Factors associated with long-term weight-loss maintenance following bariatric surgery in adolescents with severe obesity

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.

Metabolic and Bariatric Surgery for Adolescents

Obesity is a chronic, complex, and multifactorial disease. Currently, approximately 6% have severe obesity with higher rates seen among racial/ethnic minority subgroups and in rural communities. Severe obesity is associated with cardiometabolic, psychologic, and musculoskeletal comorbidities. Metabolic and bariatric surgery is an effective treatment option for adolescents endorsed by major pediatric organizations. The most common procedure is the vertical sleeve gastrectomy. Pre-operative evaluation includes an in-depth medical, nutrition, physical activity and psychosocial assessment, with a care plan developed by a multidicplinary team with the adolescent and caregiver. The post-operative plan should include monitoring for surgical complications, weight regain, micronutrient deficiencies, psychologic challenges, and transition to adult care.

Nutritional Challenges and Treatment After Bariatric Surgery

Bariatric surgery is an important weight loss tool in individuals with severe obesity. It is currently the most effective long-term weight loss treatment that lowers obesity-related comorbidities. It also has significant physiological and nutritional consequences that can result in gastrointestinal complications and micronutrient deficiencies. After gastric bypass, clinical events that negatively affect nutritional status include malabsorption, dumping syndrome, kidney stones, altered intestinal bile acid availability, bowel obstruction, ulcers, gastroesophageal reflux, and bacterial overgrowth. Risk factors for poor nutritional status and excessive loss of lean body mass and bone include reduced dietary quality and inadequate intake, altered nutrient absorption, and poor patient compliance with nutrient supplementation. There are unique concerns in adolescents, older individuals, and individuals who become pregnant postoperatively. With careful management, health-care professionals can assist with long-term weight loss success and minimize the risk of acute and long-term nutrition complications after bariatric surgery.

Weight Nadir and Long-Term Weight Outcomes After Laparoscopic Sleeve Gastrectomy in a Diverse Cohort of Adolescents and Young Adults

INTRODUCTION

Laparoscopic sleeve gastrectomy (LSG) is currently the most common bariatric procedure performed in adolescents and young adults in the United States (USA), but there are limited data available on long-term postoperative weight outcomes in these patients. This single-institution US study follows longitudinal weight data in a diverse group of patients undergoing LSG at age 25 years or younger.

METHODS

We retrospectively reviewed records of all patients 25 years or younger who underwent LSG at our institution between 2013 and 2020. All weight data documented in the medical record through January 2023 was included. We calculated weight change postoperatively as percent total weight loss (%TWL) relative to preoperative weight.

RESULTS

One hundred forty-one patients underwent LSG, at a mean age of 23.1 years. Within this cohort, 56.1% identified as non-Hispanic Black or Hispanic, and 39.7% had private health insurance. The mean %TWL at weight nadir was 28.5% at a mean of 1.35 years postoperatively. The mean long-term %TWL (in patients with ≥ 4 years of follow-up) was 11.8% at a mean of 5.6 years postoperatively, with 43 of the 84 patients with long-term weight data (51%) within 10% of their preoperative weight at most recent follow-up.

CONCLUSION

Adolescents and young adults undergoing LSG at our institution had weight nadir comparable to published results during the first 1 to 2 years postoperatively, but the majority developed significant weight recurrence over the ensuing years. Our findings highlight the need for adjuvant weight loss strategies to improve the durability of weight outcomes after LSG in this population.

Perceived Responsibility for Bariatric Surgery, Eating, and Exercise Behaviors Among Adolescent Bariatric Surgery Candidates

Background: Adolescents' perceived responsibility for weight management behaviors has yet to be studied in relation to bariatric surgery. The current study examined perceived responsibility to pursue bariatric surgery and engage in specific weight management behaviors among adolescents seeking bariatric surgery and its associations with demographic, family support, and eating disorder symptoms. Methods: Data were collected using retrospective chart review of adolescent bariatric surgery candidates presenting to a tertiary interdisciplinary clinic. Data included demographics and adolescents' self-report of (1) perceived responsibility (i.e., primarily adolescent; primarily parent; shared) for the decision to pursue bariatric surgery and weight management behaviors, (2) family support for eating and exercise behaviors, and (3) eating disorder symptoms. Analyses included one-way analysis of covariance, chi-squared tests, and Kruskal-Wallis tests. Results: Participants reporting primarily teen or shared responsibility for seeking bariatric surgery were older than those reporting primarily parent responsibility (p = 0.023). Teens perceiving primary responsibility for their own healthy eating reported less family encouragement for healthy eating (p = 0.011) and more eating disorder symptoms (p = 0.002) than those reporting primarily parent or shared responsibility. Teens reporting primary responsibility for exercise reported less family encouragement for healthy eating (p = 0.012) compared with those reporting shared responsibility. Conclusions: This study is the first to provide a description of health behavior responsibilities in a sample of adolescents with severe obesity seeking bariatric surgery. Not only will these insights improve our understanding of this population, but it can also inform presurgical discussions with adolescents and their parents.

Presurgery health influences outcomes following vertical sleeve gastrectomy in adolescents

OBJECTIVE

Weight loss following vertical sleeve gastrectomy (VSG) in youth can range from 10% to 50%. We examined whether there are differences in demographic or metabolic parameters before VSG in youth who achieve above-average weight loss (AAWL) versus below-average weight loss (BAWL) at 1 year post VSG and if youth with BAWL still achieve metabolic health improvements at 1 year post VSG.

METHODS

Demographic, anthropometric, and clinical lab data were collected before VSG and at 1, 3, 6, and 12 months after VSG.

RESULTS

Forty-three youth with a mean age of 16.9 (SD 1.7) years before VSG were studied; 70% were female, 19% non-Hispanic Black, 58% non-Hispanic White, and 23% mixed/other race. Mean baseline BMI was 51.1 (SD 10.5) kg/m2. Average weight loss was 25.8%. The AAWL group lost 18.6 kg/m2 (35.3%) versus the BAWL group, who lost 8.8 kg/m2 (17.5%). BMI, age, race, sex, and socioeconomic status at baseline were similar between AAWL and BAWL groups; however, the BAWL group had a higher frequency of pre-VSG dysglycemia, steatotic liver disease, and dyslipidemia. At 1 year post VSG, fewer youth in the BAWL group achieved ideal health parameters, and they had less resolution of comorbidities.

CONCLUSIONS

The presence of comorbidities before VSG is associated with less weight loss and reduced resolution of metabolic conditions at 1 year post VSG.

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.

