Information needs among adolescent bariatric surgery patients and their caregivers

What matters to adolescents with obesity, and their caregivers, when considering bariatric surgery or weight loss devices? A qualitative evidence synthesis

BACKGROUND

Bariatric surgery and weight loss devices have been considered as a therapeutic option in some settings for adolescents with severe obesity. We conducted a systematic review and qualitative evidence synthesis of factors affecting adolescent and caregiver decision-making processes around such interventions, as well as post-surgery demands and challenges, so that their experiences might be better understood and improved support given. No previous qualitative evidence synthesis has been published on this topic.

METHODS AND FINDINGS

We searched 10 bibliographic databases and followed-up gray literature and citations sources. We performed a qualitative evidence synthesis on 19 primary qualitative research studies in adolescents aged 13 years or older. They reported diverse motivations and incentives for considering these interventions, including the physical and social problems resulting from living with obesity, and an awareness of the benefits and limitations of interventions. They reported that they need: information, physical and emotional support and, in some cases, financial assistance. There was high confidence in a majority of these findings (GRADE CERQual).

CONCLUSIONS

We found that supportive interventions accompanying bariatric surgery should be in place to offer: practical help; address anxieties and uncertainties; and facilitate both appropriate decision-making and the achievement of young people's desired outcomes.

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.

A qualitative exploration on the needs of health care providers working with adolescents who are undergoing bariatric surgery

Background

With increasing prevalence of severe obesity in youth, more adolescents are becoming candidates for bariatric surgery. In Canada, bariatric surgery in adolescents is in its infancy, and long-term health outcomes are not well known. It is unknown what health care providers (HCPs) are using to prepare and guide their adolescent patients for bariatric surgery. The needs of HCPs should be explored with the aim to improve patient outcomes. Therefore, the purpose of this study was to investigate the resource needs of HCPs working with adolescents living with severe obesity who are undergoing bariatric surgery.

Methods

This qualitative study consisted of a focus group with seven HCPs from an adolescent bariatric program using a semi-structured interview guide. The focus group discussion was audio-recorded, and the recording was transcribed verbatim. A thematic analysis was conducted.

Results

Four data-generated themes emerged highlighting the perceived needs and challenges faced by HCPs. These included (1) gaps in patient education materials on the subject of the bariatric surgery process, obesity as a chronic disease and mental health, (2) the need for designing resources that are teen-friendly, adaptable, and accessible, (3) the need for resources to facilitate decision-making and patient evaluation delivering more streamlined care and; (4) challenges to addressing resource needs due to limited clinical time and budgets.

Conclusion

This needs assessment study highlights the need for appropriate resources for patient education, as well as pre and post-operative preparation. The hope is that HCPs can improve quality of care delivered and positively impact surgical outcomes in their patients.

Incorporation of patient and family values and preferences for health-related outcomes in paediatric obesity management: A systematic review

OBJECTIVE

A systematic review of value and preference studies conducted in children and their caregivers related to the estimated benefits and harms of interventions for managing paediatric obesity.

METHODS

We searched Ovid Medline (1946-2022), Ovid Embase (1974-2022), EBSCO CINAHL (inception to 2022), Elsevier Scopus (inception to 2022), and ProQuest Dissertations & Theses (inception to 2022). Reports were eligible if they included: behavioural and psychological, pharmacological, or surgical interventions; participants between (or had a mean age within) 0-18 years old with overweight or obesity; systematic reviews, primary quantitative, qualitative, or mixed/multiple methods studies; and values and preferences as main study outcomes. At least two team members independently screened studies, abstracted data, and appraised study quality.

RESULTS

Our search yielded 11 010 reports; eight met the inclusion criteria. One study directly assessed values and preferences based on hypothetical pharmacological treatment for hyperphagia in individuals with Prader-Willi Syndrome. Although not having reported on values and preferences using our a priori definitions, the remaining seven qualitative studies (n = 6 surgical; n = 1 pharmacological) explored general beliefs, attitudes, and perceptions about surgical and pharmacological interventions. No studies pertained to behavioural and psychological interventions.

CONCLUSION

Future research is needed to elicit the values and preferences of children and caregivers using the best available estimates of the benefits and harms for pharmacological, surgical, and behavioural and psychological interventions.

Healthcare delivery and information provision in bariatric surgery in Germany: qualitative interviews with bariatric surgeons

Background

There are several healthcare professionals involved in health information provision regarding bariatric surgery, such as bariatric surgeons, nutritionists, and medical doctors in outpatient settings. Trustworthy health information supports patients in understanding their diagnosis, treatment decisions, and possible prognosis. Therefore, it is necessary to provide health information on bariatric surgery. This study has two distinct objectives. The first is to outline the delivery of healthcare regarding bariatric surgery in Germany. The second is to describe the information provision within healthcare delivery.

