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

Adolescent Bariatric Surgery: The Need for Tailored Educational Materials

Rates of class III, or greater, obesity have risen among adolescents in the United States. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for severe obesity among teenagers that results in improvements in cardiometabolic and psychosocial health. Despite its effectiveness, MBS remains largely underutilized and misconceptions exist among providers, parents/guardians, and adolescents. In addition, adolescents who have undergone MBS procedures report there are some topics they wish they had known more about before surgery and express concern that their unique needs are not understood. One potential solution to address these concerns includes preoperative educational materials tailored for adolescents. Currently, there are no standardized recommendations for preoperative educational materials. This editorial suggests the use of community-engaged research, and qualitative methodology, to consult with the primary stakeholder groups of preoperative adolescents, postoperative adolescents, parents/guardians, and clinicians to develop tailored materials that address the unique needs of adolescents undergoing surgical treatment for obesity.

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.

Marijuana, e-cigarette, and tobacco product use in young adults who underwent pediatric bariatric surgery

BACKGROUND

The postoperative course after pediatric metabolic and bariatric surgery (MBS) cuts across a developmental phase when substance-use behaviors emerge as significant public health concerns.

OBJECTIVE

We examined use of marijuana, conventional cigarettes, and alternate tobacco products/devices (e.g., e-cigarettes, hookah, smokeless, dissolvable) in young adults (YA) to 6 years postsurgery.

SETTING

Five academic medical centers.

METHODS

In a prospective observational cohort series, 139 surgical (Mage = 16.9, Mbody mass index [BMI] = 51.5, 80% female, 66% white) and 83 nonsurgical comparisons (Mage = 16.1, MBMI = 44.9, 82% female, 54% white) completed assessments at presurgery/baseline and postsurgery years 2, 4, and 6 (year 6 [2014-2018]: surgical n = 123 [89%], Mage = 23.0, MBMI = 39.8; nonsurgical n = 63 [76%], Mage = 22.4, MBMI = 53.6). Lifetime and current (past 30 days) use were reported.

RESULTS

Consistent with national YA trends (2014-2018), the most commonly used were (1) conventional cigarettes (30% surgical, 41% nonsurgical, nonsignificant [ns]); (2) marijuana (25% surgical, 27% nonsurgical, ns); and (3) e-cigarettes (12% surgical, 10% nonsurgical). A sizable minority (26% surgical, 18% nonsurgical) used one or more alternate tobacco product/device. Many YA reported persistent and/or heavy use (e.g., >50% marijuana at year 6 and year 2 or 4; ≈50% ≥.5 pack/d of cigarettes), suggesting more established (versus intermittent) health risk behaviors. For the surgical group at year 6, current tobacco product/device use was associated with lower BMI (P < .001) and greater percent weight loss (P = .002).

CONCLUSIONS

Pediatric MBS demonstrates promise in lowering risks for adult chronic disease, which may be diminished by age-typical health risk behaviors. Developmentally salient and holistic pediatric postoperative care guidelines are needed.

Obesity Pillars roundtable: Metabolic and bariatric surgery in children and adolescents

Background

Obesity is a chronic disease which frequently begins in childhood and requires a life-long multidisciplinary approach. Metabolic-bariatric surgery (MBS) is a key component of the treatment of severe obesity in children, adolescents and adults. Children and adolescents who have class II obesity and a complication of obesity or have class III obesity should be considered for MBS, regardless of age, race, sex, or gender. Children and adolescents with cognitive disabilities, a history of mental illness, a treated eating disorder, immature bone growth, or low Tanner Stage should not be denied treatment. Early intervention can reduce the risk of persistent obesity, end organ damage, and sequelae from long-standing complications of obesity.

Methods

This roundtable discussion includes three pediatric obesity specialists with experience in the medical and surgical management of children and adolescents with obesity. Included are citations regarding metabolic-bariatric surgery in children and adolescents.

Results

MBS in pediatric patients is increasingly recognized as an essential part of managing the disease of obesity in combination with medication, nutrition, behavioral training, and physical activity. Vertical sleeve gastrectomy or Roux-en-Y gastric bypass in patients meeting criteria for severe obesity should be considered, especially when children have complications such as poor quality of life, orthopedic disease, idiopathic intracranial hypertension, type 2 diabetes mellitus, obstructive sleep apnea, or cardiovascular risk. Children and adolescents with autism, developmental delay, or syndromic obesity should be considered for MBS on a case-by-case basis. Early intervention may result in improved long-term outcomes, and referral for MBS should not be conditional based on stage of pubertal development (Tanner Staging), bone age, or prior weight loss attempts.

Conclusions

Children and adolescents who suffer from severe obesity need the entire spectrum of treatment modalities available to achieve a healthy weight and control obesity-related complications. This treatment spectrum should include MBS. These children and adolescents should be cared for by a pediatric weight management team prepared to care for them until they transition to adult care.

"Your own pace, your own path": perspectives of adolescents navigating life after bariatric surgery

INTRODUCTION

Bariatric surgery, an established weight-loss tool, may be offered to some adolescents with severe obesity. However, few studies explore adolescents' postoperative experiences beyond physical and metabolic outcomes and quality-of-life measures.