Recent advances in bariatric surgery: a narrative review of weight loss procedures

Bariatric surgery has emerged as a highly effective option for individuals with obesity, offering significant and sustainable weight loss outcomes. This surgical approach involves various procedures that alter the anatomy of the gastrointestinal tract, leading to reduced food intake and nutrient absorption. Established procedures such as sleeve gastrectomy, gastric bypass, adjustable gastric banding, and biliopancreatic diversion with duodenal switch have proven track records. In contrast, emerging options like intragastric balloons, AspireAssist devices, and endoscopic sleeve gastroplasty show promise but require further investigation. Numerous studies have highlighted the remarkable benefits of bariatric surgery, not only in weight loss but also in the resolution of obesity-related comorbidities and significant improvements in quality of life. However, successful outcomes rely on a multidisciplinary approach, encompassing preoperative evaluation, patient selection, comprehensive postoperative care, nutritional support, and psychological counseling. Regular follow-up and adherence to postsurgical recommendations are crucial for sustained weight loss and positive long-term results. As bariatric surgery continues to evolve, tailored procedures based on individual needs and ongoing research hold the potential for even more refined and effective approaches. Through this ongoing advancement, bariatric surgery is poised to offer improved patient outcomes, transforming lives for those grappling with the challenges of obesity.

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.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity. In addition, this report will provide an evidence base to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are clinically based, effective treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori key questions.

The role of obesity and bariatric surgery-induced weight loss in breast cancer

Obesity is a complex metabolic condition considered a worldwide public health crisis, and a deeper mechanistic understanding of obesity-associated diseases is urgently needed. Obesity comorbidities include many associated cancers and are estimated to account for 20% of female cancer deaths in the USA. Breast cancer, in particular, is associated with obesity and is the focus of this review. The exact causal links between obesity and breast cancer remain unclear. Still, interactions have emerged between body mass index, tumor molecular subtype, genetic background, and environmental factors that strongly suggest obesity influences the risk and progression of certain breast cancers. Supportive preclinical research uses various diet-induced obesity models to demonstrate that weight loss, via dietary interventions or changes in energy expenditure, reduces the onset or progression of breast cancers. Ongoing and future studies are now aimed at elucidating the underpinning mechanisms behind weight-loss-driven observations to improve therapy and outcomes in patients with breast cancer and reduce risk. This review aims to summarize the rapidly emerging literature on obesity and weight loss strategies with a focused discussion of bariatric surgery in both clinical and preclinical studies detailing the complex interactions between metabolism, immune response, and immunotherapy in the setting of obesity and breast cancer.

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

Background

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

Methods

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

Results

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

Conclusion

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

Severe Obesity in Children and Adolescents: Metabolic Effects, Assessment, and Treatment

Childhood obesity has been increasing steadily in recent decades, and severe childhood obesity has emerged as a major public health problem both nationally and internationally. A current concern is that lockdown due to the coronavirus disease 2019 (COVID-19) pandemic could exacerbate the spread of childhood obesity and increase the gap in obesity risk. Recent research results indicate the aggravation of obesity after school closures. The consequences of severe childhood obesity are more devastating than those of mild to moderate obesity. Children with severe obesity are at greater risk than others for hypertension, type 2 diabetes, metabolic syndrome, non-alcoholic fatty liver disease, atherosclerosis, and adult obesity. Accurately assessing and diagnosing a child with severe obesity is the key to implementing successful therapy. A detailed and accurate patient history and physical examination are important to discriminate monogenic obesity and metabolic syndrome diagnoses from severe obesity without an underlying cause. Psychosocial factors, including eating behaviors, should be assessed to facilitate better weight management outcomes. Treatment options for severe pediatric obesity include lifestyle modification therapy, pharmacotherapy, and metabolic and bariatric surgery. However, lifestyle modification should be the priority. Although progress has been made, safe and effective treatment for severe pediatric obesity is still challenging. More efforts and innovations are needed to find a solution for the huge medical and emotional burden that these children and their families carry. Public health organizations also need to make efforts to encourage and normalize healthy eating habits and exercise to prevent severe obesity in childhood.

Adolescent obesity treatments: news, views, and evidence

Obesity is a complex and multifactorial disease that is influenced by physiological, environmental, socioeconomic, and genetic factors. In recent decades, this serious disease has impacted a large number of adolescents as a result of lifestyle factors. A lack of exercise and the consumption of excessive calories from an inadequate diet are the main contributors to adolescent obesity. However, genetic and hormonal factors might also play a role. The short- and long-term consequences of this disease include chronic issues such as type 2 diabetes and cardiovascular disorders and an increase in early mortality rates. Although it is a serious disease, obesity in adolescents can be controlled with diet and exercise. When these lifestyle changes do not obtain the expected results, we can intensify the treatment by adding medication to the practice of diet and exercise. Additionally, for more severe cases, bariatric surgery can be an option. The purpose of this review is to clarify the current epidemiology, risks, and comorbidities and discuss news about the main treatments and the necessary improvements in this context.

Telomere length in patients with obesity submitted to bariatric surgery: A systematic review

BACKGROUND

Patients with obesity show evidence of increased levels of inflammation, oxidative stress and premature ageing. Telomere length (TL) is a key marker of cellular ageing, and patients with obesity often present shorter TL. Bariatric surgery (BS) is currently the most effective treatment for severe obesity. The aim of this systematic review was to explore whether the beneficial health effects observed after surgery in obese patients correspond to a restoration in TL or slower rates of shortening. As a secondary aim, we evaluated, at baseline and post-surgery, the relationship between TL and different factors that could play a role in TL changes along time.

METHODS

Searches for relevant articles were performed in MEDLINE, Web of Knowledge and SCOPUS. Prospective longitudinal studies that evaluated leukocyte TL in adult patients who had undergone BS were included. Data were extracted and evaluated by two independent researchers. The protocol was registered in PROSPERO with the number CRD42020197711.

RESULTS

Seven studies based on independent samples that fulfilled our inclusion criteria were included. Obese patients showed shorter telomeres compared to healthy individuals. Long-term studies (>2 years) seem to suggest an improvement in TL after surgery presumably due to the improvement of the inflammatory and oxidative levels of the patients induced by weight loss.

CONCLUSION

Studies seem to point towards a beneficial long-term effect of BS on TL recovery. However, the scarce number of studies and the heterogeneity in the variables analysed in the different cohorts make it difficult to draw a firm conclusion. More studies are needed to evaluate long-term changes to TL following BS.

