5-year mental health and eating pattern outcomes following bariatric surgery in adolescents: a prospective cohort study

Effect of Pediatric Obesity Treatment on Long-Term Health

IMPORTANCE

Data regarding the long-term impact of treating childhood obesity on the risk of obesity-related events, including premature mortality, are limited.

OBJECTIVE

To evaluate the long-term effect of different responses to pediatric obesity treatment on critical health outcomes in young adulthood.

Design, Setting, and Participants

The study included a dynamic prospective cohort of children and adolescents with obesity within The Swedish Childhood Obesity Treatment Register (BORIS) and general population comparators, linked with national registers. Baseline data were collected between 1996 and 2019. Formal analyses for this study was conducted in 2023. Outcomes were assessed from individuals aged 18 to 30 years (2005 to 2020). Participants included children and adolescents aged 6 to 17 years receiving at least 1 year of obesity treatment. General population comparators were matched on a ratio of 1:5 on sex, year of birth, and geographical area.

EXPOSURE

Pediatric obesity treatment response was based on changes in body mass index standard deviation score and categorized as poor, intermediate, and good response and obesity remission.

MAIN OUTCOMES

Obesity-related events included type 2 diabetes (T2D), dyslipidemia, hypertension, depression or anxiety, and weight-loss bariatric surgery. Additionally, mortality was assessed.

RESULTS

Of 6713 individuals (3777 male [56%] and 2936 female [44%]), the median age at obesity treatment initiation was 12.1 (quartile 1; quartile 3: 10.1; 14.3) years and treatment duration was 3.0 (1.8; 4.9) years. For T2D, hypertension, dyslipidemia, weight-loss bariatric surgery, and depression or anxiety outcomes, unadjusted incidence rates tended to decrease with better treatment response and the lowest estimate was observed among general population comparators. Compared with poor response, obesity remission or a good response in obesity treatment was associated with reduced risk of mortality (adjusted hazard ratio [HR], 0.12; 95% CI, 0.03-0.46). Good response was also associated with lower risk of TD2 (HR, 0.42; 95% CI, 0.23-0.77), dyslipidemia (HR, 0.31; 95% CI, 0.13-0.75), and bariatric surgery (HR, 0.42; 95% CI, 0.30-0.58). Obesity remission showed similar reduced risk, but also a reduced risk of hypertension (HR, 0.40; 95% CI, 0.24-0.65). Treatment response was not associated with depression or anxiety.

CONCLUSIONS AND RELEVANCE

In this study, beneficial pediatric obesity treatment response yielded enduring health benefits, markedly lowering future morbidity and mortality risks in young adulthood.

Psychosocial outcomes after adolescent metabolic and bariatric surgery: a narrative review of the literature

The prevalence of severe obesity among adolescents continues to be a significant global concern. Metabolic and bariatric surgery (MBS) has increasingly shown to produce safe, efficacious, and durable effects on weight loss and related physical health complications, and evidence of psychosocial outcomes are beginning to mature. The revised American Society for Metabolic and Bariatric Surgery pediatric guidelines published in 2018 reported emergent data regarding key psychosocial outcomes, including mental health, disordered eating, and quality of life, although data were limited by small, short-term studies and often without comparison groups. The purpose of this narrative review was to expand the relevant findings regarding youth with severe obesity who receive MBS to further clarify the impact of surgery on psychosocial outcomes.

Metabolic and bariatric surgery for adolescents with severe obesity: Benefits, risks, and specific considerations

International and national guidelines recommend metabolic and bariatric surgery (MBS) as a treatment option for adolescents with severe obesity, but few countries offer MBS to adolescents in routine clinical care. This narrative review summarizes existing adolescent MBS guidelines and the available underpinning evidence. Two randomized trials and additional prospective studies have demonstrated efficacy and safety in adolescent MBS, and the health benefits appear to be similar or superior to outcomes in adults. However, there are specific challenges regarding the intervention during adolescence related to decision-making capacity and a peak in risk-taking behavior. Adolescents with severe obesity have-as a group-a mental health vulnerability, and specific nutritional concerns need to be addressed in relation to MBS. This review also describes how study findings can be translated into clinical care. We use Sweden as an example, where the National Board of Health and Welfare recommends MBS for selected adolescents with severe obesity aged 15 years or older. We present practical advice for implementing and integrating MBS in adolescents in the framework of multidisciplinary pediatric and adolescent care for obesity.

Effectiveness of surgical interventions for managing obesity in children and adolescents: A systematic review and meta-analysis framed using minimal important difference estimates based on GRADE guidance to inform a clinical practice guideline

OBJECTIVE

To summarize the literature on bariatric surgery for managing pediatric obesity, including intervention effects to improve patient-reported outcome measures (PROMs), cardiometabolic risk factors, anthropometry, and assess adverse events (AEs).

METHODS

Eligible studies were published between January 2012 and January 2022 and included randomized controlled trials (RCTs) and observational (controlled and uncontrolled) studies before and after surgery with a mean age <18 years old. Outcomes and subgroups were selected a priori by stakeholders; estimates of effect for outcomes were presented relative to minimal important differences (MIDs) and GRADE certainty of evidence. We examined data on PROMs, cardiometabolic risk factors, anthropometry, and AEs. Subgroup analyses examined outcomes by follow-up duration and surgical technique, when possible.

