Back to the basics: Guidance for designing good literature searches

The number of scientific publications is growing at an unprecedented rate. Failure to properly evaluate existing literature at the start of a project may result in a researcher wasting time and resources. As pharmacy researchers and scholars look to conceptualize new studies, it is imperative to begin with a high-quality literature review that reveals what is known and unknown about a given topic. The purpose of this commentary is to provide useful guidance on conducting rigorous searches of the literature that inform the design and execution of research. Guidance for less formal literature reviews can be adapted from best practices utilized within the formalized field of evidence synthesis. Additionally, researchers can draw on guidance from PRESS (Peer Review of Electronic Search Strategies) to engage in self-evaluation of their search strategies. Finally, developing an awareness of common pitfalls when designing literature searches can provide researchers with confidence that their research is designed to fill clearly articulated gaps in knowledge.

Food and alcohol disturbance among people who have undergone bariatric surgery

There have been numerous investigations of aberrant eating and substance abuse among patients who have undergone bariatric surgery, which affects the metabolism and the pharmacokinetics of alcohol. However, there is a dearth of literature considering the complex interplay between changes in post-surgery food and alcohol consumption. Furthermore, despite the increasing recognition of issues surrounding replacing food consumption with alcohol consumption (Food and Alcohol Disturbance [FAD]), most emerging research has focused on young adult populations. This perspective reviews and synthesizes the small but growing body of research on the interplay between food and alcohol consumption, particularly FAD, and considers its application to bariatric surgery in general. There are unique considerations for patients who have undergone bariatric surgery. Patients experience altered gastric anatomy, which affects food and alcohol metabolism, and are advised to abstain from drinking alcohol after surgery. After reviewing the available literature, this perspective highlights future directions for research and practice in bariatric surgery.

Experiences of loss of control eating in women after bariatric surgery: A qualitative study

OBJECTIVE

Loss of control (LOC) eating following bariatric surgery remains insufficiently understood, reflected in a lack of clear conceptualization, valid measurements, and effective treatments. This study explored patients' perspectives on LOC eating post-bariatric surgery, focusing on the relevance of the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) indicators of impaired control, and patients' experiences before (precipitating factors), during (eating patterns, perpetuating factors), and after the episodes (strategies used to stop eating).

METHODS

This was a qualitative study using descriptive phenomenology. Participants were adults who have undergone gastric bypass or sleeve gastrectomy and self-reported recent LOC eating. Data were collected by semi-structured interviews and analyzed using a combined inductive and deductive approach.

RESULTS

Participants were all women (N = 15; age: 34.5 ± 9.2 years). Results suggested that (1) except for feeling disgusted, guilty, or depressed after eating, other DSM-5 indicators did not seem to be highly relevant to this bariatric cohort; (2) LOC eating could occur across contexts, with food access, boredom, and food craving being consistent triggers; (3) the food amount consumed during a LOC episode was not necessarily considered excessive; (4) "mindlessness" and "satisfying hedonic, physiological, and mental needs" were the main perpetuating factors of LOC eating; and (5) self-talk and distracting attention were the most adopted strategies to stop eating.

DISCUSSION

Study findings have implications concerning the conceptualization, measurement, and intervention of LOC eating among bariatric patients. For example, results suggested the need for more data to determine the appropriate indicators of LOC eating and the inclusion of boredom as an intervention target in bariatric patients.

PUBLIC SIGNIFICANCE

Loss of control (LOC) eating is characterized by a sense of being unable to stop while eating. LOC eating is prevalent in patients who have undergone weight loss surgery and is associated with worse surgical outcomes. This qualitative study that explored post-bariatric surgery patients' experiences of LOC eating will inform efforts to better assess and intervene in this disordered eating behavior, thus ultimately optimizing patients' health following weight loss surgery.

Interrater reliability and internal consistency of the eating disorder examination in the longitudinal assessment of bariatric surgery study

BACKGROUND

Psychometric studies of eating disorder measures within bariatric surgery populations are limited.

OBJECTIVES

To examine the interrater reliability and internal consistency of the Eating Disorder Examination (EDE) among patients before and after bariatric surgery.

SETTING

Three clinical centers of the Longitudinal Assessment of Bariatric Surgery Research Consortium.

METHODS

The EDE-Bariatric Surgery Version was administered and audio-recorded by trained interviewers before and at annual assessments after bariatric surgery. Approximately 20% of interviews were randomly selected for rating by a second interviewer. Reliability of the original and brief EDE subscales was examined.

RESULTS

Interrater reliability of the EDE subscales ranged from .86-.97 for the original subscales and .83-.95 for brief subscales before surgery, and .90-.98 for the original subscales and .92-.97 for brief subscales after bariatric surgery. Interrater agreement (based on kappa) was almost perfect for overeating and binge-eating behaviors and substantial for loss-of-control eating before surgery. Similar interrater agreements (based on kappa) were observed after surgery for subjective overeating and binge-eating episodes. Internal consistency of the subscale and global scores was variable, ranging from .41-.97.

CONCLUSION

Findings provide support of the interrater reliability of the EDE, albeit with variable internal consistency, before and after bariatric surgery. Despite support for trained raters to reliably assess EDE constructs, variability in internal consistency suggests that further psychometric testing and rigorous scale development of disordered eating may be needed for the bariatric surgery population.

Adherence to mobile‐app‐based dietary self‐monitoring—Impact on weight loss in adults

Objectives

Greater dietary self‐monitoring adherence is associated with weight loss, however, the dietary self‐monitoring adherence criteria that predict weight loss are unknown. The criteria used to define adherence to dietary self‐monitoring in obesity treatment tend to vary, particularly in studies that include dietary self‐monitoring via mobile applications (apps). The objectives of this study were to (a) determine weight change outcomes related to app‐based dietary self‐monitoring and (b) determine the associations between the frequency, consistency, and completeness of dietary self‐monitoring and weight change.

Methods

In this single‐arm uncontrolled prospective study, employees at a large, urban health system who had overweight or obesity self‐monitored dietary intake for 8 weeks using the Calorie Counter by FatSecret app. A paired sample t‐test examined the association of app‐based dietary self‐monitoring and weight change; linear regression examined the associations of frequent, consistent, and complete dietary self‐monitoring and weight change.

Results

A significant mean difference [t (89) = 6.59, p < 0.001] was found between baseline and 8‐week weight (M = −1.5 ± 2.1 kg) in the sample (N = 90). Linear regression revealed a significant association [F (1, 88) = 7.18, p = 0.009] between total weeks of consistent dietary self‐monitoring (M = 4.4 ± 2.8) and percent weight loss (M = −1.54% ± 2.26%), and a significant association [F (1, 88) = 6.42, p = 0.013] between dietary self‐monitoring frequency (M = 50.1% ± 33.3%) and percent weight loss. The total weeks of complete dietary self‐monitoring (M = 3.42 ± 2.87) was not associated [F (1, 88) = 3.57, p = 0.062] with percent weight loss.

Conclusions

Consistent and frequent app‐based dietary self‐monitoring were associated with short‐term weight loss. Emphasizing these aspects of self‐monitoring may be an avenue for decreasing the burden of self‐monitoring.

Bariatric surgery in the Middle East and North Africa: narrative review with focus on culture-specific considerations

There is an increasing volume of bariatric surgeries in the Middle East and North Africa (MENA), but the context of bariatric surgery in the region is not fully understood. Incorporating culture-specific considerations in the provision of care to patients who undergo bariatric surgery may help to optimize outcomes after surgery. We conducted a narrative review of published research studies on bariatric surgery in the MENA region, highlighting cultural and contextual aspects relevant to the care of bariatric surgery patients who undergo surgery in this geographic area. The authors searched the following online databases: PubMed, CINAHL, Embase, and Academic Search Elite from 2010-2020 for studies conducted in 18 countries in the MENA region. This narrative review identifies cultural-specific considerations that may affect bariatric care and outcomes in 6 domains: knowledge of bariatric surgery; mental health, body image, and quality of life; influence of family; religion and lifestyle; preoperative practices; and healthcare access. Provision of culturally congruent care may help patients to achieve the best possible outcomes after bariatric surgery. Results may inform efforts to provide safe and culture-specific care in the MENA region, as well as those who migrate or seek care in other countries. More research is warranted on this heterogeneous population to optimize postsurgery weight trajectory and psychosocial adjustment.