Higher Socioeconomic Status is Associated with Improved Outcomes After Obesity Surgery Among Women in Germany

Background

Low socioeconomic status (SES) is associated with an increased prevalence of obesity. It is unknown whether SES influences the outcome after bariatric surgery in Germany. Therefore, the aim of our study was to investigate whether the SES is linked with an inferior outcome after bariatric surgery.

Methods

We included all patients who underwent bariatric surgery in our university hospital from 2012–2014. Net income was estimated by matching the zip codes of patient residency with the region-specific purchasing power index. We analyzed the relationship between SES, weight loss and remission of comorbidities.

Results

We included 559 patients in this study and detected a mean 5-year percentage excess weight loss (%EWL) of 52.3%. We detected a significantly lower initial body mass index (BMI) and weight in patients with a higher income. One year after surgery, we did not find a significant difference. Further analysis revealed that only women with a higher income had a significantly lower BMI and weight 3 and 5 years after surgery.

Conclusions

Bariatric surgery is beneficial for all patients regardless of income. Furthermore, we demonstrated that women with high SES have a better outcome after bariatric surgery.

Trends in metabolic bariatric surgery in adolescents in France: a nationwide analysis on an 11- year period

BACKGROUND

As the prevalence of obesity in adolescents has reached an alarming level of 16%, the rate of metabolic bariatric surgery (MBS) in this population is also rising in several countries.

OBJECTIVES

This study aimed to compare the trends in types of MBS, short-term safety, and revisional rates, in younger adolescents aged < 18 years, compared with older adolescents (aged 18-19 yr) and adults aged >20 years.

SETTING

Clinical research center, general hospital in France.

METHODS

Using a national administrative database (Programme de Médicalisation des Systèmes d'Information [PMSI]), data regarding all patients undergoing MBS between 2008 and 2018 in France were examined. Demographic parameters, body mass index (BMI), co-morbidities, types of surgery, early complications, and long-term revisional rates were analyzed, comparing younger adolescents (<18 yr), older adolescents (18-19 yr), and adults (≥20 yr).

RESULTS

The number of bariatric procedures in adolescents initially increased from 59 in 2008 to 135 in 2014, and then progressively declined to 56 procedures in 2018. Adjustable gastric banding (AGB) decreased from 83.1% (n = 49) of procedures to 32.1% (n = 18) of procedures during the study period, while sleeve gastrectomy (SG) increased from 6.8% (n = 4) to 46.4% (n = 26). In the early postoperative period, younger adolescents undergoing MBS experienced fewer episodes of reoperation (1.0% versus 1.3% in older adolescents and 2.6% in adults, P < .001) and intensive care unit (ICU) stays (.2% versus .2% in older adolescents and .6% in adults, P < .001), and no deaths were observed in younger adolescents (.02% in older adolescents and .1% in adults, P = .18). At 10 years, the AGB removal rate was lower in younger adolescents (24.8%) compared with that in older adolescents (29.6%) and adults (50.3%, P < .001). Similarly, rates of revisional surgery after SG were different in the 3 groups: 2.9%, 4.6% and 12.2% in younger adolescents, older adolescents, and adults, respectively.

CONCLUSION

Despite significantly lower early complication rates and long-term revisional rates in young adolescents (<18 yr), we observed a progressive decrease in the utilization of MBS in this population in France, compared with adults (≥20 yr) and older adolescents (18-19 yr).

Update on Metabolic Bariatric Surgery for Morbidly Obese Adolescents

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

Factors Related to Weight Loss Maintenance in the Medium-Long Term after Bariatric Surgery: A Review

Despite bariatric surgery being the most effective treatment for obesity, some individuals do not respond adequately, especially in the long term. Identifying the predictors of correct weight maintenance in the medium (from 1 to 3 years after surgery) and long term (from 3 years and above) is of vital importance to reduce failure after bariatric surgery; therefore, we summarize the evidence about certain factors, among which we highlight surgical technique, psychological factors, physical activity, adherence to diet, gastrointestinal hormones or neurological factors related to appetite control. We conducted a search in PubMed focused on the last five years (2015–2021). Main findings are as follows: despite Roux-en-Y gastric bypass being more effective in the long term, sleeve gastrectomy shows a more beneficial effectiveness–complications balance; pre-surgical psychological and behavioral evaluation along with post-surgical treatment improve long-term surgical outcomes; physical activity programs after bariatric surgery, in addition to continuous and comprehensive care interventions regarding diet habits, improve weight loss maintenance, but it is necessary to improve adherence; the impact of bariatric surgery on the gut–brain axis seems to influence weight maintenance. In conclusion, although interesting findings exist, the evidence is contradictory in some places, and long-term clinical trials are necessary to draw more robust conclusions.

Relationship between bariatric surgery outcomes and the preoperative gastrointestinal microbiota: a cohort study

BACKGROUND

The composition of the gastrointestinal microbiota is associated with obesity. We hypothesized that the gut microbiota influences the outcomes of bariatric surgery.

OBJECTIVES

We aimed to analyze using oral swabs and stool samples the microbiota of patients with morbid obesity who were undergoing laparoscopic sleeve gastrectomy (SG).

SETTING

A university hospital in Poland.

METHODS

This prospective cohort study was conducted between November 2018 and June 2019. Participants underwent SG or no surgery (controls). Results were then analyzed as a group 1 (surgical participants who achieved a percentage of excess weight loss [%EWL] >50%), group 2 (surgical participants who achieved a %EWL <50%), and group 3 (nonsurgical controls). %EWL was measured 6 months following surgery. Before surgery, oral swabs were obtained and stool samples were provided. The endpoint was the composition of the gut microbiota.

RESULTS

Group 1 comprised 19 participants, group 2 comprised 11 participants, and group 3 comprised 16 participants. No participants were lost to follow-up during the study. Participants in group 1 had an oral microbiota that was enriched in the phyla Proteobacteria, and Bacteroidetes. Their intestinal microbiota was enriched in the Proteobacteria. In contrast, the oral microbiota of group 2 was enriched in the Actinobacteria and the intestinal microbiota was enriched in the phyla Bacteroidetes and Firmicutes.

CONCLUSIONS

The compositions of the microbiota of the oral cavity and large intestine are related to the weight loss achieved following SG.

Influence of Weight Loss on Obesity-Associated Complications After Metabolic and Bariatric Surgery in Adolescents

OBJECTIVE

Following metabolic and bariatric surgery (MBS), most adolescents experience weight loss and improvement of many obesity-associated complications (OACs). The relationship between weight loss and remission of OACs after MBS in adolescents has not been well described.

