Psychological outcomes and predictors of initial weight loss outcomes among severely obese adolescents receiving laparoscopic adjustable gastric banding

Depressive symptoms at short-, medium-, and long-term follow-up after bariatric surgical procedures: A systematic review and meta-analysis

IMPORTANCE

Patients experience both positive and negative changes in mood following bariatric surgery and mental health outcomes have been reported to differ between procedure types. Understanding changes in symptoms over time and between surgical procedures is vital to providing meaningful, long-term, patient-centered care.

OBJECTIVE

To examine the nature and time course of changes in depressive symptoms after different bariatric procedures.

EVIDENCE REVIEW

Medline, Embase, Emcare, PsycINFO, CINAHL, and CENTRAL databases were systematically searched from inception to January 18, 2024. Ninety publications describing patient-reported depressive symptoms in 13,146 individuals undergoing bariatric procedures were included.

FINDINGS

Qualitative analysis indicated a reduction of depressive symptoms at all time points following all bariatric procedure types. However, a subset of patients experienced worsening symptoms post-surgery. Meta-analyses indicated depressive symptoms improve following bariatric surgery by an SMD of -0.6 (95% CI: -0.8, -0.4) in the short term (0-4 months post-surgery), -0.9 (95% CI: -1.0, -0.8) in the medium term (5-12 months), and -0.7 (95% CI: -0.9, -0.5) in the long term (> 12 months). There was no evidence that surgery type was associated with the change in depressive symptoms at any time point post-surgery.

CONCLUSIONS AND RELEVANCE

Patient-reported depressive symptoms improve following bariatric surgery with improvements peaking in the medium term and diminishing over time. Significant heterogeneity in the results cannot be explained by surgery type, baseline depression, or depression instrument used across studies. Long-term management of post-bariatric surgery patients must consider the potential for adverse psychological effects of surgery.

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.

Pediatric metabolic and bariatric surgery: indications and preoperative multidisciplinary evaluation

The standard of care for pediatric patients with severe obesity considering metabolic and bariatric surgery is a preoperative multidisciplinary evaluation. A multidisciplinary team allows for the efficient use of variable personnel expertise to evaluate, manage, and support a pediatric patient and family through metabolic and bariatric surgery. This review discusses the purpose, recommended team members, patient selection, content, and benefits of the multidisciplinary preoperative evaluation. This evaluation should reduce barriers to care and optimize patient safety and outcomes while taking into consideration the unique developmental needs of this age group.

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.

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.

The Relationship between Metabolic Comorbidities and Post-Surgical Weight Loss Outcomes in Adolescents Undergoing Laparoscopic Sleeve Gastrectomy

INTRODUCTION

Little is known about the relationship between metabolic factors and weight loss success in adolescents undergoing bariatric surgery.

METHODS

The objective of this study was to assess if baseline metabolic characteristics associate with weight loss in adolescents undergoing laparoscopic sleeve gastrectomy. A retrospective study was conducted in a comprehensive adolescent bariatric surgery center of 151 subjects (34 male, 117 female). Anthropometric measurements and metabolic factors including blood pressure, fasting glucose, hemoglobin A1c (HbA1c), metabolic syndrome (MeS), liver function, triglycerides, and waist circumference were collected at one pre-surgical visit and at 6- and/or 12-month post-laparoscopic sleeve gastrectomy. Weight loss was compared between subjects with normal or abnormal baseline metabolic factors. Absolute BMI change was used to measure successful weight loss.

RESULTS

Higher baseline systolic blood pressure (SBP) was associated with greater weight loss as measured by body mass index (BMI) change and BMI standard deviation score (BMI-SDS) change at 6 and 12 months. Those patients in the 6-month follow-up group with an abnormal HbA1c at baseline had significantly more weight loss as measured by BMI-SDS. None of the other parameters, including fasting glucose, MeS, liver function, triglycerides, and waist circumference showed a predictive relationship.

CONCLUSION

Elevated SBP and HbA1c in adolescents with morbid obesity may reflect a population more likely to achieve successful weight loss and, thus, may be a good target for bariatric surgery, specifically laparoscopic sleeve gastrectomy, as an intervention for severe obesity. An assessment of behavioral differences in patients with and without elevated BP and HbA1c might explain the mechanism for the improved weight loss.

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.

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.

Trajectory Analysis and Predictors of the Percentage of Body Fat Among Chinese Sleeve Gastrectomy Patients

BACKGROUND

The weight loss in Chinese patients after sleeve gastrectomy is different, and the differences can be evaluated through the trajectories of the percentage of body fat (BF%). Patients' baseline psychosocial factors may be associated with these trajectories.

MATERIALS AND METHODS

We selected 267 patients who received sleeve gastrectomy for the first time. The BF% at baseline and 1, 3, 6, 12 months after surgery and baseline psychosocial variables were retrospectively collected. The trajectory model was established according to BF% based on the growth mixture model. The baseline psychosocial variables were compared among different trajectory classes.

RESULTS

Four types of trajectory classes were obtained. The differences in preoperative dietary self-efficacy, exercise self-efficacy, depression, social support, working status, alcohol consumption, and gender among the classes were statistically significant. The pairwise comparison of the above variables revealed that the differences of gender, dietary self-efficacy and exercise self-efficacy among classes were highly effective.

CONCLUSION

Female gender, low dietary self-efficacy and low exercise self-efficacy were predictors for poor BF% trajectory in sleeve gastrectomy patients. Health professionals can early identify patients who are most likely to lose weight in a not-ideal manner based on the above predictors.

Self-harm hospitalization following bariatric surgery in adolescents and young adults

BACKGROUND

While bariatric surgery has demonstrated physical and psychological benefits, a risk of suicide and non-fatal self-harm has also been shown. The aim of this study was to compared the rate of hospitalization for self-harm during a three-year observational follow-up period between adolescents/young adults who underwent bariatric surgery in France in 2013-2014 and two control groups.

METHODS

All individuals aged 12-25 years old who underwent bariatric surgery in France between January 1st, 2013, and December 31st, 2014, were identified with a validated algorithm from the French national hospital database, and compared to a healthy sample of the general population matched for age and gender. Information relative to hospitalizations, including for self-harm (ICD-10 codes X60-84), were extracted i) between 2008 and the surgery, and ii) for a three-year follow-up period. A second unmatched control group with obesity but no bariatric surgery was also identified. Survival analyses with adjustments for confounding variables were used.

