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The number of bariatric surgical procedures performed in the United States has increased steadily during the past decade. Currently accepted criteria for consideration of bariatric surgery include a body mass index (calculated as weight in kilograms divided by the square of height in meters) of 40 kg/m2 or greater (or >35 kg/m2 with obesity-related comorbidities), documented or high probability of failure of nonsurgical weight loss treatments, and assurance that the patient is well informed, motivated, and compliant. Appropriate patient selection is important in achieving optimal outcomes after bariatric surgery. In this article, we review our approach to the medical and psychological assessment of patients who want to undergo bariatric surgery. The medical evaluation is designed to identify and optimally treat medical comorbidities that may affect perioperative risks and long-term outcomes. The psychiatric and psychological assessment identifies factors that may influence long-term success in maintaining weight loss and prepares the patient for the lifestyle changes needed both before and after surgery. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To determine the safety and efficacy of bariatric surgery in obese patients with documented coronary artery disease (CAD). PATIENTS AND METHODS: Among patients with class II or III obesity who underwent bariatric surgery between March 1995 and January 2002 at the Mayo Clinic in Rochester, Minn, the rates of major in-hospital cardiovascular complications and mortality of 52 patients with clinical CAD were compared with those of 507 patients without CAD. The efficacy of bariatric surgery was measured by changes in body weight and other cardiovascular risk factors at follow-up. RESULTS: There were no in-hospital deaths in either group. Three patients with documented CAD (5.8%; 95% confidence interval, 0%-12.2%) and 7 patients without CAD (1.4%; 95% confidence interval, 0.4%-2.4%) had cardiovascular complications (P=.06). After a mean follow-up of 2.5 years (range, 77-2403 days) of patients with CAD, the following values decreased postoperatively (all at P<.001): weight, from 147+/-36 kg to 103+/-22 kg; body mass index, from 50+/-11 kg/m2 to 36+/-9 kg/m2; fasting serum glucose, from 149+/-52 mg/dL to 113+/-31 mg/dL; glycosylated hemoglobin, from 9%+/-3% to 6%+/-2%; and blood pressure, from 142/82 mm Hg to 132/73 mm Hg. Low-density lipoprotein cholesterol decreased postoperatively from 116+/-31 mg/dL to 75+/-26 mg/dL, and triglycerides decreased from 198+/-85 mg/dL to 119+/-52 mg/dL (P<.01 for both). CONCLUSION: Bariatric surgery should be considered for treating patients with CAD and class II or III obesity. [ABSTRACT FROM AUTHOR]

The epidemic of obesity in developed countries has resulted in patients with extreme (class III) obesity undergoing the full breadth of medical and surgical procedures. The popularity of bariatric surgery in the treatment of extreme obesity has raised awareness of the unique considerations in the care of this patient population. Minimizing the risk of perioperative complications that contribute to morbidity and mortality requires input from several clinical disciplines and begins with the preoperative assessment of the patient. Airway management, intravenous fluid administration, physiologic responses to pneumoperitoneum during laparoscopic procedures, and the risk of thrombotic complications and peripheral nerve injuries in extremely obese patients are among the factors that present special intraoperative challenges that affect postoperative recovery of the bariatric patient. Early recognition of perioperative complications and education of the patient regarding postoperative issues, including nutrition and vitamin supplementation therapy, can improve patient outcomes. A suitable physical environment and appropriate nursing and dietetic support provide a safe and dignified hospital experience. This article reviews the multidisciplinary management of extremely obese patients who undergo bariatric surgery at the Mayo Clinic. [ABSTRACT FROM AUTHOR]

Metabolic and Bariatric Surgery (MBS) is effective in improving metabolic outcomes and reducing weight in patients with obesity and diabetes, with less explored benefits in type 1 diabetes (T1D). This study aimed to evaluate the impact of MBS on weight loss and insulin requirements in T1D patients compared to insulin-treated type 2 diabetes (T2D) patients over a 5-year period. This retrospective analysis included patients who underwent primary sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) with a confirmed preoperative diagnosis of either T1D or insulin-treated T2D. Primary endpoints focusing on weight loss and secondary outcomes assessing changes in insulin dosage and glycemic control. After 5 years, weight loss was similar across groups, with total weight loss at 14.2% for T1D and 17.6% for insulin-treated T2D in SG, and 22.6% for T1D vs. 26.8% for insulin-treated T2D in RYGB. Additionally, there was a significant reduction in median daily insulin doses from 140.5 units at baseline to 77.5 units at 1 year postoperatively, sustained at 90 units at 5 years. The differential impact of MBS procedure was also highlighted, where RYGB patients showed a more pronounced and enduring decrease in insulin requirements compared to SG., (© 2024 World Obesity Federation.)

Background: Semaglutide demonstrated inferior weight loss responses in patients with type 2 diabetes (T2D) compared to patients with obesity without T2D. The individualized metabolic surgery (IMS) score was validated to predict T2D remission after bariatric surgery. The parameters of the IMS are HbA1c (<7%), insulin use, T2D medications and T2D duration. We aim to assess weight loss outcomes of semaglutide based on IMS score in patients with obesity and T2D., Methods: This is a retrospective multicentered cohort study of patients with T2D and BMI≥ 27 kg/m 2 taking ≥1 mg of semaglutide recruited from January 2020 to December 2022. We excluded patients with a history of bariatric surgery or taking other anti-obesity medications. IMS was calculated at baseline and patients weight change was recorded at baseline, 3, 6, 9 and 12 months. IMS was classified as mild (0-24.9 points), moderate (25-94.9 points), and severe (95-180 points). Analysis was performed based on IMS score quartiles and combination of Mild-Moderate vs Severe categories. We performed mixed linear regression models including age, sex, and baseline weight to assess associations between IMS categories with total body weight loss percentage (TBWL%)., Findings: We included 297 patients (42% female, mean age 62 ± 12 years) in the analysis. At 12 months, there was a stepwise decrease in weight loss outcomes when comparing patients by IMS quartiles (LS mean TBWL%± SE): 8.8 ± 0.8% vs 6.9 ± 0.8% vs 5.7 ± 0.9% vs 5.0 ± 0.8%. In the mixed linear model, patients in the mild-moderate category achieved significantly superior weight loss outcomes (LS mean TBWL± SE: -8.3 ± 0.7%) than patients in the severe category (-5.5 ± 0.6%; difference: -2.9, 95% CI: -5.2 to -0.5, p = 0.006) at 12 months. There was no significant difference in glycemic improvement regardless of IMS severity at baseline., Interpretation: In our cohort, lower IMS severity was associated with more weight loss in patients with obesity and T2D. Further studies are needed to understand T2D severity and its effect on semaglutide outcomes., Funding: Beyond payment to the research staff by Mayo Clinic, this research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors., Competing Interests: Dr Andres Acosta, and Mayo Clinic hold equity in Phenomix Sciences Inc. and are inventors of intellectual property licensed to Phenomix Sciences Inc. Dr Andres Acosta served as a consultant for Rhythm Pharmaceuticals, General Mills, Amgen, Bausch Health, RareStone; has contracts with Vivus Inc, Satiogen Pharmaceutical, and Rhythm Pharmaceutical., (© 2024 The Authors.)