RESULTS

Overall, 63 publications (43 original studies) met our inclusion criteria (n = 6128 participants; 66% female). Studies reported six different surgical techniques that were evaluated using uncontrolled single arm observational (n = 49), controlled observational (n = 13), and RCT (n = 1) designs. Most studies included short-term follow-up (<18 months) only. PROMs were measured in 12 (28%) studies. Surgery led to large improvements in health-related quality of life compared to baseline and control groups, and moderate to very large improvements in cardiometabolic risk factors compared to baseline. Large to very large improvements in BMIz were noted compared to baseline across all follow-up periods. There was limited evidence of AEs with most reporting mild or non-specific AEs; serious AEs were uncommon.

CONCLUSION

Bariatric surgery demonstrated primarily moderate to very large improvements across diverse outcomes with limited evidence of AEs, albeit with low to moderate certainty of evidence.

Intermittent Energy Restriction for Adolescents With Obesity: The Fast Track to Health Randomized Clinical Trial

Importance

Adolescent obesity requires effective and accessible treatment. Intensive dietary interventions have the potential to be used as adjunctive therapy for behavioral weight management.

Objective

To examine the effectiveness of 2 diet therapies, delivered as part of an intensive behavioral weight management intervention, in adolescents with metabolic complications associated with obesity.

Design, Setting, and Participants

This multisite, 52-week randomized clinical trial was conducted from January 31, 2018, to March 31, 2023, at 2 tertiary pediatric centers in Australia. Adolescents (aged 13-17 years) with obesity and 1 or more associated complications were included.

Interventions

Intensive behavioral interventions, delivered by a multidisciplinary team, comparing intermittent energy restriction (IER) or continuous energy restriction (CER), with 3 phases: very low-energy diet (weeks 0-4), intensive intervention (weeks 5-16), and continued intervention and/or maintenance (weeks 17-52).

Main Outcomes and Measures

The primary outcome was body mass index (BMI) z score at 52 weeks in the IER vs CER group. Anthropometry, body composition, and cardiometabolic health were assessed at baseline and 52 weeks. The BMI z score and percentiles were determined using Centers for Disease Control and Prevention growth charts. Insulin resistance, dyslipidemia, and elevated hepatic function were assessed.

Results

A total of 141 adolescents (median [IQR] age, 14.8 [12.9-17.9] years; 71 male [50.4%]) were enrolled, 71 in the IER group and 70 in the CER group, and 97 (68.8%) completed the intervention, 43 in the IER group and 54 in the CER group. At week 52, both groups had reduced BMI z scores (estimated marginal mean change, -0.28 [95% CI, -0.37 to -0.20] for IER and -0.28 [95% CI, -0.36 to -0.20] for CER) and reduced BMI expressed as a percentage of the 95th percentile (estimated marginal mean change, -9.56 [95% CI, -12.36 to -6.83] for IER and -9.23 [95% CI, -11.82 to -6.64] for CER). No differences were found in body composition or cardiometabolic outcomes between the groups. Both groups had a reduction in the occurrence of insulin resistance (from 52 of 68 [76.5%] to 32 of 56 [57.1%] in the IER group and from 59 of 68 [86.8%] to 31 of 60 [57.1%] in the CER group) at week 16; however, at week 52, this effect was observed in the CER group only (from 59 of 68 [86.7%] to 30 of 49 [61.2%]). The occurrence of dyslipidemia was unchanged between baseline and week 52 (60 of 137 [42.6%] and 37 of 87 [42.5%], respectively), with a small improvement in occurrence of impaired hepatic function tests (37 of 139 [27.0%] and 15 of 87 [17.2%], respectively). No differences were found in dyslipidemia or hepatic function between groups.

Conclusions and Relevance

These findings suggest that for adolescents with obesity-associated complications, IER can be incorporated into a behavioral weight management program, providing an option in addition to CER and offering participants more choice.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12617001630303.

Practical guidelines for eating disorder risk mitigation in patients undergoing obesity treatment for the pediatric provider

PURPOSE OF REVIEW

Pediatric obesity is a growing concern globally. Patients with a history of overweight/obesity often experience stigmatization, especially in the healthcare setting, and are at increased risk of developing psychological comorbidities including eating disorders. This review appraises the most recent studies evaluating eating disorder risk in youth undergoing treatment for obesity, identifies gaps in the literature, and offers practical guidelines to pediatric providers regarding the management of this population.

RECENT FINDINGS

Recent studies suggest that structured weight management programs may decrease the risk of and/or improve symptoms of certain eating disorders such as binge eating disorder and bulimia nervosa. There is a paucity of research on some components of obesity management such as obesity pharmacotherapeutics and eating disorder risk.

SUMMARY

Children and adolescents with obesity are a psychologically vulnerable population with increased risk for the development of eating disorders. Further study is needed to evaluate general risk in the setting of specialized and primary care obesity interventions and develop appropriate screening and mitigation tools. Some evidence-based strategies can aid pediatric providers in both weight management and eating disorder prevention and risk assessment.

Treatment of Binge-Eating Disorder Across the Lifespan: An Updated Review of the Literature and Considerations for Future Research

PURPOSE OF REVIEW

The present review describes the recent literature on treatment for binge-eating disorder (BED) in adults and youth, with a particular focus on research gaps, emerging treatments, and future research directions.