Methods

We conducted 15 semi-structured telephone interviews with bariatric surgeons between April 2018 and February 2019. The interviews were audio recorded and transcribed verbatim. The interview guide consisted of four sections (information about the clinic/surgeon and surgical procedures, preoperative procedure, postoperative procedure, information needs). The transcribed interviews were analyzed using qualitative content analysis supported by MAXQDA software.

Results

The pre- and postoperative processes differed substantially between clinics. Additionally, every bariatric clinic had its own information provision concept. There were several cost-related issues the surgeons claimed to be relevant for patients, such as nutritional blood tests or postoperative psychotherapy. These issues were often caused by unclearness of responsibility within the medical disciplines involved.

Conclusion

Healthcare delivery in bariatric surgery in Germany is heterogeneous in terms of pre- and postoperative care. Therefore, preoperative information provision between the clinics differs. The impact of this heterogeneous healthcare delivery and information provision on patients’ information needs regarding bariatric surgery should be further investigated among patients and other healthcare professionals involved.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06629-4.

"It's a tool, not a cure": the preoperative teen perspective on bariatric surgery

BACKGROUND

Bariatric surgery is well established in adults as the most effective tool for sustained weight loss and reduction of obesity-related co-morbidities, and is an emerging option for adolescents in whom conservative approaches have failed. Narratives are vital in understanding the motivating reasons and psychosocial profiles of adolescents considering bariatric surgery during a developmental period of evolving self-concept, body image sensitivity, peer pressure, and increased opportunity for risky behaviors.

OBJECTIVES

To explore preoperative adolescent patient perspectives on their decision to pursue bariatric surgery, anticipated physical and psychosocial effects, and preparation process.

SETTINGS

The Hospital for Sick Children (SickKids) in Toronto, Ontario, Canada.

METHODS

We conducted 14 semi-structured interviews with adolescents (16-18 yr old) 2-4 months before bariatric surgery. A theoretical thematic analysis was conducted with 3 independent reviewers (interrater reliability, Cronbach's α= .81) and conflicts were resolved through discussion.

RESULTS

Patients' perspectives are captured in 4 themes: motivation for surgery, effects on health and habits, psychosocial changes, and support systems during preparation. Participants perceived surgery as a tool but not a solution for weight loss. Most were motivated for health and daily functional improvement rather than aesthetic reasons, and some anticipated improved social interactions while maintaining their self-identity. Participants were selective in sharing news of their surgery, and received varying levels of support from families, friends, and healthcare teams.

CONCLUSION

Adolescents seem generally prepared for and informed about surgery, with expectations for weight loss and psychosocial improvements, although uncertainty and contradictory thoughts were prevalent. Insights provided by these adolescent patients will help optimize bariatric surgery assessments and support from clinical teams and inform preoperative education for future patients and families.

Short- and long-term safety and efficacy of bariatric surgery for severely obese adolescents: a narrative review

The selection criteria, safety, and efficacy of bariatric surgery are well established in adults but are less well defined for severely obese adolescents. The number of severely obese adolescents who could benefit from weight loss surgery is increasing, although referral rates have plateaued. Surgical options for these adolescents are controversial and raise several questions. Recent studies, including the prospective Teen-Longitudinal Assessment of Bariatric Surgery Study and the Adolescent Morbid Obesity Surgery Study, help answer these questions. Early bariatric surgical intervention improves body mass index but, more importantly, improves cardiovascular and metabolic co-morbidities of severe obesity. A review of the medical, psychosocial, and economic risks and benefits of bariatric surgery in severely obese adolescents is a step toward improving the management of a challenging and increasing population. We describe the current knowledge of eligibility criteria, preoperative evaluation, surgical options, outcomes, and referral barriers of adolescents for bariatric surgery.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Adolescent bariatric surgery: a qualitative exploratory study of US patient perspectives

Bariatric surgery is a safe and effective intervention to treat severe obesity and related comorbidities in adolescents. No qualitative studies have explored the perspectives of US adolescent weight-loss patients on their bariatric surgery motivations, decision-making or experiences. The purpose of this qualitative exploratory study was to explore the perspectives of adolescent patients seeking bariatric surgery while enrolled in a medical weight management programme. Eligible participants 13-21 years old were recruited through a weight management programme at a tertiary care children's hospital in the US Midwest. Interviews were conducted remotely using a video chat medium. An initial 60-min semi-structured interview was conducted with seven participants who were 16-21 years old: one deciding on bariatric surgery, one pre-operative and five post-operative. A brief follow-up interview was conducted 1 month later with four participants. Interviews were transcribed and coded using Atlas.ti software. Three broad themes emerged from participants' reflections: the long journey to surgery, time scarcity and be ready for change. The decision to pursue bariatric surgery takes place after struggling with obesity and failed weight-loss attempts since early childhood. Post-operative participants described bariatric surgery as life-changing, but determining when to schedule surgery is a challenge for adolescents.

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.