An evaluation of the bariatric surgical patient

Obesity continues to be one of the most common prevalent chronic diseases worldwide with recent data stating that it has now reached global pandemic proportions making it a major public health problem. In 2008 the World Health Organisation (WHO) stated that worldwide around 1.4 billion adults were overweight (body mass index [BMI] 25.0-29.9 kg/m2) and a further 500 million were obese (BMI ?30 kg/m2). Of note, the prevalence of obesity has tripled in Europe over the last 30 years with around 50% of the population in the majority of European countries being overweight or obese.1-4 Locally, the situation is also alarming with data from the European Health Interview Survey (EHIS) in 2011 stating that Malta had the highest rate of obese males in Europe (24.7%) and when it comes to females, Maltese women were the second most obese after British women (21.1% and 23.9% respectively).5 Even more worrisome is the fact that Malta also tops the charts for the highest prevalence of overweight and obesity in school-aged children thus accentuating the fact that urgent action needs to be taken in order to tackle effectively this world-wide epidemic.6 Unfortunately obesity is strongly linked to several co-morbid conditions such as type 2 diabetes, hypertension, cardiovascular disease, dyslipidaemia, obstructive sleep apnoea, non-alcoholic steatohepatitis, osteoarthrosis, as well as some cancers (including breast, ovary, prostate, endometrium and colon) and psychiatric illnesses and thus it stands to reason that an increase in prevalence of obesity has also led to an increase in prevalence of these co-morbidities resulting in an impaired overall quality of life and decreased life expectancy in these subjects.peer-reviewe

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 three years following bariatric surgery. Design and Methods The Longitudinal Assessment of Bariatric Surgery-2 is an observational cohort study of adults (n=2,458) who underwent a bariatric surgical procedure at one of ten US hospitals between 2006–9. 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=.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%, 1yr; 12.2%, 2yrs; 15.6%, 3yrs; ps<.001), but increased between 1 and 3 years postoperatively (p<.01). Change in depressive symptoms was significantly related to change in body mass index (r=.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

Obstructive sleep apnea is underrecognized and underdiagnosed in patients undergoing bariatric surgery

The aim of this study was to evaluate prevalence of obstructive sleep apnea among patients undergoing bariatric surgery and the predictive value of various clinical parameters: body mass index (BMI), neck circumference (NC) and the Epworth Sleepiness Scale (ESS). We performed a prospective, multidisciplinary, single-center observational study including all patients on the waiting list for bariatric surgery between June 2009 and June 2010, irrespective of history or clinical findings. Patients visited our ENT outpatient clinic for patient history, ENT and general examination and underwent a full night polysomnography, unless performed previously. As much as 69.9% of the patients fulfilled the criteria for OSA (mean BMI 44.2 ± SD 6.4 kg/m2); 40.4% of the patients met the criteria for severe OSA. The regression models found BMI to be the best clinical predictor, while the ROC curve found the NC to be the most accurate predictor of the presence of OSA. The discrepancy of the results and the poor statistical power suggest that all three clinical parameters are inadequate predictors of OSA. In conclusion, in this large patient series, 69.9% of patients undergoing BS meet the criteria for OSA. More than 40% of these patients have severe OSA. A mere 13.3% of the patients were diagnosed with OSA before being placed on the waiting list for BS. On statistical analysis, increased neck circumference, BMI and the ESS were found to be insufficient predictors of the presence of OSA. Polysomnography is an essential component of the preoperative workup of patients undergoing BS. When OSA is found, specific perioperative measures are indicated

Physical Activity Levels of Patients Undergoing Bariatric Surgery in the Longitudinal Assessment of Bariatric Surgery (LABS) Study

Background- Bariatric surgery candidates' physical activity (PA) level may contribute to the variability of weight loss and body composition changes following bariatric surgery. However, there is little research describing the PA of patients undergoing bariatric surgery to inform PA recommendations in preparation for, and following, surgery. Objectives- Describe PA assessment in the LABS-2 study and report pre-surgery PA level. Examine relationships between objectively determined PA level and 1) BMI and 2) self-reported purposeful exercise. Setting- Six sites in the U.S. Methods- Participants wore an accelerometer and completed a PA diary. Standardized measures of height and weight were obtained. Results- Of 757 participants, 20% were sedentary (<5000 steps/day), 34% low active (5000-7499 steps/day), 27% somewhat active (7500-9999 steps/day), 14% active (10000-12499 steps/day), and 6% were highly active (greater than or equal to 12500 steps/day). BMI was inversely related to mean steps/day and mean steps/minute during the most active 30 minutes each day. The most commonly reported activities were walking, 44%; gardening, 11%; playing with children, 10%; and stretching, 7%. Self-report of minutes of exercise accounted for 2% of the variance in objectively determined steps. Conclusion- Patients present for bariatric surgery with a wide range of PA levels, with almost half categorized as somewhat active or active. BMI is inversely related to total amount and intensity of PA. Few patients report a regular pre-operative exercise regimen suggesting most PA is accumulated from activities of daily living. Patient report of daily minutes of walking or exercise may not be a reliable indication of their PA level. Originally published Surgery for Obesity and Related Diseases, Vol. 4, No. 6, Nov-Dec 200

Obesity (Silver Spring)

Objective:This study examined end-of-trial health outcomes in participants in the Look AHEAD (Action for Health in Diabetes) trial who had bariatric surgery during the approximately 10-year randomized intervention.Methods:Data were obtained from the Look AHEAD public access database of 4901 individuals with type 2 diabetes and overweight/obesity who were assigned to intensive lifestyle intervention (ILI) or a diabetes support and education (DSE) control group. Changes in outcomes in participants who had bariatric surgery were compared with those in participants with a body mass index (BMI) 65 30 kg/m2 who remained in the ILI and DSE groups.Results:A total of 99 DSE and 97 ILI participants had bariatric surgery. At randomization, these 196 participants were significantly younger and more likely to be female and to have higher BMIs than the remaining ILI (N=1972) and DSE (N=2009) participants. At trial\u2019s end, surgically-treated participants lost 19.3% of baseline weight, compared with 5.6% and 3.3% for the ILI and DSE groups, respectively, and were more likely to achieve partial or full remission of their diabetes.Conclusions:The large, sustained improvements in weight and diabetes observed in this self-selected sample of surgically-treated participants are consistent with results of multiple randomized trials.U01 DK057151/DK/NIDDK NIH HHS/United StatesP30 DK048520/DK/NIDDK NIH HHS/United StatesU01 DK057135/DK/NIDDK NIH HHS/United StatesUL1 RR024153/RR/NCRR NIH HHS/United StatesP30 DK046204/DK/NIDDK NIH HHS/United StatesM01 RR002719/RR/NCRR NIH HHS/United StatesM01 RR000056/RR/NCRR NIH HHS/United StatesU01 DK057219/DK/NIDDK NIH HHS/United StatesU01 DK057154/DK/NIDDK NIH HHS/United StatesU01 DK056992/DK/NIDDK NIH HHS/United StatesU01 DK057171/DK/NIDDK NIH HHS/United StatesU01 DK057182/DK/NIDDK NIH HHS/United StatesU01 DK057136/DK/NIDDK NIH HHS/United StatesU01 DK057002/DK/NIDDK NIH HHS/United StatesU01 DK057177/DK/NIDDK NIH HHS/United StatesM01 RR001066/RR/NCRR NIH HHS/United StatesU01 DK057078/DK/NIDDK NIH HHS/United StatesU01 DK057131/DK/NIDDK NIH HHS/United StatesM01 RR000051/RR/NCRR NIH HHS/United StatesM01 RR000043/RR/NCRR NIH HHS/United StatesU01 DK056990/DK/NIDDK NIH HHS/United StatesU01 DK057178/DK/NIDDK NIH HHS/United StatesU01 DK057008/DK/NIDDK NIH HHS/United StatesU01 DK057149/DK/NIDDK NIH HHS/United StatesK23 NR017209/NR/NINR NIH HHS/United StatesM01 RR001346/RR/NCRR NIH HHS/United StatesK23 NR017209/NR/NINR NIH HHS/United States2020-04-01T00:00:00Z30900413PMC6432947693

Retention and Attrition in Bariatric Surgery Research: A Qualitative Study

Problem: Longitudinal bariatric surgical research studies often lack information on retention and attrition of study participants and the strategies utilized to optimize these. The potential for attrition bias with adverse effects on validity, reliability, and generalizability increases over time. The many factors potentially affecting retention and attrition in research, have been under studied. Purpose: The purpose was to explore factors affecting research participation of bariatric surgical patients who are subjects in the Longitudinal Assessment of Bariatric Surgery (LABS) study. The research questions explored research participants’ perceptions, motivations, and attitudes concerning participation in the study, specifically participation in annual in-person visits as well as routine annual clinical follow-up, and factors that impeded or facilitated “complete” participation. Design and Methods: A qualitative descriptive design with a non-probability, maximal variation sampling technique were utilized. Because the purpose was to explore factors related to research participation from the perspective of bariatric surgical research subjects, the statistically nonrepresentative stratified sampling approach was employed primarily according to levels of prior bariatric surgical research participation. Data collection consisted of one-time individual interviews. The Applied Thematic Analysis process guided the content analysis. Results: Thirty-six interviews were completed and arrived at analytic saturation. Fifteen motivational themes were identified. The 3 most frequently cited were: Sharing one’s own experiences to help others, study participation was helpful to my own goals, and desire to support research. Motivation changed over time and did not appear related to prior participation. A small majority (22) responded that they would return to annual research visits with poor weight loss. Extensive questionnaire completion was perceived as a significant barrier. A sizable subgroup (15) of participants perceived distance to the center and travel time as a barrier. Study participants perceived strategies that better enabled them to manage their time and availability and provided them with a progress report of personal measurements as beneficial. A majority viewed a financial honorarium and travel reimbursement positively (31 of 33) and supportive to their participation (19 of 31). Conclusion: The motivations, barriers, and facilitators to research retention identified in this study provides an evidence-base from which to further develop current and new retention strategies. Further research should focus on evaluating the effectiveness of retention strategies and developing an optimal selection process for retention strategies