RECENT FINDINGS

Evidence supports the efficacy of several treatment modalities in adults, including self-help treatment, clinician-led psychotherapy, and pharmacotherapy; the largest effect sizes have been found for psychotherapies, most of which were cognitive-behavioral in orientation. Adapted psychotherapies for youth also show promise but lack a robust body of evidence. Predictors, moderators, and mediators of treatment outcome remain poorly understood; individuals with BED continue to experience significant barriers to treatment; and research is needed to address suboptimal treatment response. Recent work has highlighted the potential of adaptive interventions and investigation of novel mechanisms to address these gaps. Research on BED treatment continues to grow, though critical questions must be answered to improve treatment efficacy across the lifespan.

Bone health following paediatric and adolescent bariatric surgery: a systematic review and meta-analysis

Background

Childhood obesity is a pressing health crisis of epidemic proportions. Bariatric surgery (BS) is an effective weight loss solution however its role in the paediatric population is contentious owing to the paucity of weight specific and generalised health outcomes. This systematic review and meta-analysis aimed to assess the impact of paediatric BS on bone health.

Methods

This prospectively registered systematic review (PROSPERO ID: CRD42023432035) was performed in accordance with PRISMA guidelines. We searched MEDLINE (1946-1928 September 2023), EMBASE (1947-1928 September 2023) via the Ovid platform, and the Cochrane Review Library to identify scientific publications reporting bone outcome measures in patients under the age of 18 years who underwent BS. Meta-analysis was undertaken on post-operative weight and bone parameters in paediatric patients following BS. Outcomes were reported as weighted or standardized mean difference with 95 percent confidence intervals. Subgroup analysis by intervention, quality scoring and risk of bias were assessed.

Findings

Twelve studies with 681 patients across 5 countries (mean age 17 ± 0.57 years) were included. The quality of included studies was rated as high and there was substantial between-study heterogeneity for most factors included in the meta-analysis (I2 from 0% to 99.1%). Patients underwent Roux-en-Y gastric bypass (RYGB, n = 216), sleeve gastrectomy (SG, n = 257), gastric band (n = 184) or intragastric balloon placement (n = 24). BS was associated with significant weight reduction, body mass index (BMI) -12.7 kg/m2 (95% CI -14.5 to -10.9, p < 0.001), with RYGB being most effective, BMI -16.58 kg/m2 (95% CI -19.6 to -13.6, p < 0.001). Patients who underwent SG or RYGB had significantly lower lumbar bone mineral density, -0.96 g/cm2 (95% CI -0.1 to -0.03, p < 0.001), Z score, -1.132 (95% CI -1.8 to -0.45, p < 0.001) and subtotal body bone mineral density, -0.7 g/cm2 (95% CI -1.2 to -0.2, p < 0.001) following surgery. This was accompanied with higher markers of bone resorption, C-terminal telopeptide of type 1 collagen 0.22 ng/ml (95% CI 0.12-0.32, p < 0.001) and osteocalcin, 10.83 ng/ml (95% CI 6.01-15.67, p < 0.001). There was a significant reduction in calcium levels following BS, -3.78 mg/dl (95% CI -6.1 to -1.5, p < 0.001) but no difference in 25-hydroxyvitamin D, phosphate, bone alkaline phosphatase, procollagen type 1 N propeptide or parathyroid hormone.

Interpretation

BS effectively reduces weight in paediatric patients, but RYGB and SG may have adverse effects on bone health in the medium term. It is crucial to monitor and support bone health through appropriate nutritional supplementation and judicious follow-up. Long-term data is needed to fully understand the clinical implications of these findings on bone outcomes.

Funding

Medical Research Council (MRC), United Kingdom.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

CLINICALTRIALS

GOV IDENTIFIER

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

Long-term Outcomes Following Adolescent Metabolic and Bariatric Surgery

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Child and adolescent obesity

The prevalence of child and adolescent obesity has plateaued at high levels in most high-income countries and is increasing in many low-income and middle-income countries. Obesity arises when a mix of genetic and epigenetic factors, behavioural risk patterns and broader environmental and sociocultural influences affect the two body weight regulation systems: energy homeostasis, including leptin and gastrointestinal tract signals, operating predominantly at an unconscious level, and cognitive-emotional control that is regulated by higher brain centres, operating at a conscious level. Health-related quality of life is reduced in those with obesity. Comorbidities of obesity, including type 2 diabetes mellitus, fatty liver disease and depression, are more likely in adolescents and in those with severe obesity. Treatment incorporates a respectful, stigma-free and family-based approach involving multiple components, and addresses dietary, physical activity, sedentary and sleep behaviours. In adolescents in particular, adjunctive therapies can be valuable, such as more intensive dietary therapies, pharmacotherapy and bariatric surgery. Prevention of obesity requires a whole-system approach and joined-up policy initiatives across government departments. Development and implementation of interventions to prevent paediatric obesity in children should focus on interventions that are feasible, effective and likely to reduce gaps in health inequalities.

Occupational characteristics and incident anxiety and depression: A prospective cohort study of 206,790 participants

BACKGROUND

This study aimed to analyze the impact of a wide spectrum of occupational characteristics on the incidence of anxiety and depression, and to determine the features affecting adaptation to specific characteristics.

METHODS

Participants in paid employment or self-employed at baseline in UKB were included, with occupational characteristics extracted from O*NET. Cox-proportional-hazard models were conducted in the main analyses and subgroup analyses.

