Psychosocial and Behavioral Aspects of Bariatric Surgery

Bariatric surgery has become an increasingly popular treatment option for individuals with extreme obesity (defined as a BMI ≥ 40 kg/m²) or those with less severe obesity accompanied by significant comorbidities. Sustained postoperative weight loss and improvements in obesity‐related health problems make bariatric surgery the most effective treatment for this population. Nevertheless, most experts agree that psychosocial and behavioral factors contribute to successful postoperative outcomes. This paper reviews the literature on the preoperative psychosocial status, eating behaviors, and quality of life of patients who seek bariatric surgery. In addition, the paper examines studies that investigated changes in these factors postoperatively. The review concludes with an agenda for future research in this area.     

Weight-specific health-related quality of life in adolescents with extreme obesity

The objectives of this multisite study were to: (i) examine differences by gender and race on generic and weight- specific health-related quality of life (HRQOL) in adolescents with extreme obesity (BMI > or = 40 kg/m(2)) and (ii) explore HRQOL differences based on treatment pursued (behavioral vs. bariatric surgery). Study participants included 145 obese adolescents (mean age = 15.3 years; 68% female; 46% black; mean BMI = 50.6) referred to pediatric weight management programs. Participants completed generic (PedsQL) and weight-specific (Impact of Weight on Quality of Life-Kids (IWQOL-Kids)) HRQOL measures. Generic and weight-specific measures indicated global (e.g., all domains) HRQOL impairment and significant differences by race. Physical, emotional, and social scores of the PedsQL (Ps < 0.01) and the physical comfort and body esteem scores of the IWQOL-Kids (Ps < 0.001) were significantly higher for black compared to white adolescents with extreme obesity. Extremely obese adolescents pursuing bariatric surgery reported similar HRQOL to adolescents pursuing behavioral treatment (n = 30 matched pairs). HRQOL did not differ for extremely obese adolescents based on type of treatment sought, but race/ethnicity should be considered when characterizing these youth. Although racial differences in adolescent body image/esteem have been reported, it is unknown why black adolescents with extreme obesity would report less impact of weight on their physical functioning. Overall, these data suggest that HRQOL is not homogenous in adolescents with extreme obesity.     

Position of intragastric balloons in global initiative for obesity treatment

Obesity is chronic disease with multiple health consequences and among the most severe health problems worldwide. According to public health records around 65% of population in Croatia are overweight and 20% obese. National physicians chamber with support of Health and Social Welfare Ministry gave recommendations on diagnosing and treating of obesity in form of national consensus. Treatment of obesity is complex and enrolls multiple clinical specialties. Change of life style, strenuous physical activity and pharmacotherapy are part of conservative treatments. Patients are treated more efficiently by minimally invasive endoscopic procedures or bariatric surgery depending on starting body mass index score. Implantation of intragastric balloons is conceptually simple method of obesity treatment. Modern devices as Bio-Enterics intragastric balloons (BIB), (Inamed Health, USA) are gaining wide popularity among both patients and physicians. BIB intragastric offers the best gains with individuals ranging BMI from 35 to 40. Efficiency has relative timeline dependance from 85% at 6 months to 24% at 36 months. BIB offers substantial ameliorative influence on obesity comorbidities, particularly cardiovascular risk. Treatment with BIB is also efficient but transient treatment modality in morbidly and superobese individuals to reduce preoperative risks of general and bariatric surgery. Obesity treatment with BIB is well tolerated and safe, offering better quality of life. Nevertheless, due to relative poor results of conservative obesity treatments on long-term follow up further investigations defining new clinical parameters for solving treatment resistance. In order to provide resourcefully individualized approach modern perspectives are focused on endocrine constitutes of obesity. Hormonal effects of BIB treatment in compare to bariatric surgery are potentially interesting for the prospect studies.     

