Change, predictors and correlates of weight- and health-related quality of life in adolescents 2-years following bariatric surgery

Scientific Evidence for the Updated Guidelines on Indications for Metabolic and Bariatric Surgery (IFSO/ASMBS)

The 2022 American Society of Metabolic and Bariatric Surgery (ASMBS) and International Federation for the Surgery of Obesity and Metabolic Disorders (IFSO) updated the indications for Metabolic and Bariatric Surgery (MBS), replacing the previous guidelines established by the NIH over 30 years ago. The evidence supporting these updated guidelines has been strengthened to assist metabolic and bariatric surgeons, nutritionists, and other members of multidisciplinary teams, as well as patients. This study aims to assess the level of evidence and the strength of recommendations compared to the previously published criteria.

The Long-term Value of Bariatric Surgery Interventions for American Adults With Type 2 Diabetes Mellitus

BACKGROUND

Bariatric surgery can cause type 2 diabetes (diabetes) remission for individuals with comorbid obesity, yet utilization is <1%. Surgery eligibility is currently limited to body mass index (BMI) ≥35 kg/m 2 , though the American Diabetes Association recommends expansion to BMI ≥30 kg/m 2 .

OBJECTIVE

We estimate the individual-level net social value benefits of diabetes remission through bariatric surgery and compare the population-level effects of expanding eligibility alone versus improving utilization for currently eligible individuals.

METHODS

Using microsimulation, we quantified the net social value (difference in lifetime health/economic benefits and costs) of bariatric surgery-related diabetes remission for Americans with obesity and diabetes. We compared projected lifetime surgical outcomes to conventional management at individual and population levels for current utilization (1%) and eligibility (BMI ≥35 kg/m 2 ) and expansions of both (>1%, and BMI ≥30 kg/m 2 ).

RESULTS

The per capita net social value of bariatric surgery-related diabetes remission was $264,670 (95% confidence interval: $234,527-294,814) under current and $227,114 (95% confidence interval: $205,300-248,928) under expanded eligibility, an 11.1% and 9.16% improvement over conventional management. Quality-adjusted life expectancy represented the largest gains (current: $194,706; expanded: $169,002); followed by earnings ($51,395 and $46,466), and medical savings ($41,769 and $34,866) balanced against the surgery cost ($23,200). Doubling surgical utilization for currently eligible patients provides higher population gains ($34.9B) than only expanding eligibility at current utilization ($29.0B).

CONCLUSIONS

Diabetes remission following bariatric surgery improves healthy life expectancy and provides net social benefit despite high procedural costs. Per capita benefits appear greater among currently eligible individuals. Therefore, policies that increase utilization may produce larger societal value than expanding eligibility criteria alone.

Self-worth and developmental outcomes in young adults after pediatric bariatric surgery

OBJECTIVES

Bariatric surgery has emerged as a safe/effective treatment for adolescents with severe obesity; therefore, understanding its impact over the life course is imperative. This study examined self-worth and developmental outcomes during the transition to adulthood (19-24 years old) for youth who underwent surgery as adolescents (13-18 years old) and a nonsurgical group with severe obesity.

METHOD

As part of a prospective and multisite observational study series, adolescents (139 surgical, 83 nonsurgical) were followed for 6 years postsurgery/baseline when they completed height/weight measurements and measures of global self-worth, maturity, and occupational, educational, and social functioning as young adults. Growth curve analysis examined global self-worth change, while regressions were used to compare groups and examine adolescent-reported familial predictors and weight-related correlates for outcomes.

RESULTS

Relative to the nonsurgical group, the surgical group experienced a significant quadratic improvement in self-worth and higher year 6 romantic self-perceptions. For the surgical group only, greater family dysfunction predicted lower young adult self-worth and perceptions of maturity, while higher family connectedness predicted higher self-worth and perceptions of maturity. Greater percent weight loss was associated with higher perceptions of maturity for the surgical group.

CONCLUSIONS

Group difference findings suggest that the impact of surgery was on self-worth and romantic self-perceptions, outcomes linked in the developmental literature to body image. For both groups, functioning appeared similar to population-based findings, suggesting they are meeting "expected" age-salient developmental outcomes. The impact of earlier positive family functioning on self-worth and self-perceptions of maturity may place adolescents on pathways to success. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

Psychological Outcomes and Predictors of Weight Loss in Adolescents With Severe Obesity Following a Reversible Endoscopic Bariatric Procedure