Aim: Metabolic and bariatric surgery (MBS) is considered one of the most effective interventions for weight loss and associated type-2 diabetes mellitus (T2DM) remission. Multiple scores including the Individualized Metabolic Surgery (IMS), DiaRem, advanced DiaRem, and Robert et al. scores, have been developed predict T2DM remission after MBS. We aim to validate each of these scores in our cohort of patients undergoing MBS with long-term follow-up and assess their efficacy based on procedure type and preoperative BMI., Methods: We conducted a multicenter cohort study including patients with T2DM undergoing either Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Areas under the receiver operating characteristics (ROC) curve (AUC) were calculated to assess the discriminatory ability of the four models to detect T2DM remission., Results: A total of 503 patients (67 % females, mean age 53.5 [11] years, BMI 46.2 [8.8] kg/m 2 ) with T2DM were included. The majority (78 %) underwent RYGB, while the rest (28 %) had SG. All four scores predicted T2DM remission in our cohort with an ROC AUC of 0.79 for IMS, 0.78 for both DiaRem and advanced-DiaRem, and 0.75 for Robert et al. score. Specific subgroups for each of these scores demonstrated higher T2DM remission rates after RYGB compared to SG., Conclusion: We demonstrate the ability of the IMS, DiaRem, advanced-DiaRem and Robert et al. scores to predict T2DM remission in patients undergoing MBS. T2DM remission rates was demonstrated to decrease with more severe IMS, DiaRem and advanced-DiaRem scores and lower Robert et al. scores., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background: Obesity is associated with many co-morbidities and can cause harm to physical and mental well-being. While much has been studied in the general population about the outcomes of bariatric surgery, its implications in patients with bipolar/schizoaffective disorder (BSD) are less well understood., Objective: We aimed to describe outcomes of bariatric surgery in patients with BSD., Setting: Referral center for bariatric surgery., Methods: We conducted a retrospective chart review analysis of bariatric surgical procedures in patients with BSD between 2008 and 2021 at Mayo Clinic. Patients with BSD (cases) were matched via propensity score matching (1:2) with non-BSD controls based on surgical procedure, age, sex, body mass index, and type 2 diabetes. Hierarchical logistic regression model was performed using SAS software., Results: We matched 71 patients with BSD with 142 controls in a 1:2 ratio. After adjusting for baseline preoperative weight, patients with BSD had a 3.4% greater total weight loss compared with controls over 24 months (P = .02 [95% CI, .65-6.08]). Remission in obesity-related diseases, such as diabetes, hypertension, dyslipidemia, and sleep apnea, was similar in both groups. Perioperative complication rates were similar other than deep venous thrombosis, which showed a higher rate in patients with BSD (P = .04). Patients with long-term BSD were at increased risk of alcohol use compared with controls., Conclusions: When compared with the general bariatric population, weight loss was similar to slightly improved, with a comparable risk and complication profile. Patients with BSD have increased alcohol use after bariatric surgery, highlighting the need for psychological care before and after surgery in this population., (Copyright © 2023 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Obesity is increasingly common in kidney transplant candidates and may limit access to transplantation. Obesity and diabetes are associated with a high risk for post-transplant complications. The best approach to weight loss to facilitate active transplant listing is unknown, but bariatric surgery is rarely considered due to patient- and physician-related apprehension, among other factors., Methods: We aimed to determine the magnitude of weight loss, listing, and transplant rates in 28 candidates with a mean BMI of 44.4±4.6 kg/m 2 and diabetes treated conservatively for 1 year post weight-loss consultations (group 1). Additionally, we evaluated 15 patients (group 2) who met the inclusion criteria but received bariatric intervention within the same time frame. All patients completed a multidisciplinary weight management consultation with at least 1 year of follow-up., Results: In the conservatively managed group (group 1), the mean weight at the time of initial consultation was 126.5±18.5 kg, and the mean BMI was 44.4±4.6 kg/m 2 . At 1 year post weight-loss consultation, the mean weight decreased by 4.4±8.2 kg to 122.9±17 kg, and the mean BMI was 43±4.8 kg/m 2 , with a total mean body weight decrease of 3% ( P =0.01). Eighteen patients (64%) did not progress to become candidates for active listing/transplantation during the follow-up time of 4±2.9 years, with 15 (54%) subsequently developing renal failure/diabetes-related comorbidities prohibitive for transplantation. In contrast, mean total body weight decreased by 19% at 6 months post bariatric surgery, and the mean BMI was 34.2±4 and 32.5±3.7 kg/m 2 at 6 and 12 months, respectively. Bariatric surgery was strongly associated with subsequent kidney transplantation (HR=8.39 [95% CI 1.71 to 41.19]; P =0.009)., Conclusions: A conservative weight-loss approach involving multidisciplinary consultation was ineffective in most kidney transplant candidates with diabetes, suggesting that a more proactive approach is needed., Competing Interests: H. Amer reports research funding from Kaneka Pharma and the US Department of Defense; honoraria from the Massachusetts Medical Society; and an advisory or leadership role for Transplantation (associate editor), the American Society of Transplantation (VCA advisory council co-chair), the American Society for Reconstructive Transplantation (board member), the International Society of Vascularized Composite Allotransplantation (councilor), and The Transplantation Society (education committee member). Y.C. Kudva reports consultancy for Medtronic and Novo Nordisk; research funding from Dexcom; and an advisory or leadership role for Diabetes Technology and Therapeutics. A. Kukla reports research funding as the site subinvestigator on the multicenter international study “A Research Study to See How Semaglutide Works Compared to Placebo in People with Type 2 Diabetes and Chronic Kidney Disease (FLOW)” sponsored by Novo Nordisk, and honoraria from UpToDate. M. Mundi reports research funding from Fresenius Kabi, Nestle, Realfood Blends, and VectivBio, and an advisory or leadership role for Baxter. C. Schinstock reports research funding from CSL Bering, Sanofi, and Veloxis; honoraria from CSL Bering and Veloxis; and an advisory or leadership role for Veloxis. All remaining authors have nothing to disclose. All remaining authors have nothing to disclose., (Copyright © 2022 by the American Society of Nephrology.)

Purpose: Following bariatric surgery, patients can develop non-specific symptoms self-described as hypoglycemia. However, confirming hypoglycemia can be technically challenging, and therefore, these individuals are frequently treated empirically. This study aimed to describe what diagnostic evaluation and therapeutic interventions patients referred for post-bariatric surgery hypoglycemia undergo., Methods: Retrospective observational cohort study of patients with a history of bariatric surgery was evaluated for post-bariatric surgery hypoglycemia in a tertiary referral center from 2008 to 2017. We collected demographic and bariatric surgery information, clinical presentation of symptoms referred to as hypoglycemia, laboratory and imaging studies performed to evaluate these symptoms, and symptom management and outcomes., Results: A total of 60/2450 (2.4%) patients who underwent bariatric surgery were evaluated in the Department of Endocrinology for hypoglycemia-related symptoms. The majority were middle-aged women without type 2 diabetes who had undergone Roux-en-Y gastric bypass. Thirty-nine patients (65%) completed a biochemical assessment for hypoglycemia episodes. Six (10%) had confirmed hypoglycemia by Whipple's triad, and four (6.7%) met the criteria for post-bariatric surgery hypoglycemia based on clinical and biochemical criteria. All patients were recommended dietary modification as the initial line of treatment, and this intervention resulted in most patients reporting at least some improvement in their symptoms. Eight patients (13%) were prescribed pharmacotherapy, and two patients required additional interventions for symptom control., Conclusions: In our experience, evaluation for hypoglycemia-related symptoms after bariatric surgery was rare. Hypoglycemia was confirmed in the minority of patients. Even without establishing a diagnosis of hypoglycemia, dietary changes were a helpful strategy for symptom management for most patients., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background and Aims: Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings., Methods: We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020., Intervention: We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation., Results: The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old [IQR, 39-58]). The median follow-up time was 9.1 months [IQR, 4.2-14.1] with a median number of 3 visits [IQR, 2-4]. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects., Conclusions: AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials., (© 2021. The Author(s), under exclusive licence to Springer Nature Limited.)