Coping with obesity stigma affects depressed mood in African-American and white candidates for bariatric surgery

Depressed mood in severely obese, bariatric surgery-seeking candidates is influenced by obesity stigma, yet the strategies for coping with this stigma are less well understood. This study hypothesized that coping strategies are significantly associated with depressed mood above and beyond demographic factors and frequency of weight-related stigma, with specific coping strategies differing between racial groups. Severely obese, bariatric surgery-seeking adults (N = 234; 91 African Americans) completed the Beck Depression Inventory (BDI) and Stigmatizing Situations Inventory (SSI). Two hierarchical linear regressions were conducted separately for African Americans and whites. For both racial groups, age, sex, BMI, years overweight, annual income, and education level did not account for a significant portion of the variance in BDI scores. The frequency of stigmatizing situations and coping strategies significantly explained 16.4% and 33.2%, respectively, of the variance for whites, and 25.9% and 25%, respectively, for African Americans (P < 0.001). Greater depressed mood in whites was associated with older age, lower education, fewer positive self-statements, and less self-love and more crying; while in African Americans greater depressed mood was associated only with ignoring the situation (P < 0.05). The study found that regardless of race, depressed mood in severely obese, bariatric surgery-seeking clients is related to the frequency of stigmatizing experiences and associated coping strategies. This suggests that efforts to reduce the deleterious effects of weight-related stigma need to focus both on reducing the frequency of stigmatization and on teaching effective coping strategies. These efforts also need to take into account the client's racial background.     

The Impact of Coronavirus Disease 2019 on Bariatric Surgery: Redefining Psychosocial Care

The global outbreak of the 2019 novel coronavirus disease has had a tremendous psychological impact on individuals around the world. Individuals with obesity are susceptible to distress and psychological sequalae secondary to this pandemic, which can have detrimental effects on obesity management. In particular, individuals undergoing bariatric surgery could experience increased emotional distress, resulting in increased eating psychopathology, mental health exacerbation, and difficulties with self‐management. Addressing these challenges requires novel approaches to redefining psychosocial care before and after bariatric surgery. Emerging evidence suggests that the remote delivery of care using virtual care models, including mobile and online modalities, could extend the reach of psychosocial services to individuals after bariatric surgery and mitigate weight regain or impairment in quality of life. Because of this pandemic, the rapid integration of virtual psychosocial care in bariatric surgery programs to address patients’ needs will create new opportunities for clinical and implementational scientific research.     

Appropriateness Criteria for Bariatric Surgery: Beyond the NIH Guidelines

Careful selection of bariatric patients is critical for successful outcomes. In 1991, the NIH first established patient selection guidelines; however, some surgeons operate on individuals outside of these criteria, i.e., extreme age groups. We developed appropriateness criteria for the spectrum of patient characteristics including age, BMI, and severity of eight obesity‐related comorbidities. Candidate criteria were developed using combinations of patient characteristics including BMI: ≥40 kg/m², 35–39, 32–34, 30–31, <30; age: 12–18, 19–55, 56–64, 65+ years old; and comorbidities: prediabetes, diabetes, hypertension, dyslipidemia, sleep apnea, venous stasis disease, chronic joint pain, and gastroesophageal reflux (plus severity level). Criteria were formally validated on their appropriateness of whether the benefits of surgery clearly outweighed the risks, by an expert panel using the RAND/UCLA modified Delphi method. Nearly all comorbidity severity criteria for patients with BMI ≥40 kg/m² or BMI = 35–39 kg/m² in intermediate age groups were found to be appropriate for surgery. In contrast, patients in the extreme age categories were considered appropriate surgical candidates under fewer conditions, primarily the more severe comorbidities, such as diabetes and hypertension. For patients with a BMI of 32–34, only the most severe category of diabetes (Hgb A1c >9, on maximal medical therapy), is an appropriate criterion for those aged 19–64, whereas many mild to moderate severity comorbidity categories are “inappropriate.” There is overwhelming agreement among the panelists that the current evidence does not support performing bariatric surgery in lower BMI individuals (BMI <32). This is the first development of appropriateness criteria for bariatric surgery that includes severity categories of comorbidities. Only for the most severe degrees of comorbidities were adolescent and elderly patients deemed appropriate for surgery. Patient selection for bariatric procedures should include consideration of both patient age and comorbidity severity.     

