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Objective: To compare the risk of incident cardiovascular disease (CVD) events following sleeve gastrectomy (SG) and Roux en Y gastric bypass (RYGB)., Summary Background Data: Bariatric surgery is associated with reduced CVD risk but the differential effect of contemporary bariatric procedures is unclear., Methods: We used insurance claims to conduct a retrospective cohort study of CVD outcomes for patients who underwent RYGB versus SG between 2010 and 2021. Patients were followed for up to 5 years for a primary composite major adverse cardiovascular event (MACE) outcome as well as individual outcomes including myocardial infarction, stroke, heart failure, and arrhythmia. We compared cumulative risks of CVD events using multivariable Cox proportional hazards modeling, in overall cohorts and in sub-cohorts of older adults and those with type 2 diabetes (T2D) or pre-existing CVD and elevated morbidity., Results: Matched, weighted cohorts of 13,545 SG and RYGB patients were observed for an average of 2.5 years after surgery, with 26.2% not lost to follow-up by the end of 5 years. There was no difference in MACE risk between procedures (aHR 1.01 for RYGB vs. SG [95% CI 0.90, 1.12]) in the overall cohort or among the subgroup of older adults (aHR 0.97 for RYGB vs. SG [95% CI 0.85, 1.10]). Patients with T2D experienced lower risk of MACE following RYGB compared to SG (aHR 0.78 [95% CI 0.66, 0.92]), as did those with pre-existing CVD or elevated morbidity prior to surgery (aHR 0.81 [95% CI 0.70, 0.93])., Conclusions: These findings further support the preferential use of RYGB over SG for patients with T2D or who have pre-existing CVD. However, among other groups of patients, including older adults, we did not observe a relative benefit of RYGB during the time horizon in this study., Competing Interests: Conflicts of Interest and Source of Funding: The authors have no conflicts of interest to disclose. This research was supported through a grant from NIH / NIDDK (R01DK112750; Lewis PI)., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Antidepressants are among the most commonly prescribed medications, but evidence on comparative weight change for specific first-line treatments is limited., Objective: To compare weight change across common first-line antidepressant treatments by emulating a target trial., Design: Observational cohort study over 24 months., Setting: Electronic health record (EHR) data from 2010 to 2019 across 8 U.S. health systems., Participants: 183 118 patients., Measurements: Prescription data determined initiation of treatment with sertraline, citalopram, escitalopram, fluoxetine, paroxetine, bupropion, duloxetine, or venlafaxine. The investigators estimated the population-level effects of initiating each treatment, relative to sertraline, on mean weight change (primary) and the probability of gaining at least 5% of baseline weight (secondary) 6 months after initiation. Inverse probability weighting of repeated outcome marginal structural models was used to account for baseline confounding and informative outcome measurement. In secondary analyses, the effects of initiating and adhering to each treatment protocol were estimated., Results: Compared with that for sertraline, estimated 6-month weight gain was higher for escitalopram (difference, 0.41 kg [95% CI, 0.31 to 0.52 kg]), paroxetine (difference, 0.37 kg [CI, 0.20 to 0.54 kg]), duloxetine (difference, 0.34 kg [CI, 0.22 to 0.44 kg]), venlafaxine (difference, 0.17 kg [CI, 0.03 to 0.31 kg]), and citalopram (difference, 0.12 kg [CI, 0.02 to 0.23 kg]); similar for fluoxetine (difference, -0.07 kg [CI, -0.19 to 0.04 kg]); and lower for bupropion (difference, -0.22 kg [CI, -0.33 to -0.12 kg]). Escitalopram, paroxetine, and duloxetine were associated with 10% to 15% higher risk for gaining at least 5% of baseline weight, whereas bupropion was associated with 15% reduced risk. When the effects of initiation and adherence were estimated, associations were stronger but had wider CIs. Six-month adherence ranged from 28% (duloxetine) to 41% (bupropion)., Limitation: No data on medication dispensing, low medication adherence, incomplete data on adherence, and incomplete data on weight measures across time points., Conclusion: Small differences in mean weight change were found between 8 first-line antidepressants, with bupropion consistently showing the least weight gain, although adherence to medications over follow-up was low. Clinicians could consider potential weight gain when initiating antidepressant treatment., Primary Funding Source: National Institutes of Health., Competing Interests: Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-2742.

Sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption may promote lipid abnormalities in childhood. We examined the association between SSB/FJ intake and lipid levels using electronic health record data for 2816 adolescents. Multivariable logistic regression models treated clinical cutpoints for abnormal lipid levels (triglycerides [TG], high-density lipoprotein (HDL), low-density lipoprotein [LDL], and total cholesterol) as dependent variables. In models not adjusted for adiposity, elevated SSB and FJ consumption was associated with increased odds of having abnormally high TG (SSB: odds ratio [OR] = 1.28 (95% confidence interval [CI] = [1.07-1.52], P = .007); FJ: 1.35 ([1.09-1.69], P = .007)) and abnormally low HDL (SSB: 1.47 ([1.17-1.86], P = .001); FJ: 1.35 ([1.02-1.78], P = .03)). Adjusting for adiposity, a likely mediator of the relationship, attenuated these associations. These findings support the need for identifying unhealthy beverage consumption habits during childhood health care visits as a modifiable behavior associated with cardiometabolic risk., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Analyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery., Objectives: The Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence., Setting: Large integrated health system in Southern California with 11 surgical practices and 23 surgeons., Methods: A total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey., Results: For both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies., Conclusions: Future research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence., (Copyright © 2024 American Society for Metabolic and Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: The objective of this study was to compare the impact of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on overall and diabetes-specific health care costs among patients with type 2 diabetes., Methods: This retrospective cohort study examined patients with type 2 diabetes after SG and RYGB using data from Optum's deidentified Clinformatics® Data Mart database. The matched study group included 9608 patients who underwent SG or RYGB and were enrolled between 2007 and 2019. The primary outcomes assessed were overall and diabetes-specific health care costs., Results: Health care costs associated with type 2 diabetes declined substantially in the first few years following both SG and RYGB. RYGB was associated with a larger decrease in pharmacy costs, as well as type 2 diabetes-specific office and laboratory costs. SG was associated with lower total health care costs in the first three follow-up periods and lower acute care costs in the first 2 years after surgery., Conclusions: In this nationwide study, patients with type 2 diabetes at baseline undergoing RYGB appear to experience a reduced need for ambulatory type 2 diabetes monitoring and reduced requirements for antidiabetes medication but, despite this, did not experience an overall medical cost-benefit in the first few years after RYGB versus SG., (© 2024 The Authors. Obesity published by Wiley Periodicals LLC on behalf of The Obesity Society.)

