Published in May Issue             

Postoperative Behavioral Variables and Weight Change 3 Years After Bariatric Surgery
(JAMA Surgery)

To identify postoperative eating and weight control behaviors and describe their effects on changes in weight three years after bariatric surgery, a sample of 2,022 patients undergoing first-time bariatric surgical procedures between 2006 and 2009 were selected from the Longitudinal Assessment of Bariatric Surgery-2 (LABS-2) study. Twenty-five postoperative behaviors were identified related to eating behavior, eating problems, weight control practices, and the use of alcohol, smoking and illegal drugs. These behaviors were divided into those that were never present (preoperatively or postoperatively), those that were always present (preoperatively and postoperatively), and those that underwent a healthy change after surgery (development of a positive behavior or omission of a negative behavior). The median age of patients was 47 and the median BMI was 46. The sample included 1,513 gastric bypass patients and 509 gastric band patients. The cumulative effects of three behaviors were found to explain most of the variability in weight change: weekly self-weighing, continuing to eat when feeling full more than once a week, and eating continuously during the day. The study found a patient who postoperatively started to self-weigh, stopped eating when feeling full, and stopped eating continuously during the day after surgery would be predicted to lose a mean of 38.8% of their baseline weight. This average is about a 14% greater weight loss than those who made no positive changes in these variables and a 6% greater weight loss compared with participants who always reported positive changes in these healthy behaviors. The results suggest the importance of assessing activities related to eating behavior, eating problems, weight control practices, and the problematic use of alcohol, smoking and illegal drugs in bariatric surgery candidates.

Association of DiaRem Score With Cure of Type 2 Diabetes Following Bariatric Surgery
(JAMA Surgery)

A cohort study conducted by the Obesity Institute, Geisinger Health System examined the predictive power of the DiaRem score in determining whether bariatric surgery will lead to short-term remission of type 2 diabetes in patients with obesity. The DiaRem score is a validated score ranging from 0 (best) to 22 (worst) generated from data readily available in medical records, including age, HbA1c, insulin utilization, and use of other antiglycemic agents. The study included 8 years of follow-up data from 407 patients who had gastric-bypass surgery between 2001 and 2010. The patient cohort had a mean age of 51, an average preoperative HbA1c of 7.4% and an average BMI of 48.5. About three-quarters of the patients (77%) were receiving metformin and more than a third (37%) were using insulin; others were using a sulfonylurea (31%) or a nonmetformin insulin-sensitizing agent (31%). The patients had very diverse DiaRem scores: 0 to 2 (25% of patients); 3 to 7 (31%); 8 to 12 (11%); 13 to 17 (26%); and 18 to 22 (8%). Following surgery half of the 100 patients with the best DiaRem scores (0 to 2), but none of the 33 patients with the worst scores (18 to 22) were “cured” of their diabetes. Cure was defined as HbA1c <5.7% (complete remission) for at least 5 years, with no antiglycemic-agent use in the past year. One-in-five patients no longer had diabetes. The proportion of patients who achieved diabetes remission or cure decreased as the DiaRem scores increased. A total of 82% of the patients with the best DiaRem scores, but none of the patients with the worst DiaRem scores attained prolonged partial remission
of diabetes.

Video Ratings of Surgical Skill and Late Outcomes of Bariatric Surgery (JAMA Surgery)

A retrospective observational study measured the association between surgical skill and long-term outcomes of bariatric surgery performed in Michigan Bariatric Surgery Collaborative hospitals. Twenty surgeons submitted videos performing laparoscopic gastric bypass. These surgeons were ranked on their skill level through blinded peer video review and sorted into quartiles of skill. The patients (N = 3,631) undergoing surgery with these surgeons had 1-year postoperative follow-up data available between 2006 and 2012. Across skill levels, outcomes of bariatric surgery were then examined including: excess body weight loss at 1 year; resolution of medical comorbidities (hypertension, sleep apnea, diabetes, and hyperlipidemia); functional status; and patient satisfaction. Surgeons in the top and bottom quartiles had each been practicing for a mean of 11 years. Peer ratings of surgical skill varied from 2.6 to 4.8 on a 5-point scale. There was no difference between the best (top 25%) and worst (bottom 25%) performance quartiles when comparing excess body weight loss (67.2% vs. 68.5%) at 1 year. There were no differences in resolution of sleep apnea (62.6% vs 62.0), hypertension (47.1% vs 45.4%), or hyperlipidemia (52.3% vs 63.4%). Surgeons with the lowest skill rating had patients with higher rates of diabetes resolution (78.8%) when compared with the high-skill group (72.8%). In contrast to its effect on early complications, surgical skill did not affect postoperative weight loss or resolution of medical comorbidities at 1-year follow-up. The findings suggest that long-term outcomes after bariatric surgery may be less dependent on a surgeon’s operative skill and instead be driven by other factors.

Investigating Nutritional Deficiencies in a Group of Patients 3 Years Post Laparoscopic
Sleeve Gastrectomy
(Obesity Surgery)

A retrospective study investigated weight loss and evolution of nutritional deficiencies in patients 3 years after undergoing sleeve gastrectomy. Data included anthropometry, nutritional markers (hemoglobin, iron studies, folate, calcium, iPTH, vitamins D, and B12), and compliancy with supplementations. Ninety-one patients, average age of 51.9 and mean BMI of 42.8 were identified. Percentage of weight loss at 1 and 3 years post-operatively was 29.8% and 25.9%, respectively. Pre-operatively, the abnormalities included low hemoglobin (4%), ferritin (6%), vitamin B12 (1%), vitamin D (46%), and elevated iPTH (25%). At 3-years follow-up, the abnormal laboratory values included low hemoglobin (14%), ferritin (24%), vitamin D (20%) and elevated iPTH (17 %). Compliancy with multivitamin supplementation was noted in 66% of patients. Data from the study shows sleeve gastrectomy resulted in pronounced weight loss at 1 year post-operatively, and most of this was maintained at 3 years. Nutritional deficiencies were prevalent among patients prior to bariatric surgery. These deficiencies may persist or exacerbate post-operatively. Routine nutrition monitoring and supplementations are essential to prevent and treat these deficiencies.

Prevalence of Obesity and Severe Obesity in US Children, 1999-2014 (Obesity)

Using the National Health and Nutrition Examination Survey (NHANES), 1999–2014, investigators sought to determine the prevalence of obesity and severe obesity among U.S. children and adolescents ages 2 to 19. In 2013–2014, 17.4% of children met criteria for class I obesity, including 6.3% for class II and 2.4% for class III. These percentages were not statistically different those reported in 2011–2012. However, there was a clear, statistically significant increase in all classes of obesity from 1999 through 2014. There is no evidence of a decline in obesity prevalence in any age group, despite substantial clinical and policy efforts targeting the issue.