Objective: To determine whether early Roux-en-Y gastric bypass surgery (RYGB) reduces the risk of Major adverse cardiovascular events (MACE) in patients with obesity. Patients and Methods: We conducted a study of patients with class II and III obesity [body mass index (BMI) > 35 kg/m 2 ] from Olmsted County, Minnesota, who underwent obesity clinic consultation between the years 1993-2012, and had either RYGB surgery within 1 year (RYGB-1Y group), or medically managed (No-RYGB group). The composite endpoint of MACE (all-cause mortality, stroke, heart failure admission and acute myocardial infarction) was the primary endpoint, with new-onset AF as the secondary endpoint. Results: Of the 1,009 study patients, 308 had RYGB-1Y and 701 were medically managed (No-RYGB). Overall, the age was 44.0 ± 12.4 (mean ± SD) years; BMI was 45.0 ± 6.8 kg/m 2 . The RYGB-1Y group had a lower rate of MACE (adjusted hazard ratio (HR), 0.62; 95% CI, 0.44-0.88; P = 0.008) and lower mortality (adjusted HR, 0.51; 95% CI, 0.26-0.96; P = 0.04) than the No-RYGB group. The RYGB-1Y surgery was not associated with lower AF occurrence (HR, 0.66; 95% CI, 0.40-1.10; P = 0.11). Conclusion: An early RYGB approach for BMI reduction was associated with lower rates of MACE., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Yuan, Medina-Inojosa, Lopez-Jimenez, Miranda, Collazo-Clavell, Sarr, Chamberlain, Hodge, Bailey, Wang, Chen and Cha.)

Background: Cannabis is second only to alcohol as a substance of abuse and dependence in the United States. While there is extensive research examining alcohol use and bariatric surgery, there is currently little research and there are no published guidelines specific to cannabis use and bariatric surgery., Objectives: To identify major themes and general guidelines applied by bariatric surgery psychology clinicians., Setting: This practice survey was disseminated to bariatric surgery psychologists at various U.S. academic medical centers, hospitals, and private practices., Methods: An electronic, 35-question survey was sent to 47 bariatric surgery psychologists to collect information on current clinical practice guidelines regarding cannabis use before and after bariatric surgery., Results: The survey questionnaire was completed by 34 (72.34%) bariatric surgery psychologists. The major identified themes included: (1) the lack of a standardized assessment of cannabis use; (2) a requirement for 3 months of abstinence from cannabis before bariatric surgery; (3) recommended lifetime abstinence from cannabis after bariatric surgery; and (4) discussion of cannabis use risks following bariatric surgery, including appetite stimulation, addiction potential, and possible negative impacts on judgment., Conclusion: Cannabis use will likely further increase in the United States. This survey highlighted common bariatric surgery psychology practices in the absence of extensive research and published guidelines. These findings suggest a preliminary framework with which to address cannabis use in patients seeking bariatric surgery. It is recommended that professional organizations and societies build on these initial survey findings to develop guidelines for more consistent, evidence-based practice regarding cannabis use and bariatric surgery., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Traditional duodenal switch (DS) typically leaves a short common channel and is infrequently performed in part due to increased risk of malnutrition. We compared nutritional deficiencies between DS with a moderate channel length and standard proximal Roux-en-Y gastric bypass (RYGB)., Methods: We conducted a retrospective review of 61 matched pairs who underwent DS or RYGB using our institutional database; patients were matched on sex, age, race, and BMI. DS was performed with a common channel length between 120 and 150 cm. Thirty-day complications, total body weight loss (TBWL) %, and nutritional labs up to 24 months were compared using paired t test and Wilcoxon rank sum tests., Results: Weight loss was similar at each time point (all p > 0.1). DS patients had lower vitamin D levels at 6 months, lower calcium levels at 6 and 12 months, and lower hemoglobin at 12 months and otherwise equivalent (all p < 0.05). Revision was rare (1 DS; 0 RYGB). There were no differences in short-term complications (p = 0.28)., Conclusion: DS with a moderate common channel length is safe with a low revision rate. Weight loss and nutritional outcomes appear to be comparable to RYGB, and it may be considered an effective RYGB alternative.

As the prevalence of obesity has increased, bariatric surgery has become more common because of its proven efficacy at promoting weight loss and improving weight-related medical comorbidities. Although generally successful, bariatric surgery may also lead to complications and negatively affect health. This article highlights some common and rare complications of bariatric surgery. Specifically, it discusses the risk of nutrient deficiencies (which is influenced by surgery type) and their downstream effects, including ill-effects on bone health. Rarer complications, such as postbypass hypoglycemia and alcohol use disorder, are also discussed., Competing Interests: Disclosure The authors have nothing to disclose., (Copyright © 2020 Elsevier Inc. All rights reserved.)

The prevalence of class 3 obesity (body mass index ≥40 kg/m 2 ) is 7.7% of the United States adult population; thus, more than 25 million people may be medically appropriate for consideration of bariatric surgery as therapy for severe obesity. Although bariatric surgery is the most effective therapy for patients with severe obesity, the surgery is performed in less than 1% of patients annually for whom it may be appropriate. Patients' and medical professionals' misperceptions about obesity and bariatric surgery create barriers to accessing bariatric surgery that are not given adequate attention and clinical consideration. Commonly cited patient barriers are lack of knowledge about the severity of obesity, the perception that obesity is a lifestyle problem rather than a chronic disease, and fear that bariatric surgery is dangerous. Medical professional barriers include failing to recognize causes of obesity and weight gain, providing recommendations that are inconsistent with current obesity treatment guidelines, and being uncomfortable counseling patients about treatment options for severe obesity. Previous research has revealed that medical professional counseling and accurate perception of the health risks associated with severe obesity are strong predictors of patients' willingness to consider bariatric surgery. This article reviews patient and medical professional barriers to acceptance of bariatric surgery as a treatment of medical necessity and offers practical advice for medical professionals to rethink perspectives about bariatric surgery when it is medically and psychologically appropriate., (Copyright © 2019. Published by Elsevier Inc.)

Background: Obesity has become a global epidemic. Bariatric surgery remains the most successful modality for producing sustained weight loss. Attrition rates after bariatric surgery are currently reported between 3 and 63% depending on the type of bariatric operation and the length of follow-up provided by the bariatric surgery team. It is currently unknown if patient attrition from bariatric surgery programs impact clinical outcomes. The availability of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) and the Mayo Clinic Midwest unified electronic medical record (EMR) provide a unique opportunity to explore this topic., Methods: Raw data was downloaded from MBSAQIP database for all laparoscopic Roux-en-Y gastric bypass (LRYGB) cases between May 1, 2008 and January 8, 2015 (N = 1242). Baseline weight and preexisting comorbidities (type 2 diabetes, hypertension, and hyperlipidemia) were recorded using the MBSAQIP database and the EMR. Current weight and comorbidity data (type 2 diabetes, hypertension, and hyperlipidemia) were subsequently collected at the time closest to the patient's surgical anniversary dates during the following assessment periods: years 1, 2, and 3 after surgery. Mean percentage total weight loss (TWL) was calculated at each time frame for each patient. Data was summarized using descriptive statistics, including counts and percentages for categorical variables by either year or year and location., Results: The number of patients seen by the bariatric surgery practice (BSP) compared to those seen by other providers within our practice (attrition to bariatric surgery practice (ABSP)) was highest in year 1 and reduced each subsequent year (year 1: BSP N = 740, ABSP N = 166, year 2: BSP N = 425, ABSP N = 309, and year 3: BSP N = 235, ABSP N = 325). The mean TWL in the BSP and ABSP groups at year 1 was 31.84% versus 30.19%, at year 2 was 31.34% versus 29.67%, and at year 3 was 29.01% versus 27.71% respectively. Differences were statistically significant between groups at years 1 and 2 (p < 0.05). A statistically significant difference was not found in year 3 despite a trend towards higher TWL in the BSP group. Among all patients, statistically significant differences (p < 0.0001) were observed between baseline and years 1, 2, and 3 for type 2 diabetes, hypertension, and hyperlipidemia., Conclusions: Our study confirms the problem of patient attrition to follow up at our BSP. It is also the first to suggest a difference in weight loss outcomes among patients seen in BSP compared to those seen by other providers (ABSP) at 1 and 2 years after Roux-en-Y gastric bypass (LRYGB). The potential implications of this observation on long-term weight maintenance after LRYGB and the impact on metabolic comorbidities remain unknown but warrant further investigation. It also warrants the development of strategies to improve patient retention in BSP and/or engagement of medical providers to achieve that end.

