was lower for those who received sleeve gastrectomy and laparoscopic banding during the study period (HR 0.4, P <.001; HR 0.43, P =.02) and alcohol misuse increased for Roux-en-Y and sleeve gastrectomy recipients (HR 1.86 and 1.35, P <.001, respectively). In those who had surgery before 2008, women had increased risk of AC and alcohol misuse compared to women without bariatric surgery (HR 2.1 [95% CI: 1.79-2.41] for AC; HR 1.98 [95% CI 1.93-2.04]).

CONCLUSIONS

Bariatric surgery is associated with a short-term decreased risk of AC but potential long-term increased risk of AC in women. Post-operative alcohol surveillance is necessary to reduce this risk.

Addiction Transfer and Other Behavioral Changes Following Bariatric Surgery

Despite its important treatment implications for obesity and related comorbidities, bariatric surgery requires several behavioral changes that warrant comprehensive evaluation and support before and after surgery. This article outlines emerging scientific and anecdotal evidence for addiction transfer after bariatric surgery. Other common behavioral changes that impact adherence, weight loss, and psychiatric risk after surgery are also reviewed. Last, recommendations for presurgical psychological evaluation and postoperative support are provided.

Resting Energy Expenditure and Organ-Tissue Body Composition 5 Years After Bariatric Surgery

INTRODUCTION

Bariatric surgery-induced weight loss may reduce resting energy expenditure (REE) and fat-free mass (FFM) disproportionately thereby predisposing patients to weight regain and sarcopenia.

METHODS

We compared REE and body composition of African-American and Caucasian Roux-en-Y gastric bypass (RYGB) patients after surgery with a group of non-operated controls (CON). REE by indirect calorimetry; skeletal muscle (SM), trunk organs, and brain volumes by MRI; and FFM by DXA were measured at post-surgery visits and compared with CON (N = 84) using linear regression models that adjusted for relevant covariates. Ns in RYGB were 50, 42, and 30 for anthropometry and 39, 27, 17 for MRI body composition at years 1, 2, and 5 after surgery, respectively.

RESULTS

Regression models adjusted for age, weight, height, ethnicity, and sex showed REE differences (RYGB minus CON; mean ± s.e.): year 1 (43.2 ± 34 kcal/day, p = 0.20); year 2 (- 27.9 ± 37.3 kcal/day, p = 0.46); year 5 (114.6 ± 42.3 kcal/day, p = 0.008). Analysis of FFM components showed that RYGB had greater trunk organ mass (~ 0.4 kg) and less SM (~ 1.34 kg) than CON at each visit. REE models adjusted for FFM, SM, trunk organs, and brain mass showed no between-group differences in REE (- 15.9 ± 54.8 kcal/day, p = 0.8; - 46.9 ± 64.9 kcal/day, p = 0.47; 47.7 ± 83.0 kcal/day, p = 0.57, at years 1, 2, and 5, respectively).

CONCLUSIONS

Post bariatric surgery patients maintain a larger mass of high-metabolic rate trunk organs than non-operated controls of similar anthropometrics. Interpreting REE changes after weight loss requires an accurate understanding of fat-free mass composition at both the organ and tissue levels.

CLINICAL TRIAL REGISTRATION

Long-term Effects of Bariatric Surgery (LABS-2) NCT00465829.

Eating patterns and unhealthy weight control behaviors are associated with loss-of-control eating following bariatric surgery

BACKGROUND

Loss-of-control (LOC) eating is associated with poor weight-loss outcomes following bariatric surgery. It is not clear whether eating patterns (e.g., total number of daily meals/snacks, eating after suppertime, eating when not hungry) and unhealthy weight control behaviors (e.g., smoking, using laxatives) are associated with or predictive of LOC eating.

OBJECTIVES

To examine whether eating patterns and unhealthy weight-control behaviors are associated with LOC eating and, if so, whether they predict LOC eating in bariatric patients.

SETTING

Multicenter study, United States.

METHODS

This is a secondary analysis of the Longitudinal Assessment of Bariatric Surgery-2 study. Assessments were conducted before surgery and at 12, 24, 36, 48, 60, and 84 months after surgery. Logistic mixed models were used to examine the longitudinal associations between eating patterns, unhealthy weight-control behaviors, and LOC eating. Time-lag techniques were applied to examine whether the associated patterns and behaviors predict LOC eating.