A Qualitative Exploration of Patients' Experiences with Lifestyle Changes After Sleeve Gastrectomy in China

PURPOSE

Sleeve gastrectomy (SG) is the most widely used surgical treatment for severe obesity worldwide. Individuals who have undergone SG usually need to change lifestyle behaviors as a response to the anatomical changes imposed by SG, and patients need to sustain lifestyle changes for long-term surgical success. Little is known about how patients experience and manage lifestyle changes following SG. In China, where SG comprises over 70% of bariatric surgical procedures, there have been no reports addressing this issue. This study aimed to describe individuals' experiences related to lifestyle changes after SG in China.

MATERIALS AND METHODS

Semi-structured interviews were conducted at the Shanghai Huashan Hospital in China with adults who had undergone SG between 2012 and 2018. Two independent researchers used an interpretive thematic approach to analyze transcripts for themes and sub-themes.

RESULTS

Interviews (N = 15) revealed three major themes of participants' experiences with postoperative lifestyle changes: advantages outweigh disadvantages; developing self-management strategies (i.e., adopting new behaviors and developing habits, continuing self-monitoring, focusing on health over weight, staying determined); and experiencing culture-specific difficulties in adherence to follow-up visits and lifestyle recommendations.

CONCLUSION

The data from this study provided a rich description of the postoperative experiences of patients in China. Participants reported that surgical benefits supersede the surgery-related side effects, and participants were able to develop self-management strategies in order to achieve success. However, personal and social barriers, such as the challenges of applying postoperative dietary guidelines into daily practice, may impede patients making and sustaining recommended behavioral changes.

Disordered eating following bariatric surgery: a review of measurement and conceptual considerations

Eating disorders are associated with significant medical morbidity and mortality and serious psychological impairment. Individuals seeking bariatric surgery represent a high-risk group for evidencing disordered eating and eating disorders, with some patients experiencing the persistence or onset of disordered eating postsurgery. This review synthesizes the available literature on problematic or disordered eating in the bariatric field, followed by a review of measurement and conceptual considerations related to the use of eating disorder assessment tools within the bariatric population.

Fostering Innovation in Prevention and Treatment of Obesity in Youth: Digitally Mediated Physical Play as an Exemplar

Novel approaches to obesity prevention among youth are needed. Accordingly, the Office of Women's Health, Department of Health and Human Services, sponsored a challenge to create an interactive video game for obesity prevention. Our team took a theory-based, evidence-informed approach to increasing physical activity in girls. Our approach-digitally mediated physical play-allowed us to include computing-based strategies that promote activity without keeping players in front of a screen. Our prize-winning prototype app, Frolic, helps girls choose the perfect game to play in any context, engaging parents for support. The app is used to highlight some opportunities and challenges for interdisciplinary collaboration. However, much work remains to be done to deploy innovative digital obesity interventions and fully capture the contributions of these tools. In order to accelerate advances, funding is needed for projects that combine engineering design principles with traditional obesity research paradigms.

Eating patterns and unhealthy weight control behaviors are associated with loss-of-control eating following bariatric surgery

BACKGROUND

Loss-of-control (LOC) eating is associated with poor weight-loss outcomes following bariatric surgery. It is not clear whether eating patterns (e.g., total number of daily meals/snacks, eating after suppertime, eating when not hungry) and unhealthy weight control behaviors (e.g., smoking, using laxatives) are associated with or predictive of LOC eating.

OBJECTIVES

To examine whether eating patterns and unhealthy weight-control behaviors are associated with LOC eating and, if so, whether they predict LOC eating in bariatric patients.

SETTING

Multicenter study, United States.

METHODS

This is a secondary analysis of the Longitudinal Assessment of Bariatric Surgery-2 study. Assessments were conducted before surgery and at 12, 24, 36, 48, 60, and 84 months after surgery. Logistic mixed models were used to examine the longitudinal associations between eating patterns, unhealthy weight-control behaviors, and LOC eating. Time-lag techniques were applied to examine whether the associated patterns and behaviors predict LOC eating.

RESULTS

The participants (n = 1477) were mostly women (80%), white (86.9%), and married (62.5%). At the time of surgery, the mean age was 45.4 ± 11.0 years and the mean body mass index was 47.8 ± 7.5 kg/m². The total number of daily meals/snacks, food intake after suppertime, eating when not hungry, eating when feeling full, and use of any unhealthy weight-control behaviors were positively associated with LOC eating (P < .05). Food intake after suppertime, eating when not hungry, and eating when feeling full predicted LOC eating (P < .05).

CONCLUSION

Meal patterns and unhealthy weight control behaviors may be important intervention targets for addressing LOC eating after bariatric surgery.

Exploring Factors Linked to Weight Status in Salvadoran Infants

INTRODUCTION

Potential risk factors of infant overweight/obesity in Salvadoran mother-infant dyads (N = 88) at routine 9- to 12-month wellbaby visits were examined in a correlational study at two pediatric offices on Long Island, New York.

METHOD

Maternal factors and infant feeding practices in the first 5 months were self-reported; infant birth weight, current weight/recumbent length were obtained. Bivariate logistic regression measured the relationship of the variables with infant weight status >85th percentile weight-for-length (WFL) for sex.

RESULTS

The majority of mothers were born in El Salvador, with a mean age of 28.5 years (SD = 5.9); 43% of infants had WFL >85th percentile. Infant birth weight was significantly associated with WFL >85th percentile, p = .0007. After controlling for maternal age, insurance type, education, and marital status, no significant associations with infant WFL >85th percentile were found. Feeding practices during infants' first 5 months, mothers' pre-pregnancy weight, pregnancy weight gain, and history of gestational diabetes mellitus, were not associated with infant weight status.

CONCLUSION

This was the first study to examine infant weight status in Salvadorans. Future studies should objectively measure infant feeding practices and other potential factors among Salvadoran mother infant dyads, since nearly half of the infants had WFL >85th percentile.

Reported nutrient intake over 7 years after Roux-en-Y gastric bypass in the Longitudinal Assessment of Bariatric Surgery-3 (LABS-3) psychosocial study

BACKGROUND

Bariatric surgery is the most effective therapy for severe obesity. It reduces gastric capacity and may modify regulation of appetite, satiety, insulin, and other physiologic processes, resulting in weight loss.

OBJECTIVE

Long-term data on postsurgical nutrient intake are lacking.

SETTING

The Longitudinal Assessment of Bariatric Surgery-3 psychosocial study.

METHODS

Reported dietary intake was assessed in a subset of participants (n = 72) of the Longitudinal Assessment of Bariatric Surgery-3 psychosocial study who underwent Roux-en-Y gastric bypass surgery. Two 24-hour diet recalls at presurgery and annual assessments over 7 years were obtained. Reported diets were evaluated for energy, macro- and micronutrient intake, and assessed for adequacy by comparison to the dietary reference intakes.

RESULTS

After surgery, reported intake of total energy, and all macronutrients were significantly reduced. At least a quarter of participants reported protein intake below the recommended dietary allowance. Over half of participants reported intake of several vitamins (C, D, A, E, thiamin, folate) and minerals (zinc, calcium) below recommended levels over 7 years. Compared with presurgery, reported energy intake was reduced over 7 years. This study was registered at ClinicalTrials.gov as NCT02495142.

CONCLUSIONS

The reduction in energy resulted in intakes below the dietary reference intakes for many micronutrients among the majority of participants and below the recommended dietary allowance for protein in a substantial subgroup. These data support continued long-term nutrition education, monitoring, and supplementation.