RESULTS

Direct work with the public and exposure to disease/infections were first time demonstrated to be risk factors for both anxiety and depression, along with occupations involving more physical activities and dealing with unpleasant/physically aggressive people. Protective factors for both: time spent sitting, communication, decision making, creativity and reasoning, and responsibility in work. Protective factors for anxiety only: Coordinating/leading, fluency of ideas, originality, problem sensitivity, decision latitude, and time pressure. Risk factor for depression only: Exposure to contaminants. Females were found more sensitive to dealing with unpleasant/physically aggressive people. The impact of exposure to disease/infections was more significant among those with lower education levels. Those with BMI over 24 were more sensitive to the risk factors.

LIMITATIONS

The short-term effect of the above exposures remained unclear. The scores of occupational characteristics were based on self-reported questionnaires. There was the potential for undiagnosed anxiety or depression events. The participants included only those aged from 40 to 69. Participants included in this cohort were mainly White British.

CONCLUSIONS

Our findings advocate closer monitoring of the mental health of workers with risk work-related factors.

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.

Metabolic and bariatric surgery versus intensive non-surgical treatment for adolescents with severe obesity (AMOS2): a multicentre, randomised, controlled trial in Sweden

BACKGROUND

Severe obesity in adolescents has a profound impact on current and future health. Metabolic and bariatric surgery (MBS) is increasingly used in adolescents internationally. However, to our knowledge, there are no randomised trials examining the currently most used surgical techniques. Our aim was to evaluate changes in BMI and secondary health and safety outcomes after MBS.

METHODS

The Adolescent Morbid Obesity Surgery 2 (AMOS2) study is a randomised, open-label, multicentre trial done at three university hospitals in Sweden (located in Stockholm, Gothenburg, and Malmö). Adolescents aged 13-16 years with a BMI of at least 35 kg/m2, who had attended treatment for obesity for at least 1 year, passed assessments from a paediatric psychologist and a paediatrician, and had a Tanner pubertal stage of at least 3, were randomly assigned (1:1) to MBS or intensive non-surgical treatment. Exclusion criteria included monogenic or syndromic obesity, major psychiatric illness, and regular self-induced vomiting. Computerised randomisation was stratified for sex and recruitment site. Allocation was concealed for both staff and participants until the end of the inclusion day, and then all participants were unmasked to treatment intervention. One group underwent MBS (primarily gastric bypass), while the other group received intensive non-surgical treatment starting with 8 weeks of low-calorie diet. The primary outcome was 2-year change in BMI, analysed as intention-to-treat. The trial is registered at ClinicalTrials.gov, NCT02378259.

FINDINGS

500 people were assessed for eligibility between Aug 27, 2014, and June 7, 2017. 450 participants were excluded (397 did not meet inclusion criteria, 39 declined to participate, and 14 were excluded for various other reasons). Of the 50 remaining participants, 25 (19 females and six males) were randomly assigned to receive MBS and 25 (18 females and seven males) were assigned to intensive non-surgical treatment. Three participants (6%; one in the MBS group and two in the intensive non-surgical treatment group) did not participate in the 2-year follow-up, and in total 47 (94%) participants were assessed for the primary endpoint. Mean age of participants was 15·8 years (SD 0·9) and mean BMI at baseline was 42·6 kg/m2 (SD 5·2). After 2 years, BMI change was -12·6 kg/m2 (-35·9 kg; n=24) among adolescents undergoing MBS (Roux-en-Y gastric bypass [n=23], sleeve gastrectomy [n=2]) and -0·2 kg/m2 (0·4 kg; [n=23]) among participants in the intensive non-surgical treatment group (mean difference -12·4 kg/m2 [95% CI -15·5 to -9·3]; p<0·0001). Five (20%) patients in the intensive non-surgical group crossed over to MBS during the second year. Adverse events (n=4) after MBS were mild but included one cholecystectomy. Regarding safety outcomes, surgical patients had a reduction in bone mineral density, while controls were unchanged after 2 years (z-score change mean difference -0·9 [95% CI -1·2 to -0·6]). There were no significant differences between the groups in vitamin and mineral levels, gastrointestinal symptoms (except less reflux in the surgical group), or in mental health at the 2-year follow-up.

INTERPRETATION

MBS is an effective and well tolerated treatment for adolescents with severe obesity resulting in substantial weight loss and improvements in several aspects of metabolic health and physical quality of life over 2 years, and should be considered in adolescents with severe obesity.

FUNDING

Sweden's Innovation Agency, Swedish Research Council Health.

Long-term changes in dietary intake and its association with eating-related problems after gastric bypass in adolescents

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery is an established, effective treatment for severe adolescent obesity. Long-term dietary intake and the relationship to eating-related problems are scarcely evaluated in this population.

OBJECTIVES

Assess changes in dietary intake in adolescents after RYGB and explore associations between dietary intake and eating-related problems.

SETTING

Multicenter study in Swedish university hospitals.

METHOD

Diet history, binge eating scale (BES), and Three-Factor Eating Questionnaire were assessed preoperatively and 1, 2, and 5 years after RYGB in 85 adolescents (67% female) aged 16.5 ± 1.2 years with a body mass index (BMI) of 45.5 ± 6.0 kg/m² and compared with control individuals at 5 years.