RESULTS

The participants (n = 1477) were mostly women (80%), white (86.9%), and married (62.5%). At the time of surgery, the mean age was 45.4 ± 11.0 years and the mean body mass index was 47.8 ± 7.5 kg/m². The total number of daily meals/snacks, food intake after suppertime, eating when not hungry, eating when feeling full, and use of any unhealthy weight-control behaviors were positively associated with LOC eating (P < .05). Food intake after suppertime, eating when not hungry, and eating when feeling full predicted LOC eating (P < .05).

CONCLUSION

Meal patterns and unhealthy weight control behaviors may be important intervention targets for addressing LOC eating after bariatric surgery.

Validation of the Yale Food Addiction Scale 2.0 in Patients Seeking Bariatric Surgery

BACKGROUND

The Yale Food Addiction Scale (YFAS) was developed in 2009 to assess food addiction (FA); a revised version was released in 2016 (YFAS 2.0). The objective of this study was to determine the statistical and clinical validity of the YFAS 2.0 in adults seeking bariatric surgery.

METHODS

Patients who underwent a preoperative psychological evaluation in preparation for bariatric surgery from 2015 to 2018 were included. The YFAS 2.0 was administered as part of routine clinical care and validated against an assessment battery of standardized clinical measures. Statistical analyses included chi-square and Wilcoxon rank sum tests and calculation of Spearman's rank correlation coefficients.

RESULTS

Overall, 1061 patients were included. Mean age and BMI were 47.5 ± 12.9 years and 46.9 ± 13.4 kg/m², respectively. There were 196 (18%) patients who screened positive on the YFAS 2.0 (21% mild, 23% moderate, and 56% severe FA). The YFAS 2.0 demonstrated strong convergent validity where patients who met criteria for FA had significantly increased levels of binge eating (p < 0.001), emotional eating (p < 0.001), and lower self-efficacy (p < 0.001). Discriminant validity was demonstrated by lack of association with alcohol use (p = 0.319). The YFAS 2.0 was significantly correlated with total scores for depression (p < 0.001), anxiety (p < 0.001), bipolar disorder symptoms (p < 0.001), and trauma history (p < 0.001).

CONCLUSIONS

The prevalence of FA in a large sample of patients seeking bariatric surgery was consistent with previous literature. These data suggest that the YFAS 2.0 is psychometrically valid, demonstrating strong construct validity, and is a clinically useful measure of FA severity in patients pursuing bariatric surgery.

Predictors of change in cardiovascular disease risk and events following gastric bypass: a 7-year prospective multicenter study

BACKGROUND

Change in short-term (i.e., 10-year) and lifetime risk of cardiovascular disease (CVD) following Roux-en-Y gastric bypass (RYGB) has significant heterogeneity.

OBJECTIVE

To identify predictors of change in CVD risk and cardiovascular events following RYGB.

METHODS

Between 2006-2009, 1625 adults without a history of CVD enrolled in a prospective cohort study and underwent RYGB at 1 of 10 U.S. hospitals. Participants were followed annually for a maximum of 7 years. Associations between presurgery characteristics (anthropometric, sociodemographic, physical and mental health, alcohol/drug use, eating behaviors) and 1) pre to postsurgery change in 10 year and lifetime atherosclerotic CVD (ASCVD) risk scores, respectively, and 2) having a CVD event (nonfatal myocardial infarction, stroke, ischemic heart disease, congestive heart failure, angina, percutaneous coronary intervention, coronary artery bypass grafting, or CVD-attributed death) as repeated measures (yr 1-7) were evaluated.

SETTING

Observational cohort study at ten hospitals throughout the United States.

RESULTS

Presurgery factors independently associated with decreases in both 10-year and lifetime risk scores 1-7 years post-RYGB were higher CVD risk score, female sex, higher household income, and normal kidney function. Additionally, Black race and having diabetes were independently associated with decreases in 10-year risk, while not having diabetes and a higher (better) composite mental health score were independently related to decreases in lifetime risk. A lower (worse) presurgery composite physical health score was associated with a higher CVD event risk (RR = 1.68, per 10 points).