METHODS

The Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) is a multi-institutional prospective observational study of adolescents who underwent MBS between 2007 and 2012. Lower-weight-loss responders (LWLRs) were defined as having <20% total body weight loss (TBWL) and higher-weight-loss responders (HWLRs) were defined as having ≥20% TBWL at 5 years after MBS. The prevalence of OACs was compared at baseline and 5 years after MBS.

RESULTS

Both LWLRs (n = 114) and HWLRs (n = 78) lost significant weight within the first year following MBS; however, the TBWL at 5 years for the LWLRs was 8.6% ± 9.5% compared with 33.8% ± 9.2% for the HWLRs. Those in the HWLR group were more likely to experience durable remission of composite dyslipidemia at 5 years, whereas there were no differences between groups in remission rates of all other OACs.

CONCLUSIONS

Greater weight loss after MBS in adolescents was associated with greater remission of composite dyslipidemia; however, remission of other OACs was not dependent on major sustained weight loss.

Physical activity, musculoskeletal disorders, sleep, depression, and quality of life before and after bariatric surgery

Objectives

This study aims to evaluate physical activity, sleep, depression, quality of life, and musculoskeletal problems pre- and postoperatively in morbidly obese patients who underwent bariatric surgery and analyze the factors that are strongly associated with physical activity.

Patients and methods

This prospective study conducted between January 2016 and May 2017 included 27 patients (4 males, 23 females; mean age 37.1±10.4 years; range, 18 to 52 years) who underwent bariatric surgery and 20 healthy controls (3 males, 17 females; mean age 32.0±5.7 years; range, 26 to 46 years). All patients were evaluated by using the short form of International Physical Activity Questionnaire (IPAQ), Pittsburgh Sleep Quality Index (PSQI), Beck Depression Inventory (BDI), and short form 36 (SF-36). Patients were evaluated for regional musculoskeletal pain including back, waist, hip, knee, ankle, heel, and metatarsal pain using Visual Analog Scale. Presence of pes planus was recorded. The examinations and tests performed in the preoperative period were repeated at postoperative six months and the results were compared with the control group.

Results

The body mass index was 46.2±5.2 kg/m² preoperatively and 33.8±5.0 kg/m² postoperatively (p<0.001). The total IPAQ was 345.4±172.8 metabolic equivalent (MET)-min/week preoperatively and 672.8±227.8 MET-min/week postoperatively (p<0.001). Pittsburgh Sleep Quality Index was 7.6±3.0 preoperatively and 3.5±2.4 postoperatively, whereas BDI was 20.2±8.5 preoperatively and 9.9±7.4 postoperatively. The results were statistically significant (p<0.001, p<0.001, respectively). A statistically significant improvement was found in all subsections of the SF-36. Pre- and postoperative results of the 27 patients were compared with those of the control group.

Conclusion

Obesity is significantly associated with joint pain, physical function impairment, depression, and sleep disorders. Significant weight loss after bariatric surgery improves functional recovery and patient's psychology in a short time.

A Bivariate Mixed Model Approach in Characterizing the Evolution of Longitudinal Body Mass Index and Quality of Life Processes in Adolescents with Severe Obesity Following Bariatric Surgery: A 5-year follow-up of the TeenLABS cohort

Obesity is identified as a major global health problem. Along with measuring body mass index (BMI), the most common metric for defining weight status, health related quality of life (HRQol) has been accepted as a routine method to evaluate how body weight may be impacted by psychosocial factors. The objective of the current study is to characterize the joint association of change in longitudinal BMI and HRQol following metabolic and bariatric surgery and to examine the correlation between these two outcomes measured concurrently over time. We identified the optimal modeling strategy by comparing four models, all of which involved the covariance structures appropriate for correlated outcomes, BMI and HRQol in a repeated measures analysis. The bivariate random effects models performed better than the univariate random effects models. Moreover, bivariate models with composite covariate structures had better model fit compared to the bivariate random slope models. The bivariate models with composite covariate structures reflected that changes in HRQol (and BMI) were most significant during the first 6 months, a clinically useful window to monitor changes in post-operative HRQol and BMI, and if there might need to be additional interventions or at least, closer monitoring.

Binge eating scores pre-bariatric surgery and subsequent weight loss: A prospective, 5 years follow-up study

BACKGROUND & AIMS

To compare groups of bariatric patients with preoperative scores of Binge Eating Scale (BES) above and below the clinical cut off value on weight outcomes up to 60 months following surgery.

METHODS

This is a prospective observational study involving 108 Brazilian patients (follow-up rate: 48.1%) operated by Roux-en-Y gastric bypass. In the preoperative period, they were clinically evaluated, and BES was applied. Based on the scores, patients were categorized as high or low according to established cut off 17 for binge eaters. Follow-up weight loss was obtained (3, 6, 12, 24, 36, 48, and 60 months) using data from medical records. The percentage of total weight loss (%TWL) was examined by generalized linear model.

RESULTS

41.7% of patients had BES scores higher than 17 at baseline. Weight loss was significant up to 12 months. The greatest weight loss was at 24 months of follow-up, ranging from 2.7 to 110.4 kg (mean 42.9 ± 17.8 kg). In the short postoperative period (3, 24, and 36 months), %TWL was significantly different between groups. At 24 months, patients with higher scores lost more %TWL than those with lower scores (35.1 ± 0.8% vs 31.6 ± 0.7%, p = 0.029). However, this difference was not fount at 60 months postoperatively (mean 28.9 ± 9.6%). In a multivariate analysis, the presence of depression, age, and BES score were not associated with %TWL at 24 and 60 months.

CONCLUSIONS

The results suggest that preoperative BES scores point to a similar weight loss after bariatric surgery. Further studies with long-term follow-up are necessary to evaluate this finding.

FTO variants are associated with ANGPTL4 abundances and correlated with body weight reduction after bariatric surgery

BACKGROUND

The FTO (fat mass- and obesity-associated) gene variant is an established obesity-susceptibility locus. FTO protein is a nucleic acid demethylase and FTO genetic variants form long-range functional connections with IRX3, which regulates fat mass and metabolism in humans. From our previous results, we found FTO regulates the metabolism of triglyceride in adipocytes through demethylating Angptl4 (angiopoietin-like protein 4) mRNA in mice. We hypothesized that the FTO genetic variants regulate ANGPTL4 abundances in human adipose tissues and affect the outcome after bariatric surgery.

METHODS AND RESULTS

We recruited 188 obesity subjects with body mass indices (BMI)>35kg/m² and 102 non-obese subjects with BMI<30kg/m² from the OCEAN registry between 2011 and 2014. The distribution of FTO variants rs9939609 among participates was 73.79% TT, 23.79% AT, and 2.41% AA. The subjects with FTO variants AA or AT were correlated with higher BMI than those with FTO variants TT. The serum ANGPTL4 levels were significantly higher in obese subjects and positively correlated with the presence of FTO AA or AT haplotype. Of these participates, 84 obese subjects underwent bariatric surgery and adipose Angptl4 expressions were analyzed. The adipose Angptl4 mRNA levels and protein abundances were correlated with FTO AA or AT haplotype. The magnitude of excess body weight reduction 2 years after bariatric surgery was correlated with the adipose ANGPTL4 protein levels.

CONCLUSION

Adipose ANGPTL4 abundances were affected by the presence of FTO obesity risk haplotype and correlated with excess weight loss percentage after bariatric surgery. These data signify the critical role of FTO variants and adipose ANGPTL4 in fatty acid metabolism and bariatric outcomes in humans.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Novel Insights into the Pathogenesis and Management of the Metabolic Syndrome

The metabolic syndrome, by definition, is not a disease but is a clustering of individual metabolic risk factors including abdominal obesity, hyperglycemia, hypertriglyceridemia, hypertension, and low high-density lipoprotein cholesterol levels. These risk factors could dramatically increase the prevalence of type 2 diabetes and cardiovascular disease. The reported prevalence of the metabolic syndrome varies, greatly depending on the definition used, gender, age, socioeconomic status, and the ethnic background of study cohorts. Clinical and epidemiological studies have clearly demonstrated that the metabolic syndrome starts with central obesity. Because the prevalence of obesity has doubly increased worldwide over the past 30 years, the prevalence of the metabolic syndrome has markedly boosted in parallel. Therefore, obesity has been recognized as the leading cause for the metabolic syndrome since it is strongly associated with all metabolic risk factors. High prevalence of the metabolic syndrome is not unique to the USA and Europe and it is also increasing in most Asian countries. Insulin resistance has elucidated most, if not all, of the pathophysiology of the metabolic syndrome because it contributes to hyperglycemia. Furthermore, a major contributor to the development of insulin resistance is an overabundance of circulating fatty acids. Plasma fatty acids are derived mainly from the triglycerides stored in adipose tissues, which are released through the action of the cyclic AMP-dependent enzyme, hormone sensitive lipase. This review summarizes the latest concepts in the definition, pathogenesis, pathophysiology, and diagnosis of the metabolic syndrome, as well as its preventive measures and therapeutic strategies in children and adolescents.

Thirty-Year Risk of Cardiovascular Disease Events in Adolescents with Severe Obesity

OBJECTIVE

Quantifying risk for cardiovascular disease (CVD) events among adolescents is difficult owing to the long latent period between risk factor development and disease outcomes. This study examined the 30-year CVD event risk among adolescents with severe obesity treated with and without metabolic and bariatric surgery (MBS), compared with youths with moderate obesity, overweight, or normal weight.

METHODS

Cross-sectional and longitudinal comparisons of five frequency-matched (age and diabetes status) groups were performed: normal weight (n = 247), overweight (n = 54), obesity (n = 131), severe obesity without MBS (n = 302), and severe obesity undergoing MBS (n = 215). A 30-year CVD event score developed by the Framingham Heart Study was the primary outcome. Data are mean (SD) with differences between time points for MBS examined using linear mixed models.

RESULTS

Preoperatively, the likelihood of CVD events was higher among adolescents undergoing MBS (7.9% [6.7%]) compared with adolescents with severe obesity not referred for MBS (5.5% [4.0%]), obesity (3.9% [3.0%]), overweight (3.1% [2.4%]), and normal weight (1.8% [0.8%]; all P < 0.001). At 1 year after MBS, event risk was significantly reduced (7.9% [6.7%] to 4.0% [3.4%], P < 0.0001) and was sustained for up to 5 years after MBS (P < 0.0001, all years vs. baseline).

CONCLUSIONS

Adolescents with severe obesity are at elevated risk for future CVD events. Following MBS, the predicted risk of CVD events was substantially and sustainably reduced.

High prevalence of attention-deficit/hyperactivity disorder in adolescents with severe obesity seeking bariatric surgery

AIM

To examine the prevalence of attention-deficit/hyperactivity disorder (ADHD) and related post-surgical weight loss in adolescents with severe obesity seeking bariatric surgery.

METHODS

The study population included 84 adolescents (age 13-19 years; 44 males, 40 females) with severe obesity who sought bariatric surgery at the Sheba Medical Centre in Israel during the years 2011-2017. Anthropometric and clinical data were collected from medical records. A subgroup of 20 participants filled questionnaires that evaluated ADHD-like symptoms, eating behaviours and quality of life. Data on adolescents that ultimately underwent surgery (n = 45) were also obtained.

RESULTS

The prevalence of ADHD was 28.6% in adolescents seeking bariatric surgery, much higher than that of the general adolescent population of Israel (17.1%, P < .001). There were no significant differences in reductions of weight, body mass index, body mass index standard deviation scores and body fat percent between participants with or without ADHD. In the subgroup that filled questionnaires, higher scores on ADHD-Rating Scale at baseline were associated with greater excess weight loss.

CONCLUSION

The prevalence of ADHD in adolescents seeking bariatric surgery was very high. Diagnosed ADHD was not related to post-surgical weight loss, whereas baseline ADHD-related behaviour was associated with higher post-surgical weight loss.

Cardiovascular Effects of Metabolic Surgery on Type 2 Diabetes

INTRODUCTION

Cardiovascular, together with renal disease, claims a significant proportion of morbidity and mortality in association with type 2 diabetes mellitus (T2DM) and obesity. To improve the long-term renal and cardiovascular outcome, there is the incorporation of bariatric surgery (BS), which seems to be a pivotal intervention. Areas Explored: Cohort studies and randomized controlled trial (RCT) research of BS among patients with T2DM, were conducted by screening, and then information on renal effects and the cardiovascular outcome was gathered. Metabolic surgery (MS) and BS reduce both mortality and the risk of cardiovascular disorder, chronic kidney diseases and albuminuria. MS refers to a surgical approach, the primary intent of which is the control of metabolic alterations/hyperglycemia in contrast to BS which is a mere weight-reduction therapy. Patients suffering from poor glycaemic control and other macro and micro-vascular diseases will benefit from a surgical approach. The approach implicates hypertension glomerular remission, gut microbiota shift, reduced renal inflammation and fewer instances of chronic cardiac remodelling.

CONCLUSION

MS is beneficial where the main aim is to attain significant and long-lasting weight loss results. The RCTs have depicted the superiority which surgical mechanisms hold over medically- based therapy, for enhancing glycaemic control, and achieving remission of diabetes. This type of surgery improves life quality, reduces incidences of other obesity and diabetes related diseases like microvascular disases, sleep apnea, fatal disorder, and fatty liver disease.

Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery

To ensure successful outcomes in pediatric patients with severe obesity who undergo metabolic and bariatric surgery (MBS), a number of pre-operative patient management options should be considered. This manuscript will review the indications and contraindications of MBS and special considerations for youth who might benefit from MBS. The treatment team conducts a thorough pre-operative evaluation, assessing risks and benefits of surgical intervention, and prepares patients and families to be successful with MBS by providing education about the surgical intervention and lifestyle changes that will be necessary. This article reviews the pre-operative considerations for adolescents with severe obesity who are being considered for MBS, based upon recent clinical practice guidelines.

Lifestyle and pharmacologic management before and after bariatric surgery

As metabolic and bariatric surgery (MBS) increasingly becomes a treatment of choice for adolescents with severe obesity, there is a need to understand how to deliver pre- and postoperative care in ways that maximize long-term safety and efficacy. This article describes major pre- and postoperative goals, lifestyle modification targets, and, when necessary, pharmacologic management strategies for adolescents undergoing MBS. Three categories of evidence were used-studies of pre- and postoperative interventions and factors influencing MBS outcomes in adolescents, studies of pre- and postoperative associations and interventions in adults, and studies of non-surgical weight management applicable to adolescents pursuing MBS. Finally, priority areas for future research within this topic are identified.

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.

Partnering Support Interventions with Bariatric Surgery to Maximize Health Outcomes in Adolescents with Severe Obesity

OBJECTIVE

Rates of adolescents with severe obesity continue to rise worldwide, with concurrent increases in metabolic and bariatric surgery (MBS) uptake. The gap between support (lifestyle, pharmacotherapy) interventions and MBS as treatment options for adolescents has been understudied. This review, couched in a socio-ecological framework, investigates how support interventions for adolescents with severe obesity could be combined or sequenced with MBS to optimize health outcomes.

METHODS

A comprehensive search revealed 36 published articles between 1995 and 2019 that included the combination of support interventions and MBS among adolescents.

RESULTS

There were no studies that specifically reported outcomes or effect sizes for the combination of lifestyle intervention with MBS. Previous studies have reported individual results for either lifestyle intervention or MBS but not for their compound effect.

CONCLUSIONS

As rates of adolescents with severe obesity are on the rise globally, future research should focus on how partnering support interventions with MBS can amplify positive short- and long-term health outcomes and within a socio-ecological framework. Understanding the sequence of these approaches will be of particular importance. High-risk and vulnerable populations such as ethnic minorities who have suffered a disproportionate burden of the obesity epidemic must be included in rigorously tested future trials of combination interventions to maximize health outcomes worldwide.

Risk factors and complications after body-contouring surgery and the amount of stromal vascular fraction cells found in subcutaneous tissue

Body contouring surgery following massive weight loss is often prone to complications. Subcutaneous adipose tissue is a rich source of stromal vascular fraction (SVF) cells, and moreover it plays an important role in the pathophysiology of obesity, metabolic syndrome, and wound healing. In this retrospective, single-centred appraisal, complications are examined and correlated with individual SVF numbers in abdominal subcutaneous fat tissue. We analysed whether the weight loss method affected complications. Eighty seven massive weight loss patients undergoing body contouring surgery between 2010 and 2017 were included in the study. In total, 57 cases with at least one complication were recorded (65.5%). Maximum lifetime weight was 109.6 kg (range 48-184 kg). Half of the complications (50.8%) were minor complications without the need for surgical revision. The mean number of SVF found in the resected tissue was 714 997.63 cells/g fat tissue. We found no statistical difference in complication rates dependent on cell numbers. Smoking (P = .049) and a high BMI at the time point of surgery (P = .031) led to significantly more complications. Also, a high resection weight (P = .057) showed a tendency for impaired wound healing. However, there was no difference in complication rates following body contouring procedures attributable to the method of weight loss in this study.

Severe Obesity in the Pediatric Population: Current Concepts in Clinical Care

PURPOSE OF REVIEW

This review describes (1) the clinical assessment of pediatric patients with severe obesity, including a summary of salient biological, psychological, and social factors that may be contributing to the patient's obesity and (2) the current state of treatment strategies for pediatric severe obesity, including lifestyle modification therapy, pharmacotherapy, and metabolic and bariatric surgery.

RECENT FINDINGS

Lifestyle modification therapy alone is insufficient for achieving clinically significant BMI reduction for most youth with severe obesity and metabolic and bariatric surgery, though effective and durable, is not a scalable treatment strategy. Pharmacological agents in the pipeline may 1 day fill this gap in treatment. Treatment of severe pediatric obesity requires a chronic care management approach utilizing multidisciplinary teams of health care providers and multi-pronged therapies.

Weight loss after sleeve gastrectomy in developmentally delayed adolescents and young adults

BACKGROUND

Adolescent obesity is a significant factor in caring for patients with developmental delay (DD). Sleeve gastrectomy provides durable weight loss for teens with obesity but requires behavioral change that may not occur in patients with DD.

OBJECTIVES

To determine whether patients with DD had similar weight loss and adverse outcomes to patients without a diagnosis of DD after sleeve gastrectomy.

SETTING

Academic children's hospital, United States.

METHODS

Patients with DD undergoing sleeve gastrectomy were matched to adolescents without DD. Chart review was performed to determine etiology and severity of DD, weight, and body mass index (BMI) change in each group at 3, 6, 9, and 12 months postoperatively. One-year emergency department visits, readmissions, and reoperations were reviewed.

RESULTS

Ten patients with DD and 44 patients without DD underwent sleeve gastrectomy between 2008 and 2017. Six patients with DD (60%) had mild cognitive impairment, 3 patients (30%) had moderate cognitive impairment, and 1 patient (10%) had severe cognitive impairment. Patients were 81.5% female, had a mean age of 17.3 years, and had a preoperative BMI of 48.6 kg/m². Preoperative BMI was similar in the 2 groups, and percent BMI reduction at 1 year was -29% (95% confidence interval: -35 to -23) and -26% (95% confidence interval: -29 to -23) in groups with and without DD respectively (group by time interaction, P = .27).

CONCLUSION

Adolescents with DD experience similar 1-year weight loss and adverse events following sleeve gastrectomy to adolescents without DD. Understanding the long-term outcomes for this population is crucial to ensure appropriate implementation of surgical weight loss programs.

Precision medicine in adult and pediatric obesity: a clinical perspective

It remains largely unknown as to why some individuals experience substantial weight loss with obesity interventions, while others receiving these same interventions do not. Person-specific characteristics likely play a significant role in this heterogeneity in treatment response. The practice of precision medicine accounts for an individual's genes, environment, and lifestyle when deciding upon treatment type and intensity in order to optimize benefit and minimize risk. In this review, we first discuss biopsychosocial determinants of obesity, as understanding the complexity of this disease is necessary for appreciating how difficult it is to develop individualized treatment plans. Next, we present literature on person-specific characteristics associated with, and predictive of, weight loss response to various obesity treatments including lifestyle modification, pharmacotherapy, metabolic and bariatric surgery, and medical devices. Finally, we discuss important gaps in our understanding of the causes of obesity in relation to the suboptimal treatment outcomes in certain patients, and offer solutions that may lead to the development of more effective and targeted obesity therapies.

Resting Energy Expenditure and Metabolic Adaptation in Adolescents at 12 Months After Bariatric Surgery

BACKGROUND

Evidence suggests that metabolic adaptation occurs after bariatric surgery such that resting energy expenditure (REE) declines more than accounted for by body weight or body composition changes in adults. Little is known about REE and metabolic adaptation among adolescents after bariatric surgery.

OBJECTIVE

To examine changes in REE and metabolic adaptation among adolescents at 12 months (12M) after bariatric surgery.

SETTING

Pediatric hospital, Canada.

METHODS

Adolescents undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) were followed. Bioelectrical impedance analysis and indirect calorimetry were completed to measure body composition and REE, respectively. Predicted REE was calculated using the Mifflin equation before and after bariatric surgery and a predictive equation using preoperative data.

RESULTS

Among 20 patients (15 girls), the mean age and body mass index at surgery were 17.2 ± 0.8 years and 48.7 ± 7.4 kg/m2, respectively. REE had decreased by 548.3 kcal/d at 12M postoperatively (P < 0.001). Metabolic adaptation, determined by two procedures, was negative and significantly different from baseline (P < 0.05). When stratified by surgery type, REE change at 12M was not significantly different (RYGB, -494.0 ± 260.9 kcal/d, n = 11; SG, -614.6 ± 344.4 kcal/d, n = 9; P = 0.384). Among 13 patients with REE data at 6 and 12M, no statistically significant difference was found (P = 0.368).

CONCLUSIONS

Predicted and measured REE was 19% and 25% lower at 12M, respectively, irrespective of bariatric surgery type. Metabolic adaptation might predispose adolescents to weight regain after bariatric surgery and warrants careful nutritional management and counseling.

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

Background/Objectives:

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

Subjects/Methods:

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

Results:

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

Conclusions:

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

Physical Activity Improves Lipid and Weight-Loss Outcomes After Metabolic Bariatric Surgery in Adolescents with Severe Obesity

OBJECTIVE

This study tested the hypothesis that physical activity improves cardiovascular disease-related lipids beyond that associated with weight loss in adolescents with severe obesity after metabolic/bariatric surgery (MBS).

METHODS

Objective activity monitor data from 108 participants of the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) study from baseline to 3 years post MBS were used. Primary outcomes included absolute change in LDL cholesterol (LDL-C) and non-HDL cholesterol (non-HDL-C) from baseline. Baseline measurement, visit, surgical procedure, and percent change in iliac waist circumference or BMI from baseline in linear regression models were adjusted for use of generalized estimating equations. PROC TRAJ in SAS generated optimal activity trajectories based on individual step count.

RESULTS

Despite low step counts and slow cadence, differences by activity trajectory were found. Greater absolute decreases in LDL-C and non-HDL-C (-15 mg/dL [95% CI: -28 to -2], P  = 0.026; and -15 mg/dL [95% CI: -28 to -1], P  = 0.035), respectively, were associated with more activity. More activity was associated with greater resolution of triglycerides, LDL-C, and non-HDL-C dyslipidemia and with greater weight loss 3 years post MBS.

CONCLUSIONS

More activity in adolescents was associated with improvements in cardiovascular disease-related lipid measures and weight loss after MBS.

Preoperative exercise as a predictor of weight loss in adolescents and young adults following sleeve gastrectomy: a cohort study

BACKGROUND

Preoperative exercise is associated with weight loss following bariatric surgery in adults, but this relationship in adolescents and young adults (AYA) is not well studied.

OBJECTIVES

The present study examined AYA-reported preoperative exercise and demographic factors and their prediction of percent excess body mass index (BMI) loss at 6 and 12 months following sleeve gastrectomy.

SETTING

The setting for recruitment and surgeries was in a children's hospital in the United States.

METHODS

Participants were 173 AYA aged 12-21 years (mean age, 16.5 [SD, 2.0] yr; mean preoperative BMI, 50 [SD, 8.5] kg/m²). Demographic characteristics including age, sex, ethnicity, and preoperative BMI were extracted from the medical record. Preoperatively, adolescents self-reported on exercise using 5 items from the Center for Disease Control's Youth Risk Behavior Surveillance Survey. The study evaluated the association of self-reported preoperative exercise in total and obtained a threshold of higher exercise to weight loss at 6 and 12 months after surgery.

RESULTS

More preoperative exercise was associated with greater weight loss at 12 months. Grouping participants by those who reported exercising at high levels (≥5 hr/wk) compared with those who reported <5 hr/wk, high levels of exercise predicted greater weight loss at 6 and marginally at 12 months postoperatively. Lower preoperative BMI was a significant predictor of weight loss in all analyses.

CONCLUSIONS

Preoperative exercise may predict and contribute to weight loss in AYA and could be a target for pre- and postoperative intervention to improve outcomes. The importance of lower preoperative BMI for maximizing postoperative weight loss was also supported.

Recent trends of bariatric surgery in adolescent population in the state of New York

BACKGROUND

In the United States the percentage of adolescents with obesity has reached an alarming level of 21%. Bariatric surgery has emerged as a successful intervention in the weight loss for adolescents.

OBJECTIVE

To compare bariatric procedures performed in adolescent and adult populations.

SETTING

University Hospital, United States.

METHODS

Using the Statewide Planning and Research Cooperative System (SPARCS) database, records from the adolescent (age 12-21years) and adult populations undergoing bariatric surgery during 2005-2014 were examined. Patients' demographics, surgery type (Roux-en-Y gastric bypass (RYGB), Sleeve Gastrectomy (SG), Laparoscopic Adjustable Gastric Banding (LAGB), length of stay (LOS), complications and comorbidities were analyzed.

