Treatment Option For Severe Obesity Research Articles

Adolescent Bariatric Surgery: The Need for Tailored Educational Materials.

Rates of class III, or greater, obesity have risen among adolescents in the United States. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for severe obesity among teenagers that results in improvements in cardiometabolic and psychosocial health. Despite its effectiveness, MBS remains largely underutilized and misconceptions exist among providers, parents/guardians, and adolescents. In addition, adolescents who have undergone MBS procedures report there are some topics they wish they had known more about before surgery and express concern that their unique needs are not understood. One potential solution to address these concerns includes preoperative educational materials tailored for adolescents. Currently, there are no standardized recommendations for preoperative educational materials. This editorial suggests the use of community-engaged research, and qualitative methodology, to consult with the primary stakeholder groups of preoperative adolescents, postoperative adolescents, parents/guardians, and clinicians to develop tailored materials that address the unique needs of adolescents undergoing surgical treatment for obesity.

Impact of the COVID-19 Pandemic on Metabolic and Bariatric Surgery Utilization and Safety in the United States.

BackgroundMetabolic and bariatric surgery (MBS) is a safe and effective treatment option for severe obesity. The utilization and health and safety outcomes of MBS in the United States (US) during the COVID-19 pandemic versus 2015–2019 among adolescent and adult populations and by ethnic group is largely unknown.MethodsThe 2015–2020 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) longitudinal (30-day) cohort data was used to compare adolescent and adult (N = 1,134,522) post-operative outcomes and to calculate MBS utilization pre-pandemic (2015–2019) versus pandemic (2020). Cochran-Armitage trend tests compared MBS utilization and safety outcomes over time from 2015 to 2020. Logistic regression analysis compared the odds of hospital readmission and MBS completion pre-pandemic versus pandemic by key characteristics.ResultsMBS utilization increased by 8.1% among youth (from 970 to 1140 procedures) and decreased by 10.2% among adults (from 205,232 to 167,384) from 2019 to 2020, respectively. MBS increased by 18.5% during the pandemic for youth who identified as other/multiracial (P trend < 0.001). Among US youth, the number of reoperations and reinterventions significantly decreased over the 6-year time frame (P trend < .001). Among US adults, 30-day post MBS mortality, reoperations, readmissions, and reinterventions all showed a significant decrease over time (P trend < .001) while septic shock and sepsis increased from pre-pandemic to the first year of the pandemic (P trend < 0.001).ConclusionIn comparison to 2019 (or to previous years), US MBS utilization increased for youth but decreased for adults during the first year of the COVID-19 pandemic. Safety outcomes were comparable to those of the pre-pandemic years.Graphical abstract

Longitudinal Outcomes in Adolescents After Referral for Metabolic and Bariatric Surgery.

Metabolic and bariatric surgery (MBS) can be a well tolerated and effective treatment option for severe obesity in adolescents. We compared outcomes for adolescents that did and did not proceed to surgery. A single-center longitudinal study (2015-2020). Patients were identified as LSG if they completed laparoscopic sleeve gastrectomy within 6 months of initial visit and NoLSG if they did not. Chi-square, Fisher exact, nonparametric Kruskal-Wallis tests, and Linear Mixed Models (LMM) were used to compare outcomes over 2 years. Three hundred fifty-two adolescents were referred with a mean age of 15.6 ± 1.4, 69% girls, 38% Hispanic, and 78% had noncommercial insurance. The median baseline weight was 135 kg and body mass index (BMI) was 48 kg/m2; 42% had a BMI >50. Seventy-nine (22%) underwent LSG whereas 273 (78%) did not complete MBS primarily because of lack of interest. LSG patients had 21% total weight loss and 22% total BMI loss at 24 months whereas NoLSG patients had 4% total weight gain and 3% BMI gain (P < 0.01). Obesity-associated conditions improved in the LSG group (P < 0.01). Follow-up in both groups was poor (≤30% at 24 months). Patients with public insurance and those with BMI from 50 to 59.9 kg/m2 were high performing LSG patients. A minority (22%) of adolescents referred for MBS proceeded to surgery, despite its demonstrated efficacy and safety in adolescence. Those that did not undergo surgery continued to gain weight. Further research is needed to understand patient preferences or concerns related to MBS utilization during adolescence.