CONCLUSION

This study identified multiple presurgery factors that characterize patients who may have more cardiovascular benefit from RYGB, and patients who might require additional support to improve their cardiovascular health.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Self-Reported Smoking Compared to Serum Cotinine in Bariatric Surgery Patients: Smoking Is Underreported Before the Operation

BACKGROUND

Smoking has been associated with postoperative complications and mortality in bariatric surgery. The evidence for smoking is based on self-report and medical charts, which can lead to misclassification and miscalculation of the associations. Determination of cotinine can objectively define nicotine exposure. We determined the accuracy of self-reported smoking compared to cotinine measurement in three phases of the bariatric surgery trajectory.

METHODS

Patients in the phase of screening (screening), on the day of surgery (surgery), and more than 18 months after surgery (follow-up) were consecutively selected. Self-reported smoking was registered and serum cotinine was measured. We evaluated the accuracy of self-reported smoking compared to cotinine, and the level of agreement between self-report and cotinine for each phase.

RESULTS

In total, 715 patients were included. In the screening, surgery, and follow-up group, 25.6%, 18.0%, and 15.5%, respectively, was smoking based on cotinine. The sensitivity of self-reported smoking was 72.5%, 31.0%, and 93.5% in the screening, surgery, and follow-up group, respectively (p < 0.001). The specificity of self-report was > 95% in all groups (p < 0.02). The level of agreement between self-report and cotinine was 0.778, 0.414, and 0.855 for the screening, surgery, and follow-up group, respectively.

CONCLUSIONS

Underreporting of smoking occurs before bariatric surgery, mainly on the day of surgery. Future studies on effects of smoking and smoking cessation in bariatric surgery should include methods taking into account the issue of underreporting.

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

BACKGROUND

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

OBJECTIVE

Long-term data on postsurgical nutrient intake are lacking.

SETTING

The Longitudinal Assessment of Bariatric Surgery-3 psychosocial study.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Change in predicted 10-year and lifetime cardiovascular disease risk after Roux-en-Y gastric bypass

BACKGROUND

Long-term changes in cardiovascular disease (CVD) risk after bariatric surgery are not well characterized.

OBJECTIVE

To report sex-specific changes in CVD risk after Roux-en-Y gastric bypass surgery (RYGB).

SETTING

Observational cohort study at ten hospitals throughout the United States.

METHODS

Between 2006 and 2009, 1770 adults enrolled in a prospective cohort study underwent RYGB at 1 of 10 U.S. hospitals. Research assessments were conducted presurgery and annually postsurgery over 7 years. Sex specific-predicted 10-year and lifetime CVD risk were calculated using the Framingham10-year and lifetime risk scores, Framingham-body mass index, and atherosclerotic CVD scoring algorithms among participants with no history of CVD. Of 1566 eligible participants, 1234 (75.9%) with CVD risk determination pre- and postsurgery were included (1013 females, 221 males).

RESULTS

Based on the Framingham10-year and lifetime risk scores, the percentage of females with predicted high (>20%) 10-year CVD risk declined from presurgery (6.5% [95% confidence interval: 6.7-7.5]) to 1 year postsurgery (1.0% [95% confidence interval: .8-1.2]; P < .001), then increased 1 to 7 years postsurgery (to 2.8% [95% confidence interval: 1.6-3.3]; P = .003), but was lower 7 years postsurgery versus presurgery (P < .001). Time trends for percentage of high-risk participants and mean CVD risk scores were similar for both sexes and other evaluated CVD risk scores. For example, among males mean lifetime atherosclerotic CVD score declined from presurgery to 1 year postsurgery, then increased 1 to 7 years postsurgery. However, there was a net decline from presurgery (P < .001).

CONCLUSION

Among both females and males, predicted 10-year and lifetime CVD risk was substantially lower 7 years post RYGB than presurgery, suggesting RYGB surgery can lead to sustained improvements in short- and long-term CVD risk.

Bariatric Surgery in France from 1997 to 2018

BACKGROUND

Bariatric surgery is 1 of the major treatments of obesity.

OBJECTIVES

This study describes the development of the bariatric surgery in France and look at some factors of this evolution.

SETTING

It concerns the activity of all the French hospitals over a 22-year period.

METHODS

Hospitalization databases from 1997 to 2018 have been used to study the evolution of the number of bariatric operations, their types, the characteristics of both patients and hospitals performing this surgery.