Introduction/purpose: Adverse childhood experiences (ACEs) are known risk factors for obesity and poor outcomes following weight loss interventions. ACEs are also associated with addictive behaviors and, potentially, food addiction (FA). This study examined the relationship between ACEs and FA, and their association to undergoing bariatric surgery and post-surgical weight loss outcomes., Materials and Methods: Between June 2013 and January 2016, 1586 bariatric-surgery-seeking patients completed a psychological evaluation. During their evaluation, the patients were administered measures including the ACE questionnaire and the Yale Food Addiction Scale., Results: 19.2% of those seeking bariatric surgery reported being the victim of childhood sexual abuse, and 22.1% reported being the victim of childhood physical abuse. An elevated ACE score corresponded to increased likelihood of screening positive for FA and more severe FA. When the type of ACE was analyzed separately, ACE was not associated with bariatric surgery completion or percent total weight loss (%TWL). Screening positive for FA corresponded to less %TWL 1 year post-surgery as the total number of ACEs increased, yet there was no association with %TWL 2 years post-surgery. The participants were classified into two groups, those positive for an ACE or FA versus those negative for both. Those who screened positive were significantly less likely to undergo bariatric surgery., Conclusion: Screening positive for experiencing ACEs was related to severity of FA, and screening positive for being the victim of either childhood abuse or FA reduced the likelihood of completing bariatric surgery. More research is needed to determine how these psychosocial factors might influence bariatric surgery outcomes.

Background: Case reports of inflammatory bowel diseases [IBD] have been reported in patients with a history of bariatric surgery. Our aim was to characterize patients who were diagnosed with IBD after having undergone bariatric surgery., Methods: Electronic medical records were reviewed at two institutions to identify patients who developed de-novo Crohn's disease or ulcerative colitis [UC] after bariatric surgery. Data on demographics, type of bariatric surgical procedure, IBD subtype, phenotype and medication usage were obtained. The incidence rate of de-novo IBD after bariatric surgery [per 100000 person-years] and standardized incidence ratio [SIR] were estimated from a prospective bariatric surgery database., Results: A total of 44 patients with de-novo IBD after bariatric surgery were identified [31 Crohn's disease, 12 UC, one IBD unclassified]. Most patients were female [88.6%], with median age at IBD onset of 44 years [IQR, 37-52] and median time to IBD diagnosis after bariatric surgery of 7 years [IQR, 3-10]. Sixty-eight per cent underwent Roux-en-Y gastric bypass. In the prospective database, the incidence of IBD in patients who underwent bariatric surgery was 26.7 per 100000 person-years [4.5 for UC and 22.3 for Crohn's disease]. The age-adjusted SIR ranged from 3.56 in the 40-49 year age group to 4.73 in the 30-39 year age group., Conclusion: We described a case series of patients developing de-novo IBD after bariatric surgery. There appears to be a numerically higher incidence of Crohn's disease in this population. Confirmation of causality is required in larger patient cohorts.

Despite the large number of U.S. adults who overweight or obese, few providers have ready access to comprehensive lifestyle interventions, the cornerstone of medical obesity management. Our goal was to establish a research infrastructure embedded in a comprehensive lifestyle intervention treatment for obesity. The Obesity Treatment Research Program (OTRP) is a multi-specialty project at Mayo Clinic in Rochester, Minnesota designed to provide a high intensity, year-long, comprehensive lifestyle obesity treatment. The program includes a nutritional intervention designed to reduce energy intake, a physical activity program and a cognitive behavioral approach to increase the likelihood of long-term adherence. The behavioral intervention template incorporated the Diabetes Prevention Program and the Look AHEAD trial materials. The OTRP is consistent with national recommendations for the management of overweight and obesity in adults, but with embedded features designed to identify patient characteristics that might help predict outcomes, assure long-term follow up and support various research initiatives. Our goal was to develop approaches to understand whether there are patient characteristics that predict treatment outcomes.

Background and Aims: Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature., Methods: Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used., Results: 130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4  kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5-10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported., Conclusion: When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

Weight gain accompanied by an increased tendency for central fat distribution is common among women in midlife. These changes are a result of aging, decreasing estrogen levels after menopause, and other unique influences in menopausal women that interfere with the adoption of healthy lifestyle measures. Central obesity, in particular, results in several adverse metabolic consequences, including dysglycemia, dyslipidemia, hypertension, and cardiovascular disease. Given that cardiovascular disease is the leading cause of death in postmenopausal women, the importance of weight management in midlife cannot be overemphasized. In addition, weight gain in midlife contributes to other health risks including cancer, arthritis, mood disorders, and sexual dysfunction. It is imperative that primary care physicians screen midlife women for overweight/obesity and offer appropriate advice and referral. In addition to counseling regarding lifestyle change, behavioral modification, and psychological support, it is important to address the unique barriers to adoption of healthy lifestyle measures in postmenopausal women, including the presence of vasomotor symptoms, mood disorders, and sleep disturbance. When indicated, menopausal hormone therapy should be considered to manage bothersome symptoms. Despite its favorable influence on body fat distribution, menopausal hormone therapy cannot be recommended as a treatment for central obesity in midlife women., (Copyright © 2017 Mayo Foundation for Medical Education and Research. Published by Elsevier Inc. All rights reserved.)

Background: Roux-en-Y gastric bypass (RYGB) is associated with nutrient deficiencies, but the optimal supplement regimen remains unclear. We assessed patient-reported adherence to and efficacy of Mayo Clinic's post-RYGB vitamin/mineral supplement protocol and the related incidence of common nutrient deficiencies., Methods: Data were collected on 287 obese patients who underwent RYGB. Patient-reported supplement adherence was assessed via medication/supplement lists generated by medication reconciliation in hospital dismissal summaries and clinic notes at 6, 12, and 18-36 months postsurgery. Deficiencies were assessed via measurements of hemoglobin, ferritin, 25-hydroxyvitamin D, and vitamins A, E, and B 12 in the setting of our supplementation protocol., Results: Patient-reported adherence to multivitamin/minerals and subcutaneous vitamin B 12 was sustained in >92 % of patients, correlating with low rates of vitamin A, E, and B 12 deficiencies (4.9, 0, and 3.7 %, respectively). Rates of calcium supplementation decreased (94.1 to 78.7 %) while rates of vitamin D and iron use increased over time (39.7 to 65.8 and 6.3 to 23.1 %, respectively). At 18-36 months, vitamin D deficiency persisted in 16.2 % of patients, iron deficiency in 6.7 % of women and 17.2 % of men, and anemia in 12.2 % of women and 34.3 % of men., Conclusion: Compared to previous reports, we found a lower prevalence of micronutrient deficiencies and excellent patient-reported adherence to a standardized multivitamin/mineral and vitamin B 12 regimen. Continued prevalence of vitamin D deficiency prompts consideration of standardized vitamin D supplementation after RYGB. Anemia and iron deficiency were observed at lower rates than previously reported, but were more common in men compared to women.

Introduction/purpose: Distress intolerance is characterized by a low threshold for negative emotional experiences and lack of emotion regulation and has been shown to predict various health outcomes. As such, the primary aim of this study was to determine the association between distress tolerance and psychological variables (eating behaviors, mood, substance use, trauma history), completion of bariatric surgery, and post-bariatric surgery weight loss outcomes and follow up with a provider., Materials and Methods: Two hundred forty-eight patients (75 % female, 89 % Caucasian) underwent a multidisciplinary evaluation for bariatric surgery and were assessed for psychiatric disorders via semi-structured clinical interview and psychometric questionnaires., Results: Low distress tolerance was associated with symptoms of depression (p ≤ 0.001), anxiety (p ≤ 0.001), disordered eating behaviors (p ≤ 0.001), substance abuse (p ≤ 0.001), a history of being the victim of childhood sexual abuse (p ≤ 0.001), and with high BMI (p < .05). Patients endorsing higher levels of distress tolerance were more likely to undergo bariatric surgery (p < .01). Distress tolerance was not related to 2-year post-surgical weight loss outcomes or follow up with a provider., Conclusion: The ability to tolerate negative affect may be a variable that differentiates which patients undergo bariatric surgery rather than early postoperative outcomes.

Aim: Obesity is a major cardiovascular (CV) risk factor. Bariatric surgery (BSx) is an approved therapeutic alternative for class II-III obesity, but little evidence focuses on older adults. We assessed the effect of BSx on cardiometabolic variables and long-term CV risk in older adults., Methods: We carried out a population-based, observational study from 1990-2009, of 40 consecutive elderly (age ≥60 years) residents of Olmsted County, MN, USA, with class II-III obesity treated with BSx at a University-based, academic health center. Data were obtained from the Rochester Epidemiology Project. Metabolic syndrome (MetS) was defined using American Heart Association/National Heart, Lung, Blood Institute (AHA/NHLBI) criteria (increased triglycerides, low high-density lipoprotein, increased blood pressure, increased glucose and body mass index as a modified measure of obesity instead of waist circumference). Change in CV risk factors, MetS prevalence, and impact on predicted CV risk using the Framingham risk score was ascertained at 1 year postoperatively and assessed statistically., Results: Mean age and body mass index were 64.4 ± 3.7 and 45.0 ± 6.3 kg/m(2) , respectively, and 28 out of 40 (70%) were women. One participant died during the 11-month study period after BSx from respiratory complications related to BSx, and one participant died at 2 years. Percentage of excess weight loss decreased by 57.5% at 1 year. Prevalence 1 year after BSx decreased for diabetes (57.5% to 22.5%; P < 0.03), hypertension 87.5% to 73.7% (P = 0.003), dyslipidemia (80% to 42.5%; P < 0.001) and sleep apnea (62.5% to 23.7%; P < 0.001).MetS prevalence decreased from 80% to 45% (P < 0.002). Baseline risk was 14.1%, which changed at follow up at 8.2%., Conclusions: In older adults, BSx induces considerable weight loss, improves CV risk factors, decreases MetS prevalence and is an effective treatment in this population. Geriatr Gerontol Int 2016; 16: 618-624., (© 2015 Japan Geriatrics Society.)

Background: Bariatric surgery is the most effective means of long-term weight loss. Knowledge gaps and lack of engagement in pre-operative patients can result in suboptimal outcome after surgery. Mobile technology, utilizing ecological momentary assessment (EMA)/intervention (EMI), has shown tremendous promise in changing behaviors. The primary objective of the study is to assess feasibility of using smartphone app with EMA/EMI functionality to prepare patients for bariatric surgery., Methods: Subjects seeking primary bariatric surgery were provided a smartphone app containing video-based education modules with linked assessments to evaluate mastery of topic. Subjects received algorithmic EMA text messages soliciting a response regarding lifestyle behavior. Upon answering, subjects received tailored EMI text messaging supporting healthy lifestyle., Results: Thirty subjects (27 female and 3 male), with age of 41.3 ± 11.4 years and BMI of 46.3 ± 7.4 kg/m(2) were enrolled. Twenty subjects completed the study. Ten subjects withdrew. On average, seven out of nine education modules were completed (70.9 ± 27.3%), and 37.8/123 EMA were answered (30.7 ± 21.7%), with response time of 17.4 ± 4.4 min. Subjects reported high satisfaction with the app. Many felt that the app fit into their routine "somewhat easily" or "very easily" (n = 12), had "perfect" amount of EMA messages (n = 8), and was very helpful in preparing for surgery (n = 7)., Conclusions: This study is the first to reveal the feasibility of using a smartphone app in the education and engagement of patients prior to bariatric surgery. The app was well-received based on subject satisfaction scores and revealed trends toward positive behavior change and increased weight loss. Randomized trials are necessary to delineate true efficacy.

Background: A subset of bariatric patients fails to achieve or maintain long-term successful weight loss. Psychological and behavioral factors contributing to poor long-term outcomes include decreased adherence to surgical eating guidelines, life stressors that derail weight maintenance, unhealthy eating patterns, and substance use., Objectives: A 6-week pilot group behavioral intervention utilizing techniques of cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) was developed to treat bariatric patients experiencing weight regain., Setting: Patients were treated at a large Midwestern academic medical center., Methods: Twenty-eight patients (93% female, 100% Caucasian) with a mean age of 53 and a mean BMI of 35.6 had regained an average of 17 kg or 37% of the weight lost after initially successful Roux-en-Y gastric bypass (RYGB). All patients completed the Structured Clinical Interview for DSM-IV-TR (SCID I) modules assessing mood and substance dependence, and completed a series of questionnaires before and after group treatment, with weekly assessment of depressive symptoms, binge eating, and alcohol use. Results were analyzed utilizing repeated measures ANOVA., Results: Weight decreased during the intervention by an average of 1.6 ± 2.38 kg (p ≤ 0.01). Level of depressive symptoms improved for treatment completers (p ≤ 0.01). Food records indicated that grazing patterns decreased (p ≤ 0.01) and subjective binge eating episodes decreased (p ≤ 0.03)., Conclusions: A 6-week pilot group behavioral intervention demonstrated an ability to help patients reverse their pattern of weight regain. Tailored behavioral interventions may be a useful treatment to enhance maintenance of long-term weight loss.

Objective: To report the impact of bariatric surgery on metabolic outcomes in patients with type 1 diabetes (DM1) versus insulin-requiring type 2 diabetes mellitus (IRDM2)., Methods: Ten subjects with DM1 were compared with 118 subjects with IRDM2 at baseline and at 1 and 2 years post-bariatric surgery for: anthropometric measures, HbA1c, and number of medications (anti-hyperglycemic, anti-hypertensive, lipid-lowering)., Results: DM1 and IRDM2 groups lost similar amounts of weight 2 years post-bariatric surgery (39.5 ± 14.7 kg vs. 40.3 ± 24.4 kg). IRDM2 subjects had significant improvements in HbA1c (7.8% ± 1.4% vs. 6.8% ± 1.4%, P value <0.0001) and decreases in number of anti-hyperglycemic (2.4 ± 0.8 vs. 0.7 ± 0.8, P value <0.0001), anti-hypertensive (2.2 ± 1.3 vs. 1.3 ± 1.2, P value <0.0001), and lipid-lowering (1.1 ± 0.8 vs. 0.6 ± 0.6, P value <0.0001) medications. DM1 subjects had no improvement in HbA1c (8.2% ± 1.6% vs. 7.8% ± 0.9%) or use of anti-hypertensive medications (2.1 ± 1.4 vs. 2.3 ± 1.5). Their use of lipid-lowering medications improved (1.0 ± 0.5 vs. 0.5 ± 0.8, P value 0.04)., Conclusions: Our study suggests that improved glycemic control may not be an expected outcome when considering bariatric surgery in patients with DM1; however, additional investigation is warranted., (© 2015 The Obesity Society.)