Bariatric surgery can acutely modulate ER-stress and inflammation on subcutaneous adipose tissue in non-diabetic patients with obesity

BackgroundBariatric surgery, especially Roux-en-Y gastric bypass (RYGB), is the most effective and durable treatment option for severe obesity. The mechanisms involving adipose tissue may be important to explain the effects of surgery.MethodsWe aimed to identify the genetic signatures of adipose tissue in patients undergoing RYGB. We evaluated 13 obese, non-diabetic patients (mean age 37 years, 100% women, Body mass index (BMI) 42.2 kg/m2) one day before surgery, 3 and 6 months (M) after RYGB.ResultsAnalysis of gene expression in adipose tissue collected at surgery compared with samples collected at 3 M and 6 M Post-RYGB showed that interleukins [Interleukin 6, Tumor necrosis factor-α (TNF-α), and Monocyte chemoattractant protein-1(MCP1)] and endoplasmic reticulum stress (ERS) genes [Eukaryotic translation initiation factor 2 alpha kinase 3 (EIF2AK3) and Calreticulin (CALR)] decreased during the follow-up (P ≤ 0.01 for all). Otherwise, genes involved in energy homeostasis [Adiponectin and AMP-activated protein kinase (AMPK)], cellular response to oxidative stress [Sirtuin 1, Sirtuin 3, and Nuclear factor erythroid 2-related factor 2 (NRF2)], mitochondrial biogenesis [Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC1α)] and amino acids metabolism [General control nonderepressible 2 (GCN2)] increased from baseline to all other time points evaluated (P ≤ 0.01 for all). Also, expression of Peroxisome proliferator-activated receptor gamma (PPARϒ) (adipogenesis regulation) was significantly decreased after RYGB (P < 0.05). Additionally, we observed that PGC1α, SIRT1 and AMPK strongly correlated to BMI at 3 M (P ≤ 0.01 for all), as well as ADIPOQ and SIRT1 to BMI at 6 M (P ≤ 0.01 for all).ConclusionsOur findings demonstrate that weight loss is associated with amelioration of inflammation and ERS and increased protection against oxidative stress in adipose tissue. These observations are strongly correlated with a decrease in BMI and essential genes that control cellular energy homeostasis, suggesting an adaptive process on a gene expression level during the caloric restriction and weight loss period after RYGB.Trial registration CAAE: 73,585,317.0.0000.5440

A sympathetic gut connection drives the metabolic benefits of Roux-en-Y gastric bypass.

Surgery is regarded by many as the go-to treatment option for severe obesity; yet how physically altering the gastrointestinal tract produces such striking results on body weight and overall metabolic health is poorly understood. In a recent issue of Cell Reports Ye et al. (2020) compare mouse models of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG), the two most commonly performed weight loss surgeries in the clinic today, to show that the former reconfiguring procedure selectively increases resting metabolic rate through splanchnic nerve-mediated browning of mesenteric white fat. More significantly, they demonstrate that this effect for RYGB is required for the maintained negative energy balance and improved glycemic control that it confers.

Type 2 diabetes is an independent predictor of weight loss in Tier 3 Weight Assessment and Management Services

Introduction: A specialist weight management service provides an effective treatment option for severe obesity; however, there are limited data exploring the baseline predictors of response and effect on HbA1c following engagement with the service.Methods: We used prospective data from the regional weight management services within the Hull University Teaching Hospitals NHS Trust Tier 3 Obesity Programme. Data were available for 249 patients referred to the service. T-tests were used for univariate baseline characteristics of those with and without 5% weight loss after engagement with the service. Logistic regression analysis was used to identify independent predictors of weight loss at 12 months.Results: A total of 309 patients were referred to the Tier 3 adult weight management service, of which 249 (80.6%) participated in the programme and had at least one follow-up. The median age of the study population was 46 years (range 36–55) and consisted of 66% females with a median baseline body mass index of 44 kg/m2 (range 42–45). The prevalence of type 2 diabetes was 31%, hypertension was 35%, gastro-oesophageal reflux disease was 34% and osteoarthritis was 29%. The median baseline weight on enrolment in the programme was 126 kg (range 115–138). During the follow-up period of 1 year, the median weight fell to 120.5 kg at 3 months, 119.6 kg at 6 months, 117.7 kg at 9 months and 117.5 kg at 12 months. The median HbA1c fell from a baseline of 60.25 mmol/mol to 54.4 mmol/mol during the follow-up period. Sixty-four patients had a baseline HbA1c of &gt;53 mmol/mol (7% HbA1c), which fell to &lt;53 mmol/mol in 21% of patients during the follow-up period. In the logistic regression model, higher age (OR 1.05, p=0.0001), type 2 diabetes (OR 2.54, p=0.002) and dyslipidaemia (OR 2.21, p=0.03) were independently associated with more than 5% weight loss at 12 months follow-up.Conclusion: Engagement with Tier 3 adult weight management is associated with significant weight loss and improvement in glycaemic control in a large proportion of patients at one year. Higher age, diabetes and dyslipidaemia at baseline are independent predictors of weight loss on the Tier 3 weight management service.