RESULTS

The number of operations grew from 2800 in 1997 to 52,500 in 2018, with 2 interruptions in this growth, in 2002 and from 2017 to date. The rate of operations is 4 times higher for women than for men, with a peak in the 35-44 age group. The adjustable gastric banding was the most popular operation until 2010, then replaced by sleeve gastrectomy since 2010. Private for-profit hospitals carried out the majority of these operations, even if the public hospitals activity progressed regularly during the past 2 decades.

CONCLUSIONS

Compared to other countries, the rate of bariatric operations in France is rather high whereas the obesity rate is medium to low. Easy accessibility to bariatric surgery should play a role in the high rate, but specific studies are necessary to evaluate if the operations are delivered adequately to the obese population.

HEADS UP: Design and Methods of a Louisiana State-Funded Surgical and Non-Surgical Weight Loss Program

This paper describes the methodology, design and procedures used in the HEADS UP Project, an observational study to examine the feasibility of a state-funded weight loss program. HEADS UP offered two weight loss approaches: bariatric surgery or a non-surgical intervention composed of medical management, a low-calorie liquid diet and lifestyle change promotion. Participants were recruited through a multi-stage screening process, in-person interviews, and an initial low-calorie diet program. Eligible participants were entered into a lottery system, with 100 participants selected for the surgical group and 200 selected for the non-surgical group annually for five years. Anthropometric, clinical, and psychosocial assessments were completed at baseline and follow-ups. More than 6800 individuals completed the initial web screening. Screening procedures yielded 1412 participants (490 surgical and 922 non-surgical). Approximately 84% of the total participant population were female and 38% were Black. Participants had an average body mass index of 47.9 and 43 kg/m² in the surgical and non-surgical groups, respectively. Recruitment and enrollment results of the HEADS UP study demonstrated significant interest in both the surgical and non-surgical treatment programs for obesity. These results support the feasibility of providing a state-funded weight loss program within a healthcare setting.

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

BACKGROUND

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

OBJECTIVE

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

SETTING

Ten U.S. clinical facilities.

METHODS

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

RESULTS

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

CONCLUSIONS

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

Weight loss after bariatric surgery in cancer survivors

BACKGROUND

With improved methods of identification and treatment, the numbers of cancer survivors are increasing. Weight loss is encouraged to reduce recurrence. After cancer treatment, will survivors respond to weight change and receive the benefits of bariatric surgery?

OBJECTIVE

To compare weight loss after bariatric surgery of patients treated for cancer with those never diagnosed with cancer.

SETTING

The 10 surgical centers participating in the Longitudinal Assessment of Bariatric Surgery (LABS2).

METHODS

A retrospective review of the LABS database of 2458 participants was completed to determine which patients had answered the question that they had been told they had cancer with a positive response. Cancer survivors were compared for body mass index (calculated as weight in kilograms divided by height in meters squared) at baseline and 1, 3, 5, and 7 years after bariatric surgery with those who responded negatively to this question. Descriptive statistics, Fisher's exact tests, 2-sample independent t tests, Wilcoxon rank sum tests, and multiple linear regression were used.

RESULTS

Groups were significantly different in age (P < .0001) and surgery type (P = .02). Other demographic and clinical comparisons were nonsignificant at the .05 significance level. Cancer survivors demonstrated less weight loss at 1 year (P = .0001). Over 7 years, there was no significant difference between the 2 groups. Adjusting for age, sex, baseline body mass index, and surgery type, cancer history was not found to be significant predictor of body mass index change 1-year postbariatric surgery.

CONCLUSIONS

Patients treated for cancer are not different than the general population in their capacity for long-term weight loss with surgical assistance.

Physical and Mental Health-Related Quality of Life Changes Among Insurer Subgroups Following Bariatric Surgery

OBJECTIVE

This study sought to determine improvements in mental and physical health-related quality of life (HRQOL) following bariatric surgery in Medicaid and commercially insured patients.

METHODS

Using data from the Longitudinal Assessment of Bariatric Surgery, an observational cohort study of adults undergoing bariatric surgery (2006-2009), changes in Short Form 36 mental component summary (MCS) and physical component summary (PCS) scores were examined in 1,529 patients who underwent Roux-en-Y gastric bypass, laparoscopic adjustable band, or sleeve gastrectomy and were followed for 5 years. Piecewise linear mixed-effects models estimated MCS and PCS scores as a function of insurance group (Medicaid, N = 177; commercial, N = 1,352) from 0 to 1 year and from 1 to 5 years after surgery, with interactions between insurance group and surgery type.

RESULTS

Patients with Medicaid had lower PCS and MCS scores at baseline. At 1 year after surgery, patients with Medicaid and commercial insurance experienced similar improvement in PCS scores (commercial-Medicaid difference in PCS change [95% CI]: Roux-en-Y gastric bypass, 1.5 [-0.2, 3.3]; laparoscopic adjustable band, 1.9 [-2.2, 6.0]; sleeve gastrectomy, 6.4 [0.0, 12.8]). One-year MCS score improvement was minimal and similar between insurance groups. In years 1 to 5, PCS and MCS scores were stable in all groups.

CONCLUSIONS

Both insurance groups experienced improvements in physical HRQOL and minimal changes in mental HRQOL.

Five-year kidney outcomes of bariatric surgery differ in severely obese adolescents and adults with and without type 2 diabetes

Bariatric surgery improves markers of kidney health in severe obesity, yet it is unclear if kidney disease outcomes differ according to age at surgery. Therefore, we examined health effects of Roux-en-Y gastric bypass between 161 adolescents and 396 adults participating in two related but distinct studies. Primary outcomes were elevated urine albumin-to-creatinine ratio (UACR) of 30 mg/g or more and hyperfiltration (an estimated glomerular filtration rate of 135 ml/min/1.73m² or more). Analyses were stratified by the presence of pre-operative type 2 diabetes. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of elevated UACR prior to surgery compared to adults (22.5 vs. 9.0%). Resolution of elevated UACR following surgery differed between adolescents and adults with type 2 diabetes, with adolescents experiencing a significantly earlier improvement following surgery. Adolescents without pre-operative type 2 diabetes demonstrated a significantly increased prevalence of UACR prior to surgery compared to adults (9.4 vs. 4.5%), with no improvement occurring in either group post-operatively. Adolescents with pre-operative type 2 diabetes had a significantly increased prevalence of hyperfiltration that remained throughout the study period, whereas hyperfiltration prevalence was similar among those without type 2 diabetes. Thus, adolescents with pre-operative type 2 diabetes experienced earlier attenuation of elevated UACR compared to adults with pre-operative type 2 diabetes in response to gastric bypass.

Sitting time and long-term weight change in adolescents with severe obesity undergoing surgical and nonoperative weight management

BACKGROUND

Prolonged sitting time has been associated with numerous deleterious effects on humans. The degree to which sitting time influences weight loss outcomes of obesity treatments is poorly understood.

OBJECTIVES

The objective was to characterize and describe the amount of time spent sitting in an adolescent bariatric surgical and nonoperative cohort and evaluate its relationship with long-term change in body mass index (BMI).

SETTING

Tertiary care hospital, United States.

METHODS

From 2011 to 2014, a 1-time study visit was conducted to collect long-term outcomes of Roux-en-Y gastric bypass (RYGB; n = 58) and nonoperative (n = 30) management of adolescents with severe obesity. The International Physical Activity Questionnaire was used to assess sitting time. Linear regression was used to evaluate the association between sitting time and percent BMI change from baseline.

RESULTS

A total of 88 patients participated in the long-term follow-up visit at an average of 8 years from baseline. Percent BMI loss for participants who underwent RYGB (mean age at follow-up 25 yr) and for nonoperative (mean age at follow-up 23 yr) participants was -29% and +8%, respectively. The surgical group reported a median sitting time of 5.1 hr/d, while the nonoperative group reported a median sitting time of 7.0 hr/d (P = .11). Increasing sitting time was significantly associated with decreased percent BMI loss (P < .01).

CONCLUSIONS

RYGB was associated with long-term weight loss. Those participants with and without prior RYGB self-reported similar amounts of time spent sitting each day. Irrespective of whether participants had previously undergone surgery, lower levels of sitting time were found to be associated with greater BMI loss many years later.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Impact of intentional weight loss on diabetic kidney disease

Type 2 diabetes mellitus (T2DM) and obesity constitute interwoven pandemics challenging healthcare systems in developed countries, where diabetic kidney disease (DKD) is the most common cause of end-stage renal disease. Obesity accelerates renal functional decline in people with T2DM. Intentional weight loss (IWL) strategies in this population hold promise as a means of arresting DKD progression. In the present paper, we summarize the impact of IWL strategies (stratified by lifestyle intervention, medications, and metabolic surgery) on renal outcomes in obese people with DKD. We reviewed the Medline, EMBASE and Cochrane databases for relevant randomized control trials and observational studies published between August 1, 2018 and April 15, 2019. We found that IWL improves renal outcomes in the setting of DKD and obesity. Rate of progression of DKD slows with IWL, but varying outcome measures among studies makes direct comparison difficult. Furthermore, established means of estimating renal function are imperfect owing to loss of lean muscle mass with IWL strategies. The choice of optimal IWL strategy needs to be individualized; future work should establish the comparative efficacy of IWL strategies in obese people with DKD to better inform such decisions.

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

Importance

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

Objective

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

Design, Setting, and Participants

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

Main Outcome and Measures

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

Results

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

Conclusions and Relevance

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

Trial Registration

clinicaltrials.gov Identifier: NCT00465829.

Preoperative high respiratory quotient correlates with lower weight loss after bariatric surgery

BACKGROUND

The respiratory coefficient (RQ), as determined by indirect calorimetry (IC), classifies diet as being carbohydrate rich (RQ = 0.7-0.8), fat rich (RQ = 0.9-1.0), or overfeeding (RQ > 1). We hypothesized that preoperative RQ may be associated with weight-loss outcomes after bariatric surgery.

METHODS

From 2016 to 2018, 137 obese patients were enrolled in a Bariatric Registry and underwent dietary and behavioral counseling, followed by preoperative IC. Resting energy expenditure (REE) and RQ of all patients was measured. Patients were classified as over-feeders (OF; 42, 31%) with RQ > 1 or non-over-feeders (NOF; 95, 69%) with RQ < 1. At baseline, there was no difference between groups in gender [female: 105 (76.6%), male: 32 (23.4%)], body mass index (BMI; OF: 46.8 ± 7.8 vs. NOF: 44.8 ± 7.4 kg/m², p = 0.40), or baseline REE (OF: 1897 ± 622 vs. NOF: 1874 ± 579, p = 0.74), although OF were younger [mean age (OF: 47.1 ± 13.0 years vs. NOF: 43.1 ± 13.4; p = 0.009). At 6-month follow-up 94 patients [53.28%; OF: 35 (83%) vs. NOF: 59 (62%), p = 0.016] were seen and 48 [35.03%; OF: 23 (55%) vs. NOF: 25 (59%), p = 0.001] at 12-month follow-up. On preoperative psychological assessment, OF had a significantly higher rate of childhood neglect (OF: 28 (47.46%) vs. NOF: 40 (28.99%); p = 0.01).

RESULTS

At 1 year postoperatively, the OF had a significantly higher BMI (OF: 34.3 ± 6.5 vs. NOF: 29.3 ± 5.1 kg/m², p = 0.009). Differences in weight were not significant at 6-month (OF: 36.0 ± 6.5 vs. NOF: 33.5 ± 5.9 kg/m², p = 0.07). There was no difference between type of operation and RQ group (RYGB; OF: 55 (75%) vs. NOF: 18 (25%) and SG; OF: 40 (62%) vs. NOF: 24 (38%), p = 0.14), nor in BMI loss after operation.

CONCLUSION

Evidence of overfeeding in the preoperative period prior to bariatric surgery is associated with higher resultant BMI at 1 year. Calculation of the RQ with IC has prognostic significance in bariatric surgery, and calculation of REE based on assumed normal RQ potentiates error. It is unclear if overfeeding is purely behavioral or secondary to potentially reversible metabolic etiology.

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

BACKGROUND

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

OBJECTIVE

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

SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The Association Between Kidney Disease and Diabetes Remission in Bariatric Surgery Patients With Type 2 Diabetes

RATIONALE & OBJECTIVE

The association between bariatric surgery, type 2 diabetes, and chronic kidney disease (CKD) is poorly understood. We studied whether remission of type 2 diabetes induced by bariatric surgery influences markers of kidney disease, if CKD is associated with remission of diabetes after bariatric surgery, and if baseline levels of gut hormones and peptides modify these associations.

STUDY DESIGN

Prospective observational study.

