Five-year changes in dietary intake and body composition in adolescents with severe obesity undergoing laparoscopic Roux-en-Y gastric bypass surgery

Metabolic and bariatric surgery for adolescents with severe obesity: Benefits, risks, and specific considerations

International and national guidelines recommend metabolic and bariatric surgery (MBS) as a treatment option for adolescents with severe obesity, but few countries offer MBS to adolescents in routine clinical care. This narrative review summarizes existing adolescent MBS guidelines and the available underpinning evidence. Two randomized trials and additional prospective studies have demonstrated efficacy and safety in adolescent MBS, and the health benefits appear to be similar or superior to outcomes in adults. However, there are specific challenges regarding the intervention during adolescence related to decision-making capacity and a peak in risk-taking behavior. Adolescents with severe obesity have-as a group-a mental health vulnerability, and specific nutritional concerns need to be addressed in relation to MBS. This review also describes how study findings can be translated into clinical care. We use Sweden as an example, where the National Board of Health and Welfare recommends MBS for selected adolescents with severe obesity aged 15 years or older. We present practical advice for implementing and integrating MBS in adolescents in the framework of multidisciplinary pediatric and adolescent care for obesity.

Assessment and medical management of weight regain after adolescent metabolic and bariatric surgery: a narrative review

Metabolic and bariatric surgery (MBS) in adolescents results in durable treatment of severe obesity and related complications for most. However, substantial weight regain can undermine long-term health benefits. There is no evidence-based standard of care for the medical management of weight regain after MBS in pediatrics or adults. This narrative review summarizes current pediatric evidence pertaining to the assessment and medical management of post-MBS weight regain, identifies gaps, and offers recommendations. A PubMed search was conducted through March 2024 and focused on adolescents after sleeve gastrectomy or Roux-en-Y gastric bypass. Domains included nutrition, activity, mental health, antiobesity medications, type 2 diabetes, hypothalamic obesity, and transition of care. In total, 600 articles were screened and 61 were included in this review. Recent consensus definitions for post-MBS weight regain have been established for adults but have not been validated in pediatrics. Limited, high-quality evidence was identified in the nutrition domain, where targets that may mitigate weight regain include adequate protein intake (≥60 g/d), absence of loss-of-control eating, and micronutrient sufficiency. Emerging data for post-MBS antiobesity medications in adults with/without diabetes and in adolescents with persistent obesity are promising. Large gaps include post-MBS interventions focused on physical activity and mental health. The overall quality of pediatric-specific evidence for the assessment and medical management of post-MBS weight regain is low. A standard definition of weight regain associated with health outcomes in pediatrics would be valuable. Clarifying risk and protective factors for weight regain can guide more precise risk stratification and treatment.

Body Composition Changes in Adolescents Who Underwent Bariatric Surgery: A Systematic Review and Meta-analysis

PURPOSE OF REVIEW

The purpose of this review and meta-analysis is to characterize the changes in body composition of children and adolescents who underwent bariatric surgery and identify possible negative effects of performing this procedure during pediatric ages.

RECENT FINDINGS

Bariatric surgery in children and adolescents is an emerging strategy to promote higher and faster body weight and fat mass losses. However, possible negative effects usually observed in surgical patients' muscle-skeletal system raise a major concern perform this intervention during growth. Despite these possible issues, most experimental studies and reviews analyze bariatric surgery's effectiveness only by assessing anthropometric outcomes such as body weight and BMI, disregarding the short- and long-term impact of bariatric surgery on all body composition outcomes. Bariatric surgery is effective to reduce fat mass in adolescents, as well as body weight, waist circumference, and BMI. Significant reduction in lean mass and fat-free mass is also observed. Bone mass seems not to be impaired. All outcomes reduction were observed only in the first 12 months after surgery. Sensitivity analysis suggests possible sex and type of surgery-related differences, favoring a higher fat mass, body weight, and BMI losses in boys and in patients who underwent RYGB.

Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions

The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity. In addition, this report will provide an evidence base to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents. To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) "What are clinically based, effective treatments for obesity?" and (KQ2) "What is the risk of comorbidities among children with obesity?" See Appendix 1 for the conceptual framework and a priori key questions.