Bariatric surgery in HIV-infected patients: review of literature

Obesity is now a common problem among HIV-infected patients receiving antiretroviral therapy (ART). Until recently, HIV infection has been considered a contraindication to bariatric surgery for various reasons. Insurance carriers have considered HIV a terminal disease, and surgeons have been reluctant to operate HIV-infected patients because of this, as well as the associated risk of infectious transmissions, although this has been changing. Gastric bypass surgery may be an option for some patients who have failed diet and therapeutic lifestyle changes, modification in ART or other treatment modalities for HIV/ART-related lipohypertrophy and obesity. However, few data are available regarding HIV-related outcomes after such surgery and its impact on ART tolerability. The aim of this study is to review bariatric surgery in HIV-infected patients

Urinary Incontinence Before and After Bariatric Surgery

IMPORTANCE: Among women and men with severe obesity, evidence for improvement in urinary incontinence beyond the first year after bariatric surgery–induced weight loss is lacking. OBJECTIVES: To examine change in urinary incontinence before and after bariatric surgery and to identify factors associated with improvement and remission among women and men in the first 3 years after bariatric surgery. DESIGN, SETTING, AND PARTICIPANTS: The Longitudinal Assessment of Bariatric Surgery 2 is an observational cohort study at 10 US hospitals in 6 geographically diverse clinical centers. Participants were recruited between February 21, 2005, and February 17, 2009. Adults undergoing first-time bariatric surgical procedures as part of clinical care by participating surgeons between March 14, 2006, and April 24, 2009, were followed up for 3 years (through October 24, 2012). INTERVENTION: Participants undergoing bariatric surgery completed research assessments before the procedure and annually thereafter. MAIN OUTCOMES AND MEASURES: The frequency and type of urinary incontinence episodes in the past 3 months were assessed using a validated questionnaire. Prevalent urinary incontinence was defined as at least weekly urinary incontinence episodes, and remission was defined as change from prevalent urinary incontinence at baseline to less than weekly urinary incontinence episodes at follow-up. RESULTS: Of 2458 participants, 1987 (80.8%) completed baseline and follow-up assessments. At baseline, the median age was 47 years (age range, 18-78 years), the median body mass index was 46 kg/m(2) (range, 34-94 kg/m(2)), and 1565 of 1987 (78.8%) were women. Urinary incontinence was more prevalent among women (49.3%; 95% CI, 46.9%-51.9%) than men (21.8%; 95% CI, 18.2%-26.1%) (P < .001). After a mean 1-year weight loss of 29.5% (95% CI, 29.0%-30.1%) in women and 27.0% (95% CI, 25.9%-28.6%) in men, year 1 urinary incontinence prevalence was significantly lower among women (18.3%; 95% CI, 16.4%-20.4%) and men (9.8%; 95% CI, 7.2%-13.4%) (P < .001 for all). The 3-year prevalence was higher than the 1-year prevalence for both sexes (24.8%; 95% CI, 21.8%-26.5% among women and 12.2%; 95% CI, 9.0%-16.4% among men) but was substantially lower than baseline (P < .001 for all). Weight loss was independently related to urinary incontinence remission (relative risk, 1.08; 95% CI, 1.06-1.10 in women and 1.07; 95% CI, 1.02-1.13 in men) per 5% weight loss, as were younger age and the absence of a severe walking limitation. CONCLUSIONS AND RELEVANCE: Among women and men with severe obesity, bariatric surgery was associated with substantially reduced urinary incontinence over 3 years. Improvement in urinary incontinence may be an important benefit of bariatric surgery

Safety, Effectiveness, and Cost Effectiveness of Metabolic Surgery in the Treatment of Type 2 Diabetes Mellitus

Remission of type 2 diabetes mellitus with metabolic surgery is a field of active investigation and development. The extraordinary results obtained in diabetic patients with BMI > 35 kg/m2 have led investigators to query if similar results could be achieved in patients with BMI < 35 kg/m2. A few studies have been recently conducted to evaluate the safety, effectiveness, and cost effectiveness of bariatric surgery in diabetic patients with BMI BMI < 35 kg/m2. However, stronger evidence would be required before insurance coverage is extended for bariatric surgery to all type 2 diabetic patients, in addition to those with BMI ≥ 35 kg/m2 for whom eligibility is already established. In addition, the hormonal and metabolic mechanisms of diabetes remission after gastrointestinal surgery are yet to be determined. This paper will review the evidence about safety, effectiveness, and cost effectiveness of bariatric surgery in type 2 diabetes mellitus remission and the potential socioeconomic impact of offering bariatric surgery to diabetic patients with BMI BMI < 35 kg/m2