RESULTS

In 2013-2014, 1984 youths had bariatric surgery in France. During follow-up, 1.5% were hospitalized for self-harm vs. 0.3% for controls (p < 0.0001). After adjustment, subsequent hospitalization for self-harm was associated with bariatric surgery (HR 3.64, 95% CI 1.70-7.81), prior psychiatric disorders (HR 7.76, 95% CI 3.76-16.01), and prior self-harm (HR 4.43, 95% CI 1.75-11.24). When compared to non-operated youths with obesity, bariatric surgery was not associated with self-harm while prior mental disorders and self-harm were. Mortality reached 0.3% after surgery.

CONCLUSIONS

Bariatric surgery is associated with an increased risk of self-harm, mainly in relation to preexisting psychological conditions. Vigilance and appropriate care are thus warranted in vulnerable individuals.

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.

Depressive and anxiety symptoms and suicidality in adolescent and young adult females with moderate to severe obesity before and after weight loss surgery

Data are conflicting regarding the impact of weight loss on mood and anxiety in adolescent and young adult females with moderate to severe obesity (OB), who are at increased risk for mood dysfunction compared with normal-weight females (NW). We examined depressive and anxiety symptoms in 94 females 13-21 years old: 39 in the NW group (body mass index [BMI]: 5th -85th percentiles) and 55 in the OB group (BMI >40 kg/m2 or >35 kg/m2 with comorbidities). Fifteen participants in the OB group who underwent bariatric surgery (gastric bypass or sleeve gastrectomy) and 15 getting routine care were re-assessed after 6 months. The Beck Depression Inventory-II (BDI-II) and State-Trait Anxiety Inventory (STAI) assessed depressive and anxiety symptoms, respectively. The OB group had higher BDI-II and STAI T-scores (P < .0001), a higher prevalence of clinical depression and anxiety (P < .001), and reported greater suicidal ideation (P = .02) vs the NW group. The bariatric surgery and non-surgical groups did not differ for changes in BDI-II and STAI T-Scores and suicidality over 6-month follow-up, despite greater weight loss in the former. Depressive and anxiety symptoms and suicidality were more frequently observed in the OB vs NW group. These symptoms did not improve following bariatric surgery despite significant weight loss, underscoring the need to investigate determinants of emergence and resolution of these symptoms in the OB group.

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.

Improving the assessment and management of obesity in UK children and adolescents: the PROMISE research programme including a RCT

Background

Five linked studies were undertaken to inform identified evidence gaps in the childhood obesity pathway.

Objectives

(1) To scope the impact of the National Child Measurement Programme (NCMP) (study A). (2) To develop a brief evidence-based electronic assessment and management tool (study B). (3) To develop evidence-based algorithms for identifying the risk of obesity comorbidities (study B). (4) To conduct an efficacy trial of the Healthy Eating and Lifestyle Programme (HELP) (study C). (5) To improve the prescribing of anti-obesity drugs in UK adolescents (study D). (6) To investigate the safety, outcomes and predictors of outcome of adolescent bariatric surgery in the UK (study E).

Methods

Five substudies – (1) a parental survey before and after feedback from the National Childhood Measurement Programme, (2) risk algorithm development and piloting of a new primary care management tool, (3) a randomised controlled trial of the Healthy Eating and Lifestyle Programme, (4) quantitative and qualitative studies of anti-obesity drug treatment in adolescents and (5) a prospective clinical audit and cost-effectiveness evaluation of adolescent bariatric surgery in one centre.

Results

Study A – before the National Childhood Measurement Programme feedback, three-quarters of parents of overweight and obese children did not recognise their child to be overweight. Eighty-seven per cent of parents found the National Childhood Measurement Programme feedback to be helpful. Feedback had positive effects on parental knowledge, perceptions and intentions. Study B – risk estimation models for cardiovascular and psychosocial comorbidities of obesity require further development. An online consultation tool for primary care practitioners is acceptable and feasible. Study C – the Healthy Eating and Lifestyle Programme, when delivered in the community by graduate mental health workers, showed no significant effect on body mass index at 6 months (primary outcome) when compared with enhanced usual care. Study D – anti-obesity drugs appear efficacious in meta-analysis, and their use has expanded rapidly in the last decade. However, the majority of prescriptions are rapidly discontinued after 1–3 months of treatment. Few young people described positive experiences of anti-obesity drugs. Prescribing was rarely compliant with the National Institute for Health and Care Excellence guidance. Study E – bariatric surgery appears safe, effective and highly cost-effective in adolescents in the NHS.

Future work and limitations

Work is needed to evaluate behaviour and body mass index change in the National Childhood Measurement Programme more accurately and improve primary care professionals’ understanding of the National Childhood Measurement Programme feedback, update and further evaluate the Computer-Assisted Treatment of CHildren (CATCH) tool, investigate delivery of weight management interventions to young people from deprived backgrounds and those with significant psychological distress and obtain longer-term data on anti-obesity drug use and bariatric surgery outcomes in adolescence.

Trial registration

Current Controlled Trials ISRCTN99840111.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 8, No. 3. See the NIHR Journals Library website for further project information.

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.

Naturalistic, multimethod exploratory study of sleep duration and quality as predictors of dysregulated eating in youth with overweight and obesity

Although poor sleep has been found to adversely impact eating and weight regulation in youth, past research is limited by retrospective reporting and/or non-naturalistic designs. We investigated the feasibility of combining three momentary, ecologically valid approaches to assessing sleep and eating behavior, and associations between these constructs, among youth (aged 8-14y) with overweight/obesity (n = 40). Participants completed 14 overlapping days of actigraphy assessment and smartphone-based ecological momentary assessment (EMA) of eating behavior, of which 3 days also included computerized, self-guided 24-h dietary recall. Feasibility of completing measures concurrently was evaluated by generating frequencies of compliance. Associations between sleep indices and next-day eating behavior were examined via generalized estimating equations. Of 29 participants who provided EMA and 24-h recall data that aligned with previous night actigraphy data, both EMA and sleep data were available on an average of 8.6 out of 14 possible days, and both 24-h recall and sleep data on an average of 2.7 out of 3 possible days. Each additional hour of sleep was associated with consuming fewer calories from solid fats, alcohol, and added sugars (b = 0.70; p = .04). Combining naturalistic, momentary assessments of sleep and eating behavior appears to be acceptable in youth. Larger experimental studies are needed to further understand associations between sleep parameters and eating behavior.

Cognitive Performance as Predictor and Outcome of Adolescent Bariatric Surgery: A Nonrandomized Pilot Study

Objectives

Evidence in adults suggests that improvements in cognitive performance may follow weight loss resulting from bariatric surgery, and baseline cognitive performance may be associated with weight loss following surgery. This has not been evaluated in adolescents.

Method

Participants were 38 adolescents of age 14-21 years composed of three groups: (1) 12 adolescents with severe obesity who received vertical sleeve gastrectomy during the study (VSG); (2) 14 adolescents with severe obesity who were wait-listed for VSG (WL); and (3) 12 healthy weight controls (HC). Participants completed testing of visual memory, verbal memory, and executive functioning at baseline (T1), which occurred presurgery for the VSG group, and approximately 4 months after baseline (T2). Body mass index (BMI) was assessed at T1, T2, and additionally at 6 months following VSG for the adolescents who received surgery.

Results

Although there was evidence of greater improvement for the VSG as compared with WL and HC groups in visual and verbal memory, group differences did not reach significance and effect sizes were small (η2 < 0.01). There was a significant positive association between indices of baseline executive functioning and excess BMI loss at 6 months postsurgery.

Conclusions

This small pilot study showed no significant differences by group in cognitive performance post-VSG. There was a significant association of baseline cognitive performance with weight loss outcomes. Given the very preliminary nature of these results in a small sample, future research should examine these relationships in a larger sample and evaluate mechanisms of these associations (e.g., insulin resistance, sleep, physical activity).

Characteristics Associated with Successful Weight Management in Youth with Obesity

OBJECTIVE

To identify the medical, demographic, and behavioral factors associated with a reduction of body mass index percent of the 95th percentile (BMIp95) after 1 year for patients receiving care at a tertiary care obesity management clinic.

STUDY DESIGN

A retrospective review of data from first and 12 ± 3-month follow-up visits of subjects aged 8-17 years with obesity. Data included anthropometrics, demographics, medical/psychological history, reported diet patterns, and participation in moderate/vigorous physical activity. After analyzing factors associated with 1-year follow-up, we used a forward conditional logistic regression model, controlling for subject's sex, to examine associations with a BMIp95 ≥5-point decrease at 1 year.

RESULTS

Of 769 subjects, 184 (23.9%) had 1-year follow-up. Boys more often had follow-up (28.4% vs girls, 19.1%; P = .003). The follow-up sample was 62.0% male, 65.8% Hispanic, and 77.7% with public insurance; 33.2% achieved a ≥5-point decrease in BMIp95. In regression results, the ≥5-point decrease group was more likely to have completed an initial visit in April-September (OR 2.0, 95% CI 1.1-3.9); have increased physical activity by 1-2 d/wk (OR 3.4, 95% CI 1.4-7.8) or increased physical activity by ≥ 3 d/wk at 1 year (OR 2.7, 95% CI 1.1-6.3); and less likely to have been depressed at presentation (OR 0.4, 95% CI 0.2-0.9). Demographic and dietary factors were not significantly associated with BMIp95 group status.

CONCLUSIONS

Strategies improving follow-up rates, addressing mental health concerns, and promoting year-round physical activity are needed to increase the effectiveness of obesity management clinics.

Early weight loss in adolescents following bariatric surgery predicts weight loss at 12 and 24 months

BACKGROUND

Growing evidence supports the efficacy of paediatric bariatric surgery. However, there is a paucity of data examining adolescent outcomes post surgery. Among adults, studies have shown that early weight loss is associated with long-term weight loss. Therefore, the aim of our study was to investigate the association between early weight loss at 3 months with longer-term weight loss at 12 and 24 months in adolescents post surgery. We hypothesized that patients who have greater weight loss within the first 3 months will have greater weight loss at 12 and 24 months post surgery.

METHODS

A retrospective chart review of bariatric surgery patients (n = 28) was conducted. Anthropometric measurements at baseline and 3, 12, and 24 months were analysed.

RESULTS

Percent of excess weight loss (%EWL) at 3, 12, and 24 months were 33.6 ± 11.3%, 55.0 ± 20.5%, and 55.1 ± 27.1%, respectively. %EWL at 3 months was positively associated with %EWL at 12 and 24 months (P < 0.05). Receiver operating characteristic curve results identified a cut-off of greater than or equal to 30%EWL at 3 months predicted successful weight loss, defined as greater than or equal to 50%EWL at 12 and 24 months.

CONCLUSION

These findings demonstrate that majority of weight loss among adolescents occurs within the first postoperative year. Greater %EWL by 3 months post surgery predicts successful and sustained weight loss over time.

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.

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.

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.

Psychological distress among bariatric surgery candidates: The roles of body image and emotional eating

The increased risk of psychological distress among bariatric surgery candidates may be attributed, at least in part, to body image dissatisfaction (BID). The aim of the present study was to test the hypotheses that body image could be correlated with the psychological distress variables, and that emotional eating behaviours could mediate the relationship between body image and psychological distress. A sample of consecutive participants seeking bariatric surgery (N = 169, 67% females, mean age, 41.8 years [SD = 11.46], mean body mass index 42.0 kg/m² [SD = 11.0]) was recruited from a university-based bariatric centre, a week prior to scheduled surgery. Results showed that BID was positively correlated with suicidality (r = 0.18, P < 0.05), depression (r = 0.39, P < 0.01) and anxiety (r = 0.20, P < 0.05). The relation between BID and depression was partially mediated by emotional eating, whereas the relation between BID and suicidality was fully mediated by emotional eating. Physicians and other health professionals who treat bariatric surgery patients should be encouraged to detect behaviours indicating emotional eating, as these could be an indicator of psychological distress resulting from poor body image.

The effect of a very low calorie diet on subjective depressive symptoms and anxiety: meta-analysis and systematic review

There are conflicting findings regarding the effect very low calorie diets (VLCDs) have on self-reported depressive symptoms and anxiety levels. Some studies have reported decreased subjective depressive symptoms and anxiety post-diet, whereas other studies have not. Further complicating matters, the protocol for VLCDs vary substantially across studies, which could account for the mixed findings. The primary goal of this meta-analysis and systematic review was to determine the effect VLCDs have on subjective depressive symptoms and anxiety pre- to post-diet. In addition, potential moderators (the presence/absence of behavioral therapy, duration of diet, inclusion/exclusion of low intensity exercise, and amount of weight lost) were examined to assess the effect of procedural deviations across VLCD studies on depressive symptoms and anxiety. A random-effects model was used for the meta-analysis and included nine studies with 16 independent samples. To further explain the results, study rigor was examined in the systematic review, which included 11 studies with 20 independent samples. Depressive symptoms significantly decreased pre- to post-diet when behavioral therapy was implemented during the diet, the duration of the diet was relatively long (8-16 weeks), low intensity exercise was included, and the dieters lost 14.1 kg or more post-diet. However, no difference in depressive symptoms were observed pre- to post-diet when behavioral therapy was not included, the diet was shorter (1-7 weeks), no exercise was implemented and dieters lost <14 kg of weight post-diet. There was no change in anxiety pre- to post-diet. Health care providers involved in supervising VLCDs should consider using a VLCD of at least 8 weeks that includes behavioral therapy and low intensity exercise in order to enhance the potential benefits of VLCDs on depressive symptoms. More research is required to examine the effect of VLCDs on anxiety.

Perceived Social Support for Exercise and Weight Loss in Adolescents Undergoing Sleeve Gastrectomy

OBJECTIVES

Bariatric surgery is an effective treatment for youth with severe obesity. However, outcomes are variable and there remains sparse understanding of predictors of weight loss following surgery. The current study examines the role of adolescent-reported pre-operative social support around exercise, binge eating, and exercise to predict excess body mass index (EBMI) loss from 3 to 12 months post-surgery.

METHOD

Participants were 101 adolescents ages 12-21 (M age = 16.6, SD = 1.8). Pre-operative body mass index (BMI) ranged from 35 to 87 (M = 50.3, SD = 8.6). Structural equation modeling (SEM) was used to evaluate a model of the association of adolescent report of perceived social support for exercise with less binge eating (items from the Eating Disorder Diagnostic Scale) and more self-reported exercise (items from the Youth Risk Behavior Surveillance System). The model was used to predict EBMI loss at 3, 6, 9, and 12 months post-surgery.

RESULTS

Social support significantly predicted exercise and demonstrated a trend for predicting binge eating, such that more social support was associated with more exercise and a trend for less binge eating. Binge eating was associated with less EBMI loss. However, there was no association of exercise with EBMI loss.

CONCLUSIONS

Pre-operative binge eating should be a target for identification and treatment prior to sleeve gastrectomy in adolescents. Although not directly or indirectly associated with EBMI loss, perceived social support around exercise was associated with increased exercise, which may make it a consideration for a target for intervention as well.

A Multisite 2-Year Follow Up of Psychopathology Prevalence, Predictors, and Correlates Among Adolescents Who Did or Did Not Undergo Weight Loss Surgery

PURPOSE

We aimed to characterize prevalence, change, predictors, and correlates of psychopathology and associations with weight loss in adolescents with severe obesity 24 months after weight loss surgery (WLS) utilizing a controlled multisite sample design.

METHODS

Adolescents undergoing WLS (n = 139) and nonsurgical comparisons with severe obesity (NSComp; n = 83) completed validated questionnaires assessing psychopathology and potential predictors and correlates at presurgery/baseline and 24 months postoperatively/follow-up.

RESULTS

At 24 months, 34.7% of WLS and 37.7% of nonsurgical comparisons were categorized as "symptomatic" (Youth Self-Report ≥ borderline on at least one DSM scale). The majority maintained their symptomatic or nonsymptomatic status from baseline to 24 months postbaseline. Remission of symptoms was more common than the development of new symptomatology at 24 months. Beyond demographics, separate models of baseline predictors and concurrent correlates of 24-month psychopathology identified baseline psychopathology and loss of control (LOC) eating as significant. Alcohol use disorder (AUD) and LOC eating emerged as correlates in the concurrent model. For the WLS group, preoperative, postoperative, and change in symptomatology were not related to 24-month percent weight loss.

CONCLUSIONS

At 2 years, approximately one in three adolescents were symptomatic with psychopathology. Maintenance of symptomatic/nonsymptomatic status over time or remission was more common than new incidence. Although symptomatology was not predictive of surgical weight loss outcomes at 2 years, preoperative psychopathology and several other predictors (LOC eating) and correlates (LOC eating, AUD) emerged as signals for persistent mental health risks, underscoring the importance of pre- and postoperative psychosocial monitoring and the availability of adjunctive intervention resources.

ASMBS pediatric metabolic and bariatric surgery guidelines, 2018

The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.

Psychiatric Diagnoses and Weight Loss Among Adolescents Receiving Sleeve Gastrectomy

BACKGROUND AND OBJECTIVES

Severe obesity is associated with higher risk of psychiatric difficulties. Bariatric surgery is the most effective treatment of severe obesity. Few guidelines exist regarding the association of psychiatric diagnoses in adolescents and outcomes after surgery because of the lack of longitudinal research. Our objective is to evaluate the rates of psychiatric diagnoses in adolescents undergoing surgery compared with those not receiving surgery and the association of preoperative psychiatric diagnoses with postsurgical weight loss outcomes.

METHODS

Adolescents (N = 222) referred for psychological evaluation at one institution for bariatric surgery (2009-2017) completed semistructured clinical interviews to assess the presence and number of psychiatric diagnoses. Comparison analyses were conducted between those who did not end up receiving surgery (N = 53) and those who did (N = 169). Using longitudinal modeling, we assessed the association of preoperative diagnoses with weight loss outcomes between 3 and 12 months after surgery.

RESULTS

Seventy-one percent of adolescents qualified for a psychiatric disorder. There were no differences in rates of specific disorders or numbers of diagnoses between those receiving surgery and those not receiving surgery. The presence or absence or number of diagnoses before surgery was not associated with weight loss outcomes after surgery.

CONCLUSIONS

Psychiatric diagnoses are prevalent among adolescents with severe obesity. These diagnoses are not associated with weight loss outcomes. The presurgical psychological evaluation serves as an opportunity to identify adolescents experiencing psychiatric problems and provide them with care but should not necessarily be considered a contraindication to surgery.

Adolescent Loss-of-Control Eating and Weight Loss Maintenance After Bariatric Surgery

BACKGROUND

Loss-of-control (LOC) eating is common in adults undergoing bariatric surgery and is associated with poorer weight outcomes. Its long-term course in adolescent bariatric surgery patients and associations with weight outcomes are unclear.

METHODS

Adolescents (n = 234; age range = 13-19 years) undergoing bariatric surgery across 5 US sites were assessed for postsurgery follow-up at 6 months and 1, 2, 3, and 4 years. Descriptive statistics and generalized linear mixed models were used to describe the prevalence of LOC eating episodes involving objectively large amounts of food and continuous eating, respectively. Generalized linear mixed models investigated the association of any LOC eating with short- and long-term BMI changes.

RESULTS

At baseline, objectively large LOC eating was reported by 15.4% of adolescents, and continuous LOC eating by 27.8% of adolescents. Both forms of LOC eating were significantly lower at all postsurgical time points relative to presurgery (range = 0.5%-14.5%; Ps < .05). However, both behaviors gradually increased from 6-month to 4-year follow-up (Ps < .05). Presurgical LOC eating was not related to percent BMI change over follow-up (P = .79). However, LOC eating at 1-, 2-, and 3-year follow-up was associated with lower percent BMI change from baseline at the next consecutive assessment (Ps < .05).

CONCLUSIONS

Although presurgical LOC eating was not related to relative weight loss after surgery, postoperative LOC eating may adversely affect long-term weight outcomes. Rates of LOC eating decreased from presurgery to 6-months postsurgery but increased thereafter. Therefore, this behavior may warrant additional empirical and clinical attention.

Who seeks bariatric surgery? Psychosocial functioning among adolescent candidates, other treatment-seeking adolescents with obesity and healthy controls

Limited data are available on the characteristics of adolescents with obesity who seek bariatric surgery. Existing data suggest that adolescent surgery candidates have a higher body mass index (BMI) than comparison adolescents with obesity, but the limited findings regarding psychosocial functioning are mixed. This study aimed to compare BMI and psychosocial functioning among adolescent bariatric surgery candidates, outpatient medical-treatment-seeking adolescents with obesity (receiving lifestyle modification), and adolescents in the normal-weight range. All adolescents completed self-report measures of impulsivity, delay discounting, depression, anxiety, stress, eating pathology, family functioning and quality of life, and had their height and weight measured. Adolescent surgical candidates had higher BMIs than both comparison groups. Surgical candidates did not differ from medical-treatment-seeking adolescents with obesity on any measure of psychosocial functioning, but both groups of adolescents with obesity reported greater anxiety and eating pathology and poorer quality of life than normal-weight adolescents. Quality of life no longer differed across groups after controlling for BMI, suggesting that it is highly related to weight status. Adolescents with obesity may experience greater anxiety, eating pathology, and quality of life impairments than their peers in the normal-weight range regardless of whether they are seeking surgery or outpatient medical treatment. Clinical implications and directions for future research are discussed.

Socioenvironmental, Personal, and Behavioral Correlates of Severe Obesity among an Ethnically/Racially Diverse Sample of US Adolescents

BACKGROUND

Severe obesity among adolescents, also known as class 2 and 3 obesity, is increasing in prevalence, yet, little is known about adolescents with severe obesity. The objective of this study was to identify the socioenvironmental, personal, and behavioral correlates of severe obesity among an ethnically/racially diverse sample of US adolescents.

METHODS

A cross-sectional analysis of data from participants in the EAT 2010 study (n = 2706) was conducted. Adolescents completed in-class surveys, and height and weight were measured. Severe obesity was defined as a BMI ≥120% of the 95th percentile or ≥35 kg/m²; class 1 obesity as a BMI ≥95th percentile but below severe obesity cut points, overweight as a BMI <95th percentile but ≥85th percentile, and normal weight as a BMI <85th but >5th percentile. General linear models were used to identify differences between adolescents by weight status, adjusted for covariates.

RESULTS

Nine percent of adolescents had severe obesity. Compared with peers of other weight statuses, a greater proportion of adolescents with severe obesity reported parental encouragement to diet and peer weight teasing. Adolescents with severe obesity also reported lower self-esteem and body satisfaction. Binge eating was three times as prevalent among adolescents with severe obesity compared with peers of normal weight and twice as prevalent as among peers with class 1 obesity.

CONCLUSIONS

Adolescents with severe obesity report several unique socioenvironmental, personal, and behavioral concerns that may diminish quality of life and may predict increased weight gain over time.

From adolescence to young adulthood: trajectories of psychosocial health following Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) in adolescence results in substantial bodyweight reduction and cardiometabolic benefits into young adulthood. Knowledge gaps remain in understanding psychosocial health.

OBJECTIVE

Describe trajectories of weight and psychosocial health in adolescents who underwent RYGB into young adulthood.

SETTING

Academic Pediatric Medical Center.

METHODS

Fourteen adolescents (presurgery: mean body mass index = 59.2±8.9; mean age = 16.0±1.3 yr; 64.3% female) participated in 2 sequential observational studies. Height and weight were measured, and participants completed measures of weight-related quality of life (WRQOL), mental health, and adaptive functioning at presurgery and 6, 12, 18, 24, and 72+months postsurgery. Substance use behaviors were assessed at 72+months.

RESULTS

Modeling demonstrated rapid improvement in body mass index and WROQL across postoperative year 1, followed by stabilization and modest weight regain/WRQOL decline (P<.001), with 50% remaining severely obese. Presurgery, 11 adolescents presented with symptoms outside of the normal range for≥1 mental health domain. Postoperative profiles indicated either remittance (n = 5) or persistent symptomatology (n = 6: anxious/depressed, withdrawn/depressed, and/or thought problems) in young adulthood. No new incidence of mental health vulnerability occurred in young adults not already identified preoperatively. Adaptive functioning and substance use were within normal range.

CONCLUSIONS

Although adolescent RYGB resulted in improvement in weight and WRQOL into young adulthood, mental health trajectories were more variable, with some experiencing positive change while others experienced persistent mental health vulnerability. Research focused on larger contemporary samples using a controlled design is critical to inform targets for prevention and intervention to optimize both physical and psychosocial health outcomes in this younger patient population.

Are loss of control while eating and overeating valid constructs? A critical review of the literature

BACKGROUND

Binge eating is a marker of weight gain and obesity, and a hallmark feature of eating disorders. Yet its component constructs - overeating and loss of control (LOC) while eating - are poorly understood and difficult to measure.

OBJECTIVE

The objective of this study is to critically review the human literature concerning the validity of LOC and overeating across the age and weight spectrum.

DATA SOURCES

English-language articles addressing the face, convergent, discriminant and predictive validity of LOC and overeating were included.

RESULTS

Loss of control and overeating appear to have adequate face validity. Emerging evidence supports the convergent and predictive validity of the LOC construct, given its unique cross-sectional and prospective associations with numerous anthropometric, psychosocial and eating behaviour-related factors. Overeating may be best conceptualized as a marker of excess weight status.

LIMITATIONS

Binge eating constructs, particularly in the context of subjectively large episodes, are challenging to measure reliably. Few studies addressed overeating in the absence of LOC, thereby limiting conclusions about the validity of the overeating construct independent of LOC. Additional studies addressing the discriminant validity of both constructs are warranted.

DISCUSSION

Suggestions for future weight-related research and for appropriately defining binge eating in the eating disorders diagnostic scheme are presented.

Family factors that characterize adolescents with severe obesity and their role in weight loss surgery outcomes

OBJECTIVE

To comprehensively assess family characteristics of adolescents with severe obesity and whether family factors impact weight loss outcomes following weight loss surgery (WLS).

METHODS

Multisite prospective data from 138 adolescents undergoing WLS and primary caregivers (adolescent: M_age  = 16.9; M_BMI = 51.5 kg/m² ; caregiver: M_age  = 44.5; 93% female) and 83 nonsurgical comparators (NSComp: adolescent: M_age  = 16.1; M_{BMI =} 46.9 kg/m² ; caregiver: M_age  = 43.9; 94% female) were collected using standardized measures at presurgery/baseline and at 1 and 2 years.

RESULTS

The majority (77.3%) of caregivers had obesity, with rates of caregiver WLS significantly higher in the WLS (23.8%) versus NSComp group (3.7%, P < 0.001). Family dysfunction was prevalent (≈1 in every two to three families), with rates higher for NSComp than the WLS group. For the WLS group, preoperative family factors (i.e., caregiver BMI or WLS history, dysfunction, social support) were not significant predictors of adolescent weight loss at 1 and 2 years postoperatively, although change in family functioning over time emerged as a significant correlate of percent weight loss.

CONCLUSIONS

Rates of severe obesity in caregivers as well as family dysfunction were clinically noteworthy, although not related to adolescent weight loss success following WLS. However, change in family communication and emotional climate over time emerged as potential targets to optimize weight loss outcomes.

Loss of control eating and eating disorders in adolescents before bariatric surgery

OBJECTIVE

This study assessed loss of control (LOC) eating and eating disorders (EDs) in adolescents undergoing bariatric surgery for severe obesity.

METHOD

Preoperative baseline data from the Teen Longitudinal Assessment of Bariatric Surgery (Teen-LABS) multisite observational study (n = 242; median BMI = 51 kg/m2 ; mean age= 17; 76% female adolescents; 72% Caucasian) included anthropometric and self-report questionnaires, including the Questionnaire of Eating and Weight Patterns-Revised (QEWP-R), the Night Eating Questionnaire (NEQ), the Beck Depression Inventory (BDI-II), and the Impact of Weight on Quality of Life-Kids (IWQOL-Kids) RESULTS: LOC eating (27%) was common and ED diagnoses included binge-eating disorder (7%), night eating syndrome (5%), and bulimia nervosa (1%). Compared to those without LOC eating, those with LOC eating reported greater depressive symptomatology and greater impairment in weight-related quality of life.

DISCUSSION

Before undergoing bariatric surgery, adolescents with severe obesity present with problematic disordered eating behaviors and meet diagnostic criteria for EDs. LOC eating, in particular, was associated with several negative psychosocial factors. Findings highlight targets for assessment and intervention in adolescents before bariatric surgery. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:947-952).

Comparative results of gastric banding in adolescents and young adults

BACKGROUND/PURPOSE

Obesity has become a major public health priority. Because of disappointing results obtained with dietary and medical programs, bariatric surgery has been offered to adolescents, although this practice remains controversial. Our aim was to evaluate laparoscopic adjustable gastric banding (LAGB) in adolescents at 2-year follow-up.

MATERIAL AND METHODS

This prospective study, from 2008 to 2013, compared results between adolescent patients and young adult controls. The LAGB technique and the follow-up program were similar. Weight loss and comorbid disease were analyzed.

RESULTS

Thirty-six adolescents (mean age at surgery=16.7±1.3years) were operated on and compared to 53 young adults (mean age at surgery=21.7±1.9years). The mean weight and BMI at surgery were 124.4±20.7 and 43.9±5.5kg/m(2), respectively. Among the adolescents, none were diabetic or hypertensive. The mean glycated hemoglobin was 5.6±1.2%. In four cases (11%) dyslipidemia was observed. There was no significant difference between the two groups in terms of initial preoperative weight or BMI. The absolute BMI values at 6, 12 and 24months after surgery were comparable between adolescents and young adults: 38.7 vs 39.8, 36.0 vs 37.6 and 33.5 vs 36.1kg/m(2), respectively. The excess weight loss was higher in adolescents at 12 and 24months: 48.6 vs 37.6% (p=0.03); and 62.3 vs 45.5% (p=0.02). During this period, insulin resistance and dyslipidemia decreased similarly in both groups.

CONCLUSION

Provided there is careful selection of patients and a supportive multidisciplinary team, satisfying results can be obtained after LAGB in adolescents, comparable to those obtained in young adults at 2-year follow-up.

Characteristics of adolescents with poor mental health after bariatric surgery

BACKGROUND

About 20% of adolescents experience substantial mental health problems after bariatric surgery.

OBJECTIVES

The aim of this study was to explore differences between adolescents with poor mental health (PMH) 2 years after surgery and those with average/good mental health.

SETTING

Three university hospitals in Sweden.

METHODS

Mental health and health-related quality of life were assessed in 82 of 88 adolescents (mean age: 16.8 yr, 67% female) at baseline and 1 and 2 years after laparoscopic gastric bypass. Possible associations among mental health, weight, and biochemical outcomes were explored.

RESULTS

Two years after surgery 16 (20%) adolescents were identified as having PMH. More symptoms of anxiety and depression and worse mental health at baseline significantly predicted PMH 2 years later. The decline in mental health for the PMH group happened mainly during the second year after surgery. Suicidal ideation was reported in 14% of the total sample 2 years postsurgery and was more frequent in the PMH group. Weight outcomes between groups were comparable at all time points, and physical health was equally improved 2 years after surgery.

CONCLUSIONS

Although adolescents with PMH after surgery lose as much weight and have similar improvements in physical health compared with other adolescents, special attention should be given to adolescents who report mental health problems at baseline and follow-up, especially during the second year after gastric bypass. The high prevalence of suicidal ideation in adolescents 2 years after bariatric surgery is another indication that longer follow-up is necessary.

Weight-related correlates of psychological dysregulation in adolescent and young adult (AYA) females with severe obesity

OBJECTIVE

Severe obesity is the fastest growing pediatric subgroup of excess weight levels. Psychological dysregulation (i.e., impairments in regulating cognitive, emotional, and/or behavioral processes) has been associated with obesity and poorer weight loss outcomes. The present study explored associations of dysregulation with weight-related variables among adolescent and young adult (AYA) females with severe obesity.

METHODS

Fifty-four AYA females with severe obesity (MBMI = 48.71 kg/m(2); Mage = 18.29, R = 15-21 years; 59.3% White) completed self-report measures of psychological dysregulation and weight-related constructs including meal patterns, problematic eating behaviors, and body and weight dissatisfaction, as non-surgical comparison participants in a multi-site study of adolescent bariatric surgery outcomes. Pearson and bivariate correlations were conducted and stratified by age group to analyze associations between dysregulation subscales (affective, behavioral, cognitive) and weight-related variables.

RESULTS

Breakfast was the most frequently skipped meal (consumed 3-4 times/week). Eating out was common (4-5 times/week) and mostly occurred at fast-food restaurants. Evening hyperphagia (61.11%) and eating in the absence of hunger (37.04%) were commonly endorsed, while unplanned eating (29.63%), a sense of loss of control over eating (22.22%), eating beyond satiety (22.22%), night eating (12.96%), and binge eating (11.11%) were less common. Almost half of the sample endorsed extreme weight dissatisfaction. Dysregulation was associated with most weight-related attitudes and behaviors of interest in young adults but select patterns emerged for adolescents.

CONCLUSIONS

Higher levels of psychological dysregulation are associated with greater BMI, problematic eating patterns and behaviors, and body dissatisfaction in AYA females with severe obesity. These findings have implications for developing novel intervention strategies for severe obesity in AYAs that may have a multidimensional impact on functioning (e.g., psychosocial health, weight loss behaviors).

Long-Term (7 Years) Follow-Up of Roux-en-Y Gastric Bypass on Obese Adolescent Patients (<18 Years)

BACKGROUND

Few data are available about obesity surgery in adolescent patients.

OBJECTIVE

To assess long-term outcomes after laparoscopic Roux-en-Y gastric bypass (LRYGB) in patients <18 years.

SETTING

University Hospital, Europe.

METHODS

A retrospective study of prospectively collected data of patients <18 years (childhood group; ChG) (n = 28) treated by LRYGB of which 19 were available for follow-up between 2.4 and 10.2 years (mean 7.2 years). This group of patients was matched with an adult control group (AdG) of randomly chosen patients with similar characteristics who underwent LRYGB during the same period. The extensive survey included a telephonic questionnaire.

RESULTS

19 (12 females) of the 28 patients (67.9%) were available for follow-up. Preoperatively, 3 had type 2 diabetes mellitus (T2DM), 1 arterial hypertension, 5 dyslipidemia and 1 sleep apnea. In the ChG, average BMI after 7 years dropped from 38.9 kg/m2 preoperatively to 27.5 kg/m2. In the AdG, average BMI decreased from 39.4 to 27.1 kg/m2 in the same time period (nonsignificant between groups). One patient in the ChG needed a reoperation (internal hernia) versus 3 patients in the AdG (1 leak, 2 obstructions). All patients resolved their initial comorbidities. Two of 12 female patients in the ChG became pregnant 6 and 8 years after surgery, respectively, despite seemingly adequate oral contraception. Compliance with postoperative guidelines was good in 16/19 patients in ChG and in 14/18 patients in the AdG. Overall degree of satisfaction was high: 8.2/10 (SD 1.2, range 6-10) in the ChG and 8.9/10 (SD 1.7, range 5-10) in the AdG.

CONCLUSION

LRYGB seems to be safe, provide good weight loss, and cure comorbidities in an adolescent population. Satisfaction degree is high. Inadvertent pregnancy despite conventional contraception is a possible issue.