Perceptions and experiences of appetite awareness training among African-American women who binge eat

INTRODUCTION

Binge eating may contribute to the prevalence of obesity in African-American women. Yet, there has been scant intervention research on the treatment of binge eating in this population. We tested the feasibility of an appetite awareness training (AAT) intervention in a sample of African-American women with binge and overeating behaviors. Participants who completed AAT were recruited to participate in focus groups to elicit information about their perceptions and experiences with this intervention to inform the design of future interventions to treat binge eating and obesity in African-American women.

METHODS

African-American women, aged 18-70 years, who had completed an 8-week randomized AAT intervention, were invited to attend a focus group discussion. Session content was recorded and transcribed. Data were analyzed by use of open coding. Themes were identified that described their perceptions and experiences of participating in the intervention.

RESULTS

Seventeen women participated in three focus group discussions. Pertinent themes identified included: paying attention to internal cues of hunger and satiety, influence of culture on eating patterns, breaking patterns of disordered eating, and perceptions about weight. Overall, participants were satisfied with their experience of AAT, and reported they found it valuable to learn about listening to biological signals of hunger and satiety and to learn specific strategies to reduce maladaptive eating patterns.

CONCLUSION

AAT was acceptable and provided helpful eating behavior instruction to African-American women with reported binge and overeating behaviors. Future research should examine the potential of AAT to improve weight management in this underserved population.

LEVEL OF EVIDENCE

Level V, qualitative descriptive study.

Association of Prescription Opioid Exposure and Patient Factors With Prolonged Postoperative Opioid Use in Opioid-Naïve Patients

The purpose of this research study was to identify factors associated with prolonged postoperative opioid use in opioid-naïve patients in 2 domains: specific patient characteristics and exposure through postoperative opioid prescriptions. A retrospective analysis was conducted of electronic medical records of opioid-naïve adult orthopedic surgical patients at a large academic medical center from January 1, 2012, through December 31, 2017. In this cohort, 4% continued to refill opioid prescriptions more than 90 days after their surgical procedure. Prolonged use was associated with an initial prescription that had an oral morphine milligram equivalent above 675. Receipt of opioid prescription refills was a significant predictor for receiving additional opioid prescriptions over time. Multivariate logistic regression indicated that the independent predictors of prolonged postoperative opioid use were alcohol abuse, black race, Medicaid insurance, and the following comorbidities: diabetes, mood disorder, hypertension, and chronic kidney disease. To decrease the rate of prolonged postoperative opioid use, clinical changes can be investigated, including collaborative perioperative pain management strategies using nonopioid pain control methods; perioperative patient screening; education of patients and clinicians; and close postoperative follow-up, especially in the most vulnerable populations.

Examining emotion-, personality-, and reward-related dispositional tendencies in relation to eating pathology and weight change over seven years in the Longitudinal Assessment of Bariatric Surgery (LABS) study

This study examined dispositional emotion-, personality/temperament-, and reward-related variables in relation to post-surgery eating pathology and weight-change among 107 adults who underwent Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB). As part of a prospective cohort study, annual post-surgical assessments were conducted to evaluate eating pathology, using the Eating Disorder Examination-Bariatric Surgery Version, and percent weight change from pre-surgery. Dispositional measures were administered at the 6- or 7-year assessment and included the Affect Intensity Measure, Difficulties in Emotion Regulation Scale, UPPS-P Impulsive Behavior Scale, Adult Temperament Questionnaire-Effortful Control Scale, and Sensitivity to Punishment/Sensitivity to Reward Questionnaire. Results from a series of linear mixed models revealed significant associations of emotion dysregulation, affect intensity, positive and negative urgency, effortful control, and reward sensitivity with eating pathology severity across 7 years; additionally, all but two of the subscales comprising the total scores were also significantly associated. Fewer statistically significant results were found in relation to weight change; emotion dysregulation and affect intensity (along with several subscales) were significantly associated with lower percent weight change (i.e., less weight loss), but of the reward-related and personality/temperament variables, only total effortful control emerged as significant. However, the associations of the other variables with both outcomes were consistently in the expected direction. Associations also appeared consistent across surgical procedures. Taken together, findings suggest that certain dispositional tendencies may relate to less optimal long-term outcomes following bariatric surgery and thus may be useful to assess in pre-surgical or early post-surgical evaluations to inform targeted recommendations.

The impact of childhood trauma on change in depressive symptoms, eating pathology, and weight after Roux-en-Y gastric bypass

BACKGROUND

History of childhood trauma is associated with increased risk of mental disorders, eating pathology, and obesity.

OBJECTIVE

To examine associations between childhood trauma and changes in depressive symptoms, eating pathology, and weight after Roux-en-Y Gastric Bypass (RYGB).

SETTING

Three U.S. academic medical centers.

METHOD

Adults undergoing bariatric surgery (2007-2011) were enrolled in a cohort study. Participants (96 of 114; 86%) completed the Beck Depression Inventory-1 (BDI-1) to assess depressive symptomology, the interviewer-administered Eating Disorder Examination (EDE) to assess subthreshold eating pathology, weight assessment before and 6 months and annually after RYGB for ≥7 years, and the Childhood Trauma Questionnaire (CTQ) once post-RYGB.

RESULTS

Presurgery, median age was 46 years, and median body mass index was 47 kg/m²; 79% were female. Data completeness across 7-year follow-up was 78% to 90%, 66% to 91%, and 93% to 100% for the BDI-1, EDE, and weight, respectively. Using mixed models, presence/severity of childhood emotional abuse, emotional neglect, and physical neglect, but not sexual abuse or physical abuse, were significantly associated (P < .05) with change (i.e., less improvement/worsening) in the BDI-1 and EDE global scores, as were higher total CTQ score and more types of moderate-intensity trauma. All CTQ measures were associated (P < .05) with less improvement or worsening in the EDE eating concern and shape concern scores. CTQ measures were not significantly related to weight loss or regain.

CONCLUSIONS

Although childhood trauma did not affect weight outcomes after RYGB, those who experienced childhood trauma had less improvement in depressive symptomology and eating pathology and therefore might benefit from clinical intervention.

Predictors of weight regain after sleeve gastrectomy: an integrative review

BACKGROUND

Sleeve gastrectomy (SG) is one of the most effective treatments for severe obesity, but weight regain after surgery is a challenging issue. The mechanism of postoperative weight relapse is barely understood because of the lack of long-term data.

OBJECTIVES

To review and synthesize current evidence related to factors that contribute to weight regain after SG.

METHODS

Whittemore and Knafl's integrative method guided the research. The databases PubMed, EMBASE, and CINAHL, as well as 2 selected journals, were searched through October 2018 to gather English-language journal articles on the potential predictors of post-SG weight regain among adult populations. Only articles with sample size ≥10 were included. A narrative synthesis was used to analyze the 17 studies included in the review.

RESULTS

In recent years there has been an upward trend in the published reports of SG on longer-term outcomes. After a review of 6863 records, 17 eligible studies were identified, reporting various definitions of weight regain and 3 main categories of predictors: surgical/anatomic factors, hormonal/metabolic imbalance, and behavioral/mood factors. The 17 studies used quantitative (n = 16) and qualitative methods (n = 1).

CONCLUSION

There is a dearth of available literature addressing predictors of weight regain after SG, and the inconsistency in the definition of regain limited the comparability between studies. Besides the surgical/anatomic factors that have been reported as significant predictors, other modifiable factors such as behavioral and psychosocial determinants need to be further investigated.

Psychosocial Concerns Following Bariatric Surgery: Current Status

PURPOSE OF REVIEW

The purpose of this paper is to review the current status of research on psychosocial concerns following bariatric surgery.

RECENT FINDINGS

Bariatric surgery has a positive overall impact on weight and obesity-related comorbidities, as well as a positive short-term impact on mental health and psychosocial functioning. Nonetheless, research has documented a number of different psychosocial concerns that may emerge following surgery including maladaptive eating, substance use disorders, suicide, lack of social support, and excess skin. Moreover, special populations of patients may have distinctive psychosocial concerns based on sociodemographic factors such as age or severity of obesity. Available studies suggest that psychosocial interventions have a positive impact on post-surgery outcomes, particularly maladaptive eating. However, research is limited, and long-term data are lacking. Monitoring patients after bariatric surgery for negative psychosocial outcomes is warranted. Research is needed to develop and evaluate personalized approaches to optimize long-term weight loss and psychosocial adjustment.

Correction to: Psychosocial Concerns Following Bariatric Surgery: Current Status

A word was inadvertently omitted in the original version of this article.

Mental disorders and weight change in a prospective study of bariatric surgery patients: 7 years of follow-up

BACKGROUND

Long-term, longitudinal data are limited on mental disorders after bariatric surgery.

OBJECTIVE

To report mental disorders through 7 years postsurgery and examine their relationship with changes in weight and health-related quality of life.

SETTING

Three U.S. academic medical centers.

METHOD

As a substudy of the Longitudinal Assessment of Bariatric Surgery Consortium, 199 adults completed the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, 4^th Edition prior to Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric band. Participants who completed ≥1 follow-up through 7 years postsurgery are included (n = 173; 86.9%). Mixed models were used to examine mental disorders over time, and among the RYGB subgroup (n = 104), their relationship with long-term (≥4 yr) pre- to postsurgery changes in weight and health-related quality of life, measured with the Short Form-36 Health Survey, and with weight regain from nadir.

RESULTS

Compared with presurgery (34.7%), the prevalence of having any mental disorder was significantly lower 4 years (21.3%; P < .01) and 5 years (19.2%; P = .01), but not 7 years (29.1%; P = .27) after RYGB. The most common disorders were not related to long-term weight loss postRYGB. However, independent of weight change, mood and anxiety disorders, both pre- and postRYGB, were significantly related to less improvement in mental (but not physical) health-related quality of life. Having a concurrent mood disorder appeared to be associated with greater weight regain (6.4% of maximum weight lost, 95% confidence interval, -.3 to 13.1), but this was not statistically significant (P = .06).

CONCLUSIONS

Bariatric surgery does not result in consistent long-term reductions in mental disorders. Mood disorders may impact long-term outcomes of bariatric surgery.

Eating pathology and associations with long-term changes in weight and quality of life in the longitudinal assessment of bariatric surgery study

OBJECTIVE

This study examines the course of eating pathology and its associations with change in weight and health-related quality of life following bariatric surgery.

METHOD

Participants (N = 184) completed the eating disorder examination-bariatric surgery version (EDE-BSV) and the medical outcomes study 36-Item short form health survey (SF-36) prior to and annually following Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB) for up to 7 years.

RESULTS

The prevalence of ≥ weekly loss of control (LOC) eating, picking/nibbling, and cravings declined post-RYGB and remained lower through 7 years (LOC: 5.4% at Year-7 vs. 16.2% pre-RYGB, p = .03; picking/nibbling: 7.0% vs. 32.4%, p < .001; and cravings: 19.4% vs. 33.6%, p = .02). The prevalence of picking/nibbling was significantly lower 7 years following LAGB vs. pre-LAGB (29.4% vs 45.8%, p = .049), while cravings (p = .13) and LOC eating (p = .95) were not. EDE-BSV global score and ratings of hunger and enjoyment of eating were lower 7 years following both RYGB and LAGB versus pre-surgery (p's for all <.05). LOC eating following RYGB was associated with less long-term weight loss from surgery (p < .01) and greater weight regain from weight nadir (p < .001). Higher post-surgery EDE-BSV global score was associated with less weight loss/greater regain (both p < .001) and worsening/less improvement from surgery in the SF-36 mental component summary scores (p < .01).

DISCUSSION

Initial improvements in eating pathology following RYGB and LAGB were sustained across 7 years of follow-up. Individuals with eating pathology post-RYGB, reflected by LOC eating and/or higher EDE-BSV global score, may be at risk for suboptimal long-term outcomes.

The relationship between childhood maltreatment and psychopathology in adults undergoing bariatric surgery

BACKGROUND

A history of childhood maltreatment and psychopathology are common in adults with obesity.

OBJECTIVES

To report childhood maltreatment and to evaluate associations between severity and type of childhood maltreatment and lifetime history of psychopathology among adults with severe obesity awaiting bariatric surgery.

SETTING

Four clinical centers of the Longitudinal Assessment of Bariatric Surgery Research Consortium.

METHODS

The Childhood Trauma Questionnaire, which assesses presence/severity (i.e., none, mild, moderate, severe) of physical abuse, mental abuse, physical neglect, mental neglect, and sexual abuse, was completed by 302 female and 66 male bariatric surgery patients. Presurgery lifetime history of psychopathology and suicidal ideation/behavior were assessed with the Structured Clinical Interview for DSM-IV and the Suicidal Behavioral Questionnaire-Revised, respectively. Presurgery lifetime history of antidepressant use was self-reported.

RESULTS

Two thirds (66.6%) of females and 47.0% of males reported at least 1 form of childhood trauma; 42.4% and 24.2%, respectively, at greater than or equal to moderate severity. Among women, presence/greater severity of childhood mental or physical abuse or neglect was associated with a higher risk of history of psychopathology (i.e., major depressive disorder, posttraumatic stress disorder, other anxiety disorder, alcohol use disorder, binge eating disorder), suicidal ideation/behavior and antidepressant use (P for all ≤ .02). These associations were independent of age, race, education, body mass index, and childhood sexual abuse. Childhood sexual abuse was independently associated with a history of suicidal ideation/behavior and antidepressant use only (P for both ≤ .05). Statistical power was limited to evaluate these associations among men.

CONCLUSION

Among women with obesity, presence/severity of childhood trauma was positively associated with relatively common psychiatric disorders.

The feasibility of a binge eating intervention in Black women with obesity

INTRODUCTION

U.S. Black women have the highest rates of obesity and report frequent binge eating behaviors. To our knowledge, no intervention research has aimed to treat binge eating specifically among Black women. The purpose of this study was to investigate the feasibility and preliminary effect of Appetite Awareness Treatment (AAT), an 8-week cognitive-behavioral binge eating intervention, among Black women with obesity, and who report binge eating.

METHODS

Participants (N = 31), had a mean (±SD) age of 48.8 ± 12.8 years, a body mass index of 33.7 ± 3.9 kg/m², and reported at least one binge eating episode monthly over the last three months. Using a randomized controlled trial design, Black women were randomized to AAT or a wait-list control group (WAIT) group. We examined recruitment, attendance, retention, and adherence. Linear mixed models explored preliminary differences between the AAT and WAIT on the primary outcome variables of binge eating and eating self-efficacy measured at baseline and 8-weeks.

RESULTS

Approximately one-third of screened participants were eligible and did enroll. Participants completed 55% of homework assignments, and attended 59% of intervention sessions. Retention to AAT was 87.5%. Compared to participants in the WAIT group, AAT participants had greater decreases in binge eating scores and greater improvements in eating self-efficacy scores at the end of Week 8.

CONCLUSION

Results suggest that AAT is feasible among Black women with binge eating behaviors, with evidence of preliminary efficacy, providing a rationale for a trial of AAT in a larger sample of Black women.

Applying Ecological Frameworks in Obesity Intervention Studies in Hispanic/Latino Youth:

Introduction:

In the United States, Hispanic children have higher rates of obesity compared with non-Hispanic White children. An ecological framework provides a holistic view of the environment to which Hispanic/Latino children are exposed that can potentially inform prevention and treatment initiatives for this vulnerable population.

Method:

This systematic review examines the existing evidence on the use of an ecological framework in intervention studies targeting overweight and obesity in Hispanic youth from birth to 8 years. Key terms guided the search of PubMed, Google Scholar, CINAHL, and EBSCOhost databases from 1997 to 2016. Results were organized using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) method.

Results:

Seven studies met the inclusion and exclusion criteria. Significant improvements in body mass index z scores in treatment children were evident in five of the seven studies. Increases in fruit, water, and vegetable consumption and physical activity levels were reported in four of the seven studies.

