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Mejaddam A, Höskuldsdóttir G, Lenér F, Wallenius V, Trimpou P, Fändriks L, Mossberg K, Eliasson B, Landin-Wilhelmsen K. Effects of medical and surgical treatment on vitamin D levels in obesity. PLoS One 2023; 18:e0292780. [PMID: 38134006 PMCID: PMC10745143 DOI: 10.1371/journal.pone.0292780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/27/2023] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION Persons living with obesity treated with bariatric surgery are at a high risk of developing nutritional deficiencies. The primary aim of this observational cohort study was to compare vitamin D levels in patients two years after bariatric surgery (Roux-en-Y gastric bypass/RYGB and sleeve gastrectomy/SG) with a very low-energy diet (VLED). The same subjects were also compared with a population sample from the same region at baseline. The primary hypothesis was that surgery, especially RYGB, would lead to an increased prevalence of vitamin D deficiency compared to subjects treated with VLED. 971 individuals eligible for surgical, RYGB (n = 388), SG (n = 201), and medical treatment (n = 382), in routine care, were included consecutively between 2015 and 2017. A random population sample from the WHO-MONICA project was used as a reference, (n = 414). S-calcium, S-25(OH)D (vitamin D), and S-PTH (parathyroid hormone) were measured in all persons with obesity at baseline and two years after treatment (n = 713). Self-reported use of vitamin D and calcium supplementation was registered. RESULTS Vitamin D deficiency (S-25(OH)D <25mmol/l) was found in 5.2% of the persons with obesity at baseline versus 1.7% of the general population (SMD>0.1). S-25(OH)D increased for all treatment groups but was higher in RYGB and SG (SMD>0.1, standardized mean difference). Thirteen subjects (1.8%) had vitamin D deficiency after obesity treatment. CONCLUSION Surgical intervention for obesity followed by vitamin D supplementation was not associated with a higher risk for vitamin D deficiency, irrespective of surgery type, compared to individuals on medical treatment. However, persons living with obesity seeking weight loss treatment are more likely to have deficient vitamin D levels compared to the general population.
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Affiliation(s)
- Ala Mejaddam
- Department of Internal Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gudrún Höskuldsdóttir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section for Endocrinology and Diabetology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frida Lenér
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Public Health and Community Medicine Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ville Wallenius
- Department of Surgery, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section for Endocrinology and Diabetology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Fändriks
- Department of Surgery, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Mossberg
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Public Health and Community Medicine Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Section for Endocrinology and Diabetology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Landin-Wilhelmsen
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Section for Endocrinology and Diabetology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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Lenér F, Höskuldsdóttir G, Landin-Wilhelmsen K, Björkelund C, Eliasson B, Fändriks L, Wallenius V, Engström M, Mossberg K. Anaemia in patients with self-reported use of iron supplements in the BAriatric surgery SUbstitution and nutrition study: A prospective cohort study. Nutr Metab Cardiovasc Dis 2023; 33:998-1006. [PMID: 36890072 DOI: 10.1016/j.numecd.2023.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 02/05/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023]
Abstract
BACKGROUND AND AIMS After bariatric surgery, micronutrient deficiencies may lead to anaemia. To prevent post-operative deficiencies, patients are recommended lifelong micronutrient supplementation. Studies investigating the effectiveness of supplementation to prevent anaemia after bariatric surgery are scarce. This study aimed to investigate the relationship between nutritional deficiencies and anaemia in patients who report use of supplementation two years after bariatric surgery versus patients who do not. METHODS AND RESULTS Obese (BMI≥35 kg/m2) individuals (n = 971) were recruited at Sahlgrenska University Hospital in Gothenburg, Sweden between 2015 and 2017. The interventions were Roux-en-Y gastric bypass (RYGB), n = 382, sleeve gastrectomy (SG), n = 201, or medical treatment (MT), n = 388. Blood samples and self-reported data on supplements were collected at baseline and two years post treatment. Anaemia was defined as haemoglobin <120 g/L for females and <130 g/L for males. Standard statistical methods, including a logistic regression model and a machine learning algorithm, were used to analyse data. The frequency of anaemia increased from baseline in patients treated with RYGB (3·0% vs 10·5%; p < 0·05). Neither iron-dependent biochemistry nor frequency of anaemia differed between participants who reported use of iron supplements and those who did not at the two-year follow-up. Low preoperative level of haemoglobin and high postoperative percent excessive BMI loss increased the predicted probability of anaemia two years after surgery. CONCLUSION The results from this study indicate that iron deficiency or anaemia may not be prevented by substitutional treatment per current guidelines after bariatric surgery and highlights there is reason to ensure adequate preoperative micronutrient levels. TRIAL REGISTRATION March 03, 2015; NCT03152617.