Introduction: Adolescent and children obesity is a growing concern worldwide. Bariatric surgery is used as an effective treatment for adolescents with obesity and provides physical and mental health benefits. Application of alternative, minimally invasive, safe, and reversible endoscopic procedures, such as the Duodenojejunal bypass liner (DJBL), has been recently suggested as an effective treatment for adolescents with obesity. We explored specific psychological outcomes of adolescents with obesity during a year of follow-up after undergoing a reversible endoscopic bariatric procedure, and a year after removal. We were also interested in identifying psychological factors that could predict successful weight loss after the procedure. Methods: Nineteen adolescent with severe obesity undergoing DJBL procedure were psychologically assessed in an open-label, prospective clinical trial (NTC0218393), at the implantation of device and at the removal of device after 12 months. Control group of 26 adolescents with severe obesity were recruited from the same outpatient clinic undergoing only conservative treatment. In addition, adolescents from the intervention group were followed for 12 months after the removal of the device. The Youth Self Report (YSR) was used to assess adolescents' emotional and behavioural problems; The Multidimensional Body-Self Relations Questionnaire (MBSRQ) to assess body image and The Eating Disorder Examination Questionnaire (EDE-Q) to assess attitudes and behaviours related to eating disorder. Results: Significant improvements in somatic complain (F = 12.478, p = 0.001), emotional and behavioural problems (F = 7.169, p = 0.011) and food restraining (F = 9.605, p = 0.004) were found in the intervention group at device removal compared to the control group. Moreover, at the time of device removal compared to baseline, improvements in several psychological outcomes were found (F = 32.178 p = 0.000 for emotional and behavioural problems). Adolescents also became more satisfied with their appearance (F = 6.789, p = 0.019). Majority of observed changes remained stable at the next follow up a year after the device removal. Significant predictors of successful weight loss at device removal were fewer overeating episodes (B = 0.147, p = 0.022) and lower body satisfaction (B = 0.932, p = 0.013). Discussion: Following a reversible bariatric procedure, improvements of psychological (emotional and behavioural) factors were found in adolescents with severe obesity. Psychological predictors of successful weight loss were identified, showing the greatest importance of eating behaviour and body satisfaction in successful weight loss.

Quality of life and psychopathology in candidates to bariatric surgery: relationship with BMI class

PURPOSE

This cross-sectional study aimed at comparing the quality of life (Qol), the prevalence of psychiatric diagnosis and pharmacological treatment in 104 candidates to bariatric surgery according to the degree of obesity (class 2 vs. class ≥ 3 obesity).

METHODS

All surgical candidates underwent a detailed psychiatric interview based on DSM-5 criteria, including sociodemographic, clinical, psychological and psychiatric data. Participants completed the Binge Eating Scale (BES) and the 12-Item Short Form Health Survey (SF-12).

RESULTS

Overall, bariatric candidates reported a significant impairment in the physical (PCS 38.8 [95% CI 36.2-41.5]) and mental (MCS 42.2 [95% CI 40.4-43.9]) components of Qol compared to population norms (p < 0.001 for both). Subjects with class 2 obesity scored significantly lower in the MCS compared to those with class 3 (38.7 (8.1) vs. 43.6 (8.4), p = 0.008). No other statistically significant differences were found between the two groups in terms of sociodemographic and clinical variables.

CONCLUSION

These data support the usefulness of Qol assessment in bariatric candidates as a sensible screening parameter, especially in patients with lower BMI, in whom MCS could identify the need for early psychosocial intervention.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Development and application of an ethical framework for pediatric metabolic and bariatric surgery evaluation

BACKGROUND

As severe obesity continues to rise among youth, metabolic and bariatric surgery (MBS) will increasingly be used as a treatment of choice for durable weight loss and improvement of obesity-related complications. MBS for youth with intellectual and developmental disabilities (IDD) and for preadolescents has raised ethical questions.

OBJECTIVES

The purpose of this article is to present the creation and application of an ethical framework that supports why MBS should be considered in pediatrics based on the principle of justice without automatic exclusions. This framework also provides a guide for how to conduct a robust, ethically grounded evaluation of pediatric patients presenting for MBS in general, and among subpopulations including youth with IDD and preadolescents.

SETTING

Academic medical center, United States.

METHODS

An ethical framework was developed and applied through a collaboration between an MBS center at a children's hospital and the institution's ethics consult service.

RESULTS

Application of the ethical framework to address 4 core ethical questions is illustrated using 2 hypothetical cases: 1 that highlights an adolescent with IDD and 1 that highlights a preadolescent.

CONCLUSIONS

We have demonstrated the application of a novel, overarching framework to conduct the ethical evaluation of youth presenting for MBS. This framework resulted from a collaboration between MBS and ethics consult teams and has the potential to be used as a prototype for other youth-focused MBS programs. Next steps include prospective data collection to test the framework and determine its validity in the target population.

Novel Insights into the Pathogenesis and Management of the Metabolic Syndrome

The metabolic syndrome, by definition, is not a disease but is a clustering of individual metabolic risk factors including abdominal obesity, hyperglycemia, hypertriglyceridemia, hypertension, and low high-density lipoprotein cholesterol levels. These risk factors could dramatically increase the prevalence of type 2 diabetes and cardiovascular disease. The reported prevalence of the metabolic syndrome varies, greatly depending on the definition used, gender, age, socioeconomic status, and the ethnic background of study cohorts. Clinical and epidemiological studies have clearly demonstrated that the metabolic syndrome starts with central obesity. Because the prevalence of obesity has doubly increased worldwide over the past 30 years, the prevalence of the metabolic syndrome has markedly boosted in parallel. Therefore, obesity has been recognized as the leading cause for the metabolic syndrome since it is strongly associated with all metabolic risk factors. High prevalence of the metabolic syndrome is not unique to the USA and Europe and it is also increasing in most Asian countries. Insulin resistance has elucidated most, if not all, of the pathophysiology of the metabolic syndrome because it contributes to hyperglycemia. Furthermore, a major contributor to the development of insulin resistance is an overabundance of circulating fatty acids. Plasma fatty acids are derived mainly from the triglycerides stored in adipose tissues, which are released through the action of the cyclic AMP-dependent enzyme, hormone sensitive lipase. This review summarizes the latest concepts in the definition, pathogenesis, pathophysiology, and diagnosis of the metabolic syndrome, as well as its preventive measures and therapeutic strategies in children and adolescents.