Obesity and sexual quality of life

Objectives : Reduced sexual quality of life is a frequently reported yet rarely studied consequence of obesity. The objectives of this study were to 1) examine the prevalence of sexual quality‐of‐life difficulties in obese individuals and 2) investigate the association between sexual quality of life and BMI class, sex, and obesity treatment—seeking status. Research Methods and Procedures : Subjects consisted of 1) 500 participants in an intensive residential program for weight loss and lifestyle modification (BMI = 41.3 kg/m²), 2) 372 patients evaluated for gastric bypass surgery (BMI = 47.1 kg/m²), and 3) 286 obese control subjects not seeking weight loss treatment (BMI = 43.6 kg/m²). Participants completed the Impact of Weight on Quality of Life‐Lite, a measure of weight‐related quality of life. Responses to the four Sexual Life items (assessing enjoyment, desire, performance, and avoidance) were analyzed by BMI, sex, and group. Results : Higher BMI was associated with greater impairments in sexual quality of life. Obese women reported more impairment in sexual quality of life than obese men for three of four items. Gastric bypass surgery candidates reported more impairment in sexual quality of life than residential patients and controls for most items. In general, residential patients reported levels of impairment greater than or equal to controls. Discussion : Obesity is associated with lack of enjoyment of sexual activity, lack of sexual desire, difficulties with sexual performance, and avoidance of sexual encounters. Sexual quality of life is most impaired for women, individuals with Class III obesity, and patients seeking gastric bypass surgery.     

Gender,Race, and Obesity‐Related Quality of Life at Extreme Levels of Obesity

Objective: Research investigating obesity‐related quality of life (QOL) has shown that at increasing levels of overweight, individuals report more impaired QOL. Further, some research has indicated that white women suffer more impairment than men and African Americans. The current study sought to expand the existing literature by investigating an extreme subsample of the obese population. It was expected that participants in the current study would report more impaired obesity‐related QOL than in previous research conducted with less obese individuals. It was also hypothesized that race and gender groups would differ in obesity‐related QOL and that the relationship between degree of overweight and QOL would not be consistent across race and gender groups. Research Methods and Procedures: Impact of Weight on Quality of Life Questionnaire‐Lite Version data were collected from 512 individuals seeking gastric bypass surgery (mean BMI = 53.3) Results: Results confirmed the study hypotheses. In general, white women reported the most QOL impairment, despite having significantly lower BMI than other race/gender groups. Compared with previous studies, the observed relationships between BMI and QOL were somewhat attenuated. Discussion: Various domains of QOL may be differentially affected by degree of obesity; these relationships are not homogeneous throughout the obese population.     

Loss of control is central to psychological disturbance associated with binge eating disorder

Objective: Binge eating disorder (BED) is positively associated with obesity and psychological distress, yet the behavioral features of BED that drive these associations are largely unexplored. The primary aim of this study was to investigate which core behavioral features of binge eating are most strongly related to psychological disturbance. Methods and Procedures: A cross‐sectional study involved 180 bariatric surgery candidates, 93 members of a non‐surgical weight loss support group, and 158 general community respondents (81 men/350 women, mean age 45.8 ± 13.3, mean BMI 34.8 ± 10.8, BMI range 17.7–66.7). Validated questionnaires assessed BED and binge eating, symptoms of depression, appearance dissatisfaction (AD), quality of life (QoL) and eating‐related behaviors. Features of binge eating were confirmed by interview. BMI was determined by clinical assessment and self‐report. Results: The loss of control (LOC) over eating, that is, being unable to stop eating or control what or how much was consumed was most closely related to psychological markers of distress common in BED. In particular, those who experienced severe emotional disturbance due to feelings of LOC reported higher symptoms of depression (P < 0.001), AD (P = 0.009), and poorer mental health–related QoL (P = 0.027). Discussion: Persons who report subjective binge episodes or do not meet BED frequency criteria for objective binge episodes may still be at elevated risk of psychological disturbance and benefit from clinical intervention. Feelings of LOC could drive binge eaters to seek bariatric surgery in an attempt to gain control over body weight and psychologically disturbing eating behavior.     

Surgical management of metabolic dysfunction in PCOS

Metabolic disturbances are common in women with polycystic ovary syndrome (PCOS). Obesity is the major link in the association of PCOS with diabetes, metabolic syndrome, hypertension, low-grade chronic inflammation and increased body iron stores, among others. Metabolic prevention in PCOS women should start as early as possible, usually meaning at diagnosis. Among preventive strategies, those promoting a healthy life-style based on diet, regular exercising and smoking cessation are possibly the most effective therapies, but also are the most difficult to achieve. To this regard, every effort must be made to avoid weight gain and obesity, given the deleterious impact that obesity exerts on the metabolic and cardiovascular associations of PCOS. Unfortunately, classic strategies that address obesity by life-style modification and dieting are seldom successful on a long-term basis, especially in women with severe obesity. In selected cases, metabolic surgery in severely obese women may resolve signs and symptoms of PCOS restoring insulin sensitivity and fertility, and avoiding the long-term risks associated with PCOS and morbid obesity. Surgical techniques for bariatric surgery have evolved in the past decades and newer procedures do not longer carry the severe side effects associated with earlier bariatric procedures. The choice of bariatric procedure should consider both the severity of obesity and the possibility of future pregnancy, since fertility may be restored by the sustained and marked weight loss usually attained after bariatric surgery. Finally, avoidance of the risks associated with morbid obesity compensate for the possible residual risks for pregnancy derived from the previous bariatric procedure itself.     

减重手术改善肥胖症认知功能障碍及其机制

越来越多的证据表明，肥胖会对大脑功能和结构产生负面影响。肥胖个体在食物线索、味觉和嗅觉、静息状态活动和功能连接方面显示出异常的神经反应，同时在决策、抑制控制、学习、记忆和注意力等认知任务中表现出异常。减重手术作为一种专门的治疗方案，可以改变消化系统解剖和生理机制，从而限制食物摄入或改变营养吸收来实现短期和长期的减重效果，改善并发症，降低死亡率，并提高生活质量。最近的研究表明，减重手术对改善肥胖症相关的认知功能障碍具有积极的影响。本文概述了肥胖与认知功能之间的关联，并重点阐述了近年来减重手术改善肥胖相关认知损伤的研究进展。涉及的内容包括奖励处理、食物摄入控制、大脑区域对认知功能的调控、大脑结构异常的恢复、激素调节改变以及对肠道微生物组成的改变，这些变化可能会影响脑功能和认知过程，这些研究成果有望为改善肥胖症患者的认知功能提供新的治疗策略和临床指导。     

Skeletal muscle lipid metabolism with obesity

The objectives of this study were to 1). examine skeletal muscle fatty acid oxidation in individuals with varying degrees of adiposity and 2). determine the relationship between skeletal muscle fatty acid oxidation and the accumulation of long-chain fatty acyl-CoAs. Muscle was obtained from normal-weight [n = 8; body mass index (BMI) 23.8 +/- 0.58 kg/m(2)], overweight/obese (n = 8; BMI 30.2 +/- 0.81 kg/m(2)), and extremely obese (n = 8; BMI 53.8 +/- 3.5 kg/m(2)) females undergoing abdominal surgery. Skeletal muscle fatty acid oxidation was assessed in intact muscle strips. Long-chain fatty acyl-CoA concentrations were measured in a separate portion of the same muscle tissue in which fatty acid oxidation was determined. Palmitate oxidation was 58 and 83% lower in skeletal muscle from extremely obese (44.9 +/- 5.2 nmol x g(-1) x h(-1)) patients compared with normal-weight (71.0 +/- 5.0 nmol x g(-1) x h(-1)) and overweight/obese (82.2 +/- 8.7 nmol x g(-1) x h(-1)) patients, respectively. Palmitate oxidation was negatively (R = -0.44, P = 0.003) associated with BMI. Long-chain fatty acyl-CoA content was higher in both the overweight/obese and extremely obese patients compared with normal-weight patients, despite significantly lower fatty acid oxidation only in the extremely obese. No associations were observed between long-chain fatty acyl-CoA content and palmitate oxidation. These data suggest that there is a defect in skeletal muscle fatty acid oxidation with extreme obesity but not overweight/obesity and that the accumulation of intramyocellular long-chain fatty acyl-CoAs is not solely a result of reduced fatty acid oxidation.     

Impact of Information About Obesity Genomics on the Stigmatization of Overweight Individuals: An Experimental Study

Advances in genomic technologies are rapidly leading to new understandings of the roles that genetic variations play in obesity. Increasing public dissemination of information regarding the role of genetics in obesity could have beneficial, harmful, or neutral effects on the stigmatization of obese individuals. This study used an online survey and experimental design to examine the impact of genetic versus non‐genetic information on obesity stigma among self‐perceived non‐overweight individuals. Participants (n = 396) were randomly assigned to read either genetic, non‐genetic (environment), or gene—environment interaction obesity causal information. A total of 48% of participants were female; mean age was 42.7 years (range = 18–86 years); 75% were white; 45.2% had an annual household income of less than $40,000; mean BMI was 23.4 kg/m². Obesity stigma was measured using the Fat Phobia Scale — short form (FPS‐S). After reading the experimental information, participants in the genetic and gene—environment conditions were more likely to believe that genetics increase obesity risk than participants in the non‐genetic condition (both P < 0.05), but did not differ on obesity stigma. Obesity stigma was higher among whites and Asians than Hispanics and African Americans (P = 0.029), and associated with low self‐esteem (P = 0.036). Obesity stigma was also negatively associated with holding 'germ or virus' (P = 0.033) and 'overwork' (P = 0.016) causal beliefs about obesity, and positively associated with 'diet or eating habits' (P = 0.001) and 'lack of exercise' (P = 0.004) causal beliefs. Dissemination of brief information about the role of genetics in obesity may have neither a beneficial nor a harmful impact on obesity stigmatization compared with non‐genetic information among self‐perceived non‐overweight individuals.     

Impact of surgically induced weight loss on cardiovascular autonomic function: one-year follow-up

Objective: To determine the impact of surgically induced weight loss on cardiovascular autonomic function in subjects with severe obesity and examine whether the effect was comparable for persons with and without diabetes. Research Methods and Procedures: Twenty‐six severely obese individuals (BMI = 48 ± 7 kg/m²) underwent bariatric surgery (laparoscopic Roux‐en‐Y gastric bypass, n = 21; laparoscopic adjustable gastric banding, n = 5). Cardiovascular autonomic function (heart rate variation during deep breathing and the Valsalva maneuver) was assessed before and 6 and 12 months after surgery. Results: Twelve months after bariatric surgery, there was a 28% decrease in BMI. There was an increase in all parasympathetic indices of autonomic function (all assessment modalities, p < 0.05) with weight loss. The amount of improvement from baseline for all measures of autonomic function did not differ for those with or without diabetes. Discussion: Surgically induced weight loss 12 months after surgery has a favorable effect on cardiovascular autonomic function in severely obese individuals with and without diabetes.     

Family Physicians' Practices and Attitudes Regarding Care of Extremely Obese Patients

Despite the growing epidemic of extreme obesity in the United States, weight management is not adequately addressed in primary care. This study assessed family physicians' practices and attitudes regarding care of extremely obese patients and factors associated with them. A cross‐sectional, self‐administered survey was mailed to 500 family physicians in New Jersey (NJ) during March–May 2008. Measures included knowledge, weight management approaches, attitudes toward managing obesity, challenges with examinations, availability of supplies, and strategies to improve care. Response rate was 53% (N = 255). Bariatric surgery and weight loss medications were infrequently recommended, particularly in physicians with higher volume of extremely obese patients (odds ratio (OR) 0.38; 95% confidence interval (CI) 0.23, 0.62 and OR 0.51; 95% CI 0.31, 0.85 for surgery and medications, respectively). Higher knowledge was associated with increased frequency of recommendations of weight loss medications (P < 0.0001) and bariatric surgery (P < 0.0001). There was a high prevalence of negative attitudes, particularly in younger physicians and those with lower patient volume. Increased knowledge of weight‐loss diets was associated with less dislike in discussing weight loss (P < 0.0001), less frustration (P = 0.0001), less belief that treatment is often ineffective (P < 0.0001), and less pessimism about patient success (P = 0.0002). Many providers encountered challenges performing examinations on extremely obese patients. More education of primary care physicians, particularly on bariatric surgery, specific examination techniques, and availability of community resources for obese persons is needed. Further research is needed to determine if interventions to increase knowledge of physicians will lead to less negative attitudes toward weight loss and extremely obese patients.     

Surgically Induced Interpregnancy Weight Loss and Prevalence of Overweight and Obesity in Offspring

Introduction

According to the fetal overnutrition hypothesis, obesity in pregnancy predisposes the offspring to obesity. Previous studies have suggested that after biliopancreatic surgery for obesity, the offspring is less likely to be obese. This study aims to further compare the BMI development of children born before and after maternal surgical weight loss.

Method

Women with at least one child born before and one child born after bariatric surgery were identified by record-linkage. Information about maternal BMI was extracted from medical records, as was information about the children''s BMI from birth to 10 years of age. We retrieved BMI data at four years of age for 340 children, born to 223 women (164 children born before surgery (BS), 176 children born after surgery (AS)). We evaluated prevalence of overweight/obesity and mean BMI in children born BS and AS at the ages of four, six and ten using GEE regression models. For 71 families, where we had complete data on mother and both children, we used a fixed-effects regression model to explore the association between differences in maternal BMI in w10 of the pre- and post-operative pregnancies with siblings'' BMI differences at age four.

Results

In no age group did we see a significantly reduced prevalence of overweight/obesity AS. For 10-year-old girls, the AS group had significantly higher rates of obesity. There was no association between differences in maternal BMI in early pregnancy and differences in siblings'' BMI at four years of age (β = −0.01, CI 95% = −0.11; 0.09).

Conclusions

We have been unable to demonstrate any effect of bariatric surgery on weight development in offspring. It seems unlikely that restrictive bariatric surgery conveys a protective effect in offspring with regards to obesity.     

High Body Mass Index is A Significant Barrier to Gender-Confirmation Surgery for Transgender and Gender-Nonbinary Individuals

Objective: Transgender and gender-nonbinary individuals (TGNB) are disproportionately impacted by obesity. In addition to the associated health impact, obesity represents a significant barrier to accessing gender-confirmation surgery (GCS). The purpose of this study was to determine the prevalence of obesity among TGNB surgical candidates at an urban academic medical center and evaluate the efficacy of self-monitored weight management.Methods: The study was conducted at the Center for Transgender Medicine and Surgery at Mount Sinai in New York City. Data abstraction from a quality improvement database was completed for patients with a documented body mass index (BMI) and a GCS consult from October 2015 through February 2019. A total of 1,457 TGNB patients with a documented BMI and a GCS consult in the historical period of review were included in analysis. Data were abstracted to determine the prevalence of obesity among GCS candidates and evaluate the current default pre-operative self-monitored weight management protocol.Results: Of 1,457 TGNB patients, 382 (26%) were obese (BMI ≥30 kg/m²) at initial surgical consult. In addition, 369 (27%) were obese at a subsequent follow-up, suggesting no statistically significant change in the rate of obesity among evaluated TGNB despite self-monitored weight management (P = .5272).Conclusion: Obesity is a significant barrier to gender affirming surgery for transgender individuals. Self-monitored weight management is an unsuccessful strategy for improvement even among individuals who would be predicted to be motivated.Abbreviations: BMI = body mass index; CTMS = Center for Transgender Medicine and Surgery (at Mount Sinai); GCS = gender confirmation surgery; TGNB = transgender and gender-nonbinary     

Bariatric surgery for patients with type 2 diabetes mellitus requiring insulin: Clinical outcome and cost-effectiveness analyses

BackgroundAlthough bariatric surgery is well established as an effective treatment for patients with obesity and type 2 diabetes mellitus (T2DM), there exists reluctance to increase its availability for patients with severe T2DM. The aims of this study were to examine the impact of bariatric surgery on T2DM resolution in patients with obesity and T2DM requiring insulin (T2DM-Ins) using data from a national database and to develop a health economic model to evaluate the cost-effectiveness of surgery in this cohort when compared to best medical treatment (BMT).Methods and findingsClinical data from the National Bariatric Surgical Registry (NBSR), a comprehensive database of bariatric surgery in the United Kingdom, were extracted to analyse outcomes of patients with obesity and T2DM-Ins who underwent primary bariatric surgery between 2009 and 2017. Outcomes for this group were combined with data sourced from a comprehensive literature review in order to develop a state-transition microsimulation model to evaluate cost-effectiveness of bariatric surgery versus BMT for patients over a 5-year time horizon. The main outcome measure for the clinical study was insulin cessation at 1-year post-surgery: relative risks (RR) summarising predictive factors were determined, unadjusted, and after adjusting for variables including age, initial body mass index (BMI), duration of T2DM, and weight loss. Main outcome measures for the economic evaluation were total costs, total quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER) at willingness-to-pay threshold of GBP£20,000.A total of 2,484 patients were eligible for inclusion, of which 1,847 had 1-year follow-up data (mean age of 51 years, mean initial BMI 47.2 kg/m², and 64% female). 67% of patients no longer required insulin at 1-year postoperatively: these rates persisted for 4 years. Roux-en-Y gastric bypass (RYGB) was associated with a higher rate of insulin cessation (71.7%) than sleeve gastrectomy (SG; 64.5%; RR 0.92, confidence interval (CI) 0.86–0.99) and adjustable gastric band (AGB; 33.6%; RR 0.45, CI 0.34–0.60; p < 0.001). When adjusted for percentage total weight loss and demographic variables, insulin cessation following surgery was comparable for RYGB and SG (RR 0.97, CI 0.90–1.04), with AGB having the lowest cessation rates (RR 0.55, CI 0.40–0.74; p < 0.001). Over 5 years, bariatric surgery was cost saving compared to BMT (total cost GBP£22,057 versus GBP£26,286 respectively, incremental difference GBP£4,229). This was due to lower treatment costs as well as reduced diabetes-related complications costs and increased health benefits. Limitations of this study include loss to follow-up of patients within the NBSR dataset and that the time horizon for the economic analysis is limited to 5 years. In addition, the study reflects current medical and surgical treatment regimens for this cohort of patients, which may change.ConclusionsIn this study, we observed that in patients with obesity and T2DM-Ins, bariatric surgery was associated with high rates of postoperative cessation of insulin therapy, which is, in turn, a major driver of overall reductions in direct healthcare cost. Our findings suggest that a strategy utilising bariatric surgery for patients with obesity and T2DM-Ins is cost saving to the national healthcare provider (National Health Service (NHS)) over a 5-year time horizon.

Emma Rose McGlone and colleagues report the clinical and cost- effectiveness of bariatric surgery for patients with Type 2 diabetes.     