METHODS

Between 2016 and 2021, 45 semi-structured interviews were conducted with adolescents (16-20 years) at 6 months (N = 15), 12 months (N = 15), and 24 months (N = 15) following bariatric surgery. A deductive thematic analysis framework was applied by two independent coders (Cronbach's α = 0.84). Themes were identified and refined iteratively, and discrepancies were resolved through discussion.

RESULTS

Five major themes emerged related to: (1) weight-loss expectations vs. reality, (2) social landscape, (3) body image, (4) eating and moving, and (5) challenges for long-term success. The pace of and satisfaction with weight loss and side effects was heterogenous among participants, with most changes occurring early and stabilizing by 24 months. Adolescents adapted over time to their new social landscapes (e.g., relationships) and reported improved body image and confidence, yet persistently struggled to reconcile their internal identity with evolving external perceptions and discomfort with new attention. Participants experienced changes to lifestyle routines after surgery (e.g., eating, moving, habits), which introduced distress at 6 months but resolved over time. Life transitions in early adulthood (e.g., moving away, university/college, employment), concurrent with their evolving and increasing autonomy, physical, social, and financial independence, imposed unexpected challenges to postoperative routines and support systems. Participants unanimously reaffirmed that bariatric surgery is a lifelong journey and that they were committed to long-term success.

CONCLUSION

Our findings provide insight into optimizing adolescent selection for bariatric surgery and perioperative support. Specifically, important life transitions during this developmental period impact postoperative experiences and outcomes and adolescents may benefit from postoperative counseling focused on managing weight-loss expectations and adapting to evolving nutritional needs and changing social circumstances.

Women in larger bodies' experiences with contraception: a scoping review

Background

As the prevalence of obesity increases and the age of onset decreases, more women of reproductive age will be living in larger bodies. Research on weight-related efficacy and safety has informed clinical guidelines for routine and emergency contraceptive use by women with a higher body mass index; however, patient perspectives are needed to understand women in larger bodies’ experiences with contraception and contraceptive care. This scoping review summarizes the literature on women in larger bodies’ experiences with contraception with the goal of gaining a better understanding of the nature of these experiences and identifying gaps in the existing research.

Methods

Following Arksey and O’Malley’s framework, a scoping review of the literature was conducted. Four databases (PubMed, PsycINFO, SCOPUS, and CINAHL) were searched for peer-reviewed, empirical articles published in English between 2010 and 2020, with a focus on North America, Europe, Australia, and New Zealand. Data were summarized by identifying key themes in the reviewed literature.

Results

Twenty-nine articles meeting the eligibility criteria were reviewed. The literature was predominantly quantitative (n = 27), with only one qualitative study and one systematic review, respectively. Five themes were identified, including (1) use of contraception among women in larger bodies; (2) knowledge, attitudes towards and beliefs about contraception; (3) contraceptive (dis)satisfaction among women in larger bodies; (4) contraceptive counseling; and (5) barriers to contraception. The findings revealed that women in larger bodies may have unmet contraceptive care needs. Despite many articles addressing the need to improve contraceptive counseling for women in larger bodies (n = 26), few explored how women felt about their care (n = 2). Finally, only two articles focused on emergency contraception, indicating a need for further research.

Conclusion

This scoping review emphasizes the pressing need for qualitative research to explore women in larger bodies’ experiences with routine and emergency contraception, as well as receiving contraceptive counseling and care. Future research exploring the lived experiences of women in larger bodies is necessary to better characterize their contraceptive needs and identify avenues to improve patient care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01139-2.

As obesity becomes more prevalent, more women of reproductive age will be living in larger bodies. This review highlights what is known about women in larger bodies’ experiences with contraception and suggests where future research is needed. We searched four databases for papers published in English from 2010 to 2020. Our review included 29 articles. Nearly all of the studies were quantitative, with one qualitative study and one review. Most articles talked about contraceptive use, but few of them included emergency contraception. Some papers highlighted women’s knowledge and opinions about contraception, whereas others talked about their contraceptive (dis)satisfaction. Many articles discussed contraceptive counseling. Finally, some papers considered potential barriers to contraception. Our findings suggest that women in larger bodies have unmet contraceptive needs. Notably, this review aimed to focus on patient experiences but women’s voices were rarely represented. Future qualitative research on women’s lived experiences will provide a better understanding of women in larger bodies’ contraceptive needs and suggest how care can be improved.

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.

Optimizing contraceptive access for women undergoing bariatric surgery

With the dramatic increase in the prevalence of obesity, there is a corresponding increase in surgical procedures to treat obesity. Reproductive aged women (18-45 years old) undergo half of the bariatric surgical procedures performed in the United States each year. These women experience profound physiologic changes in response to bariatric surgery, including dramatic changes in reproductive function. Current guidelines recommend delaying attempts at conception for 12-24 months after bariatric surgery during the time of most profound weight loss. Despite these recommendations, many women report unprotected intercourse during this time, and many use less efficacious contraceptive options. Herein, we address contraceptive considerations in women of reproductive age who undergo bariatric surgery and opportunities to maximize a multidisciplinary surgical approach to optimize their overall health.

Review: Sex-Specific Aspects in the Bariatric Treatment of Severely Obese Women

This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. A systematic literature search was carried out according to Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. After the literature selection, the following categories were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined. A summary that includes key messages is given for each subsection. An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks.