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The objective of the study is to provide evidence-based guidance on nutritional management and optimal care for pregnancy after bariatric surgery. A consensus meeting of international and multidisciplinary experts was held to identify relevant research questions in relation to pregnancy after bariatric surgery. A systematic search of available literature was performed, and the ADAPTE protocol for guideline development followed. All available evidence was graded and further discussed during group meetings to formulate recommendations. Where evidence of sufficient quality was lacking, the group made consensus recommendations based on expert clinical experience. The main outcome measures are timing of pregnancy, contraceptive choice, nutritional advice and supplementation, clinical follow-up of pregnancy, and breastfeeding. We provide recommendations for periconception, antenatal, and postnatal care for women following surgery. These recommendations are summarized in a table and print-friendly format. Women of reproductive age with a history of bariatric surgery should receive specialized care regarding their reproductive health. Many recommendations are not supported by high-quality evidence and warrant further research. These areas are highlighted in the paper., (© 2019 The Authors. Obesity Reviews published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Obesity prevalence has been increasing with devastating health and economic consequences. Botulinum toxin type A (BTX-A), a neurotoxin, is used clinically for conditions characterized by prolonged muscular contraction. Its inhibitory effects on gastric smooth muscles, in theory, make it a potential agent for obesity treatment through delayed gastric emptying and increased satiety. This review aims to examine the evidence for the use of endoscopic BTX-A injection for treating obesity. The literature search identified 60 articles with 11 primary studies as relevant for the scope of the review. Several studies have been conducted to examine the effect of BTX-A injections on obesity, including both animal and human studies. Current evidence from identified studies does not demonstrate sustained weight loss through the use of endoscopic BTX-A injection.

Context: Obstructive sleep apnea (OSA) has been shown to be associated with type 2 diabetes mellitus (DM). Studies on healthy individuals found that OSA is associated with lower insulin sensitivity. We hypothesized that nocturnal hypoxemia from OSA is associated with poorer glycemia in severely obese DM individuals., Design and Setting: This was a retrospective observational study of 122 non-DM, 126 non-insulin-treated DM, and 35 insulin-treated DM patients. Data were collected on demographic characteristics, body mass index, and comorbidities. An overnight sleep study was performed in all patients, and OSA was defined as an apnea-hypopnea index of ≥5 events/h., Results: There were more males (P = .003) and a lower proportion of white Europeans (P = .010) among DM patients. The prevalence of OSA was 80.1% in DM and 63.1% in non-DM individuals (P = .001). DM individuals also had lower oxygen saturation (O2) (P = .0106), greater percentage of time spent under 90% oxygen saturation (%TST<90%) (P = .0067), and higher apnea-hypopnea index (P = .0085). Regression analysis showed that %TST<90% and minimum O2 saturations were associated with worse hemoglobin A1c results among DM individuals. Every 10% reduction in minimum O2 was associated with a 0.3% increase in HbA1c, whereas a 10% increase in %TST<90% was associated with a 0.2% increase in hemoglobin A1c after adjusting for a range of potential confounders., Conclusion: The high OSA prevalence in DM individuals and a positive relationship between nocturnal hypoxemia and glycemia supports the need to assess correction of hypoxemia as a management strategy for glycemic control.

Study Objectives: Diabetes mellitus (DM) is associated with obstructive sleep apnea (OSA) and nephropathy. The hypoxemia associated with OSA may exacerbate renal deterioration in DM nephropathy. We examined the role of hypoxemia in the development of DM nephropathy in severely obese patients., Methods: This cross-sectional study examined anonymized data from 90 DM patients with extreme obesity attending a weight management service. All patients underwent a routine overnight sleep study. Respiratory parameters measured included apnea-hypopnea index (AHI), mean and minimum oxygen (O2) saturations, and time spent under 90% O2 saturation (%TST < 90%). Chronic kidney disease (CKD+) was defined as estimated glomerular filtration rate (eGFR) ≤ 60 mL/min/1.73 m(2)., Results: Twenty (22%) patients were CKD+. These patients were 7 years older (mean age ± SD 57 ± 11 years, p = 0.003) and had greater adiposity (mean body mass index [BMI] ± SD 50.6 ± 8.7 kg/m(2), p = 0.012). No significant differences were found for median AHI and minimum O2 saturation. %TST < 90% was 4 times greater in CKD+ group (p = 0.046). Multivariate regression analysis showed that AHI (β = -0.17, 95% CI: -0.316 to -0.024) and %TST < 90% (β = -0.215, 95% CI: -0.406 to -0.023) were negatively correlated with eGFR after adjustment for age, gender, BMI, comorbidities, insulin treatment, and drugs affecting the renin-angiotensin system. No associations were found between mean and minimum O2 saturations, and eGFR., Conclusion: Apnea and hypopnea events as well as duration of nocturnal hypoxemia were inversely associated with renal function after adjusting for potential confounders. Given the significant burden of renal disease in diabetes, greater vigilance is required in identifying OSA in DM patients with extreme obesity.

Objectives: To explore the cross-sectional association between adiposity, mental well-being, and quality of life in extreme obese individuals entering a UK specialist weight management service prior to treatment commencement., Methods: The sample comprised 263 extreme obese individuals who were referred to the service as a result of having a body mass index (BMI) ≥40 kg/m2 or ≥35 kg/m2 with a co-morbid health condition. In a retrospective analysis, routinely collected baseline clinical examination data and self-report questionnaires (Impact of Weight on Quality of Life: IWQOL-Lite, EQ5D-3L, and Hospital Anxiety and Depression Scale: HADS) were analysed to examine the cross-sectional association between adiposity and quality of life., Results: The sample was predominantly female (74.8%) with mean BMI 47.0±7.9 kg/m2. Increasing adiposity was significantly negatively associated with quality of life, with an increase of 1 BMI unit associated with decreases of 1.93 in physical function (95% CI -2.86 - -1.00, p<0.001), 1.62 in self-esteem (95% CI -2.67 - -0.57, p<0.05), 2.69 in public distress (95% CI -3.75 - -1.62, p<0.001), 1.33 in work (95% CI -2.63 - -0.02, p<0.05), and 1.79 in total IWQOL-Lite scores (95% CI -2.65 - -0.93, p<0.001). Adiposity was associated with significantly increased risk of problems in mobility (OR = 3.44, 95% CI 1.47-8.05), and performing usual activities (OR = 2.45, 95% CI 1.10-5.46) in highest relative to lowest BMI tertile. The prevalence of experience of symptoms of anxiety (70.3%) and depression (66.2%) as measured by HADS was consistently high., Conclusions: We identified a high prevalence of psychological co-morbidity, including widespread experience of symptoms of anxiety and depressive disorders and reduced quality of life among these extreme obese individuals seeking weight management treatment. Clinical implications include the need for the incorporation of strategies to improve mental well-being into multi-disciplinary weight management interventions.

Introduction: Sleep duration and quality have been associated with obesity. Sleep disturbance has been reported to be associated with stress and depression among non-obese populations, but these relationships have not been previously examined in the obese population. The objective of the current study was to examine the complex associations among sleep disturbance, quality of life, anxiety, and depression in a patient sample with severe obesity., Methods: Two hundred seventy consecutively recruited patients with a mean body mass index (BMI) of 47.0 kg/m² were studied. The correlation coefficient, multiple linear regressions, and structural equation modeling (SEM) analysis were used to evaluate the association between the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Impact of Weight on Quality of Life-Lite (IWQOL-Lite) and Hospital Anxiety and Depression Scale (HADS)., Results: The mean (standard deviation; SD) PSQI score was 8.59 (5.11), and mean ESS score was 8.84 (5.79). After controlling for potential confounders, poor sleep quality and excessive daytime sleepiness were found to be significantly associated of all the components of IWQOL-Lite; physical function (β = -0.32, β = -0.27; P < 0.01), self-esteem (β = -0.23, β = -0.30; P < 0.05), sexual-life (β = -0.30, β = -0.35; P < 0.05), public distress (β = -0.39, β = -0.39; P < 0.01), and work (β = -0.26, β = -0.48; P < 0.01). We also found that the PSQI global score had a positive significant association with anxiety (β = 0.29; P = 0.01) and depression (β = 0.31; P = 0.01) components of HADS., Conclusion: Poor sleep quality was strongly associated with mood disturbance and poor quality of life among extremely obese patients. Future interventions are needed to address sleep disturbance to prevent further development of psychological co-morbidity and potentially worsening of obesity among these individuals.