Systematic review of psychological and social outcomes of adolescents undergoing bariatric surgery, and predictors of success

The psychological and social outcomes of bariatric surgery in adolescents, together with psychological and social predictors of success, were systematically reviewed. PubMed, EMBASE, ISI Web of Science and PsychInfo were searched on July 2014. Existing data were sparse; 15 were suitable for qualitative review and six for meta-analysis (four quality of life [QOL], two depression). One study was a randomized controlled trial. A total of 139 subjects underwent Roux-en-Y gastric bypass, 202 underwent adjustable gastric band and 64 underwent sleeve gastrectomy. Overall QOL improved after bariatric surgery, regardless of surgical type with peak improvement at 6-12 months. Meta-analysis of four studies showed changed in overall QOL at latest follow-up of 2.80 standard deviation (SD) (95% confidence interval [CI] 1.23-4.37). Depression improved across all studies, regardless of procedure (effect size -0.47 SD [95% CI -0.76, -0.18] at 4-6 months). Two cohorts reported changes in both overall QOL and depression following a quadratic trajectory, with overall improvement over 2 years and deterioration in the second post-operative year. There were limited data on other psychological and social outcomes. There were insufficient data on psychosocial predictors of outcome to form evidence-based recommendations for patient selection for bariatric surgery at this time.

Outcome analysis of single incision vs traditional multiport sleeve gastrectomy: a matched cohort study

BACKGROUND

Single incision laparoscopy remains controversial due to technical challenges which may cause suboptimal outcomes. This study aims to evaluate the feasibility and equivalency of the single incision sleeve gastrectomy (SISG) when compared to the traditional multiport sleeve gastrectomy (MPSG) approach in a matched cohort evaluating technical aspects and postoperative results.

METHODS

This is a retrospective analysis of prospectively collected data in a consecutive cohort of 113 SG (MPSG = 77, SISG = 36). The 36 patients who underwent SISG were included as the case group. Thirty-six MPSG patients were included in the control group, in 1:1 ratio with cases after matching for BMI, age, race, gender, and additional demographic data. Operative time (OT) in minutes and length of stay (LOS) in days was measured and excess weight loss (EWL) at 6 months and 1 year was collected and evaluated.

RESULTS

Mean BMI was equivalent (SISG 43.06, MPSG 43.72, p = 0.36). Mean OT for the SISG was 116.78 and 118.25 for the MPSG (p = 0.84), and mean LOS was 1.80 for the SISG and 1.75 for the MSPG (p = 0.75). EWL at 6 months was 58.4 % for the SISG and 58.5 % for the MPSG (p = 0.98) and 72.3 and 74.1 % (p = 0.77) for 1 year, respectively. There were no leaks in either group. There was one reoperation for postoperative bleeding in the MPSG group.

CONCLUSIONS

Sleeve gastrectomy can be performed safely using single incision techniques with equivalent outcomes for weight loss.

Two-year trends in psychological outcomes after gastric bypass in adolescents with severe obesity

OBJECTIVE

This study aimed to evaluate changes in mental health over 2 years in adolescents undergoing gastric bypass.

METHODS

Eighty-eight adolescents (65% girls) aged 13 to 18 years were assessed at baseline and 1 and 2 years after surgery. Generic and obesity-specific questionnaires were used to evaluate outcomes in mental health, also in relation to age- and gender-specific norms.

RESULTS

Symptoms of anxiety (P = 0.001), depression (P = 0.001), anger (P = 0.001), and disruptive behavior (P = 0.022) were significantly reduced at 2 years after surgery, as were obesity-related problems (P < 0.001). Self-esteem (P < 0.001), self-concept (P < 0.001), and overall mood (P = 0.025) improved significantly. Improvements were mainly observed during the first year after surgery. The second year was characterized by stabilization. Symptoms of anxiety, depression, anger, disruptive behavior, and self-concept were at normative levels after surgery. However, 19% of the adolescents had depressive symptoms in the clinical range.

CONCLUSIONS

A substantial improvement in mental health in adolescents over the first 2 years after gastric bypass was found. Most adolescents had a level of mental health and self-concept similar to norms, but a marked subgroup showed substantial depressive symptoms 2 years after surgery.

Suicidal Ideation and Behaviours Among Adolescents Receiving Bariatric Surgery: A Case-Control Study

OBJECTIVE

This study examined the prevalence and correlates of suicidal ideation and behaviour (SI/B) among adolescents receiving bariatric surgery.

METHOD

Charts of 206 adolescents receiving bariatric surgery were reviewed. Cases with SI/B (current/lifetime reported at baseline or event occurring in the programme n = 31, 15%) were case matched on gender, age and surgery type to 31 adolescents reporting current or past psychiatric treatment and 31 adolescents denying lifetime SI/B or psychiatric treatment.

RESULTS

Before surgery, adolescents with SI/B reported significantly lower total levels of health-related quality of life (p = 0.01) and greater depressive symptoms (p = 0.004) in comparison with candidates who never received psychiatric treatment. No significant differences were found between groups for the change in depressive symptoms or body mass index following surgery.

CONCLUSIONS

As in studies of adults, a notable subset of adolescents receiving bariatric surgery indicated pre-operative or post-operative SI/B. It is critical that clinicians evaluate and monitor adolescent patients undergoing bariatric surgery for risk of SI/B.

Comanagement of Pediatric Depression and Obesity: A Clear Need for Evidence

PURPOSE

The purpose of this article is to provide a review of the existing literature for the comanagement of depression and obesity in the pediatric population.

METHODS

A review of the current literature was conducted using EBSCOhost and EMBASE to identify evidence and recommendations for the comanagement of depression and obesity among children and adolescents (aged 2-18 years). Additional search criteria included peer-reviewed, English language-only full-text articles published before August 2015.

FINDINGS

Multiple factors contribute to and influence the interplay of obesity and depression in the pediatric population. These 2 chronic conditions are affected by multiple factors, including the roles of the family, school, health care practitioners, and access to health care. In addition, there are no formal recommendations for the treatment of depression in the setting of obesity for pediatric or adult populations, and there is only medication approved by the Food and Drug Administration (orlistat) for the treatment of obesity in the adolescent population. Bariatric surgery may play a role in some adolescents, but larger and long-term clinical studies with the use of therapeutic agents in conjunction with lifestyle modification need to be conducted to support this.

IMPLICATIONS

The interrelatedness of these 2 separate diseases is not well understood; the presence of 1 of the diseases clearly contributes to the manifestation of the other and likely to the ability to treat the other disease. Current focus is on modifying behavior to decrease weight. Weight loss is associated with improvement in depressive symptoms but may not be adequate to treat depression.