Conclusion:

Multilevel interventions targeting a child’s home and community suggest efficacy in reducing or preventing obesity; increasing fruit, water, and vegetable consumption; and increasing physical activity in overweight/obese young Hispanic children. Future research is needed to explore the sustainability of multilevel obesity prevention interventions in this vulnerable population.

Use of prescribed opioids before and after bariatric surgery: prospective evidence from a U.S. multicenter cohort study

BACKGROUND

Limited evidence suggests bariatric surgery may not reduce opioid analgesic use, despite improvements in pain.

OBJECTIVE

To determine if use of prescribed opioid analgesics changes in the short and long term after bariatric surgery and to identify factors associated with continued and postsurgery initiated use.

SETTING

Ten U.S. hospitals.

METHODS

The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study. Assessments were conducted presurgery, 6 months postsurgery, and annually postsurgery for up to 7 years until January 2015. Opioid use was defined as self-reported daily, weekly, or "as needed" use of a prescribed medication classified as an opioid analgesic.

RESULTS

Of 2258 participants with baseline data, 2218 completed follow-up assessment(s) (78.7% were female, median body mass index: 46; 70.6% underwent Roux-en-Y gastric bypass). Prevalence of opioid use decreased after surgery from 14.7% (95% CI: 13.3-16.2) at baseline to 12.9% (95% CI: 11.5-14.4) at month 6 but then increased to 20.3%, above baseline levels, as time progressed (95% CI: 18.2-22.5) at year 7. Among participants without baseline opioid use (n = 1892), opioid use prevalence increased from 5.8% (95% CI: 4.7-6.9) at month 6 to 14.2% (95% CI: 12.2-16.3) at year 7. Public versus private health insurance, more pain presurgery, undergoing subsequent surgeries, worsening or less improvement in pain, and starting or continuing nonopioid analgesics postsurgery were significantly associated with higher risk of postsurgery initiated opioid use.

CONCLUSION

After bariatric surgery, prevalence of prescribed opioid analgesic use initially decreased but then increased to surpass baseline prevalence, suggesting the need for alternative methods of pain management in this population.

A Health Services Research Agenda for Bariatric Surgery Within the Veterans Health Administration

In 2016, the Veterans Health Administration (VHA) held a Weight Management State of the Art conference to identify evidence gaps and develop a research agenda for population-based weight management for veterans. Included were behavioral, pharmacologic, and bariatric surgery workgroups. This article summarizes the bariatric surgery workgroup (BSWG) findings and recommendations for future research. The BSWG agreed that there is evidence from randomized trials and large observational studies suggesting that bariatric surgery is superior to medical therapy for short- and intermediate-term remission of type 2 diabetes, long-term weight loss, and long-term survival. Priority evidence gaps include long-term comorbidity remission, mental health, substance abuse, and health care costs. Evidence of the role of endoscopic weight loss options is also lacking. The BSWG also noted the limited evidence regarding optimal timing for bariatric surgery referral, barriers to bariatric surgery itself, and management of high-risk bariatric surgery patients. Clinical trials of pre- and post-surgery interventions may help to optimize patient outcomes. A registry of overweight and obese veterans and a workforce assessment to determine the VHA's capacity to increase bariatric surgery access were recommended. These will help inform policy modifications and focus the research agenda to improve the ability of the VHA to deliver population-based weight management.

Alcohol and other substance use after bariatric surgery: prospective evidence from a U.S. multicenter cohort study

BACKGROUND

Empirical evidence suggests Roux-en-Y gastric bypass (RYGB) increases risk of developing alcohol use disorder (AUD). However, prospective assessment of substance use disorders (SUD) after bariatric surgery is limited.

OBJECTIVE

To report SUD-related outcomes after RYGB and laparoscopic adjustable gastric banding (LAGB). To identify factors associated with incident SUD-related outcomes.

SETTING

10 U.S. hospitals METHODS: The Longitudinal Assessment of Bariatric Surgery-2 is a prospective cohort study. Participants self-reported past-year AUD symptoms (determined by the Alcohol Use Disorders Identification Test), illicit drug use (cocaine, hallucinogens, inhalants, phencyclidine, amphetamines, or marijuana), and SUD treatment (counseling or hospitalization for alcohol or drugs) presurgery and annually postsurgery for up to 7 years through January 2015.

RESULTS

Of 2348 participants who underwent RYGB or LAGB, 2003 completed baseline and follow-up assessments (79.2% women, baseline median age: 47 years, median body mass index 45.6). The year-5 cumulative incidence of postsurgery onset AUD symptoms, illicit drug use, and SUD treatment were 20.8% (95% confidence interval (CI): 18.5-23.3), 7.5% (95% CI: 6.1-9.1), and 3.5% (95% CI: 2.6-4.8), respectively, post-RYGB, and 11.3% (95% CI: 8.5-14.9), 4.9% (95% CI: 3.1-7.6), and .9% (95% CI: .4-2.5) post-LAGB. Undergoing RYGB versus LAGB was associated with higher risk of incident AUD symptoms (adjusted hazard ratio or AHR = 2.08 [95% CI: 1.51-2.85]), illicit drug use (AHR = 1.76 [95% CI: 1.07-2.90]) and SUD treatment (AHR = 3.56 [95% CI: 1.26-10.07]).

CONCLUSIONS

Undergoing RYGB versus LAGB was associated with twice the risk of incident AUD symptoms. One-fifth of participants reported incident AUD symptoms within 5 years post-RYGB. AUD education, screening, evaluation, and treatment referral should be incorporated in pre- and postoperative care.

Eating pathology and experience and weight loss in a prospective study of bariatric surgery patients: 3-year follow-up

OBJECTIVE

Bariatric surgery results in significant long-term weight loss, albeit with considerable variability. This study examines the prognostic significance of eating pathology as determined by a structured interview, the Eating Disorder Examination-Bariatric Surgery Version (EDE-BSV).

METHOD

Participants (N = 183) in this substudy of the Longitudinal Assessment of Bariatric Surgery (LABS) Research Consortium were assessed using the EDE-BSV, independent of clinical care, presurgery and annually postsurgery. We examined eating pathology and experiences at several frequency thresholds (present, ≥ monthly, ≥ weekly) over 3 years, and utilized mixed models to test their associations with percentage weight loss from baseline at years 1, 2, and 3.

RESULTS

The prevalence of several forms of eating pathology declined pre- to 1-year postsurgery, including ≥weekly objective bulimic episodes (11.6-1.3%), loss of control (LOC) eating (18.3-6.2%) and picking/nibbling (36.0-20.2%) (P for all <0.01), and regular evening hyperphagia (16.5-5.0%, P = 0.01), but not cravings (P = 0.93). Mean EDE global score, and hunger and enjoyment scores, also declined (P for all <0.01). These metrics remained lower than baseline through year-3 (P for all <0.01). Presurgery eating variables were not related to weight loss (P for all ≥0.05). However, postsurgery higher EDE global score and greater hunger were independently associated with less weight loss postsurgery (P for both ≤0.01), while cravings were associated with greater weight loss (P = 0.03).

DISCUSSION

Pathological eating behaviors and experiences are common presurgery and improve markedly following surgery. Postsurgery pathological eating-related experiences and attitudes and hunger may contribute to suboptimal weight loss. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1058-1067).

Wise Choices: Nutrition and Exercise for Older Adults: A Community-Based Health Promotion Intervention

Effective interventions for older adults are needed to address lifestyle behaviors linked to chronic illnesses. We implemented a 12-week group behavioral intervention for 118 racially diverse older adults at 6 community-based senior centers to improve eating and physical activity. Assessments were completed pre- and postintervention, with 85.6% retention. We documented increases in fruit, vegetable, and whole grain intake; pace of walking; number of city blocks walked; daily steps walked; functional mobility; and self-rated general health (P < .05). Findings indicate that a relatively low-intensity lifestyle intervention can effectively be implemented for community-dwelling older adults. Further development of this approach is warranted.

Structured dietary intervention to facilitate weight loss after bariatric surgery: A randomized, controlled pilot study

OBJECTIVE

To evaluate the potential utility of a structured dietary intervention to assist bariatric surgery patients with weight management.

METHODS

Participants who underwent Roux-en-Y gastric bypass surgery 1 year previously were randomly assigned to a structured dietary intervention incorporating portion-controlled foods (intervention, n = 20) or a comparison group (control, n = 20). Both groups received instruction in behavioral weight loss (one 60-min session) followed by four monthly coaching telephone calls. Assessments were conducted at baseline, 4 months (post-intervention), and 6 months.

RESULTS

Participants were 85% female and 80% White. Average age was 46.9 (11.1) years, and body mass index was 31.3 (5.4) kg/m(2) at enrollment. Percent weight change from enrollment was significantly greater for intervention compared with control participants at 4 months [-4.56% vs. -0.13%, t(30)  = -3.29, P = 0.003] and 6 months [-4.07% vs. -0.14%, t(31)  = -2.03, P = 0.05]. Change in average daily calorie intake was greater among intervention compared with control [-108 vs. 116, t(30)  = -2.01, P = 0.05] at 4 months only.

CONCLUSIONS

A structured dietary intervention increased weight loss and reduced calorie intake when initiated 1 year following Roux-en-Y gastric bypass. This approach holds promise for optimizing postsurgery lifestyle change.

Preventing Postpartum Smoking Relapse: A Randomized Clinical Trial

IMPORTANCE

Most women who quit smoking during pregnancy will relapse postpartum. Previous efforts to prevent postpartum relapse have been unsuccessful at increasing rates of sustained abstinence.

OBJECTIVE

To evaluate the relative efficacy of 2 different approaches to prevent postpartum smoking relapse.

DESIGN, SETTING, AND PARTICIPANTS

Pregnant women who recently had quit smoking were recruited before the end of pregnancy. Intervention sessions were conducted through a combination of telephone calls and in-person visits beginning at delivery and continuing through 24 weeks postpartum. Participants completed assessments at the prenatal baseline and at 12, 24, and 52 weeks postpartum. Participants were recruited between March 2008 and December 2012. The dates of the analysis were April 2014 to February 2015.

INTERVENTIONS

Women received postpartum-adapted, behavioral smoking relapse prevention intervention and were randomly assigned to an enhanced cognitive behavioral intervention that included additional specialized strategies and content focused on women's postpartum concerns about mood, stress, and weight (Strategies to Avoid Returning to Smoking [STARTS]) or a supportive, time and attention-controlled comparison (SUPPORT). Intervention began before delivery and continued through 24 weeks postpartum.

MAIN OUTCOMES AND MEASURES

The primary outcome was biochemically confirmed sustained tobacco abstinence at 52 weeks postpartum. Secondary outcomes were self-reported mood, levels of perceived stress, and degree of concern about smoking-related weight gain.

RESULTS

The study cohort comprised 300 participants (150 randomly assigned to each group). Their mean (SD) age was 24.99 (5.65) years. Overall, 38.0% (114 of 300), 33.7% (101 of 300), and 24.0% (72 of 300) of the sample maintained abstinence at 12, 24, and 52 weeks' postpartum, respectively. There were no differences between the intervention groups in abstinence or time to relapse. Self-reported depressive symptoms and perceived stress significantly improved over time, and improvements were similar for both intervention groups. Women with more depressive symptoms and higher levels of perceived stress were more likely to relapse (hazard ratio, 1.02; 95% CI, 1.00-1.04; P = .04 for depressive symptoms and hazard ratio, 1.04; 95% CI, 1.01-1.07; P = .003 for stress).

CONCLUSIONS AND RELEVANCE

An intervention designed to address women's concerns about mood, stress, and weight did not differentially improve rates of sustained tobacco abstinence postpartum compared with a time and attention-controlled comparison. Women in STARTS and SUPPORT reported postpartum improvements in mood and stress, and the experience of fewer depressive symptoms and less perceived stress was related to sustained abstinence. Given that most pregnant quitters will relapse within 1 year postpartum and that postpartum smoking has negative health consequences for women and children, effective interventions that target postpartum mood and stress are needed.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00757068.

Prognostic Significance of Depressive Symptoms on Weight Loss and Psychosocial Outcomes Following Gastric Bypass Surgery: A Prospective 24-Month Follow-Up Study

BACKGROUND

This study examined the prognostic significance of depressive symptoms in bariatric surgery patients over 24 months of follow-ups.

METHODS

Three hundred fifty-seven patients completed a battery of assessments before and at 6, 12, and 24 months following gastric bypass surgery. In addition to weight loss and depressive symptoms, the assessments targeted eating disorder psychopathology and quality of life.

RESULTS

Clinically significant depressive symptoms, defined as a score of 15 or greater on the Beck Depression Inventory, characterized 45% of patients prior to surgery, and 12% at 6-month follow-up, 13% at 12-month follow-up, and 18% at 24-month follow-up. Preoperative depressive symptoms did not predict postoperative weight outcomes. In contrast, postsurgery depressive symptoms were predictive of weight loss outcomes. Higher postsurgery depressive symptoms at each time point predicted a greater degree of concurrent and subsequent eating disorder psychopathology and lower quality of life.

CONCLUSIONS

The frequency of elevated depressive symptoms decreases substantially following gastric bypass surgery but increases gradually over 24 months. Postoperative depressive symptoms are significantly associated with poorer weight outcomes at 6 and 12 months following surgery but do not predict longer-term weight outcomes at 24 months. Postoperative depressive symptoms prospectively predict greater eating disorder psychopathology and poorer quality of life through 24 months. Elevated depressive symptoms, readily assessed by self-report, may signal a need for clinical attention after surgery.

Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment: A Randomized Clinical Trial

IMPORTANCE

Questions remain about the role and durability of bariatric surgery for type 2 diabetes mellitus (T2DM).

OBJECTIVE

To compare the remission of T2DM following surgical and nonsurgical treatments.

DESIGN, SETTING, AND PARTICIPANTS

In this 3-arm randomized clinical trial conducted at the University of Pittsburgh Medical Center from October 1, 2009, to June 26, 2014, in Pittsburgh, Pennsylvania, outcomes were assessed 3 years after treating 61 obese participants aged 25 to 55 years with T2DM. Analysis was conducted with an intent-to-treat population.

INTERVENTIONS

Participants were randomized to either an intensive lifestyle weight loss intervention for 1 year followed by a low-level lifestyle intervention for 2 years or surgical treatments (Roux-en-Y gastric bypass [RYGB] or laparoscopic adjustable gastric banding [LAGB]) followed by low-level lifestyle intervention in years 2 and 3.

MAIN OUTCOMES AND MEASURES

Primary end points were partial and complete T2DM remission and secondary end points included diabetes medications and weight change.

RESULTS

Body mass index (calculated as weight in kilograms divided by height in meters squared) was less than 35 for 26 participants (43%), 50 (82%) were women, and 13 (21%) were African American. Mean (SD) values were 100.5 (13.7) kg for weight, 47.3 (6.6) years for age, 7.8% (1.9%) for hemoglobin A1c level, and 171.3 (72.5) mg/dL for fasting plasma glucose level. Partial or complete T2DM remission was achieved by 40% (n = 8) of RYGB, 29% (n = 6) of LAGB, and no intensive lifestyle weight loss intervention participants (P = .004). The use of diabetes medications was reduced more in the surgical groups than the lifestyle intervention-alone group, with 65% of RYGB, 33% of LAGB, and none of the intensive lifestyle weight loss intervention participants going from using insulin or oral medication at baseline to no medication at year 3 (P < .001). Mean (SE) reductions in percentage of body weight at 3 years were the greatest after RYGB at 25.0% (2.0%), followed by LAGB at 15.0% (2.0%) and lifestyle treatment at 5.7% (2.4%) (P < .01).

CONCLUSIONS AND RELEVANCE

Among obese participants with T2DM, bariatric surgery with 2 years of an adjunctive low-level lifestyle intervention resulted in more disease remission than did lifestyle intervention alone.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01047735.

Psychosocial Interventions Pre and Post Bariatric Surgery

Despite positive results overall, a substantial number of patients experience poor long-term outcomes following bariatric surgery. One reason for variability in weight loss may be difficulty in making and sustaining changes in dietary intake and physical activity; post-surgery binge eating has also been associated with poorer weight outcomes. In this paper, we review available evidence on adjunctive psychosocial interventions for bariatric surgery patients. Although the literature is limited, evidence suggests that bariatric surgery patients may benefit from a comprehensive approach targeting diet, activity and psychological factors. We think the optimal time to initiate adjunctive intervention is after surgery, but before significant weight regain has occurred. Adaptive interventions incorporating advances in technology may prove to be effective for promoting behavioural self-management and psychosocial adjustment following bariatric surgery. For some patients, pharmacotherapy and reoperation may also play a role in a personalized approach to post-surgery care.

Medication Use Among Patients Prior to Bariatric Surgery

Purpose: The aims of this study were to describe the most common medications reported by candidates for weight loss surgery and to consider the potential implications for patient care. Methods: A secondary data analysis of data from bariatric surgery patients enrolled in a randomized, controlled trial. At study entry, participants recorded their use of prescription medications they had taken in the previous 90 days. The Anatomical Therapeutic Chemical (ATC)/Defined Daily Dose (DDD) Index 2014 was used to classify medications. Results: Participants (n=265) were 85.7% female and 83.0% white. Mean body mass index was 47.9±6.5 kg/m², and age was 45.1±11 years. The average number of medications was 4.4±4.1, and the median was 3. The top three anatomical main groups were the cardiovascular system, alimentary tract and metabolism, and nervous system (28.2%, 21.6%, and 21.3% of all medications, respectively). The top therapeutic subgroups were drugs used in diabetes, psychoanaleptics, and agents acting on the renin-angiotensin system (12%, 11.3%, and 8.2% of all medications, respectively). Conclusions: Candidates for weight loss surgery report taking medications associated with obesity-related comorbidities such as diabetes, depression, and hypertension. Although many may be able to eliminate these medications, others will require close monitoring and dosage adjustment after surgery.

Preoperative lifestyle intervention in bariatric surgery: a randomized clinical trial

BACKGROUND

Studies on the impact of presurgery weight loss and lifestyle preparation on outcomes following bariatric surgery are needed.

OBJECTIVE

To evaluate whether a presurgery behavioral lifestyle intervention improves weight loss through a 24-month postsurgery period.

SETTING

Bariatric Center of Excellence at a large, urban medical center.

METHODS

Candidates for bariatric surgery were randomized to a 6-month behavioral lifestyle intervention or to 6 months of usual presurgical care. The lifestyle intervention consisted of 8 weekly face-to-face sessions, followed by 16 weeks of face-to-face and telephone sessions before surgery; the intervention also included 3 monthly telephone contacts after surgery. Assessments were conducted 6, 12, and 24 months after surgery.

RESULTS

Participants who underwent surgery (n = 143) were 90.2% female and 86.7% White. Average age was 44.9 years, and average body mass index was 47.5 kg/m(2) at study enrollment. At follow-up, 131 (91.6%), 126 (88.1%), 117 (81.8%) patients participated in the 6-, 12-, and 24-month assessments, respectively. Percent weight loss from study enrollment to 6 and 12 months after surgery was comparable for both groups, but at 24 months after surgery, the lifestyle group had significantly smaller percent weight loss compared with the usual care group (26.5% versus 29.5%, respectively, P = .02).

CONCLUSIONS

Presurgery lifestyle intervention did not improve weight loss at 24 months after surgery. The findings from this study raise questions about the utility and timing of adjunctive lifestyle interventions for bariatric surgery patients.

Surgical vs medical treatments for type 2 diabetes mellitus: a randomized clinical trial

IMPORTANCE

Many questions remain unanswered about the role of bariatric surgery for people with type 2 diabetes mellitus (T2DM).

OBJECTIVE

To determine feasibility of a randomized clinical trial (RCT) and compare initial outcomes of bariatric surgery and a structured weight loss program for treating T2DM in participants with grades I and II obesity.

DESIGN, SETTING, AND PARTICIPANTS

A 12-month, 3-arm RCT at a single center including 69 participants aged 25 to 55 years with a body mass index (calculated as weight in kilograms divided by height in meters squared) of 30 to 40 and T2DM.

INTERVENTIONS

Roux-en-Y gastric bypass (RYGB), laparoscopic adjustable gastric banding (LAGB), and an intensive lifestyle weight loss intervention (LWLI).

MAIN OUTCOMES AND MEASURES

Primary outcomes in the intention-to-treat cohort were feasibility and effectiveness measured by weight loss and improvements in glycemic control.

RESULTS

Of 667 potential participants who underwent screening, 69 (10.3%) were randomized. Among the randomized participants, 30 (43%) had grade I obesity, and 56 (81%) were women. Mean (SD) age was 47.3 (6.4) years and hemoglobin A1c level, 7.9% (2.0%). After randomization, 7 participants (10%) refused to undergo their allocated intervention (3 RYGB, 1 LAGB, and 3 LWLI), and 1 RYGB participant was excluded for current smoking. Twenty participants underwent RYGB; 21, LAGB; and 20, LWLI, with 12-month retention rates of 90%, 86%, and 70%, respectively. In the intention-to-treat cohort with multiple imputation for missing data, RYGB participants had the greatest mean weight loss from baseline (27.0%; 95% CI, 30.8-23.3) compared with LAGB (17.3%; 95% CI, 21.1-13.5) and LWLI (10.2%; 95% CI, 14.8-5.61) (P < .001). Partial and complete remission of T2DM were 50% and 17%, respectively, in the RYGB group and 27% and 23%, respectively, in the LAGB group (P < .001 and P = .047 between groups for partial and complete remission), with no remission in the LWLI group. Significant reductions in use of antidiabetics occurred in both surgical groups. No deaths were noted. The 3 serious adverse events included 1 ulcer treated medically in the RYGB group and 2 rehospitalizations for dehydration in the LAGB group.

CONCLUSIONS AND RELEVANCE

This study highlights several potential challenges to successful completion of a larger RCT for treatment of T2DM and obesity in patients with a body mass index of 30 to 40, including the difficulties associated with recruiting and randomizing patients to surgical vs nonsurgical interventions. Preliminary results show that RYGB was the most effective treatment, followed by LAGB for weight loss and T2DM outcomes at 1 year.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01047735.

Self-report of gastrointestinal side effects after bariatric surgery

BACKGROUND

Data on gastrointestinal (GI) side effects of bariatric surgery are limited because of incomplete reporting, cross-sectional samples, and nonstandardized assessments.

OBJECTIVE

To report on GI side effects over the first 6 months after Roux-en-Y gastric bypass (RYGB) and laparoscopic adjustable gastric banding (LAGB).

SETTING

Academic medical center, United States.

METHODS

One hundred forty-four patients completed a standardized clinical interview 6 months after operation, including questions on the occurrence and frequency of episodes of dumping syndrome, vomiting, and plugging for each of the past 6 months; monthly rates were stable, so results were averaged over the entire period. Although data were collected as part of a randomized controlled trial, randomization group and the interaction of group by surgical procedure were not related to GI side effects. Thus, results are reported by procedure only (RYGB, n = 87; LAGB, n = 56).

RESULTS

RYGB patients had a higher preoperative body mass index (BMI) than LAGB patients (46.8±6.8 versus 43.5±4.8 kg/m(2), respectively; P = .001), were more likely to report dumping (45.7% versus 4.7%, P<.0001), and were less likely to report plugging (45.7% versus 79.1%, P = .0005). Vomiting did not differ significantly by procedure (68.6% versus 65.1%, P = .7). Most patients experienced each GI side effect less than once per week.

CONCLUSION

Although self-reported GI side effects were common over the first 6 months after operation, the frequency of episodes was relatively low. Longer-term follow-up is needed to determine whether symptoms worsen or improve over time.