Bariatric surgery (BSx) produces clinically relevant weight loss that translates into improved quality of life, decreased mortality, and reduction in medical comorbidities, including cardiovascular (CV) risk. Little is known about patients' decision-making process to undergo BSx, but risk perception is known to influence medical decision-making. This study examined CV and BSx risk perception in obese subjects undergoing BSx (n = 268) versus those managed medically (MM) (n = 273). This retrospective population-based survey of subjects evaluated for BSx had 148 (55%) and 88 (32%) responders in the BSx and MM groups, respectively. Survey questions assessed risk perceptions and habits prior to weight loss intervention. CV risk was calculated using the Framingham Risk Score (FRS). At baseline, BSx subjects had a greater body mass index and greater prevalence of diabetes and depression. Follow-up mean weight loss was greater in the BSx group. BSx subjects perceived obesity as a greater risk to their overall health than the surgical risk. FRS declined in the BSx group (10 to 5%; p < 0.001) while there was no change in the MM group (8 to 8%; p = 0.54). Those without a measurable decrease in CV risk had a greater tendency to perceive the risk of BSx as greater than that of obesity. Obese subjects undergoing BSx are more likely than MM subjects to perceive obesity as a greater risk to their health than BSx. MM subjects generally underestimate their CV risk and overestimate the risk of BSx. Active discussion of CV risk using the FRS and the perception of risk associated with bariatric surgery can enhance patients' ability to make an informed decision regarding their management., (© The European Society of Cardiology 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)

Background: The incidence of venous thromboembolism (VTE) after bariatric surgery is uncertain., Methods: Using the resources of the Rochester Epidemiology Project and the Mayo Bariatric Surgery Registry, we identified all residents of Olmsted County, Minnesota, with incident VTE after undergoing bariatric surgery from 1987 through 2005. Using the dates of bariatric surgery and VTE events, we determined the cumulative incidence of VTE after bariatric surgery by using the Kaplan–Meier estimator. Cox proportional hazards modeling was used to assess patient age, sex, weight, and body mass index as potential predictors of VTE after bariatric surgery., Results: We identified 396 residents who underwent 402 bariatric operations. The most common operation was an open Roux-en-Y gastric bypass (n =228). Eight patients had VTE that developed within 6 months (7 within 1month) after surgery; five events occurred after hospital discharge but within 1 month after bariatric surgery. The cumulative incidence of VTE at 7, 30, 90, and 180 days was 0.3, 1.9, 2.1, and 2.1%, respectively (180-day 95% confidence interval (CI), 0.7–3.6%). Patient age was a predictor of postoperative VTE (hazard ratio, 1.89 per 10-year increase in age; 95% CI, 1.01–3.55; P=0.05)., Conclusions: In our population-based study, bariatric surgery had a high risk of VTE, especially for older patients. Because most VTE events occurred after hospital discharge, a randomized controlled trial of extended outpatient thromboprophylaxis is warranted in patients undergoing open Roux-en-Y gastric bypass for medically complicated obesity.

Obesity is a risk factor for heart failure (HF), but the benefit of weight loss in HF is unknown. We assessed the effects of bariatric surgery (BSx) compared to non-operative treatment for morbid obesity on overall quality of life (QoL), functional capacity, and symptoms in 13 HF patients undergoing BSx and six HF patients treated without surgery. In the BSx group, median age was 62, body mass index (BMI) was 55 kg/m(2), and 5/13 were males; in the non-operative group, median age was 69, BMI was 42 kg/m(2), and 1/6 were male. Median follow-up was 4.3 and 2.7 years, respectively. At follow-up, BMI was less in the BSx group (35 vs 47 kg/m(2), p < 0.001); QoL (p < 0.01), frequency of exertional dyspnea (p = 0.01), and leg edema (p = 0.04) improved only in the BSx group. BSx induced weight loss and improved QoL and symptoms in morbidly obese patients with HF.

Background & Aims: Gastric injections of botulinum toxin A (BTA) have been reported to delay gastric emptying, increase satiation, and reduce body weight, but there are few data from randomized, placebo-controlled studies., Methods: We enrolled 60 obese participants in a 24-week, double-blind, randomized, placebo-controlled, concealed allocation trial to compare the effects of gastric antral injections of BTA (100, 300, or 500 U) and saline placebo. The study was conducted at an outpatient clinical research unit. Participants were given one set of injections of BTA or placebo into the gastric antral muscularis propria by using endoscopic ultrasound guidance. Gastric emptying of solids was measured by scintigraphy; we also measured body weight, satiation (maximum tolerated volume in a caloric liquid drink test), calorie intake (by food frequency questionnaire), gastrointestinal symptoms, and psychological aspects of eating behavior (by rating scale)., Results: Compared with baseline values, 2 weeks after injections, the mean half-time for gastric emptying of solids increased by 0.8, 14, 24, and 14 minutes among subjects given placebo, 100, 300, or 500 U BTA, respectively (P = .24 overall, P = .04 for the group given 300 U vs placebo); 16 weeks after the injections, mean body weights were reduced by 2.2, 0.2, 2.3, and 3.0 kg in these groups, respectively. There were no statistically significant differences in mean body weight change, satiation volume, caloric intake, gastrointestinal symptoms, or psychological aspects of eating behavior among groups., Conclusions: Gastric antral injections of BTA may delay gastric emptying at a dose of 300 U but do not cause early satiety, altered eating behaviors, or loss of body weight. Clinicaltrials.gov identifier: NCT00976443., (Copyright © 2013 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Women with polycystic ovary syndrome (PCOS) have increased prevalence of cardiovascular (CV) risk factors. However, data on the incidence of CV events are lacking in this population. Using Rochester Epidemiology Project resources, we conducted a retrospective cohort study comparing CV events in women with PCOS with those of women without PCOS in Olmsted County, Minnesota. Between 1966 and 1988, 309 women with PCOS and 343 without PCOS were identified. Mean (SD) age at PCOS diagnosis was 25.0 (5.3) years; mean age at last follow-up was 46.7 years. Mean (SD) follow-up was 23.7 (13.7) years. Women with PCOS had a higher body mass index (29.4 kg÷m2 vs 28.3 kg÷m2; p=.01). Prevalence of type 2 diabetes mellitus and hypertension and levels of total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol and triglycerides were similar in the two groups. We observed no increase in CV events, including myocardial infarction (adjusted hazard ratio [HR] 0.74; 95% confidence interval [CI] 0.32 to 1.72; p=.48); coronary artery bypass graft surgery (adjusted HR 1.52; 95% CI 0.42 to 5.48; p=.52); death (adjusted HR 1.03; 95% CI, 0.29 to 3.71; p=.96); death due to CV disease (adjusted HR 5.67; 95% CI 0.51 to 63.7; p=.16); or stroke (adjusted HR 1.05; 95% CI 0.28 to 3.92; p=.94). Although women with PCOS weighed more than controls, there was no increased prevalence of other CV risk factors. Furthermore, we found no increase in CV events. While prospective studies are needed to confirm these findings, women with PCOS do not appear to have adverse CV outcomes in midlife.