STUDY PARTICIPANTS

737 bariatric surgery patients with type 2 diabetes who participated in a multicenter cohort study for up to 5 years.

PREDICTORS

Demographics, blood pressure, medications, type of bariatric surgery, anthropometrics, markers of kidney disease, and circulating levels of gut hormones and peptides.

OUTCOMES

Estimated glomerular filtration rate (eGFR), urinary albumin excretion, prognostic risk for CKD, and remission of diabetes.

ANALYTICAL APPROACH

Linear mixed models for eGFR; generalized linear mixed models with logit link for albuminuria, prognostic risk for CKD, and diabetes remission.

RESULTS

Remission of diabetes at 5 years post-bariatric surgery was not independently associated with eGFR but was associated with lower risk for moderate/severe increase in albuminuria (risk ratio, 0.66; 95% CI, 0.48-0.90) and stabilization in prognostic risk for CKD. These findings were modified by baseline ghrelin level. Lower preoperative eGFR and greater prognostic risk for CKD were independently associated with reduced likelihood of diabetes remission. The association with preoperative GFR was modified by C-peptide level. Higher baseline circulating ghrelin level was independently associated with a lower prognostic risk for CKD.

LIMITATIONS

A minority of participants had baseline CKD; lack of comparison group; no information on duration of diabetes, other clinical end points, or kidney biopsy results.

CONCLUSIONS

Remission of type 2 diabetes 5 years after bariatric surgery was associated with improvements in albuminuria and stabilized prognostic risk for CKD, but not with eGFR. Lower kidney function and greater prognostic risk at the time of bariatric surgery was linked to a lower likelihood of diabetes remission. These results highlight the need to identify the mechanisms through which bariatric surgery may delay the long-term progression of CKD in type 2 diabetes.

Changes in Sexual Functioning in Women and Men in the 5 Years After Bariatric Surgery

Importance

Short-term improvements in sexual functioning are reported after bariatric surgery, but to our knowledge, little is known about the durability of these improvements.

Objective

To determine the percentage of adults with impairment in sexual functioning who experience durable improvements in sexual functioning after bariatric surgery and to identify factors associated with improvements.

Design, Setting, and Participants

The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study conducted at 10 hospitals in 6 US clinical centers. Adults undergoing their first bariatric procedure were recruited from 2005 through 2009, data were collected through August 2014. Data analysis was conducted from 2016 to April 2018.

Interventions

Participants completed assessments before the procedure and annually thereafter for 5 years.

Main Outcomes and Measures

A self-administered questionnaire was used to assess clinically meaningful differences before and after surgery in past-month sexual satisfaction, desire, and activity and physical health limitations to sexual activity among subgroups who reported sexual functioning at less than domain-specific thresholds before surgery.

Results

Of 2215 participants eligible for sexual function follow-up, 2036 (91.9%) completed 1 or more follow-up assessment (1431 [64.6%] at year 5), of whom 1607 (78.9%) were women. At the presurgery assessment, median (interquartile range) age was 47 (37-55) years, and the median (interquartile range) body mass index was 45.8 (41.7-51.3). Among those who were not satisfied with their sexual life before surgery (1015 of 1456 women [69.7%]; 304 of 409 men [74.3%]), 56.0% of women (95% CI, 52.5%-59.5%) and 49.2% of men (95% CI, 42.4%-55.9%) experienced clinically meaningful improvements at year 1; these percentages did not significantly differ during further follow-up. Among those who reported physical limitations to sexual activity at baseline (892 of 1490 women [59.9%] and 267 of 406 men [65.8%]), the percentage experiencing improvement in this domain decreased during follow-up, but 73.6% (95% CI, 69.3%-78.0%) of women and 67.6% (95% CI, 59.6%-75.6%) of men continued to report improvements at year 5. Greater postsurgical reduction in depressive symptoms was independently associated with improvement in 4 domains of sexual life among women (frequency of sexual desire: adjusted relative risk [aRR] per 5-point decrease in Beck Depression Inventory score, 1.12 [95% CI, 1.07-1.18]; P < .001; frequency of sexual activity: aRR, 1.13 [95% CI, 1.08-1.18]; P < .001; the degree to which physical health limited sexual activity: aRR, 1.19 [95% CI, 1.14-1.23]; P < .001; and satisfaction with sexual life: aRR, 1.25 [95% CI, 1.19-1.31]; P < .001) and 2 domains among men (physical health limitations: aRR, 1.14 [95% CI, 1.04-1.26]; P = .008 and satisfaction with sexual life: aRR, 1.55 [95% CI, 1.33-1.81]; P < .001). Surgical procedure was not associated with improvement.

