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OBJECTIVE The aim of this work was to study weight loss and risk of cardiovascular disease (CVD) or death associated with longer-term phentermine use. METHODS Using electronic health record data, 13,972 adults were identified with a first phentermine fill in 2010 to 2015, creating exposure categories according to a patient's duration of use (referent: ≤ 3 months). Multivariable linear models were used to compare percent weight loss across categories at 6, 12, and 24 months, and Cox proportional hazards models were used to compare risk of composite CVD or death, up to 3 years after starting phentermine. RESULTS The cohort was 84% female and 45% white, with a mean (SD) baseline age 43.5 (10.7) years and BMI of 37.8 (7.2) kg/m2 . In multivariable models, longer-term users of phentermine experienced more weight loss; patients using continuously for > 12 months lost 7.4% more than the referent group at 24 months (P

Objective The aim of this study was to compare the cost and health care utilization of patients with obesity and type 2 diabetes mellitus (T2DM) randomized into either Roux-en-Y gastric bypass (RYGB) surgery or an intensive lifestyle and medical intervention (ILMI). Methods This analysis (N = 745) is based on 2-year follow-up of a small randomized controlled trial (RCT); adult patients with obesity and T2DM were recruited between 2011 and 2012 from Kaiser Permanente Washington. Comparisons were made for patients randomized into either RYGB (N = 15) or ILMI (N = 17). Results There were no significant cost savings for RYGB versus ILMI patients through the follow-up years. Pharmacy cost was lower for RYGB versus ILMI patients by about $900 in year 2 versus year 0; however, inpatient and emergency room costs were higher for surgery patients in follow-up years relative to year 0. Median total cost for nonrandomized patients was higher in year 0 and in year 2 compared to randomized patients. Conclusions Bariatric surgery is not cost saving in the short term. Moreover, the costs of patients who enter into RCTs of RYGB may differ from the costs of those who do not enter RCTs, suggesting use of caution when using such data to draw inferences about the general population with obesity.

Objective To compare bariatric surgery outcomes according to preoperative mental illness category. Methods Electronic health record data from several US healthcare systems were used to compare outcomes of four groups of patients who underwent bariatric surgery in 2012 and 2013. These included the following: people with (1) no mental illness, (2) mild-to-moderate depression or anxiety, (3) severe depression or anxiety, and (4) bipolar, psychosis, or schizophrenia spectrum disorders. Groups were compared on weight loss trajectory using generalized estimating equations using B-spline bases and on all-cause emergency department visits and hospital days using zero-inflated Poisson and negative binomial regression up to 2 years after surgery. Models were adjusted for demographic and health covariates, including baseline healthcare use. Results Among 8,192 patients, mean age was 44.3 (10.7) years, 79.9% were female, and 45.6% were white. Fifty-seven percent had preoperative mental illness. There were no differences between groups for weight loss, but patients with preoperative severe depression or anxiety or bipolar, psychosis, or schizophrenia spectrum disorders had higher follow-up levels of emergency department visits and hospital days compared to those with no mental illness. Conclusions In this multicenter study, mental illness was not associated with differential weight loss after bariatric surgery, but additional research could focus on reducing acute care use among these patients.

Objective Type 2 diabetes commonly goes into remission following Roux-en-Y gastric bypass (RYGB). As the mechanisms remain incompletely understood, a reduction in adipose tissue inflammation may contribute to these metabolic improvements. Therefore, whether RYGB reduces adipose tissue inflammation compared with equivalent weight loss from an intensive lifestyle intervention was investigated. Methods Sixteen people with obesity and type 2 diabetes were randomized to RYGB or lifestyle intervention. Fasting blood and subcutaneous abdominal adipose tissue were obtained before and after the loss of ∼7% of baseline weight. Adipose tissue inflammation was assessed by whole-tissue gene expression and flow cytometry-based quantification of tissue leukocytes. Results At 7% weight loss, insulin and metformin use were reduced among the RYGB but not the Lifestyle cohort, while fasting glucose and insulin declined in both. Adipose tissue inflammation increased modestly after RYGB and to a similar extent following nonsurgical weight loss. In both groups, the number of neutrophils increased severalfold (P < 0.001), mRNA levels of the proinflammatory cytokine interleukin-1β increased (P = 0.037), and mRNA expression of the anti-inflammatory and insulin-sensitizing adipokine adiponectin decreased (P = 0.010). Conclusions A reduction in adipose tissue inflammation is not one of the acute weight loss-independent mechanisms through which RYGB exerts its antidiabetes effects.

Objective We sought to better understand why so few severely obese patients undergo bariatric surgery in the United States. Design and Methods We conducted a telephone survey to assess the weight control practices of severely obese patients who were not actively seeking bariatric surgery in Group Health, a health system in Washington State. Results Among 295 severely obese participants surveyed (63% response rate), most reported actively working on weight loss (58%), although current use of commercial weight loss programs (10%) and obesity pharmacotherapy (0.1%) was low. Household income and white race were strongly associated with lifetime use of commercial programs, suggesting a possible disparity in use of effective treatment for obesity. Many were interested in learning more about bariatric surgery (49%) and pharmacotherapy (53%), but few had ever discussed surgery (26%) or pharmacotherapy (33%) with their physician. Finally, although only 29% had coverage for bariatric surgery, those with coverage were not more likely to have discussed bariatric surgery with their physician. Conclusions Overall, our survey of severely obese patients who are not currently seeking bariatric surgery suggests that interest in obesity treatments is high, coverage and receipt of treatment is low, and that there is a potential socioeconomic disparity related to the use of commercial programs.

Objective: Overweight and obese patients commonly suffer from depression and choice of depression therapy may alter weight. We conducted a cohort study to investigate whether obesity is associated with treatment choices for depression; and whether obesity is associated with appropriate duration of depression treatment and receipt of follow-up visits. Design and Methods: Adults with a diagnosis of depression between January 1, 2006 and March 31, 2010 who had 1+ new episodes of an antidepressant medication and/or psychotherapy were eligible. Medication use, encounters, diagnoses, height, and weight were collected from health plan databases. We modeled receipt of the different therapies (medication and psychotherapy) by BMI and BMI trajectory during the 9-months prior to initiation of therapy using logistic regression models that accommodated correlation within provider and adjusted for covariates. We modeled BMI via a restricted cubic spline. Fluoxetine was the reference treatment option in the medication models. Results: Lower BMI was associated with greater use of mirtazapine, and a declining BMI prior to treatment was associated with greater odds of initiating mirtazapine and paroxetine. Higher BMI was associated with greater odds of initiating bupropion even after adjustment for smoking status. Obese patients were less likely to receive psychotherapy and less likely to receive appropriate duration (180-days) of depression treatment compared to normal weight subjects. Conclusions: Our study provides evidence that BMI is considered when choosing therapy but associations were weak. Our results should prompt discussion about recommending and choosing depression treatment plans that optimize depression care and weight management concurrently. Differences in care and follow-up by BMI warrant additional research.