Background: The prevalence of bariatric surgery in the United States has increased significantly during the past decade, increasing the number of patients requiring postbariatric surgery follow-up care. Our objective was to develop and implement an efficient, financially viable, postbariatric surgery practice model that would be acceptable to patients. The setting was the Mayo Clinic (Rochester, MN)., Methods: By monitoring the attendance rates and using patient surveys, we tested patient acceptance of a new, shared medical appointment practice model in the care of postbariatric surgery patients. Efficiency was assessed by comparing differences in time per patient and total provider time required between the former and new care models. Individual-only patient/provider visits were replaced by combined group and individual visits (CGV)., Results: Our CGV model was well-attended and accepted. The patient attendance rate was >90% at all postoperative follow-up points. Furthermore, 83%, 85.2%, and 75.7% of the 3-, 6-, and 12-month postbariatric surgery patients, respectively, responded that they would not prefer to have only individual visits with their healthcare providers. The CGV model also resulted in greater time efficiency and cost reduction. On average, 5 patients were seen within 4.9 provider hours compared with 10.4 provider hours with the individual-only patient/provider visit model. Furthermore, the average billable charge for the CGV model's group medical nutrition therapy was 50-64% less than the equivalent individual medical nutrition therapy used in the individual-only patient/provider visit model., Conclusion: Shared medical appointments have a valuable role in the care of the postbariatric surgery population, offering a time- and cost-effective model for healthcare provision that is well-accepted by patients., (Copyright © 2012 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Hyperoxaluria and increased calcium oxalate stone formation occur after Roux-en-Y gastric bypass (RYGB) surgery for morbid obesity. The etiology of this hyperoxaluria is unknown. We hypothesized that after bariatric surgery, intestinal hyperabsorption of oxalate contributes to increases in plasma oxalate and urinary calcium oxalate supersaturation., Methods: We prospectively examined oxalate metabolism in 11 morbidly obese subjects before and 6 and 12 months after RYGB (n = 9) and biliopancreatic diversion-duodenal switch (BPD-DS) (n = 2). We measured 24-hour urinary supersaturations for calcium oxalate, apatite, brushite, uric acid, and sodium urate; fasting plasma oxalate; 72-hour fecal fat; and increases in urine oxalate following an oral oxalate load., Results: Six and 12 months after RYGB, plasma oxalate and urine calcium oxalate supersaturation increased significantly compared with similar measurements obtained before surgery (all P ≤ .02). Fecal fat excretion at 6 and 12 months was increased (P = .026 and .055, 0 vs 6 and 12 months). An increase in urine oxalate excretion after an oral dose of oxalate was observed at 6 and 12 months (all P ≤ .02). Therefore, after bariatric surgery, increases in fecal fat excretion, urinary oxalate excretion after an oral oxalate load, plasma oxalate, and urinary calcium oxalate supersaturation values were observed., Conclusion: Enteric hyperoxaluria is often present in patients after the operations of RYGB and BPD-DS that utilize an element of intestinal malabsorption as a mechanism for weight loss., (Copyright © 2011 Mosby, Inc. All rights reserved.)

Previously we showed that peripheral neuropathy occurs after bariatric surgery and was associated with malnutrition (mainly sensory polyneuropathy). This study asks whether a multidisciplinary approach to bariatric surgery lowers risk for developing peripheral neuropathy. We performed a retrospective cohort study of all patients with bariatric surgery at the Mayo Clinic between 1985 and 2002. Patients underwent intensive nutritional management before and after surgery. Potential risk factors were analyzed using life-table methods (Cox regression). Univariate analysis showed the following risk factors: increased serum glycosylated hemoglobin and triglycerides, prolonged hospitalization, postoperative gastrointestinal symptoms, and nausea and vomiting. Peripheral neuropathy occurred less frequently (7% vs. 13%, P < 0.01) and specifically the sensory polyneuropathy subtype (1% vs. 7%, P < 0.0001) than in our prior cohort. A systematic, multidisciplinary approach of intensive nutritional management before and after surgery with frequent follow-up greatly decreased development of peripheral neuropathy (especially sensory polyneuropathy) in patients receiving bariatric surgery.

Obesity and bariatric surgery have been associated with changes in ventricular function and structure. The aim of the present study was to assess the long-term changes in left ventricular (LV) and right ventricular (RV) function and structure in patients with morbid obesity-body mass index >or=40 kg/m(2) or >or=35 kg/m(2) with co-morbidities-who had lost weight after bariatric surgery compared to nonsurgical controls. We reviewed 57 patients with morbid obesity who had undergone gastric bypass surgery and who had undergone echocardiography before and after surgery. A reference group (n = 57) was frequency matched for body mass index (+/-2 kg/m(2)), gender, age (+/-2 years), and follow-up duration (+/-6 months). After a mean follow-up of 3.6 years, the LV mass and LV mass indexed by height had decreased in the patients who had undergone bariatric surgery and had lost weight. In contrast, these measurements had increased in the patients who had not undergone bariatric surgery. The difference between these 2 groups remained significant after adjusting for potential confounders. At follow-up, neither the patients nor controls showed a significant change in ejection fraction, LV myocardial performance index, or RV myocardial performance index. In the study population as a whole, multivariate analysis showed a positive correlation between the change in body weight and ventricular septum thickness (R = 0.33), posterior wall thickness (R = 0.31), LV mass (R = 0.38), RV end-diastolic area (R = 0.22), and estimated RV systolic pressure (R = 0.39), all with p values <0.05. In conclusion, body weight changes in patients with morbid obesity were associated with changes in LV structure independent of improvement in obesity-related co-morbidities, including obstructive sleep apnea. Weight loss improved the RV end-diastolic area and might prevent progression to RV dysfunction., (Copyright 2010 Elsevier Inc. All rights reserved.)

Background: Bariatric surgery leads to profound weight loss, but postoperative complications and psychosocial issues may impact long-term quality of life. The primary aim of this project was to examine whether such patients have better quality of life and self-reported functional status compared with obese adults who do not have bariatric surgery., Methods: This population-based study of patients evaluated for Roux-en-Y gastric bypass surgery involved a survey consisting of baseline and follow-up single-item overall quality-of-life items (Linear Analogue Self-Assessment Questionnaire; LASA), follow-up quality of life (Short-Form-12), and activity (Goldman's Specific Activity Scale). A total of 268 and 273 surveys were mailed, with 148 (55.2%) operative and 88 (32.2%) nonoperative survey responders assessed, respectively. Linear regression was used, adjusting for changes in co-morbidity and functional status, to assess the differences in quality of life and activity level. Individual predictors of higher or better quality-of-life scores also were assessed., Results: There were no major differences in baseline characteristics between survey responders and nonresponders. Mean follow-up was 4.0 and 3.8 years in the operative and nonoperative groups, respectively. The change in overall LASA from baseline to follow-up between groups was 3.1 + or - 0.4 (P <.001). The adjusted Short-Form-12 score was 14.4 points higher in operative patients (P <.001) at follow-up. Operative patients had symptomatic improvement as measured by Specific Activity Scale status (odds ratio 7.5, P <.001) and self-reported exercise tolerance (odds ratio 2.61, P = .01) at follow-up compared with nonoperative patients. Predictors of a high follow-up LASA (P <.05) included initial treatment for depression, percent of weight lost, and absence of dyslipidemia and cardiovascular disease. Follow-up Short-Form-12 predictors included percent of weight loss, absence of baseline diabetes, baseline depression treatment, and follow-up cardiovascular disease., Conclusions: Profound weight loss after bariatric surgery, seeking treatment for depression, and absence of medical co-morbidities appears to predict better quality of life and self-reported functional status.