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Affiliation(s)
- Frida Lenér
- Primary Care/Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gudrún Höskuldsdóttir
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Section for Endocrinology and Diabetology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Landin-Wilhelmsen
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Section for Endocrinology and Diabetology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Care/Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Section for Endocrinology and Diabetology, Department of Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Fändriks
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University hospital, Gothenburg, Sweden
| | - Ville Wallenius
- Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden; Department of Surgery, Sahlgrenska University hospital, Gothenburg, Sweden
| | - My Engström
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Department of Surgery, Gothenburg, Sweden
| | - Karin Mossberg
- Primary Care/Department of Public Health and Community Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Mejaddam A, Krantz E, Höskuldsdóttir G, Fändriks L, Mossberg K, Eliasson B, Trimpou P, Landin-Wilhelmsen K. Comorbidity and quality of life in obesity-a comparative study with the general population in Gothenburg, Sweden. PLoS One 2022; 17:e0273553. [PMID: 36194568 PMCID: PMC9531784 DOI: 10.1371/journal.pone.0273553] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 08/11/2022] [Indexed: 11/14/2022] Open
Abstract
CONTEXT Obesity is considered to have a detrimental impact on health-related quality of life (HRQoL). OBJECTIVE To compare HRQoL in a well-defined group of people with obesity with a population-based control group from the general public. DESIGN Observational cross-sectional cohort study with a reference population. SETTING The Regional Obesity Center at the Department of Medicine at Sahlgrenska University Hospital, Gothenburg, Sweden. PARTICIPANTS People with obesity (n = 1122) eligible for surgical and non-surgical obesity treatment in routine care were included consecutively between 2015 and 2017 into the BASUN study. Men and women from the WHO-MONICA-GOT project were used as a reference population (n = 414). MAIN OUTCOME MEASURES HRQoL was measured with the RAND-36/Short Form-36 questionnaire (SF-36) and a Visual Analogue Scale (VAS) for self-related health (SRH). Prescription drugs for hypertension, diabetes mellitus, depression, and anxiety were taken as a proxy for these conditions. RESULTS People with obesity rated their overall HRQoL lower than the reference population according to the SRH-VAS. Lower scores were reported on physical and social functioning, vitality, general and mental health after adjustment for age and use of prescription drugs (considered a proxy for burden of disease, or comorbidities) using the RAND-36/SF-36 questionnaire. Use of some psychopharmacological agents was more common in patients with obesity. CONCLUSION People with obesity seeking help with weight reduction are more likely to have lower physical and mental self-reported HRQoL than the general population.