RESULTS

Five-year BMI change was -28.6% ± 12.7% versus +9.9% ± 18.9% in RYGB patients versus control individuals (P < .001). Through 5 years, RYGB adolescents reported reduced energy intake, portion size of cooked meals at dinner, and milk/yoghurt consumption (P < .01). The BES scores were 9.3 ± 8.3 versus 13.4 ± 10.5 in RYGB patients versus control individuals (P = .04). Association between BES score and energy intake was stronger in control individuals (r = .27 versus r = .62 in RYGB patients versus control individuals, P < .001). At 5 years, lower energy intake was associated with greater BMI loss in all adolescents (r = .33, P < .001). Higher scores in BES and uncontrolled and emotional eating were associated with higher energy intake, cooked meals, candies/chocolates, cakes/cookies, desserts, and sugary drinks (r > .23, P < .04) and lower intake of fruits/berries (r = -.32, P = .044). A higher score in cognitive restraint was associated with a higher intake of cereals and fruits/berries (r > .22, P < .05) and a lower intake of sugary drinks (r = -.24, P < .03).

CONCLUSION

To support optimization of long-term outcomes in adolescent RYGB patients, it is important to provide management strategies to reduce energy intake. Monitoring eating-related problems could identify potential individuals at risk of poor weight loss and to initiate treatment interventions.

Pediatric obesity-Long-term consequences and effect of weight loss

Childhood obesity is, according to the WHO, one of the most serious challenges of the 21st century. More than 100 million children have obesity today. Already during childhood, almost all organs are at risk of being affected by obesity. In this review, we present the current knowledge about diseases associated with childhood obesity and how they are affected by weight loss. One major causative factor is obesity-induced low-grade chronic inflammation, which can be observed already in preschool children. This inflammation-together with endocrine, paracrine, and metabolic effects of obesity-increases the long-term risk for several severe diseases. Type 2 diabetes is increasingly prevalent in adolescents and young adults who have had obesity during childhood. When it is diagnosed in young individuals, the morbidity and mortality rate is higher than when it occurs later in life, and more dangerous than type 1 diabetes. Childhood obesity also increases the risk for several autoimmune diseases such as multiple sclerosis, Crohn's disease, arthritis, and type 1 diabetes and it is well established that childhood obesity also increases the risk for cardiovascular disease. Consequently, childhood obesity increases the risk for premature mortality, and the mortality rate is three times higher already before 30 years of age compared with the normal population. The risks associated with childhood obesity are modified by weight loss. However, the risk reduction is affected by the age at which weight loss occurs. In general, early weight loss-that is, before puberty-is more beneficial, but there are marked disease-specific differences.

Adolescents' and professionals' experiences of metabolic and bariatric surgery and requirements for preoperative and postoperative support through mHealth: a qualitative study

OBJECTIVES

This study aimed to explore adolescents' and professionals' incentives and experiences of metabolic and bariatric surgery (MBS) and to explore perceived needs and requirements for preoperative and postoperative support through an mHealth intervention to improve long-term healthy lifestyle behaviour and health outcomes.

DESIGN

An inductive qualitative study using in-depth semistructured interviews.

SETTING

Three hospital-based specialist paediatric obesity treatment units in Sweden.

PARTICIPANTS

A total of 18 participants (14 women and 4 men). Nine adolescents aged between 17 and 22 years who had undergone or were about to undergo surgery, and nine professionals, including researchers and clinicians working in various professional roles such as physiotherapist, dietician, nurse, psychologist, physician and pedagogue.

RESULTS

Both informant groups of participants highlighted that undergoing MBS is a complex process, and hence actions are required on several levels to optimise the positive, long-term effects of surgery. Efficient communication between the healthcare professionals and adolescents was considered crucial and a key success factor. Informants acknowledged the need for additional support that relates to psychosocial well-being and mental health in order to understand, form and accept new behaviours and identity. An mHealth intervention should be seen as complementary to physical appointments, and informants acknowledged that an app could be a way of improving access to healthcare, and a useful tool to allow for individually tailored and easily available support.

CONCLUSIONS

The findings address the importance of a personal encounter and a need for additional support that relates to psychosocial well-being, mental health and healthy lifestyle behaviour. These findings should be incorporated into future research concerning mHealth interventions in MBS during adolescence.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

Comparing effects of obesity treatment with very low energy diet and bariatric surgery after 2 years: a prospective cohort study

OBJECTIVES

To compare long-term effects and complications of medical treatment (MT) of obesity including very low energy diet with bariatric surgery.

DESIGN AND SETTING

This prospective study conducted in a clinical setting recruited individuals with body mass index (BMI) ≥35 kg/m2 referred for obesity treatment. Demographic and anthropometric data, laboratory samples, and questionnaire replies were collected at baseline and 2 years.

PARTICIPANTS AND INTERVENTIONS

971 individuals were recruited 2015-2017. 382 received MT, 388 Roux-en-Y gastric bypass (RYGB) and 201 sleeve gastrectomy (SG).

MAIN OUTCOME MEASURES

Primary outcomes included changes in anthropometric measures, metabolic variables and safety. These were analysed using a linear regression model. A logistic regression model was used to analyse composite variables for treatment success (secondary outcomes). A random forest (RF) model was used to examine the importance of 15 clinical domains as predictors for successful treatment.

RESULTS

Two-year data were available for 667 individuals (68.7%). Regarding primary outcomes, the decrease in excess BMI was 27.5%, 82.5% and 70.3% and proportion achieving a weight of >10% was 45.3%, 99.6% and 95.6% for MT, RYGB and SG, respectively (p<0.001). The groups were comparable regarding levels of vitamins, minerals and haemoglobin or safety measures. Likelihood for success (secondary outcome) was higher in the surgical groups (RYGB: OR 5.3 (95% CI 3.9 to 7.2) vs SG: OR 4.3 ((95% CI 3.0 to 6.2)) in reference to MT. Baseline anthropometry had the strongest predictive value for treatment success, according to the RF model.