Course of depressive symptoms and treatment in the longitudinal assessment of bariatric surgery (LABS-2) study

OBJECTIVE

To examine changes in depressive symptoms and treatment in the first 3 years following bariatric surgery.

METHODS

The longitudinal assessment of bariatric surgery-2 (LABS-2) is an observational cohort study of adults (n = 2,458) who underwent a bariatric surgical procedure at 1 of 10 US hospitals between 2006 and 2009. This study includes 2,148 participants who completed the Beck depression inventory (BDI) at baseline and ≥ one follow-up visit in years 1-3.

RESULTS

At baseline, 40.4% self-reported treatment for depression. At least mild depressive symptoms (BDI score ≥ 10) were reported by 28.3%; moderate (BDI score 19-29) and severe (BDI score ≥30) symptoms were uncommon (4.2 and 0.5%, respectively). Mild-to-severe depressive symptoms independently increased the odds (OR = 1.75; P = 0.03) of a major adverse event within 30 days of surgery. Compared with baseline, symptom severity was significantly lower at all follow-up time points (e.g., mild-to-severe symptomatology was 8.9%, 6 months; 8.4%, 1year; 12.2%, 2 years; 15.6%, 3 years; ps < 0.001), but increased between 1 and 3 years postoperatively (P < 0.01). Change in depressive symptoms was significantly related to change in body mass index (r = 0.42; P < 0001).

CONCLUSION

Bariatric surgery has a positive impact on depressive features. However, data suggest some deterioration in improvement after the first postoperative year. LABS-2, #NCT00465829, http://www.clinicaltrials.gov/ct2/show/NCT00465829.

Weight change and health outcomes at 3 years after bariatric surgery among individuals with severe obesity

IMPORTANCE

Severe obesity (body mass index [BMI] ≥35) is associated with a broad range of health risks. Bariatric surgery induces weight loss and short-term health improvements, but little is known about long-term outcomes of these operations.

OBJECTIVE

To report 3-year change in weight and select health parameters after common bariatric surgical procedures.

DESIGN AND SETTING

The Longitudinal Assessment of Bariatric Surgery (LABS) Consortium is a multicenter observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. PARTICIPANTS AND EXPOSURE: Adults undergoing first-time bariatric surgical procedures as part of routine clinical care by participating surgeons were recruited between 2006 and 2009 and followed up until September 2012. Participants completed research assessments prior to surgery and 6 months, 12 months, and then annually after surgery.

MAIN OUTCOMES AND MEASURES

Three years after Roux-en-Y gastric bypass (RYGB) or laparoscopic adjustable gastric banding (LAGB), we assessed percent weight change from baseline and the percentage of participants with diabetes achieving hemoglobin A1c levels less than 6.5% or fasting plasma glucose values less than 126 mg/dL without pharmacologic therapy. Dyslipidemia and hypertension resolution at 3 years was also assessed.

RESULTS

At baseline, participants (N = 2458) were 18 to 78 years old, 79% were women, median BMI was 45.9 (IQR, 41.7-51.5), and median weight was 129 kg (IQR, 115-147). For their first bariatric surgical procedure, 1738 participants underwent RYGB, 610 LAGB, and 110 other procedures. At baseline, 774 (33%) had diabetes, 1252 (63%) dyslipidemia, and 1601 (68%) hypertension. Three years after surgery, median actual weight loss for RYGB participants was 41 kg (IQR, 31-52), corresponding to a percentage of baseline weight lost of 31.5% (IQR, 24.6%-38.4%). For LAGB participants, actual weight loss was 20 kg (IQR, 10-29), corresponding to 15.9% (IQR, 7.9%-23.0%). The majority of weight loss was evident 1 year after surgery for both procedures. Five distinct weight change trajectory groups were identified for each procedure. Among participants who had diabetes at baseline, 216 RYGB participants (67.5%) and 28 LAGB participants (28.6%) experienced partial remission at 3 years. The incidence of diabetes was 0.9% after RYGB and 3.2% after LAGB. Dyslipidemia resolved in 237 RYGB participants (61.9%) and 39 LAGB participants (27.1%); remission of hypertension occurred in 269 RYGB participants (38.2%) and 43 LAGB participants (17.4%).

CONCLUSIONS AND RELEVANCE

Among participants with severe obesity, there was substantial weight loss 3 years after bariatric surgery, with the majority experiencing maximum weight change during the first year. However, there was variability in the amount and trajectories of weight loss and in diabetes, blood pressure, and lipid outcomes.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00465829.

Prenatal smoking cessation intervention and gestational weight gain

BACKGROUND

Quitting smoking is often associated with weight gain and prenatal cessation may lead to increased gestational weight gain (GWG). Although previous reports have suggested a link between prenatal smoking cessation and GWG, no studies have examined the relationship between cessation and guideline-recommended GWG, and there is little information about the relationship between the timing of prenatal cessation and GWG. Thus, we examine GWG among women in a community prenatal smoking cessation program and assess the relationship between the timing of prenatal cessation GWG.

METHODS

Pregnant women from care clinics serving economically disadvantaged women who participated in a smoking cessation intervention offered free of charge, self-reported weight, and provided biochemical verification of smoking. Relationships between duration of cessation and GWG were evaluated in t-tests and regression models. GWG was calculated from self-reported weight before pregnancy and self-reported weight at the last visit before delivery.

FINDINGS

Women who quit earlier during pregnancy had greater GWG (16.9 ± 7.5 kg) than did those who never quit (13.6 ± 8.9). After adjusting for timing of weight assessment and prepregnancy body mass index, however, GWG was not different between women who did and did not quit.

CONCLUSION

Quitting earlier in pregnancy is associated with greater GWG, but women who do and do not quit do not differ on total GWG. Despite increased GWG with early cessation, the maternal and fetal health benefits of prenatal smoking cessation outweigh risks of potential risks of excessive GWG.

Strategies to Avoid Returning to Smoking (STARTS): a randomized controlled trial of postpartum smoking relapse prevention interventions

The majority of women who quit smoking during pregnancy relapse postpartum and many experience increased depressive symptoms and concerns about body shape and weight. Given the relationship of weight concerns and negative mood to smoking relapse, interventions designed to address the postpartum experience are indicated. However, there are several challenges to research with postpartum women. We describe the rationale of a randomized controlled trial of postpartum smoking relapse prevention intervention and discuss methods to address the specific challenges to recruiting, retaining and conducting health behavior interventions among postpartum former smokers. Pregnant women who had quit smoking for at least one month prior to the 34 week of pregnancy and who were motivated to stay quit postpartum were recruited. Women were randomized either to a postpartum specific intervention designed to address concerns about mood, stress and weight using cognitive-behavioral techniques or to a support-only condition designed to control for time and attention. Intervention continues through six months postpartum and women complete follow-up assessments at 12-, 24- and 52-weeks after delivery. Women (n=300) who had quit smoking as a result of pregnancy were recruited and are being followed. The intervention described in this report is designed to address stress, negative mood and concerns about weight that mediate smoking relapse postpartum to sustain abstinence and improve maternal and infant health.

Structured Dietary Interventions in the Treatment of Severe Pediatric Obesity: A Pilot Study

BACKGROUND

Structured dietary interventions have been associated with improved outcomes in adult weight-control programs, but virtually no research has focused on children. Thus, we conducted an uncontrolled pilot study to determine the potential utility of structured approaches to enhance the dietary component of family-based treatment of severe pediatric obesity (body mass index [BMI] >97th percentile for age and sex).

METHOD

Children aged 8-12 years participated with a parent or guardian. Individualized menu plans were provided (MENU, n=12) alone, or along with meals and snacks for the child (MENU+MEAL, n=6). All families received up to $30/week reimbursement for foods included in the menus.

RESULTS

Median BMI change was -1.2 kg/m² for MENU (n=12), and -1.8 kg/m² for MENU+MEAL (n=6). Both approaches were associated with significant reductions in BMI (p<0.05).

CONCLUSION

Structured dietary interventions for severe pediatric obesity are acceptable to families and warrant further development.