A588 Is Bariatric Surgery Becoming Safer? Assessing MBSAQIP Data Over a Three-Year Time Period

Bariatric surgery is an underutilized treatment option for severe obesity in the United States. An estimated 228,000 bariatric procedures were performed in 2017, representing a progressive increase since 2011. However, little large-scale data exists in the literature to determine whether bariatric surgery is becoming safer over time.

Mortality related to primary bariatric surgery in England.

BackgroundBariatric surgery is an accepted treatment option for severe obesity. Previous analysis of the independently collected Hospital Episode Statistics (HES) data for outcomes after bariatric surgery demonstrated a 30‐day postoperative mortality rate of 0·3 per cent in the English National Health Service (NHS). However, there have been no published mortality data for bariatric procedures performed since 2008. This study aimed to assess mortality related to bariatric surgery in England from 2009.MethodsHES data were used to identify all patients who had primary bariatric surgery from 2009 to 2016. Clinical codes were used selectively to identify all primary bariatric procedures but exclude revision or conversion procedures and operations for malignant or other benign disease. The primary outcome measures were HES in‐hospital and Office for National Statistics (ONS) 30‐day mortality after discharge.ResultsA total of 41 241 primary bariatric procedures were carried out in the NHS between 2009 and 2016, with 29 in‐hospital deaths (0·07 per cent). The 30‐day mortality rate after discharge was 0·08 per cent (32 of 41 241). Both the in‐hospital and 30‐day mortality rates after discharge demonstrated a downward trend over the study period.ConclusionOverall in‐hospital and 30‐day mortality rates remain very low after primary bariatric surgery. An increased uptake of bariatric surgery within the English NHS has been safe.

Exploring the evidence base for Tier 3 weight management interventions for adults: a systematic review.

Specialist weight management services provide a treatment option for severe obesity. The objective of the study is to review the characteristics, impact and practice implications of specialist weight management services for adults in the UK. Systematic review: EMBASE, MEDLINE and PsycINFO were searched from January 2005 to March 2016 with supplementary searches. Adults with a body mass index of ≥40 kg m-2 , or ≥35 kg m-2 with comorbidity or ≥30 kg m-2 with type 2 diabetes and any study of multicomponent interventions, in any UK or Ireland setting, delivered by a specialist multidisciplinary team are the inclusion criteria. Fourteen studies in a variety of settings were included: 1 randomized controlled trial, 3 controlled and 10 observational studies. Mean baseline body mass index and age ranged from 40 to 54 kg m-2 and from 40 to 58 years. The studies were heterogeneous making comparisons of service characteristics difficult. Multidisciplinary team composition and eligibility criteria varied; dropout rates were high (43-62%). Statistically significant reduction in mean body mass index over time ranged from -1.4 to -3.1 kg m-2 and mean weight changes ranged from -2.2 to -12.4 kg. Completers achieving at least 5% reduction of initial body weight ranged from 32 to 51%. There was evidence for improved outcomes in diabetics. Specialist weight management services can demonstrate clinically significant weight loss and have an important role in supporting adults to manage severe and often complex forms of obesity. This review highlights important variations in provision and strongly indicates the need for further research into effective approaches to support severely obese adults.

Primary care physician decision making regarding referral for bariatric surgery: a national survey

BackgroundBariatric surgery is the most effective treatment for severe obesity. It results in significant and sustained weight loss and reduces obesity-related co-morbidities. Despite an increasing prevalence of severe obesity, the number of bariatric operations performed in Denmark has decreased during the past years. This is only partly explained by changes in the national guidelines for bariatric surgery. The purpose of the cross-sectional study is to investigate referral patterns and possible reservations regarding bariatric surgery among Danish primary care physicians (PCPs). SettingPrimary care physicians in Denmark MethodsA total of 300 Danish PCPs were invited to participate in a questionnaire survey regarding experiences with bariatric surgery, reservations about bariatric surgery, attitudes to specific patient cases, and the future treatment of severe obesity. Most questions required a response on a 5-point Likert scale (strongly disagree, disagree, neither agree nor disagree, agree, and strongly agree) and frequency distributions were calculated. Results133 completed questionnaires (44%) were returned. Most physicians found that they had good knowledge about the national referral criteria for bariatric surgery. With respect to the specific patient cases, a remarkably smaller part of physicians would refer patients on their own initiative, compared with the patient’s initiative. Fear of postoperative surgical complications and medical complications both influenced markedly the decision to refer patients for surgery. Only 9% of the respondents indicated that bariatric surgery should be the primary treatment option for severe obesity in the future. ConclusionDanish PCPs express severe concerns about surgical and medical complications following bariatric surgery. This might, in part, result in a low rate of referral to bariatric surgery.

