Associations between Lifetime Adversity and Obesity Treatment in Patients with Morbid Obesity

Childhood adversity trajectories and weight status in young adult men: a register-based study including 359,783 Danish men

BACKGROUND

Childhood adversity has previously been associated with overweight and obesity in adult life, but there is a need for larger population-based studies using prospectively obtained adversity trajectories across childhood to confirm these associations. Moreover, childhood adversity may also be associated with underweight, which is less often studied. The aim of the current study is to investigate the association between childhood adversity trajectories from 0-15 years with weight categories in young adult men.

METHODS

The Danish Life Course Cohort (DANLIFE) was linked with the Danish Conscription Registry resulting in a study sample of 359,783 men, who have been assigned to one of five previously identified adversity trajectories from 0-15 years: "low adversity", "early material deprivation", "persistent material deprivation", "loss or threat of loss", and "high adversity". Height and weight in young adulthood was assessed at a draft board examination at age 18-26 years. Associations of adversity trajectories and weight categories were investigated in multinomial regression models.

RESULTS

Compared with the "low adversity" group, the four other adversity groups had higher risks of underweight, overweight, and obesity. The "high adversity" group showed the strongest associations with both underweight (1.44 (1.32, 1.58)) and obesity (1.50 (1.39, 1.61)) when adjusted for parental origin, birth year, age at draft board examination, and maternal age.

CONCLUSION

Childhood adversity, experienced between 0 and 15 years of life, was associated with a higher risk of underweight, overweight, and obesity in young adulthood among men.

Adverse Childhood Experiences and Obesity: A One-to-One Correlation?

INTRODUCTION

Adverse childhood experiences (ACEs) have been associated with physical and emotional problems such as obesity and depression in adulthood. This study evaluated the relationship between ACE scores and the severity of obesity.

METHODS

We conducted a cross-sectional study of 119 adult patients at the GW Weight Management Clinic. They filled out an ACE survey examining trauma and household dysfunction. The main outcome was the severity of obesity measured by Body Mass Index (BMI). We estimated the adjusted mean difference between high and low ACE risk groups using - linear regression.

RESULTS

The data suggest a positive relationship between ACE score and BMI. Patients with severe obesity are more likely to be a high ACE risk (50%) compared to others (24-25%). The average BMI in the high ACE risk group is 3.64 (95% CI: 0.25-7.03) higher than those in the low ACE risk group. The linear regression also showed that as the ACE score increased by 1, BMI increased by 1 unit (95% CI: 0.15-1.77).

CONCLUSIONS

Our findings suggest ACE is not just related with the prevalence of obesity, but also the severity of obesity in the overweight and obese population. The linear regression also showed that as the ACE score increased by 1, the BMI increased by 1 unit as well.

Four-year outcomes for endoscopic sleeve gastroplasty from a single centre in India

Background

Bariatric endoscopy has emerged for non-surgical treatment of obesity, providing a treatment option for weight loss and associated comorbidities. Outcomes of endoscopic sleeve gastroplasty (ESG) of 12 months have been published by our team and there is a need for longer follow-up period understanding the effects of ESG techniques.

Aim

This report emphasises on weight loss pattern in follow-up time points and monitors the post-procedure improvement in comorbidities with minimum 4-year follow-up of patients undergoing ESG at a single academic centre in India.

Subjects and Methods

This was a prospective cohort study. All procedures were performed by the same surgeon. Patients with a body mass index of >30 kg/m² (or >27 with comorbidities) underwent ESG for treatment of obesity. Patients were systematically followed yearly after their procedure. Data collected on the primary outcome and secondary outcomes were analysed and presented.

Results

612 patients (69.3% female) with a mean age of 40.70 ± 12.66 years and mean body mass index of 34.30 ± 5.05 kg/m² underwent ESG. Out of 612 patients, follow-up rates for a 1-2-3 and 4 years were 93.1%, 90.2%, 81.7% and 81.9%, respectively. The mean percentage total body weight loss was 18.19% (95% confidence interval [CI]: 17.72-18.57) and %EWL was 49.30% (95% CI: 48.91-49.68) with 90% of participants-maintaining a percentage of total weight loss of ≥5% and 70% of patients maintaining an EWL of ≥25% at 4 years, respectively. Resolution/improvement of comorbidities was 51.2% cases of T2DM, 65.8% cases of hypertension, 73.6% cases of dyslipidaemia and 89.9% remission were in obstructive sleep apnoea. No patient required an emergency intervention, and there was no mortality or significant morbidity.

Conclusions

This study shows acceptable results with ESG at 4 years in our unit. Regular monitoring by a multidisciplinary nurtures weight loss, resolution or improvement of comorbidities and improvement of quality of life with low perioperative complications. There is a need for more reports with this approach to determine the amount and duration of weight loss outcome and medical intervention.

The Efficacy and Safety of Endoscopic Sleeve Gastroplasty as an Alternative to Laparoscopic Sleeve Gastrectomy

Endoscopic sleeve gastroplasty (ESG) is a therapeutic endoscopic technique for reducing the size of the gastric reservoir in obese patients, using a full-thickness endoscopic suturing device. The effectiveness of ESG in weight loss is significantly greater than that of high-intensity diet and lifestyle therapy and lower than that of laparoscopic sleeve gastrectomy (LSG). The efficacy at 12 months after ESG in terms of percentage of total body weight loss and excess body weight loss was approximately 16% and 60%, respectively. The well-known predictive factors for increased weight loss by ESG are good compliance with regular monitoring and post-procedure care involving a multidisciplinary team approach. Although the underlying mechanism of weight loss induced by ESG is debatable, delayed gastric emptying and early satiation are some of the proposed mechanisms. The pooled rate of adverse events after ESG reported in several meta-analysis studies ranged from 1.5% to 2.3% and the incidence of new-onset gastroesophageal reflux disease after ESG was negligible, indicating that ESG has a superior safety profile to LSG. Moreover, ESG reduced the risk of obesity-related metabolic comorbidities, evidenced by the reduction in HbA1c level, systolic blood pressure, triglyceride level, and risk of hepatic steatosis and fibrosis; it even improved the quality of life. ESG could be considered safe and qualify as an alternative treatment to LSG.

Assessing Life Stress: A Critical Priority in Obesity Research and Treatment

Significant childhood adversity and chronic life stress are highly prevalent in patients with severe obesity. Such stress has been found to increase risk of adulthood obesity by up to 50%, and it can also substantially degrade the effectiveness of evidence-based treatments for this chronic disease condition. Despite general appreciation of these facts, though, stress is not frequently measured in obesity research or routinely assessed during treatment for obesity or obesity-related complications. To address this important issue, we describe several validated tools that can be used for assessing life stress and discuss how information obtained from these instruments can be integrated into obesity treatment and research. Given the documented relevance of stress for obesity, we argue that stress assessment and management should be included in clinical treatments for obesity and that stress should be routinely measured in studies examining the long-term effects of obesity and obesity treatment.

Attitudes and knowledge regarding referrals for bariatric surgery among Danish secondary healthcare providers: A national survey

Bariatric surgery induces significant and sustained weight loss and subsequently reduces obesity-related comorbidities. However, only a small percentage of patients with severe obesity undergo bariatric surgery in Denmark. There is limited knowledge about the experiences with and possible reservations to bariatric surgery among secondary healthcare providers. The aim of this cross-sectional study was to investigate referral patterns and knowledge regarding the criteria for bariatric surgery among Danish secondary healthcare providers, treating obesity-related diseases. A questionnaire regarding experiences with and reservations to referring patients for consideration for bariatric surgery, along with thoughts to specific patient cases were sent to several specialists: endocrinologists, obstetricians and gynaecologists, orthopaedic surgeons and otorhinolaryngologists. Most questions required responses on a 5-point Likert scale and frequency distributions were calculated. A total of 345 (44%) specialists responded to the questionnaires. Good knowledge of the criteria for referral to bariatric surgery varied among the specialist from 6% to 68%. One of the main issues was a concern about the medical and surgical postoperative complications, which was a barrier to and influenced referral decisions. Furthermore, specialists were more likely to refer patients to bariatric surgery when patients requested this. Except for endocrinologists, the Danish secondary healthcare specialists interviewed have limited knowledge about bariatric surgery, which results in a reluctance in referring patients. Our results indicate that there is a need to improve knowledge among specialists, regarding the indications, criteria and outcomes for bariatric surgery to establish a more pro-active, specialist led approach to referrals.