Long-term changes in dietary intake and its association with eating-related problems after gastric bypass in adolescents

BACKGROUND

Roux-en-Y gastric bypass (RYGB) surgery is an established, effective treatment for severe adolescent obesity. Long-term dietary intake and the relationship to eating-related problems are scarcely evaluated in this population.

OBJECTIVES

Assess changes in dietary intake in adolescents after RYGB and explore associations between dietary intake and eating-related problems.

SETTING

Multicenter study in Swedish university hospitals.

METHOD

Diet history, binge eating scale (BES), and Three-Factor Eating Questionnaire were assessed preoperatively and 1, 2, and 5 years after RYGB in 85 adolescents (67% female) aged 16.5 ± 1.2 years with a body mass index (BMI) of 45.5 ± 6.0 kg/m² and compared with control individuals at 5 years.

RESULTS

Five-year BMI change was -28.6% ± 12.7% versus +9.9% ± 18.9% in RYGB patients versus control individuals (P < .001). Through 5 years, RYGB adolescents reported reduced energy intake, portion size of cooked meals at dinner, and milk/yoghurt consumption (P < .01). The BES scores were 9.3 ± 8.3 versus 13.4 ± 10.5 in RYGB patients versus control individuals (P = .04). Association between BES score and energy intake was stronger in control individuals (r = .27 versus r = .62 in RYGB patients versus control individuals, P < .001). At 5 years, lower energy intake was associated with greater BMI loss in all adolescents (r = .33, P < .001). Higher scores in BES and uncontrolled and emotional eating were associated with higher energy intake, cooked meals, candies/chocolates, cakes/cookies, desserts, and sugary drinks (r > .23, P < .04) and lower intake of fruits/berries (r = -.32, P = .044). A higher score in cognitive restraint was associated with a higher intake of cereals and fruits/berries (r > .22, P < .05) and a lower intake of sugary drinks (r = -.24, P < .03).

CONCLUSION

To support optimization of long-term outcomes in adolescent RYGB patients, it is important to provide management strategies to reduce energy intake. Monitoring eating-related problems could identify potential individuals at risk of poor weight loss and to initiate treatment interventions.

Adolescent Obesity Modeling: A Framework of Socio-Economic Analysis on Public Health

Bayesian Structural Equation Modeling (SEM-Bayesian) was applied across different research areas to model the correlation between manifest and latent variables. The primary purpose of this study is to introduce a new framework of complexity to adolescent obesity modeling based on adolescent lifestyle through the application of SEM-Bayesian. The introduced model was designed based on the relationships among several factors: household socioeconomic status, healthy food intake, unhealthy food intake, lifestyle, body mass index (BMI) and body fat. One of the main contributions of this study is from considering both BMI and body fat as dependent variables. To demonstrate the reliability of the model, especially in terms of its fitting and accuracy, real-time data were extracted and analyzed across 881 adolescents from secondary schools in Tehran, Iran. The output of this study may be helpful for researchers who are interested in adolescent obesity modeling based on the lifestyle and household socioeconomic status of adolescents.

Long-term effect of bariatric surgery on body composition in patients with morbid obesity: A systematic review and meta-analysis

We performed a meta-analysis to provide quantitative estimates of fat mass (FM) and fat-free mass (FFM) changes in patients following bariatric surgery over 1 year. A systematic search of PubMed, SCOPUS and Web of Science databases was conducted; the pooled weighted mean difference (WMD) and 95% confidence intervals (CI) were calculated using a random-effects model. Thirty-four studies including Roux en-Y gastric bypass (RYGB), sleeve gastrectomy (SG) biliopancreatic diversion (BPD) and gastric banding (GB) were analyzed. RYGB decreased in body FM (-28.99 kg [31.21, -26.77]) or FM% (-12.73% [-15.14, -10.32]) or FFM (-9.97 kg [-10.93, -9.03]), which were greater than SG and GB. Moreover, the FFM% in RYGB group (11.72% [7.33, 16.11]) was more than SG (5.7% [4.44, 6.95]) and GB (8.1% [6.15, 10.05]) groups. Bariatric surgeries, especially RYGB, might be effective for a decrease in FM and maintenance of FFM in patients with morbid obesity in over 1 year.