Conclusions and Relevance

Per this study, approximately half of women and men who were not satisfied with their sexual life prior to bariatric surgery experienced improvements in satisfaction in 5 years of follow-up.

Trial Registration

ClinicalTrials.gov Identifier: NCT00465829.

Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults

BACKGROUND

Bariatric surgery results in weight loss and health improvements in adults and adolescents. However, whether outcomes differ according to the age of the patient at the time of surgery is unclear.

METHODS

We evaluated the health effects of Roux-en-Y gastric bypass in a cohort of adolescents (161 patients enrolled from 2006 through 2012) and a cohort of adults (396 patients enrolled from 2006 through 2009). The two cohorts were participants in two related but independent studies. Linear mixed and Poisson mixed models were used to compare outcomes with regard to weight and coexisting conditions between the cohorts 5 years after surgery. The rates of death and subsequent abdominal operations and selected micronutrient levels (up to 2 years after surgery) were also compared between the cohorts.

RESULTS

There was no significant difference in percent weight change between adolescents (-26%; 95% confidence interval [CI], -29 to -23) and adults (-29%; 95% CI, -31 to -27) 5 years after surgery (P = 0.08). After surgery, adolescents were significantly more likely than adults to have remission of type 2 diabetes (86% vs. 53%; risk ratio, 1.27; 95% CI, 1.03 to 1.57) and of hypertension (68% vs. 41%; risk ratio, 1.51; 95% CI, 1.21 to 1.88). Three adolescents (1.9%) and seven adults (1.8%) died in the 5 years after surgery. The rate of abdominal reoperations was significantly higher among adolescents than among adults (19 vs. 10 reoperations per 500 person-years, P = 0.003). More adolescents than adults had low ferritin levels (72 of 132 patients [48%] vs. 54 of 179 patients [29%], P = 0.004).

CONCLUSIONS

Adolescents and adults who underwent gastric bypass had marked weight loss that was similar in magnitude 5 years after surgery. Adolescents had remission of diabetes and hypertension more often than adults. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases; ClinicalTrials.gov number, NCT00474318.).

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

BACKGROUND

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

OBJECTIVES

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

POPULATION

SETTING

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of bariatric surgery on asthma control differs among obese individuals with reported prior or current asthma, with or without metabolic syndrome

BACKGROUND

Both obesity and the metabolic syndrome have been independently associated with increased asthma morbidity. However, it is unclear whether metabolic syndrome limits the beneficial effects of weight loss on asthma.

OBJECTIVES

To evaluate whether bariatric weight loss is associated with improved asthma control, and whether this association varies by metabolic syndrome status.

METHODS

We determined the changes in asthma control, defined by the Asthma Control Test (ACT), before and after bariatric surgery among participants with asthma in the multi-center Longitudinal Assessment of Bariatric Surgery (LABS) study, stratifying our analysis by the presence or absence of metabolic syndrome.

RESULTS

Among 2,458 LABS participants, 555 participants had an asthma diagnosis and were included in our analysis. Of these, 78% (n = 433) met criteria for metabolic syndrome (MetSyn) at baseline. In patients without MetSyn, mean ACT increased from 20.4 at baseline to 22.1 by 12-24 months, ending at 21.3 at 60 months. In contrast, among those with MetSyn there was no significant improvement in ACT scores. The proportion of patients without MetSyn with adequate asthma control (ACT >19) increased from 58% at baseline to 78% and 82% at 12 and 60 months, respectively, whereas among those with MetSyn, it was 73.8% at baseline, 77.1% at 12 months, dropping to 47.1% at 60 months (p = 0.004 for interaction between metabolic syndrome and time). Having MetSyn also increased the likelihood of losing asthma control during follow-up (HR = 1.92, 95% confidence interval [CI] 1.24-2.97, p = 0.003).

CONCLUSIONS

Metabolic syndrome may negatively modify the effect of bariatric surgery-induced weight loss on asthma control.