CONCLUSIONS

In clinical practice, bariatric surgery by RYGB or SG is most effective, but meaningful weight loss is achievable by MT with strict caloric restriction and stepwise introduction of a normal diet. All treatments showed positive effects on well-being, cardiovascular risk factors, and levels of vitamins and minerals at 2-year follow-up and groups were similar regarding safety measures.

TRIAL REGISTRATION NUMBER

NCT03152617.

Mental health of adolescents after bariatric surgery: A textual analysis

Mental health after bariatric surgery during adolescence has been little explored. This is a sensitive period in terms of self-image on which bariatric surgery could have negative effects because of the rapid and significant changes in morphology it induces. Previous studies have explored mental effects using questionnaires and only related to psychopathological disorders. The objective of our study was to complement these studies by exploring, via in-depth interviews, the adolescents' views on changes after bariatric surgery at psychological as well as socio-emotional levels. Fourteen adolescents with obesity were recruited in a French hospital 6-43 months after surgery. They participated in one-on-one interviews lasting an average of 45 minutes. A lexical analysis (using ALCESTE software^© ) of their speech highlighted the most positive effects, particularly in terms of social relationships, physical activities, self-esteem and reduced stigma, along with less positive effects in terms of eating behaviour and skin. In terms of clinical implications, this study confirmed the value of bariatric surgery for adolescents at psychological and social levels and its contribution to their mental health. However, it also highlighted the importance of pre- and post-operative support.

Obesity and Eating Disorders in Children and Adolescents: The Bidirectional Link

Obesity, eating disorders and unhealthy dieting practices among children and adolescents are alarming health concerns due to their high prevalence and adverse effects on physical and psychosocial health. We present the evidence that eating disorders and obesity can be managed or prevented using the same interventions in the pediatric age. In the presence of obesity in the pediatric age, disordered eating behaviors are highly prevalent, increasing the risk of developing eating disorders. The most frequently observed in subjects with obesity are bulimia nervosa and binge-eating disorders, both of which are characterized by abnormal eating or weight-control behaviors. Various are the mechanisms overlying the interaction including environmental and individual ones, and different are the approaches to reduce the consequences. Evidence-based treatments for obesity and eating disorders in childhood include as first line approaches weight loss with nutritional management and lifestyle modification via behavioral psychotherapy, as well as treatment of psychiatric comorbidities if those are not a consequence of the eating disorder. Drugs and bariatric surgery need to be used in extreme cases. Future research is necessary for early detection of risk factors for prevention, more precise elucidation of the mechanisms that underpin these problems and, finally, in the cases requiring therapeutic intervention, to provide tailored and timely treatment. Collective efforts between the fields are crucial for reducing the factors of health disparity and improving public health.

Contextualising Eating Disorder Concerns for Paediatric Obesity Treatment

PURPOSE OF REVIEW

Eating disorders are complex mental health conditions that share risk factors with obesity. This review outlines the context for concerns that paediatric obesity treatment presents a risk for eating disorder development.

RECENT FINDINGS

Most children and adolescents undergoing professionally supervised obesity treatment will have improvements or no change to eating disorder risk profiles. However, some may subsequently develop a clinical eating disorder, and this is proposed to relate to weight-focussed dietary interventions that are standard in paediatric obesity treatment. Nevertheless, dietary restraint may not be a strong predictor of eating disorder risk in the context of paediatric obesity treatment. Most international guidelines recommend weight maintenance or weight loss as a treatment goal, and weight loss is related to improvements in cardiometabolic health but not eating disorder risk in the short term. The risk of inducing or exacerbating an eating disorder during paediatric weight management is likely to be low; however, the serious consequences combined with increasing scale of obesity treatment, and lack of empirical evidence, are of concern. There is a need for further research to identify long-term predictors of eating disorder development for children and adolescents who seek treatment for their obesity.

Addressing psychosocial health in the treatment and care of adolescents with obesity

Obesity affects 158 million youth worldwide and is associated with psychosocial comorbidity. This review describes weight management options utilized by adolescents, including both self-directed weight loss and medically supervised obesity treatment interventions, and associated psychosocial impacts. A majority of adolescents with obesity attempt to manage weight on their own, primarily through attempting weight loss, sometimes with supplement use. Approaches such as these are associated with a degree of risk, disordered eating behaviors, and further weight gain. In contrast, medically supervised multicomponent interventions are associated with improved psychosocial health, including quality of life, self-esteem, and body image, and reduced symptoms of depression, anxiety, and eating disorders. Few studies utilizing antiobesity pharmacotherapy have reported psychosocial outcomes, and trials of bariatric surgery show some early improvements with a need for sustained psychological support following surgery. Greater access to medically supervised treatment services is required to facilitate obesity care for adolescents. Early data on psychosocial health and obesity treatment offer promising outcomes; however, larger randomized controlled trials and longer-term data are needed. Future research should include both physiological and psychosocial outcomes to assess impact of interventions on the holistic health of adolescents with obesity.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Metabolic and Bariatric Surgery in Adolescents

PURPOSE OF REVIEW

The prevalence of obesity is increasing in all age groups. Following its success in adults, and with limited success using conservative therapies, metabolic and bariatric surgery (MBS) is increasingly being utilized in adolescents. This review highlights the current evidence and guidelines supporting its use.