Nutritional Risks in Adolescents After Bariatric Surgery

BACKGROUND & AIMS

Little is known about prevalence and risk factors for nutritional deficiencies in adolescents after metabolic bariatric surgery. We performed a 5-year prospective cohort study of these.

METHODS

Adolescents who had Roux-en-Y gastric bypass (RYGB, n = 161) or vertical sleeve gastrectomy (VSG, n = 67) were enrolled at 5 tertiary-care centers from March 2007 through February 2012. The final analysis cohort included 226 participants (161 who had RYGB and 65 who had VSG). We measured serum levels of ferritin; red blood cell folate; vitamins A, D, B₁, B₁₂; and parathyroid hormone at baseline and annually for 5 years. General linear mixed models were used to examine changes over time and identify factors associated with nutritional deficiencies.

RESULTS

The participants were 75% female and 72% white, with a mean age of 16.5 ± 1.6 years and mean body mass index of 52.7 ± 9.4 kg/m² at surgery. Mean body mass index decreased 23% at 5 years, and did not differ significantly between procedures. After RYGB, but not VSG, serum concentrations of vitamin B₁₂ significantly decreased whereas serum levels of transferrin and parathyroid hormone increased. Ferritin levels decreased significantly after both procedures. Hypo-ferritinemia was observed in 2.5% of patients before RYGB and 71% at 5 y after RYGB (P < .0001), and 11% of patients before VSG and 45% 5 y after VSG (P = .002). No significant changes in serum levels of folate or vitamins A, B₁, or D were found between baseline and 5 y after either procedure. By 5 y, 59% of RYGB and 27% of VSG recipients had 2 or more nutritional deficiencies. Risk factors associated with specific deficiencies included surgery type, female sex, black race, supplementation intake, weight regain, and for females, pregnancy.

CONCLUSIONS

In a prospective study of adolescents who underwent RYGB or VSG, we observed nutritional deficiencies by 5 y after the procedures-particularly in iron and B₁₂ after RYGB. Ongoing nutrient monitoring and supplementation are recommended for all patients, but surgery type, supplementation intake, sex, and race might affect risk. (Clinical trial registration: Adolescent Bariatrics: Assessing Health Benefits and Risk [also known as Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS)], NCT00474318.).

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.

Micronutrient intake and biochemistry in adolescents adherent or nonadherent to supplements 5 years after Roux-en-Y gastric bypass surgery

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is an effective obesity treatment in adults and has become established in adolescents. Lower adherence to supplementation in adolescents confers a risk for long-term nutritional deficiencies.

OBJECTIVES

To assess adherence to supplementation, micronutrient intake, and biochemistry in adolescents through 5 years after RYGB.

SETTING

University hospitals, multicenter study, Sweden.

METHODS

Micronutrient intake and adherence to supplementation were assessed by diet history interviews and biochemistry preoperatively, 1, 2, and 5 years after RYGB in 85 adolescents (67% females), aged 16.5 years (± 1.2) with a body mass index of 45.5 kg/m² (± 6.0). Adherence was defined as taking prescribed supplements ≥3 times a week. Micronutrient intake and biochemistry were compared with matched controls at 5 years.

RESULTS

Over 75% completed the dietary assessments across 5 years after RYGB. Adherence ranged between 44-61% through 5 years. At 5 years, ferritin and hemoglobin decreased (P < .04) and 61% had iron deficiency (P ≤ .001). Among females with iron deficiency, most did not adhere to supplementation (P = .005), and 59% of these had anemia (P < .001). Vitamin D insufficiency continued after surgery and 80% of participants who did not adhere to supplementation had insufficiency (P = .002). Adolescents not adhering had lower levels of vitamin D, B₁₂, and ferritin (females) compared with both adhering adolescents and the control group (all P < .04).

CONCLUSIONS

Half of adolescents after RYGB reported sufficient long-term adherence to supplementation. Adhering to supplements and reporting a higher micronutrient intake were associated with more favorable biochemistry. Results support the recommendations for monitoring micronutrient intake and biochemistry in all patients who have undergone RYGB surgery, and the recommendation of higher preventive supplementation of vitamin D and iron in both sexes. As hypothesized, adolescents not adhering had a higher prevalence of long-term micronutrient deficiencies.