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Weight loss is an effective strategy for the management of hypertension, and bariatric surgery is the most effective weight loss and maintenance strategy for obesity. The importance of bariatric surgery in the long-term management of hypertension and which operation is most effective is less clear. We compared the effectiveness of vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB) for remission and relapse of hypertension after surgery in the ENGAGE CVD cohort study (Effectiveness of Gastric Bypass Versus Gastric Sleeve for Cardiovascular Disease). Operations were done by 23 surgeons across 9 surgical practices. Hypertension remission and relapse were assessed in each year of follow-up beginning 30 days and up to 5 years postsurgery. We used a local instrumental variable approach to account for selection bias in the choice of VSG or RYGB. The study population included 4964 patients with hypertension at the time of surgery (n=3186 VSG and n=1778 RYGB). At 1 year, 27% of patients with RYGB and 28% of patients with VSG achieved remission. After 5 years, without accounting for relapse, 42% of RYGB and 43% of VSG patients had experienced hypertension remission. After accounting for relapse, only 17% of RYGB and 18% of VSG patients remained in remission 5 years after surgery. There were no statistically significant differences between VSG and RYGB for hypertension remission, relapse, or mean systolic and diastolic blood pressure at any time during follow-up.

OBJECTIVE There are few studies testing the amount of weight loss necessary to achieve initial remission of type 2 diabetes mellitus (T2DM) following bariatric surgery and no published studies with use of weight loss to predict initial T2DM remission in sleeve gastrectomy (SG) patients. RESEARCH DESIGN AND METHODS With Cox proportional hazards models we examined the relationship between initial T2DM remission and percent total weight loss (%TWL) after bariatric surgery. Categories of %TWL were included in the model as time-varying covariates. RESULTS Of patients (N = 5,928), 73% were female; mean age was 49.8 ± 10.3 years and BMI 43.8 ± 6.92 kg/m2, and 57% had Roux-en-Y gastric bypass (RYGB). Over an average follow-up of 5.9 years, 71% of patients experienced initial remission of T2DM (mean time to remission 1.0 year). With 0–5% TWL used as the reference group in Cox proportional hazards models, patients were more likely to remit with each 5% increase in TWL until 20% TWL (hazard ratio range 1.97–2.92). When categories >25% TWL were examined, all patients had a likelihood of initial remission similar to that of 20–25% TWL. Patients who achieved >20% TWL were more likely to achieve initial T2DM remission than patients with 0–5% TWL, even if they were using insulin at the time of surgery. CONCLUSIONS Weight loss after bariatric surgery is strongly associated with initial T2DM remission; however, above a threshold of 20% TWL, rates of initial T2DM remission did not increase substantially. Achieving this threshold is also associated with initial remission even in patients who traditionally experience lower rates of remission, such as patients taking insulin.

Bariatric surgery is a widely used treatment option for obesity that often provides long-term weight control and health benefits. Although a growing number of women are becoming pregnant after bariatric surgery, only a few population-based studies have assessed the impact thereof on perinatal outcomes.This study aimed to examine the association between bariatric surgery and adverse perinatal outcomes in pregnant women and to examine whether the risk for adverse perinatal outcomes is modified by the postsurgery weight, gestational weight gain, type of bariatric surgery, timing of pregnancy after bariatric surgery, and maternal comorbidities.A retrospective cohort study was performed with the use of the Bariatric Surgery Registry and hospital inpatient and outpatient physician encounter records. The International Classification of Diseases, Ninth and Tenth Revision codes from hospitalizations during pregnancy and infant birth records were used to ascertain the outcomes of interest. Women eligible for BS who delivered at ≥20 weeks of gestation (n=20,213) at Kaiser Permanente Southern California hospitals (January 1, 2007 to December 31, 2018) were included in the study. Adjusted odds ratios were derived from logistic regression models with inverse probability of treatment weighting to adjust for confounding using propensity scores.Bariatric surgery was associated with a reduction in the risks for gestational diabetes (adjusted odds ratio, 0.60; 95% confidence interval, 0.53-0.69; P.001), preeclampsia (adjusted odds ratio, 0.53; 95% confidence interval, 0.46-0.61; P.001), chorioamnionitis (adjusted odds ratio, 0.45; 95% confidence interval, 0.32-0.63; P.001), cesarean delivery (adjusted odds ratio, 0.65; 95% confidence interval, 0.59-0.72; P.001), large for gestational age neonate (adjusted odds ratio, 0.23; 95% confidence interval, 0.19-0.29; P.001), macrosomia (adjusted odds ratio, 0.24; 95% confidence interval, 0.19-0.30; P.001), and neonatal intensive care unit admission (adjusted odds ratio, 0.70; 95% confidence interval, 0.61-0.81; P.001). However, bariatric surgery was also associated with a significantly increased risk for small for gestational age neonates (adjusted odds ratio, 2.46; 95% confidence interval, 2.16-2.79; P.001). The risk for the adverse outcomes is independent of the time interval between the surgery and subsequent pregnancy.These data suggest that there are many pregnancy outcome benefits for women with severe obesity who undergo bariatric surgery; however, women who have undergone bariatric surgery before pregnancy should be monitored closely to reduce the risk for small for gestational age neonates and postpartum hemorrhage.

Emerging reports suggest that obese patients who are hospitalized with COVID-19 may have worse outcomes; whether this association extends to those who are not hospitalized is unclear. This study examines the association between obesity and death 21 days after diagnosis of COVID-19 among patients who receive care in an integrated health care system, accounting for obesity-related comorbidities and sociodemographic factors., Visual Abstract. Obesity and Mortality Among Patients Diagnosed With COVID-19 Emerging reports suggest that obese patients who are hospitalized with COVID-19 may have worse outcomes; whether this association extends to those who are not hospitalized is unclear. This study examines the association between obesity and death 21 days after diagnosis of COVID-19 among patients who receive care in an integrated health care system, accounting for obesity-related comorbidities and sociodemographic factors. Visual Abstract. Obesity and Mortality Among Patients Diagnosed With COVID-19 Emerging reports suggest that obese patients who are hospitalized with COVID-19 may have worse outcomes; whether this association extends to those who are not hospitalized is unclear. This study examines the association between obesity and death 21 days after diagnosis of COVID-19 among patients who receive care in an integrated health care system, accounting for obesity-related comorbidities and sociodemographic factors., Background: Obesity, race/ethnicity, and other correlated characteristics have emerged as high-profile risk factors for adverse coronavirus disease 2019 (COVID-19)–associated outcomes, yet studies have not adequately disentangled their effects. Objective: To determine the adjusted effect of body mass index (BMI), associated comorbidities, time, neighborhood-level sociodemographic factors, and other factors on risk for death due to COVID-19. Design: Retrospective cohort study. Setting: Kaiser Permanente Southern California, a large integrated health care organization. Patients: Kaiser Permanente Southern California members diagnosed with COVID-19 from 13 February to 2 May 2020. Measurements: Multivariable Poisson regression estimated the adjusted effect of BMI and other factors on risk for death at 21 days; models were also stratified by age and sex. Results: Among 6916 patients with COVID-19, there was a J-shaped association between BMI and risk for death, even after adjustment for obesity-related comorbidities. Compared with patients with a BMI of 18.5 to 24 kg/m2, those with BMIs of 40 to 44 kg/m2 and greater than 45 kg/m2 had relative risks of 2.68 (95% CI, 1.43 to 5.04) and 4.18 (CI, 2.12 to 8.26), respectively. This risk was most striking among those aged 60 years or younger and men. Increased risk for death associated with Black or Latino race/ethnicity or other sociodemographic characteristics was not detected. Limitation: Deaths occurring outside a health care setting and not captured in membership files may have been missed. Conclusion: Obesity plays a profound role in risk for death from COVID-19, particularly in male patients and younger populations. Our capitated system with more equalized health care access may explain the absence of effect of racial/ethnic and socioeconomic disparities on death. Our data highlight the leading role of severe obesity over correlated risk factors, providing a target for early intervention. Primary Funding Source: Roche–Genentech.

Background When compared with conventional weight loss strategies, bariatric surgery results in substantially greater durable weight loss and rates of disease remission. Objective The ENGAGE CVD (Effectiveness of Gastric Bypass versus Gastric Sleeve for Cardiovascular Disease) cohort study aimed to provide population-based, comprehensive, rigorous evidence for clinical and policy decision making regarding the choice between gastric bypass and gastric sleeve for overall cardiovascular disease (CVD) risk reduction, risk factor remission, and safety. Methods The cohort had 22,095 weight loss surgery patients from a large integrated health care system in Southern California assembled from 2009 to 2016 who were followed up through 2018. Bariatric surgery patients were followed up for the length of their membership in the health care system. Of the patients who had at least five years of follow-up (surgery between 2009 and 2013), 85.86% (13,774/16,043) could contribute to the outcome analyses for the ENGAGE CVD cohort. Results Patients in the ENGAGE CVD cohort were 44.6 (SD 11.4) years old, mostly women (17,718/22,095; 80.19%), with 18.94% (4185/22,095) non-Hispanic black and 41.80% (9235/22,095) Hispanic, and had an average BMI of 44.3 (SD 6.9) kg/m2 at the time of surgery. When compared with patients who did not contribute data to the 5-year outcome analysis for the ENGAGE CVD cohort (2269/16,043; 14.14%), patients who contributed data (13,774/16,043; 85.86%) were older (P=.002), more likely to be women (P=.02), more likely to be non-Hispanic white (P Conclusions This study had one of the largest populations of gastric sleeve patients (n=13,459). The 5-year follow-up for those patients who had surgery between 2009 and 2013 was excellent for a retrospective cohort study at 85.86% (13,774/16,043). Unlike almost any study in the literature, the majority of the ENGAGE CVD cohort was racial and ethnic minority, providing a rare opportunity to study the effects of bariatric surgery for different racial and ethnic groups, some of whom have the highest rates of severe obesity in the United States. Finally, it also used state-of-the-art statistical and econometric comparative effectiveness methods to mimic the effect of random assignment and control for sources of confounding inherent in large observational studies. International Registered Report Identifier (IRRID) RR1-10.2196/14936

Importance Bariatric surgery can lead to substantial improvements in type 2 diabetes (T2DM), but outcomes vary across procedures and populations. It is unclear which bariatric procedure has the most benefits for patients with T2DM. Objective To evaluate associations of bariatric surgery with T2DM outcomes. Design, Setting, and Participants This cohort study was conducted in 34 US health system sites in the National Patient-Centered Clinical Research Network Bariatric Study. Adult patients with T2DM who had bariatric surgery between January 1, 2005, and September 30, 2015, were included. Data analysis was conducted from April 2017 to August 2019. Interventions Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Main Outcome and Measures Type 2 diabetes remission, T2DM relapse, percentage of total weight lost, and change in glycosylated hemoglobin (hemoglobin A1c). Results A total of 9710 patients were included (median [interquartile range] follow-up time, 2.7 [2.9] years; 7051 female patients [72.6%]; mean [SD] age, 49.8 [10.5] years; mean [SD] BMI, 49.0 [8.4]; 6040 white patients [72.2%]). Weight loss was significantly greater with RYGB than SG at 1 year (mean difference, 6.3 [95% CI, 5.8-6.7] percentage points) and 5 years (mean difference, 8.1 [95% CI, 6.6-9.6] percentage points). The T2DM remission rate was approximately 10% higher in patients who had RYGB (hazard ratio, 1.10 [95% CI, 1.04-1.16]) than those who had SG. Estimated adjusted cumulative T2DM remission rates for patients who had RYGB and SG were 59.2% (95% CI, 57.7%-60.7%) and 55.9% (95% CI, 53.9%-57.9%), respectively, at 1 year and 86.1% (95% CI, 84.7%-87.3%) and 83.5% (95% CI, 81.6%-85.1%) at 5 years postsurgery. Among 6141 patients who experienced T2DM remission, the subsequent T2DM relapse rate was lower for those who had RYGB than those who had SG (hazard ratio, 0.75 [95% CI, 0.67-0.84]). Estimated relapse rates for those who had RYGB and SG were 8.4% (95% CI, 7.4%-9.3%) and 11.0% (95% CI, 9.6%-12.4%) at 1 year and 33.1% (95% CI, 29.6%-36.5%) and 41.6% (95% CI, 36.8%-46.1%) at 5 years after surgery. At 5 years, compared with baseline, hemoglobin A1cwas reduced 0.45 (95% CI, 0.27-0.63) percentage points more for patients who had RYGB vs patients who had SG. Conclusions and Relevance In this large multicenter study, patients who had RYGB had greater weight loss, a slightly higher T2DM remission rate, less T2DM relapse, and better long-term glycemic control compared with those who had SG. These findings can help inform patient-centered surgical decision-making.

Background There has been a dramatic shift in use of bariatric procedures, but little is known about their long-term comparative effectiveness. Objective To compare weight loss and safety among bariatric procedures. Design Retrospective observational cohort study, January 2005 to September 2015. (ClinicalTrials.gov: NCT02741674). Setting 41 health systems in the National Patient-Centered Clinical Research Network. Participants 65 093 patients aged 20 to 79 years with body mass index (BMI) of 35 kg/m2 or greater who had bariatric procedures. Intervention 32 208 Roux-en-Y gastric bypass (RYGB), 29 693 sleeve gastrectomy (SG), and 3192 adjustable gastric banding (AGB) procedures. Measurements Estimated percent total weight loss (TWL) at 1, 3, and 5 years; 30-day rates of major adverse events. Results Total numbers of eligible patients with weight measures at 1, 3, and 5 years were 44 978 (84%), 20 783 (68%), and 7159 (69%), respectively. Thirty-day rates of major adverse events were 5.0% for RYGB, 2.6% for SG, and 2.9% for AGB. One-year mean TWLs were 31.2% (95% CI, 31.1% to 31.3%) for RYGB, 25.2% (CI, 25.1% to 25.4%) for SG, and 13.7% (CI, 13.3% to 14.0%) for AGB. At 1 year, RYGB patients lost 5.9 (CI, 5.8 to 6.1) percentage points more weight than SG patients and 17.7 (CI, 17.3 to 18.1) percentage points more than AGB patients, and SG patients lost 12.0 (CI, 11.6 to 12.5) percentage points more than AGB patients. Five-year mean TWLs were 25.5% (CI, 25.1% to 25.9%) for RYGB, 18.8% (CI, 18.0% to 19.6%) for SG, and 11.7% (CI, 10.2% to 13.1%) for AGB. Patients with diabetes, those with BMI less than 50 kg/m2, those aged 65 years or older, African American patients, and Hispanic patients lost less weight than patients without those characteristics. Limitation Potential unobserved confounding due to nonrandomized design; electronic health record databases had missing outcome data. Conclusion Adults lost more weight with RYGB than with SG or AGB at 1, 3, and 5 years; however, RYGB had the highest 30-day rate of major adverse events. Small subgroup differences in weight loss outcomes were observed. Primary funding source Patient-Centered Outcomes Research Institute.

Kaiser Permanente, an integrated health care delivery system in the USA, takes a “whole systems” approach to the chronic disease of obesity that begins with efforts to prevent it by modifying the environment in communities and schools. Aggressive case-finding and substantial investment in intensive lifestyle modification programs target individuals at high risk of diabetes and other weight-related conditions. Kaiser Permanente regions are increasingly standardizing their approach when patients with obesity require treatment intensification using medically supervised diets, prescription medication to treat obesity, or weight loss surgery.

Background and objectives: Maintenance hemodialysis (MHD) patients with larger body or fat mass have greater survival than normal to low mass. We hypothesized that mid-arm muscle circumference (MAMC), a conveniently measured surrogate of lean body mass (LBM), has stronger association with clinical outcomes than triceps skinfold (TSF), a surrogate of fat mass. Design, settings, participants, & measurements: The associations of TSF, MAMC, and serum creatinine, another LBM surrogate, with baseline short form 36 quality-of-life scores and 5-year survival were examined in 792 MHD patients. In a randomly selected subsample of 118 subjects, LBM was measured by dual-energy x-ray absorptiometry. Results: Dual-energy x-ray absorptiometry–assessed LBM correlated most strongly with MAMC and serum creatinine. Higher MAMC was associated with better short form 36 mental health scale and lower death hazard ratios (HRs) after adjustment for case-mix, malnutrition-inflammation-cachexia syndrome, and inflammatory markers. Adjusted death HRs were 1.00, 0.86, 0.69, and 0.63 for the first to fourth MAMC quartiles, respectively. Higher serum creatinine and TSF were also associated with lower death HRs, but these associations were mitigated after multivariate adjustments. Using median values of TSF and MAMC to dichotomize, combined high MAMC with either high or low TSF (compared with low MAMC/TSF) exhibited the greatest survival, i.e., death HRs of 0.52 and 0.59, respectively. Conclusions: Higher MAMC is a surrogate of larger LBM and an independent predictor of better mental health and greater survival in MHD patients. Sarcopenia-correcting interventions to improve clinical outcomes in this patient population warrant controlled trials.

Examining the quality and quantity of food intake by appropriate methods is critical in the management of patients with chronic kidney disease (CKD). The four commonly used dietary assessment methods in CKD patients include short-term dietary recalls, several days of food records with or without dietary interviews, urea kinetic based estimates such as protein nitrogen appearance calculation, and food histories including food screeners and food frequency questionnaires (FFQ). There are a number of strengths and limitations of these dietary assessment methods. Accordingly, none of the four methods is suitable in and of itself to give sufficiently accurate dietary information for all purposes. Food frequency questionnaires, which is the preferred method for epidemiological studies, should be used for dietary comparisons of patients within a given population rather than individual assessment. Food histories including FFQ and dietary recalls may underestimate important nutrients, especially in CKD patients. Given the large and increasing number of dialysis patients and work responsibilities of renal dietitians, routine analysis of dietary records and recalls is becoming less feasible. Ongoing and future studies will ascertain additional strengths and limitations of dietary assessment methods in CKD populations including the assessment of food intake during an actual hemodialysis treatment.

Background Hyperkalemia has been associated with higher mortality in long-term hemodialysis (HD) patients. There are few data concerning the relationship between dietary potassium intake and outcome. Study Design The mortality predictability of dietary potassium intake from reported food items estimated using the Block Food Frequency Questionnaire (FFQ) at the start of the cohort was examined in a 5-year (2001-2006) cohort of 224 HD patients in Southern California using Cox proportional hazards regression. Setting & Participants 224 long-term HD patients from 8 DaVita dialysis clinics. Predictors Dietary potassium intake ranking using the Block FFQ. Outcomes 5-year survival. Results HD patients with higher potassium intake had greater dietary energy, protein, and phosphorus intakes and higher predialysis serum potassium and phosphorus levels. Greater dietary potassium intake was associated with significantly increased death HRs in unadjusted models and after incremental adjustments for case-mix, nutritional factors (including 3-month averaged predialysis serum creatinine, potassium, and phosphorus levels; body mass index; normalized protein nitrogen appearance; and energy, protein, and phosphorus intake) and inflammatory marker levels. HRs for death across the 3 higher quartiles of dietary potassium intake in the fully adjusted model (compared with the lowest quartile) were 1.4 (95% CI, 0.6-3.0), 2.2 (95% CI, 0.9-5.4), and 2.4 (95% CI, 1.1-7.5), respectively ( P for trend=0.03). Restricted cubic spline analyses confirmed the incremental mortality predictability of higher potassium intake. Limitations FFQs may underestimate individual potassium intake and should be used to rank dietary intake across the population. Conclusions Higher dietary potassium intake is associated with increased death risk in long-term HD patients, even after adjustments for serum potassium level; dietary protein; energy, and phosphorus intake; and nutritional and inflammatory marker levels. The potential role of dietary potassium in the high mortality rate of HD patients warrants clinical trials.

Objectives Periodic assessment of dietary intake across a given dialysis population may help to improve the clinical outcomes related to nutrients such as dietary protein, phosphorus, or potassium. Although dietary recalls and food records are used to assess dietary intake at individual level and over shorter periods, food frequency questionnaires (FFQ) are used to rank subjects of a given population according to their nutrient intake over longer periods. Design To modify and refine the conventional Block FFQ to develop a specific FFQ for dialysis patients. Setting A total of 8 DaVita outpatient dialysis clinics in Los Angeles area, which participated in the "Nutrition and Inflammation in Dialysis Patients" study. Patients The study included 154 patients undergoing maintenance hemodialysis (MHD). Main Outcome Measure Dietary intake of participating MHD patients using a 3-day food record, supplemented by a person-to-person dietary interview, to capture food intake over the last hemodialysis treatment day of the week and the 2 subsequent nondialysis days. Results Analyses of the food records identified the key contributors to the daily nutrient intake in the 154 participating MHD patients. A "Dialysis-FFQ" was developed to include approximately 100 food items representing the total food intake of 90% of the patients of the "Nutrition and Inflammation in Dialysis Patients" study population. Distinctions were made in several food items on the basis of key nutritional issues, such as protein, phosphorus, and potassium, in dialysis patients. Conclusions We have developed a "Dialysis FFQ" to compare and rank dialysis patients according to their diverse nutrient intake. Although the Dialysis-FFQ may be a valuable tool to compare dialysis patients and to identify those who ingest higher or lower amounts of a given nutrient, studies are needed to examine the utility of the Dialysis-FFQ for nutritional assessment of dialysis patients.