Background: Eating behaviors often predict outcomes after bariatric surgery, and in this regard, self-efficacy has been shown to predict long-term behavior. We examined current eating self-efficacy in post-bariatric surgery patients comparing them to obese non-surgery patients to determine whether weight loss is associated with increased self-efficacy in post-bariatric surgery patients., Methods: We performed a population-based study of patients evaluated for Roux-en-Y gastric bypass and administered a survey using the Weight Efficacy Lifestyle (WEL) Questionnaire. There were 148 surgical and 88 non-operative patients who responded. Overall WEL score was assessed using linear regression models. Predictors of an increased self-efficacy score were also examined., Results: Follow-up was 4.0 and 3.8 years in the operative and non-operative groups, respectively. Operative responders were slightly older and had a lesser BMI compared to non-responders, otherwise the demographics were similar. Difference in overall WEL between groups was 25.5+/-5.3 points on a 0-180 scale. A 25% change in weight was associated with a difference of 15.4 points on the total WEL between groups. Current self-efficacy scores were highly related to weight loss and correlated to quality of life at follow-up (rho=0.36)., Conclusion: Profound weight loss after bariatric surgery is associated with increased eating self-efficacy in a population of obese adults seeking medical treatment for obesity.

Obese patients have an increased prevalence of cardiovascular (CV) risk factors, which improve with bariatric surgery, but whether bariatric surgery reduces long-term CV events remains ill defined. A systematic review of published research was conducted, and CV risk models were applied in a validation cohort previously published. A standardized MEDLINE search using terms associated with obesity, bariatric surgery, and CV risk factors identified 6 test studies. The validation cohort consisted of a population-based, historical cohort of 197 patients who underwent Roux-en-Y gastric bypass and 163 control patients, identified through the Rochester Epidemiology Project. Framingham and Prospective Cardiovascular Munster Heart Study (PROCAM) risk scores were applied to calculate 10-year CV risk. In the validation cohort, absolute 10-year Framingham risk score for CV events was lower at follow-up in the bariatric surgery group (7.0% to 3.5%, p <0.001) compared with controls (7.1% to 6.5%, p = 0.13), with an intergroup absolute difference in risk reduction of 3% (p <0.001). PROCAM risk in the bariatric surgery group decreased from 4.1% to 2.0% (p <0.001), whereas the control group exhibited only a modest decrease (4.4% to 3.8%, p = 0.08). Using mean data from the validation study, the trend and directionality in risk was similar in the Roux-en-Y group. The test studies confirmed the directionality of CV risk, with estimated relative risk reductions for bariatric surgery patients ranging from 18% to 79% using the Framingham risk score compared with 8% to 62% using the PROCAM risk score. In conclusion, bariatric surgery predicts long-term decreases in CV risk in obese patients.

Aims: To assess long-term changes in left atrial (LA) volume in patients with morbid obesity [body mass index (BMI) >or=35 kg/m(2) with co-morbidities] and extreme obesity (BMI >or=40 kg/m(2)), after surgically-induced weight loss (WL) after gastric bypass surgery., Methods and Results: We reviewed 57 patients who underwent gastric bypass surgery and had echocardiograms both before and after the operation. A control group was frequency-matched for BMI, sex, age, and for duration of follow-up. After a mean follow-up of 3.6 years, LA volume did not change significantly in patients who underwent bariatric surgery, but increased in the control group by 15 +/- 28 ml (P < 0.0001), and 0.1 +/- 0.2 ml (P < 0.0001) for height-indexed LA volume, with a difference between cases and controls that remained significant after adjusting for potential confounders (P = 0.01). In the study population as a whole, there was a positive correlation between change in body weight and change in LA volume (r = 0.22, P = 0.006) independent of clinical conditions associated with LA enlargement., Conclusion: Change in body weight is associated with change in LA size independent of obesity-associated co-morbidities. Successful WL induced by bariatric surgery prevents the progressive increase in LA volume.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Bariatric surgery has become an acceptable therapy for the management of the patient with medically complicated obesity. This paper will review important considerations for the primary care provider as they identify, counsel and care for patients interested in these interventions.

Objective: To assess the effect of weight loss by bariatric surgery on the prevalence of the metabolic syndrome (MetS) and to examine predictors of MetS resolution., Patients and Methods: We performed a population-based, retrospective study of patients evaluated for bariatric surgery between January 1, 1990, and December 31, 2003, who had MetS as defined by the American Heart Association/National Heart, Lung, and Blood Institute (increased triglycerides, low high-density lipoprotein, increased blood pressure, increased fasting glucose, and a measure of obesity). Of these patients, 180 underwent Roux-en-Y gastric bypass, and 157 were assessed in a weight-reduction program but did not undergo surgery. We determined the change in MetS prevalence and used logistic regression models to determine predictors of MetS resolution. Mean follow-up was 3.4 years., Results: In the surgical group, all MetS components improved, and medication use decreased. Nonsurgical patients showed improvements in high-density lipoprotein cholesterol levels. After bariatric surgery, the number of patients with MetS decreased from 156 (87%) of 180 patients to 53 (29%); of the 157 nonsurgical patients, MetS prevalence decreased from 133 patients (85%) to 117 (75%). A relative risk reduction of 0.59 (95% confidence interval [CI], 0.48-0.67; P<.001) was observed in patients who underwent bariatric surgery and had MetS at follow-up. The number needed to treat with surgery to resolve 1 case of MetS was 2.1. Results were similar after excluding patients with diabetes or cardiovascular disease or after using diagnostic criteria other than body mass index for MetS. Significant predictors of MetS resolution included a 5% loss in excess weight (odds ratio, 1.26; 95% CI, 1.19-1.34; P<.001) and diabetes mellitus (odds ratio, 0.32; 95% CI, 0.15-0.68; P=.003)., Conclusion: Roux-en-Y gastric bypass induces considerable and persistent improvement in MetS prevalence. Our results suggest that reversibility of MetS depends more on the amount of excess weight lost than on other parameters.

Background: Body mass index (BMI) is the most widely used measure to diagnose obesity. However, the accuracy of BMI in detecting excess body adiposity in the adult general population is largely unknown., Methods: A cross-sectional design of 13 601 subjects (age 20-79.9 years; 49% men) from the Third National Health and Nutrition Examination Survey. Bioelectrical impedance analysis was used to estimate body fat percent (BF%). We assessed the diagnostic performance of BMI using the World Health Organization reference standard for obesity of BF%>25% in men and>35% in women. We tested the correlation between BMI and both BF% and lean mass by sex and age groups adjusted for race., Results: BMI-defined obesity (> or =30 kg m(-2)) was present in 19.1% of men and 24.7% of women, while BF%-defined obesity was present in 43.9% of men and 52.3% of women. A BMI> or =30 had a high specificity (men=95%, 95% confidence interval (CI), 94-96 and women=99%, 95% CI, 98-100), but a poor sensitivity (men=36%, 95% CI, 35-37 and women=49%, 95% CI, 48-50) to detect BF%-defined obesity. The diagnostic performance of BMI diminished as age increased. In men, BMI had a better correlation with lean mass than with BF%, while in women BMI correlated better with BF% than with lean mass. However, in the intermediate range of BMI (25-29.9 kg m(-2)), BMI failed to discriminate between BF% and lean mass in both sexes., Conclusions: The accuracy of BMI in diagnosing obesity is limited, particularly for individuals in the intermediate BMI ranges, in men and in the elderly. A BMI cutoff of> or =30 kg m(-2) has good specificity but misses more than half of people with excess fat. These results may help to explain the unexpected better survival in overweight/mild obese patients.