Endoscopic sleeve gastroplasty in the management of overweight and obesity: an international multicenter study

BACKGROUND AND AIMS

Obesity is a pandemic affecting approximately 700 million adults worldwide, with an additional 2 billion overweight. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric therapy that involves remodeling of the greater curvature in an effort to reduce gastric capacity and delay gastric emptying. A variety of ESG suture patterns has been reported. This study is the first to use a uniform "U" stitch pattern across all centers to simplify technical aspects of the procedure and limit cost. This also uniquely assessed outcomes in all body mass index (BMI) categories and changes in metabolic rate, lean body mass, and adipose tissue composition.

METHODS

This is a multicenter analysis of prospectively collected data from 7 centers including patients with overweight and obesity who underwent ESG. Primary outcomes included absolute weight loss, percent total body weight loss (%TWL), change in BMI, and percent excess weight loss (%EWL) at 6 and 12 months in overweight and obese classes I, II, and III. Secondary outcomes included adipose tissue, lean body mass reduction, and metabolic rate analyzed by bioimpedance. Additionally, immediate or delayed adverse events (AEs) were analyzed. Clinical success was defined as achieving ≥25% EWL at 1 year with ≤5% serious AE (SAE) rate following the American Society for Gastrointestinal Endoscopy (ASGE)/American Society for Metabolic and Bariatric Surgery (ASMBS) threshold.

RESULTS

A total of 193 patients underwent ESG during the study period. All groups had >10% TWL and >25% EWL at 6 months of follow-up. On average, %TWL was 14.25% ± 5.26% and 15.06% ± 5.22% and the %EWL 56.15% ± 22.93% and 59.41% ± 25.69% at 6 months and 1 year of follow-up, respectively. %TWL was 8.91% ± .3%, 13.92% ± 5.76%, 16.22% ± 7.69%, and 19.01% ± .95% and %EWL 56.21% ± 2.0%, 62.03% ± 27.63%, 54.13% ± 23.46%, and 46.78% ± 2.43% for overweight and obesity classes I, II, and III, respectively, at 1 year. Male sex, age <41 years, and higher BMI were predictors of achieving a TWL ≥10% at 1-year follow-up. There was a significant reduction in adipose tissue from baseline. SAEs occurred in 1.03%, including 2 perigastric collections needing surgery.

CONCLUSIONS

ESG appears to be feasible, safe, and effective in the treatment of patients with overweight and obesity according to ASGE/ASMBS thresholds.

Endoscopic sleeve gastroplasty: From whence we came and where we are going

The most effective and durable treatment for obesity is bariatric surgery. However, less than 2% of eligible patients who fulfill the criteria for bariatric surgery undergo the procedure. As a result, there is a drive to develop less invasive therapies to combat obesity. Endoscopic bariatric therapies (EBT) for weight loss are important since they are more effective than pharmacological treatments and lifestyle changes and present lower adverse event rates compared to bariatric surgery. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive EBT that involves remodeling of the greater curvature. ESG demonstrated favorable outcomes in several centers, with up to 20.9% total body weight loss and 60.4% excess weight loss (EWL) on 2-year follow-up, with a low rate of severe adverse events (SAE). As such, it could be considered safe and effective in light of ASGE/ASMBS thresholds of > 25% EWL and ≤ 5% SAE, although there are no comparative trials to support this. Additionally, ESG showed improvement in diabetes mellitus type 2, hypertension, and other obesity-related comorbidities. As this procedure continues to develop there are several areas that can be addressed to improve outcomes, including device improvements, technique standardization, patient selection, personalized medicine, combination therapies, and training standardization. In this editorial we discuss the origins of the ESG, current data, and future developments.