RECENT FINDINGS

Safety and efficacy mirror results seen in adults. The most recent evidence, as outcomes enter the long term, suggests that comorbidity resolution, including diabetes and hypertension, can even outperform that of adults. Mental health problems persist despite good weight loss. Overall, the positive early weight and comorbidity outcomes are well sustained into the long term. There is a growing need to prevent and treat adolescent obesity. Current evidence supports the use of MBS in adolescents. Ongoing and future studies will provide 10-year outcomes and assist in the refinement of multimodal pathways incorporating MBS for the treatment of severe childhood obesity.

High prevalence of neurodevelopmental problems in adolescents eligible for bariatric surgery for severe obesity

Aim

To assess the prevalence of neurodevelopmental problems in adolescents with severe obesity and their associations with binge eating and depression.

Methods

Data were collected at inclusion in a randomised study of bariatric surgery in 48 adolescents (73% girls; mean age 15.7 ± 1.0 years; mean body mass index 42.6 ± 5.2 kg/m²). Parents completed questionnaires assessing their adolescents’ symptoms of attention‐deficit/hyperactivity disorder and autism spectrum disorder and reported earlier diagnoses. Patients answered self‐report questionnaires on binge eating and depressive symptoms.

Results

The parents of 26/48 adolescents (54%) reported scores above cut‐off for symptoms of the targeted disorders in their adolescents, but only 15% reported a diagnosis, 32% of adolescents reported binge eating, and 20% reported symptoms of clinical depression. No significant associations were found between neurodevelopmental problems and binge eating or depressive symptoms. Only a third of the adolescents reported no problems in either area.

Conclusion

Two thirds of adolescents seeking surgical weight loss presented with substantial mental health problems (reported by themselves or their parents). This illustrates the importance of a multi‐professional approach and the need to screen for and treat mental health disorders in adolescents with obesity.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level III, cohort study.

CLINICAL TRIAL REGISTRATION

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

Pediatric Metabolic and Bariatric Surgery

Childhood obesity can lead to comorbidities that cause significant decrease in health-related quality of life and early mortality. Recognition of obesity as a disease of polygenic etiology can help deter implicit bias. Current guidelines for treating severe obesity in children recommend referral to a multidisciplinary treatment center that offers metabolic and bariatric surgery at any age when a child develops a body mass index that is greater than 120% of the 95th percentile. Obesity medications and lifestyle counseling about diet and exercise are not adequate treatment for severe childhood obesity. Early referral can significantly improve quality and quantity of life.

Binge Eating After Bariatric Surgery in Patients Assisted by the Reference Service in a Brazilian Hospital and the Correlation with Weight Loss

PURPOSE

Identify, 18 months after bariatric surgery, the binge eating variation and its relation with weight regain or loss.

MATERIALS AND METHODS

Cross-sectional, retrospective study with 108 patients, assisted by an obesity walk-in clinic of a specialized hospital in São Paulo (Brazil), who had undergone bariatric surgery a minimum of 18 months previously. The anthropometric and clinic data were collected from medical records, and binge eating symptoms were evaluated with the application of the Binge Eating Scale (BES). Scale outcomes were related to weight regain and loss at the application moment.

RESULTS

The average age (standard error) of the sample was 47 years (±0.91) and 93% were female. Patients had lost 52.2% of their body weight and regained 4.7% of their weight 18 months after the surgery. The elapsed surgical time (> 50 months) was associated with a higher gross weight (p<0.0001).

CONCLUSIONS

Bariatric surgery has been shown to be effective for improving diabetes mellitus as well as for controlling obesity. The variation in binge eating intensity 18 months after bariatric surgery is a factor that interferes in the amount of weight regained. The presence of binge eating symptoms negatively affects the % total weight loss (%TWL).

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

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

Preoperative Binge Eating and Weight Loss After Bariatric Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Several studies have investigated if bariatric surgery candidates with binge eating disorder (BED) are at risk for suboptimal postoperative weight loss. The aim of this systematic review with meta-analysis was to evaluate the association between binge eating diagnosed preoperatively and weight loss after bariatric surgery.

METHODS

MEDLINE, EMBASE, CENTRAL, LILACS, and other specialized databases were searched on August 2020. Clinical trials and observational studies including individuals who had undergone any type of bariatric surgical treatment with preoperative evaluation of BED and at least one postoperative measure of weight were initially selected. Four reviewers independently screened for eligibility. The mean difference was calculated using the random-effects model.

RESULTS

Nineteen studies, comprising 3223 participants (80.25% women; median age 41 years), met the inclusion criteria for meta-analysis. At 6 months postoperative, the percentage of total weight loss (%TWL) was not significantly different between BED and non-BED groups [6 studies, 914 participants: - 0.75% (95% CI, - 2.79 to 1.29; I² = 0%)], even when analyzing only those three studies that included gold standard assessment tools. No significant differences were found at 12, 24, 36, or 60 months.

CONCLUSIONS

Pre-bariatric BED seems to have little or no influence on weight loss after surgery. However, many questions remain unanswered because of the use of different measures across studies. The heterogeneity among studies emphasizes the importance of investigators using the same assessment measures.