A5083 - 30 Day Readmission Following Weight Loss Surgery: Can Psychological Factors Predict Non-Specific Indications for Readmission?

Although bariatric surgery is considered a safe and efficacious treatment option for severe obesity, 5% or more of patients are readmitted due to complications in the first 30 days. Some of these complications relate directly to surgical risks whereas others relate to more vague complaints or patient non-adherence. Such non-specific indications for surgery may reflect risks outside of the surgical procedure. A large literature has demonstrated that bariatric surgery patients are a psychiatrically vulnerable population, though no studies to date have investigated whether pre-surgical psychosocial factors are related to readmission. Patients who had been initially evaluated by our program and readmitted within 30 days post-bariatric surgery during a 4 year period (2012-2015) were identified (n=102). These patients were matched (2:1) to 204 non-readmitted patients on pre-operative BMI (48.1 vs. 48.9 kg/m2), age (48.1 vs. 48.9 years), gender (73% vs. 74% female) and race (67% vs. 65% White). Psychiatric diagnoses, treatment history, binge eating pathology (as measured by the Binge Eating Scale; BES) and psychological testing (Minnesota Multiphasic Personality Inventory-2-Restructured Form; MMPI-2-RF) at intake were compared between the 2 groups using Chi-Square and t-test analyses. Further, amongst those readmitted, the indication for hospitalization was investigated via electronic medical record. Those with specific complications (e.g., leak, infection, DVT; n=68) were further delineated from those with vague complaints (e.g., pain, nausea) or complications that could relate to non-adherence (e.g., dehydration, misuse of medications; n=34). The 3 groups (no readmission, specific indication, non-specific indication) were compared on demographics, psychiatric variables and psychological testing via Chi-Square and analysis of variance (ANOVA).Individuals who were readmitted had less education (13.4 vs. 14.22 years; t=2.15; em>p<.02) than non-readmitted patients. Readmitted patients were less likely to be in outpatient psychiatric care (48%) compared to non-readmitted patients (64%; X2=6.76; p<.02) and were on fewer psychiatric medications compared to the readmitted patients (M=.60 vs. 1.39; t=22.74; p<.001). Although matched on age and gender initially, those with non-specific readmissions were significantly younger (43.4 years vs. 49.25 in specific readmission vs. 48.9 in non-readmitted; F=2.66; p=.05) and more likely to be female (88% vs. 69% vs. 74%; X2=6.08; p=.05). Significant differences were found on the Uncommon Virtues scale of the MMPI-2-RF which reflects a tendency to under-report psychiatric symptoms using a response style in which the patient denies minor imperfections that most individuals are willing to admit (F=13.43; p<.001). Those who were readmitted with non-specific complaints had significantly higher under-reporting scores (M=64.14) compared to those with specific indications (M=59.74) which were greater than those not readmitted (M=55.11). Other MMPI-2-RF group differences and the effect of gender were no longer significant once the effect of under-reporting was removed. No significant differences were found on psychiatric diagnoses, the BES or number of weekly binge episodes although there was a trend for greater history of inpatient psychiatric hospitalizations in those were readmitted (10.3%) compared to those who were not (5.4%; X2=2.45; p=.09). Readmitted patients were more likely to psychologically present themselves in an overly positive manner, particularly among those who had non-specific indications for readmission. The tendency to under-report on psychological testing has been linked with under-reporting during the clinical interview and may also influence the veracity presented with nutrition, medicine and surgery (e.g., denying comorbidities, reporting adherence although not following treatment plan). This under-reporting style may impact the bariatric team's ability to identify risk factors that could be ameliorated prior to surgery. Similarly, patients who are readmitted were less likely to be receiving mental health care and psychopharmacology although they may be more likely to have had a significant past history of psychiatric hospitalization. Such ongoing treatment may increase monitoring and/or adherence. Finally, younger patients were more likely to be readmitted for non-specific reasons. Future research should examine better strategies for identifying patients at risk for readmission and for reducing an under-reporting style during the evaluation period.