RESULTS

The annual adolescent bariatric cases increased from 150 in 2005 to 406 in 2014. In the adolescent population, increasing utilization trends were noted in the Hispanic population (RR=1.08, p-value<0.0001), use of Public (Medicaid or Medicare) insurance (RR=1.10, p-value=0.0003) and SG procedures (RR= 1.56, p-value <0.0001). Decreasing trends were noted in the Caucasian population (RR=0.95, p-value<0.0001), RYGB (RR=0.92, p-value<0.0001) and LAGB (RR= 0.84, p-value=0.0001). Adolescents undergoing bariatric surgery had fewer comorbidities (55.4% vs 81.1%, p-value<0.0001), experienced fewer complications (3.3% vs 4.9%, p-value<0.0001) and 30-day readmissions (3.8% vs 5.0%, p-value=0.0029). Length of stay was also found to be significantly shorter for the adolescent population (1.73 vs 2.00 days, p-value<0.0001). After adjusting for other confounding factors, adolescent patients still had significantly lower complication risk (p-value=0.01) and shorter length of stay (p-value=0.0005) than adults.

CONCLUSION

Bariatric surgery procedure rates have increased in the adolescent population with increasing trend of using LSG. The data from our study supports that bariatric surgery is safe in adolescents with significantly lower complication risk and shorter length of stay as compared to the adult population.

Postoperative continuation of antidepressant therapy is associated with reduced short-term weight loss following Roux-en-Y gastric bypass surgery

PURPOSE

Bariatric surgery candidates are frequently treated with antidepressants. Several of these drugs have been associated with weight gain and could potentially interfere with weight loss after bariatric surgery. This cohort study aimed to investigate the short-term effects of antidepressants on weight loss during the first 24 months after a Roux-en-Y gastric bypass.

METHODS

Patients with a fully documented antidepressant treatment status for at least 12 months were retrospectively included. Weight loss was expressed as the percentage excess BMI loss (%EBMIL) or percentage total weight loss (%TWL). A mixed linear effects model was used to determine the impact of continued and discontinued treatment with antidepressants on weight loss.

RESULTS

A total of 751 patients were included in this study. At 24 months, patients had lost 77.38 ± 30.10 %EBMIL (30.63 ± 13.12 %TWL). In patients treated with antidepressants (n = 125), the %EBMIL and %TWL was reduced with - 2.81% (p = 0.025) and - 1.36% (p = 0.002) respectively, and with - 5.52 %EBMIL (p < 0.001; - 1.05 %TWL, p = 0.012) after multivariate adjustment. Serotonin-norepinephrine reuptake inhibitors (- 12.47 %EBMIL, p < 0.001) and tricyclic antidepressants (- 11.01 %EBMIL, p = 0.042) were predominantly responsible for worse outcomes. Beyond 24 months, at 36 months (- 4.83%, p < 0.001) and 48 months (- 3.54%, p = 0.006), the %EBMIL was still reduced. No significant effects of antidepressants on metabolic outcomes after surgery were observed.

CONCLUSIONS

Treatment with antidepressants was associated with reduced weight loss after gastric bypass surgery, but only if treatment was continued for at least 1 year postoperatively. Mainly tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors were responsible for this reduction in weight loss.

Psychosocial measures and weight change in a clinical paediatric population with obesity

PURPOSE

Poor quality of life has been shown to occur in youth with obesity. This study aimed to assess associations between health-related quality of life, general mental health and general psychological distress measures, collectively termed psychosocial health questionnaires (PSH), with weight outcomes in a busy paediatric weight management service.

METHODS

A cross-sectional longitudinal clinical cohort, 'Childhood Overweight BioRepository of Australia (COBRA)', was used (n = 250, median age 11, range 2-18 year, mean BMI z-score 2.5 ± 0.2). Clinical data were collected and HRQOL questionnaires; Pediatric Quality of Life 4.0 (PedsQL), 'Sizing Me/Them Up' (SMU/STU), and psychological well-being questionnaires; strengths and difficulties questionnaire (SDQ) and Kessler 10 (K10) were completed by the child and primary caregiver. PSH results were compared to age- and sex-adjusted BMI z-score at baseline and follow-up. Direct logistic regression modelling was performed to assess the impact of PSH factors on the likelihood of successful weight reduction over a period of ≥ 12 months.

RESULTS

Mean self-report PSH scores were: 68.0 ± 15.28 (PedsQL, range 0-100), 64.8 ± 15.8, (SMU, range 0-100), 17.3 ± 4.4 (SDQ, range 0-40) and 20.0 ± 7.7 (K10, range 0-50). A significant negative correlation was observed between PSH scores and childhood obesity (baseline BMI z-scores (p < 0.01)). No correlations were observed between psychological well-being measures and BMI z-scores. Higher subscale scores of the PedsQL and SDQ, which measure impaired psychosocial health and more difficulties with hyperactivity and inattention, significantly predict weight loss in children with obesity after 12 months.

CONCLUSION

PSH questionnaires may be useful in identifying individuals who require additional support to achieve weight loss goals in a tertiary weight management service.

Heterogeneity in Response to Treatment of Adolescents with Severe Obesity: The Need for Precision Obesity Medicine

OBJECTIVE

Treating pediatric severe obesity is challenging because of the complex biological, behavioral, and environmental factors that underpin the disease. The multifactorial etiology of obesity combined with the physiologic complexity of the energy regulatory system contributes to treatment variability. The goal of this secondary analysis of pooled data was to describe the degree of individual variation in response to various interventions among adolescents with severe obesity.

METHODS

Data from three centers across the United States conducting either lifestyle (n = 53), pharmacotherapy (n = 40), or metabolic and bariatric surgery (n = 78) interventions were pooled. Inclusion criteria were severe obesity at baseline and at least one follow-up visit > 30 days after treatment start.

RESULTS

Change in BMI following intervention ranged from -50.2% to +12.9%, with each intervention (lifestyle [range: -25.4% to 5.0%], pharmacotherapy [range: -10.8% to 12.9%], and metabolic and bariatric surgery [range: -50.2% to -13.3%]) exhibiting wide individual variation in response. Changes in cardiometabolic risk factors demonstrated similarly high variability.

CONCLUSIONS

Adolescents with severe obesity demonstrated a high degree of heterogeneity in terms of BMI reduction and cardiometabolic risk factor response across treatment modalities. Reporting individual response data in trials and identifying factors driving variability in response will be vital for advancing precision medicine approaches to address obesity.