Psychotherapy versus treatment as usual and other control interventions in children and adolescents with overweight and obesity: a protocol for systematic review with meta-analysis and Trial Sequential Analysis

INTRODUCTION

The prevalence of children with overweight and obesity is increasing worldwide. Multicomponent interventions incorporating diet, physical activity and behavioural change have shown limited improvement to body mass index (BMI). However, the impact of psychotherapy is poorly explored. This systematic review aims to assess the effects of psychotherapeutic approaches for children with all degrees of overweight.

METHODS AND ANALYSIS

We will include randomised clinical trials involving children and adolescents between 0 and 18 years with overweight and obesity, irrespective of publication type, year, status or language up to April 2020. Psychotherapy will be compared with no intervention; wait list control; treatment as usual; sham psychotherapy or pharmaceutical placebo. The following databases will be searched: Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE, Embase, PsycINFO, PubMed, Web of Science, CINAHL and LILACS. Primary outcomes will be BMI z-score, quality of life measured by a validated scale and proportion of patients with serious adverse events. Secondary outcomes will be body weight, self-esteem, anxiety, depression and proportion of patients with non-serious adverse events. Exploratory outcomes will be body fat, muscle mass and serious adverse events. Study inclusion, data extraction and bias risk assessments will be conducted independently by at least two authors. We will assess risk of bias according to Cochrane guidelines and the Cochrane Effective Practice and Organisation of Care guidance. We will use meta-analysis and control risks of random errors with Trial Sequential Analysis. The quality of the evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation Tool. The systematic review will be reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Cochrane guidelines.

ETHICS AND DISSEMINATION

As individual patient data will not be included, we do not require ethics approval. This review will be published in a peer review journal.

PROSPERO REGISTRATION NUMBER

CRD42018086458.

A randomized controlled trial comparing intensive non-surgical treatment with bariatric surgery in adolescents aged 13-16 years (AMOS2): Rationale, study design, and patient recruitment

Background

Previous non-randomized studies show similar outcomes in adolescents and adults after bariatric surgery. We describe the study protocol, recruitment, and selected baseline data of patients in a randomized multi-center study, the Adolescent Morbid Obesity Surgery 2 (AMOS2).

Methods

Three clinics in Sweden collaborated in designing the study and recruitment of patients from August 1, 2014 to June 30, 2017. Patients were selected among adolescents 13–16 years of age attending third-level obesity care for at least one year. Patients were randomized 1:1 to bariatric surgery (predominantly Roux-en-Y gastric bypass) or intensive non-surgical treatment starting with an eight-week low-calorie-diet.

Results

Fifty adolescents (37 girls) were randomized, 25 (19 girls) to bariatric surgery. Mean age was 15.7 years (range 13.3–16.9), weight 122.6 kg (range 95–183.3), Body Mass Index (BMI) 42.6 kg/m² (range 35.7–54.9) and BMI-SDS 3.45 (range 2.9–4.1). One patient had type 2 diabetes mellitus, and 12/45 (27%) had elevated liver enzymes. There were no significant differences between the groups. For the 39 eligible patients who were offered but declined inclusion, BMI was not different from included patients. However, patients who declined were younger, 15.2 years (p = 0.021). A sex difference was also noted with more of eligible girls, 37/53 (69.8%), than boys, 13/36 (36.1%), wanting to participate in the study (p = 0.002).

Conclusions

This clinical trial, randomizing adolescents with severe obesity to bariatric surgery or intensive non-surgical treatment, aims at informing about whether it is beneficial to undergo bariatric surgery in early adolescence. It will also enlighten the outcome of comprehensive non-surgical treatment. The study was registered at www.clinicalTrials.gov number NCT02378259.

•

Bariatric surgery is already a treatment option for adolescents with severe obesity in many countries.

•

We recruited 50 patients 13-16 years of age to a randomized controlled trial.

•

We aimed at investigating the optimal time point for bariatric surgery.

•

Adolescents and their families seemed to make well considered decisions to participate in the study.

Childhood and Adolescent Obesity: A Review

Obesity is a complex condition that interweaves biological, developmental, environmental, behavioral, and genetic factors; it is a significant public health problem. The most common cause of obesity throughout childhood and adolescence is an inequity in energy balance; that is, excess caloric intake without appropriate caloric expenditure. Adiposity rebound (AR) in early childhood is a risk factor for obesity in adolescence and adulthood. The increasing prevalence of childhood and adolescent obesity is associated with a rise in comorbidities previously identified in the adult population, such as Type 2 Diabetes Mellitus, Hypertension, Non-alcoholic Fatty Liver disease (NAFLD), Obstructive Sleep Apnea (OSA), and Dyslipidemia. Due to the lack of a single treatment option to address obesity, clinicians have generally relied on counseling dietary changes and exercise. Due to psychosocial issues that may accompany adolescence regarding body habitus, this approach can have negative results. Teens can develop unhealthy eating habits that result in Bulimia Nervosa (BN), Binge- Eating Disorder (BED), or Night eating syndrome (NES). Others can develop Anorexia Nervosa (AN) as they attempt to restrict their diet and overshoot their goal of "being healthy." To date, lifestyle interventions have shown only modest effects on weight loss. Emerging findings from basic science as well as interventional drug trials utilizing GLP-1 agonists have demonstrated success in effective weight loss in obese adults, adolescents, and pediatric patients. However, there is limited data on the efficacy and safety of other weight-loss medications in children and adolescents. Nearly 6% of adolescents in the United States are severely obese and bariatric surgery as a treatment consideration will be discussed. In summary, this paper will overview the pathophysiology, clinical, and psychological implications, and treatment options available for obese pediatric and adolescent patients.