Modeling the Impact of Adjustable Gastric Banding on Survival in Patients with Morbid Obesity

Objective: Morbid obesity is associated with premature death. Adjustable gastric banding may lead to substantial weight loss in patients with morbid obesity. Little is known about the impact of weight loss on survival after adjustable gastric banding. We therefore developed a mathematical model to estimate life expectancy in patients with a body mass index (BMI) ≥40 kg/m² undergoing bariatric surgery. Research Methods and Procedures: We developed a nonhomogeneous Markov chain consisting of five states: the absorbing state (“dead”) and the four recurrent states BMI ≥40 kg/m², BMI 36 to 39 kg/m², BMI 32 to 35 kg/m², and BMI 25 to 31 kg/m². Scenarios of weight loss and age‐ and sex‐dependent risk of death, as well as BMI‐dependent excess mortality were extracted from life tables and published literature. All patients entered the model through the state of BMI ≥40 kg/m². Results: In men aged either 18 or 65 years at the time of surgery, who moved from the state BMI ≥40 kg/m² to the next lower state of BMI 36 to 39 kg/m², life expectancy increased by 3 and 0.7 years, respectively. In women aged either 18 or 65 years at the time of surgery, who moved from the state BMI ≥40 kg/m² to the next lower state BMI 36 to 39 kg/m², life expectancy increased by 4.5 and 2.6 years, respectively. Weight loss to lower BMI strata resulted in further gains of life expectancy in both men and women. Discussion: Within the limitations of the modeling study, adjustable gastric banding in patients with morbid obesity may substantially increase life expectancy.     

Long-term cost-effectiveness of interventions for obesity: A mendelian randomisation study

BackgroundThe prevalence of obesity has increased in the United Kingdom, and reliably measuring the impact on quality of life and the total healthcare cost from obesity is key to informing the cost-effectiveness of interventions that target obesity, and determining healthcare funding. Current methods for estimating cost-effectiveness of interventions for obesity may be subject to confounding and reverse causation. The aim of this study is to apply a new approach using mendelian randomisation for estimating the cost-effectiveness of interventions that target body mass index (BMI), which may be less affected by confounding and reverse causation than previous approaches.Methods and findingsWe estimated health-related quality-adjusted life years (QALYs) and both primary and secondary healthcare costs for 310,913 men and women of white British ancestry aged between 39 and 72 years in UK Biobank between recruitment (2006 to 2010) and 31 March 2017. We then estimated the causal effect of differences in BMI on QALYs and total healthcare costs using mendelian randomisation. For this, we used instrumental variable regression with a polygenic risk score (PRS) for BMI, derived using a genome-wide association study (GWAS) of BMI, with age, sex, recruitment centre, and 40 genetic principal components as covariables to estimate the effect of a unit increase in BMI on QALYs and total healthcare costs. Finally, we used simulations to estimate the likely effect on BMI of policy relevant interventions for BMI, then used the mendelian randomisation estimates to estimate the cost-effectiveness of these interventions.A unit increase in BMI decreased QALYs by 0.65% of a QALY (95% confidence interval [CI]: 0.49% to 0.81%) per year and increased annual total healthcare costs by £42.23 (95% CI: £32.95 to £51.51) per person. When considering only health conditions usually considered in previous cost-effectiveness modelling studies (cancer, cardiovascular disease, cerebrovascular disease, and type 2 diabetes), we estimated that a unit increase in BMI decreased QALYs by only 0.16% of a QALY (95% CI: 0.10% to 0.22%) per year.We estimated that both laparoscopic bariatric surgery among individuals with BMI greater than 35 kg/m², and restricting volume promotions for high fat, salt, and sugar products, would increase QALYs and decrease total healthcare costs, with net monetary benefits (at £20,000 per QALY) of £13,936 (95% CI: £8,112 to £20,658) per person over 20 years, and £546 million (95% CI: £435 million to £671 million) in total per year, respectively.The main limitations of this approach are that mendelian randomisation relies on assumptions that cannot be proven, including the absence of directional pleiotropy, and that genotypes are independent of confounders.ConclusionsMendelian randomisation can be used to estimate the impact of interventions on quality of life and healthcare costs. We observed that the effect of increasing BMI on health-related quality of life is much larger when accounting for 240 chronic health conditions, compared with only a limited selection. This means that previous cost-effectiveness studies have likely underestimated the effect of BMI on quality of life and, therefore, the potential cost-effectiveness of interventions to reduce BMI.

Sean Harrison and colleagues use Mendelian randomization techniques to estimate the cost effectiveness of interventions targeting body mass index.