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Affiliation(s)
- Ala Mejaddam
- Department of Internal Medicine, Sahlgrenska University Hospital/Östra, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Gothenburg, Sweden
- * E-mail:
| | - Emily Krantz
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Gothenburg, Sweden
- Department of Respiratory Medicine, Sahlgrenska University Hospital, Gothenburg, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Gudrún Höskuldsdóttir
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Gothenburg, Sweden
- Section for Endocrinology and Diabetology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Fändriks
- Department of Surgery, Institution for Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Karin Mossberg
- Department of Public Health and Community Medicine Primary Health Care, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Björn Eliasson
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Gothenburg, Sweden
- Section for Endocrinology and Diabetology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Penelope Trimpou
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Gothenburg, Sweden
- Section for Endocrinology and Diabetology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kerstin Landin-Wilhelmsen
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Gothenburg, Sweden
- Section for Endocrinology and Diabetology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Höskuldsdóttir G, Engström M, Rawshani A, Wallenius V, Lenér F, Fändriks L, Mossberg K, Eliasson B. The BAriatic surgery SUbstitution and nutrition (BASUN) population: a data-driven exploration of predictors for obesity. BMC Endocr Disord 2021; 21:183. [PMID: 34507573 PMCID: PMC8431862 DOI: 10.1186/s12902-021-00849-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 08/18/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The development of obesity is most likely due to a combination of biological and environmental factors some of which might still be unidentified. We used a machine learning technique to examine the relative importance of more than 100 clinical variables as predictors for BMI. METHODS BASUN is a prospective non-randomized cohort study of 971 individuals that received medical or surgical treatment (treatment choice was based on patient's preferences and clinical criteria, not randomization) for obesity in the Västra Götaland county in Sweden between 2015 and 2017 with planned follow-up for 10 years. This study includes demographic data, BMI, blood tests, and questionnaires before obesity treatment that cover three main areas: gastrointestinal symptoms and eating habits, physical activity and quality of life, and psychological health. We used random forest, with conditional variable importance, to study the relative importance of roughly 100 predictors of BMI, covering 15 domains. We quantified the predictive value of each individual predictor, as well as each domain. RESULTS The participants received medical (n = 382) or surgical treatment for obesity (Roux-en-Y gastric bypass, n = 388; sleeve gastrectomy, n = 201). There were minor differences between these groups before treatment with regard to anthropometrics, laboratory measures and results from questionnaires. The 10 individual variables with the strongest predictive value, in order of decreasing strength, were country of birth, marital status, sex, calcium levels, age, levels of TSH and HbA1c, AUDIT score, BE tendencies according to QEWPR, and TG levels. The strongest domains predicting BMI were: Socioeconomic status, Demographics, Biomarkers (notably TSH), Lifestyle/habits, Biomarkers for cardiovascular disease and diabetes, and Potential anxiety and depression. CONCLUSIONS Lifestyle, habits, age, sex and socioeconomic status are some of the strongest predictors for BMI levels. Potential anxiety and / or depression and other characteristics captured using questionnaires have strong predictive value. These results confirm previously suggested associations and advocate prospective studies to examine the value of better characterization of patients eligible for obesity treatment, and consequently to evaluate the treatment effects in groups of patients. TRIAL REGISTRATION March 03, 2015; NCT03152617 .
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Affiliation(s)
- Gudrún Höskuldsdóttir
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
| | - My Engström
- Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Araz Rawshani
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ville Wallenius
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Frida Lenér
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Public Health and Community Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Fändriks
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Karin Mossberg
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Public Health and Community Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Björn Eliasson
- Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
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Höskuldsdóttir G, Sattar N, Miftaraj M, Näslund I, Ottosson J, Franzén S, Svensson AM, Eliasson B. Potential Effects of Bariatric Surgery on the Incidence of Heart Failure and Atrial Fibrillation in Patients With Type 2 Diabetes Mellitus and Obesity and on Mortality in Patients With Preexisting Heart Failure: A Nationwide, Matched, Observational Cohort Study. J Am Heart Assoc 2021; 10:e019323. [PMID: 33754795 PMCID: PMC8174344 DOI: 10.1161/jaha.120.019323] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Obesity and diabetes mellitus are strongly associated with heart failure (HF) and atrial fibrillation (AF). The benefits of bariatric surgery on cardiovascular outcomes are known in people with or without diabetes mellitus. Surgical treatment of obesity might also reduce the incidence of HF and AF in individuals with obesity and type 2 diabetes mellitus (T2DM). Methods and Results In this register‐based nationwide cohort study we compared individuals with T2DM and obesity who underwent Roux‐en‐Y gastric bypass surgery with matched individuals not treated with surgery. The main outcome measures were hospitalization for HF and/or AF and mortality in patients with preexisting HF. We identified 5321 individuals with T2DM and obesity who had undergone Roux‐en‐Y gastric bypass surgery between January 2007 and December 2013 and 5321 matched controls. The individuals included were 18 to 65 years old and had a body mass index >27.5 kg/m2. The follow‐up time for hospitalization was until the end of 2015 (mean 4.5 years) and the end of 2016 for death. Our results show a 73% lower risk for HF (hazard ratio [HR], 0.27; CI, 0.19–0.38), 41% for AF (HR, 0.59; CI, 0.44–0.78), and 77% for concomitant AF and HF (HR, 0.23; CI, 0.12–0.46) in the surgically treated group. In patients with preexisting HF we observed significantly lower mortality in the group who underwent surgery (HR, 0.23; 95% CI, 0.12–0.43). Conclusions Bariatric surgery may reduce risk for HF and AF in patients with T2DM and obesity, speculatively via positive cardiovascular and renal effects. Obesity treatment with surgery may also be a valuable alternative in selected patients with T2DM and HF.