Background: Obstructive sleep apnea (OSA) is common in obese patients with type 2 diabetes mellitus (DM) and may contribute to diabetic microvascular complications., Methods: To investigate the association between OSA, hypoxemia during sleep, and diabetic retinal complications in severe obesity. This was a prospective observational study of 93 obese patients mean (SD) age: 52(10) years; mean (SD) body mass index (BMI): 47.3(8.3) kg/m(2)) with DM undergoing retinal screening and respiratory monitoring during sleep. OSA was defined as apnea-hypopnea index (AHI) of ≥15 events/hour, resulting in two groups (OSA+ vs. OSA-)., Results: Forty-six patients were OSA+: median (95% CI) AHI = 37(23-74)/hour and 47 were OSA-ve (AHI = 7(4-11)/hour). Both groups were similar for ethnicity, BMI, cardiovascular co-morbidities, diabetes duration, HbA1c, and insulin treatment (p>0.05). The OSA+ group was significantly more hypoxemic. There was no significant difference between OSA+ and OSA- groups for the presence of retinopathy (39% vs. 38%). More OSA+ subjects had maculopathy (22% vs. 13%), but this did not reach statistical significance. Logistic regression analyses showed that AHI was not significantly associated with the presence of retinopathy or maculopathy (p>0.05). Whilst minimum oxygen saturation was not significantly associated with retinopathy, it was an independent predictor for the presence of maculopathy OR = 0.79 (95% CI: 0.65-0.95; p<0.05), after adjustment., Conclusions: The presence of OSA, as determined by AHI, was not associated with diabetic retinal complications. In contrast, severity of hypoxemia during sleep (minimum oxygen saturations) may be an important factor. The importance of hypoxia in the development of retinal complications in patients with OSA remains unclear and further studies assessing the pathogenesis of hypoxemia in patients with OSA and diabetic retinal disease are warranted.

Study Objectives: The South Asian population is at increased risk of cardiovascular disease. We compared the prevalence and severity of obstructive sleep apnea (OSA) in South Asians and white Europeans with severe obesity., Methods: Data from consecutive patients attending a specialist weight management service were analyzed. Self-reported age, gender, and ethnicity were recorded. Objective measurements of blood pressure, body mass index (BMI), and apneahypopnea index (AHI) were also acquired., Results: A total of 308 patients (72.7% women; 13% South Asian) were included, with mean age and BMI of 46 ± 12 y and 49 ± 8 kg/m2, respectively. South Asians had significantly increased prevalence of OSA compared to white Europeans (85% vs. 66% [p = 0.017]) and were more likely to have severe OSA (42.5% vs. 21.6% [p = 0.015]). South Asians had significantly higher median AHI (24 events/h: interquartile range [IQR] 9.3-57.6 vs. 9 events/h: IQR 3.4-26.6; p < 0.01), significantly lower minimum oxygen saturation (76%: IQR 64% to 84% vs. 83%: IQR 77% to 87%; p < 0.01), and spent a significantly greater amount of time < 90% oxygen saturation (8.4%: IQR 1.0% to 24.3% vs. 2.4%: IQR 0.2% to 16.0%; p = 0.03). South Asian ethnicity, independent of demographics, BMI, and comorbidities, was associated with β = 1.84 (95% CI: 1.27-2.65) increase in AHI+1 compared to white Europeans. Furthermore, we confirmed other independent OSA risk factors including increasing age, BMI, and male gender (all p < 0.001)., Conclusions: Severely obese South Asians had significantly greater prevalence and severity of OSA than white Europeans. OSA may contribute to increased cardiovascular risk in South Asians compared to white Europeans with severe obesity. Mechanisms mediating the observed associations between these ethnicities require further investigation.

Background: The prevalences of obesity and chronic kidney disease (CKD) have increased simultaneously. Should a pathophysiological relationship exist between the two conditions, bariatric surgery and associated weight loss could be an important intervention in extremely obese individuals to slow the progression of CKD., Methods: We conducted a retrospective analysis of 25 patients who had undergone biliopancreatic diversion (BPD) surgery for extreme obesity (body mass index >40 kg/m(2)), with mean follow-up of 4 years. We assessed pre- and post-surgery renal function, body weight and blood pressure (BP) obtained from electronic hospital and primary care records., Results: There was a significant reduction in mean body weight at 4 years by 50.3 kg (SD = 20.65). The creatinine and estimated glomerular filtration rate (eGFR) also improved significantly: serum creatinine reduced by 16.2 μmol/l (SD = 19.57) while the eGFR improved by 10.6 ml/min/m(2) (SD = 15.45). The greatest improvement in eGFR was in the group (n = 7) with eGFR ≤60 ml/min/m(2). A subset of patients (n = 11) had evaluable BP readings and had a reduction in BP of 17/10 mmHg (SD = 33/12)., Conclusions: This retrospective study demonstrates a clinically significant improvement in renal function following BPD. Several mechanisms including weight loss could account for the positive impact on renal function. The physiology underlying this improvement requires further study.