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Affiliation(s)
- Gudrún Höskuldsdóttir
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
| | - Naveed Sattar
- The Institute of Cardiovascular and Medical Sciences University of Glasgow United Kingdom
| | - Mervete Miftaraj
- Centre of Registers National Diabetes Register Gothenburg Sweden
| | - Ingmar Näslund
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Johan Ottosson
- Department of Surgery Faculty of Medicine and Health Örebro University Örebro Sweden
| | - Stefan Franzén
- Centre of Registers National Diabetes Register Gothenburg Sweden.,Health Metrics Unit Sahlgrenska AcademyUniversity of Gothenburg Sweden
| | - Ann-Marie Svensson
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Centre of Registers National Diabetes Register Gothenburg Sweden
| | - Björn Eliasson
- Department of Molecular and Clinical Medicine University of Gothenburg Sweden.,Department of Medicine Sahlgrenska University Hospital Gothenburg Sweden
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Höskuldsdóttir G, Mossberg K, Wallenius V, Al Nimer A, Björkvall W, Lundberg S, Behre CJ, Werling M, Eliasson B, Fändriks L. Design and baseline data in the BAriatic surgery SUbstitution and Nutrition study (BASUN): a 10-year prospective cohort study. BMC Endocr Disord 2020; 20:23. [PMID: 32059719 PMCID: PMC7023772 DOI: 10.1186/s12902-020-0503-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 02/11/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND There is still a lack of knowledge on long-term effects of surgical and non-surgical weight-lowering treatments. BASUN is a prospective study with 10 years of follow-up that will observe the effects and consequences of surgical and medical treatment of obesity. The aims are to cover areas where data on long-term outcomes are lacking, e.g., nutritional deficiencies, substance abuse, psychiatric health, as well as patient-reported outcomes. METHODS BASUN is a cohort study that recruited study persons with obesity (BMI ≥ 35 kg/m2) referred to the Regional Obesity Centre of Region Västra Götaland. The interventions were Roux-en-Y gastric bypass (RYGB) or Sleeve gastrectomy (SG), or 12 months of structured, multi-professional medical treatment (MT), including very low energy diet, followed by diet and pharmaceutical treatment. The study is not randomized, but based on patients preferences and multidisciplinary assessments. The study persons are examined at baseline, 2, 5, and 10 years with blood tests, measurements and questionnaires. The recruitment period lasted from May 2015 to November 2017. RESULTS One thousand one hundred twenty-seven patients were included (74% female). Three hundred eighty-two patients were accepted for medical treatment, 589 for surgical treatment (388 RYGB and 201 SG) and 156 patients left the study without treatment, leaving a final study population of 971 patients. There were slight differences between the treatment groups with regards to age and BMI. Pharmaceutical treatments, level of education, smoking and marital status were not significantly different between the groups. CONCLUSION This study will follow 971 obese subjects in clinical practice treated with the best surgical or medical methods currently available. It has the potential to evaluate outcomes usually not reported in short-term studies, and to assist in identifying factors that are of importance for the choices of treatment. The main limitations are non-randomization and differences in baseline characteristics. The large number of participants and the length of the prospective follow-up are major strengths of the study. BASUN is designed to identify both early and late benefits and adverse events of treatment of obesity. TRIAL REGISTRATION This trial was prospectively registered on March 03, 2015; NCT03152617.
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Affiliation(s)
- Gudrún Höskuldsdóttir
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden.
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden.
| | - Karin Mossberg
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Ville Wallenius
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Angelos Al Nimer
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Wiveka Björkvall
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sören Lundberg
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carl-Johan Behre
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Malin Werling
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Björn Eliasson
- Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
- Department of Medicine, Sahlgrenska University Hospital, 413 45, Gothenburg, Sweden
| | - Lars Fändriks
- Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
- Department of Public Health and Community Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
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