Purpose of Review: This review provides an overview of the history, mechanism of action, and expected treatment effects of the anti-obesity medication (AOM), phentermine. It also includes a summary of recent research and practical guidance for prescribing clinicians., Recent Findings: Recent research on phentermine is sparse and consists primarily of observational studies with methodologic limitations. These studies suggest that phentermine use is associated with clinically significant weight loss in adults and that the medication is generally well tolerated. Large-scale observational studies evaluating phentermine's safety have not identified an increased risk of cardiovascular events or elevations in blood pressure. There is no data to support the notion that phentermine is addictive. Although it remains the most commonly prescribed AOM in the USA, phentermine has little rigorous research to support its efficacy and safety in long-term treatment, which creates a dilemma with guideline-recommended chronic use of AOMs. While we await forthcoming conclusive data on this front, clinicians may consider using phentermine long-term in selected patients, if such prescribing is consistent with local regulatory statutes., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objectives: Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has numerous benefits, yet many eligible children remain unenrolled. This qualitative study sought to explore perceptions of a novel electronic health record (EHR) intervention to facilitate referrals to WIC and improve communication/coordination between WIC staff and healthcare professionals., Methods: WIC staff in three counties were provided EHR access and recruited to participate. An automated, EHR-embedded WIC participation screening and referral tool was implemented within 8 healthcare clinics; healthcare professionals within these clinics were eligible to participate. The interview guide was developed using the Consolidated Framework for Implementation Research to elicit perceptions of this novel EHR-based intervention. Semi-structured interviews were conducted via telephone. Interviews were recorded, transcribed, coded, and analyzed using thematic analysis., Results: Twenty semi-structured interviews were conducted with eight WIC staff, seven pediatricians, four medical assistants, and one registered nurse. Most participants self-identified as female (95%) and White (55%). We identified four primary themes: (1) healthcare professionals had a positive view of WIC but communication and coordination between WIC and healthcare professionals was limited prior to WIC having EHR access; (2) healthcare professionals favored WIC screening using the EHR but workflow challenges existed; (3) EHR connections between WIC and the healthcare system can streamline referrals to and enrollment in WIC; and (4) WIC staff and healthcare professionals recommended that WIC have EHR access., Conclusions: A novel EHR-based intervention has potential to facilitate healthcare referrals to WIC and improve communication/coordination between WIC and healthcare systems., Competing Interests: None., (© The Author(s) 2024.)

Historically, obesity was viewed as a lifestyle disease, with an associated lifestyle solution, and approaches that embody the "eat less, move more" idea have dominated obesity treatment recommendations for over half a century. Meanwhile, the prevalence and severity of obesity continue to increase globally. Enter the so-called "game changers": glucagon-like peptide-1 receptor agonists. In the media frenzy around these and other new antiobesity medications in the pipeline, lifestyle-based treatment researchers and practitioners may find themselves wondering whether behavioral approaches to obesity will become obsolete in this new therapeutic era. In this Perspective, the authors contend that medical approaches impact physiologic pathways to support the success of behavioral approaches. Similarly, behavioral approaches can improve weight loss-adjacent outcomes that are not addressed by medication. Thus, the two approaches are complementary and must coexist if we are to make a significant, population-level impact on the obesity epidemic., (© 2023 The Authors. Obesity published by Wiley Periodicals LLC on behalf of The Obesity Society.)

Purpose: Weight loss surgery is an effective, long-term treatment for severe obesity but individual response to surgery varies widely. The purpose of this study was to test a comprehensive theoretical model of factors that may be correlated with the greatest surgical weight loss at 1-3 years following surgery. Such a model would help determine what predictive factors to measure when patients are preparing for surgery that may ensure the best weight outcomes., Materials and Methods: The Bariatric Experience Long Term (BELONG) study collected self-reported and medical record-based baseline information as correlates of 1- and 3-year % total weight loss (TWL) in n = 1341 patients. Multiple linear regression was used to determine the associations between 120 baseline variables and %TWL., Results: Participants were 43.4 ± 11.3 years old, Hispanic or Black (52%; n = 699), women (86%; n = 1149), and partnered (72%; n = 965) and had annual incomes of ≥ $51,000 (60%; n = 803). A total of 1006 (75%) had 3-year follow-up weight. Regression models accounted for 10.1% of the variance in %TWL at 1-year and 13.6% at 3 years. Only bariatric operation accounted for a clinically meaningful difference (~ 5%) in %TWL at 1-year. At 3 years after surgery, only bariatric operation, Black race, and BMI ≥ 50 kg/m 2 were associated with clinically meaningful differences in %TWL., Conclusions: Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Objective: Sugary drink consumption is associated with adverse health outcomes in children, highlighting the need for scalable family interventions that address barriers to water consumption. To inform development of a scalable, health-care-system-based intervention targeting family beverage choice, a formative qualitative study was conducted using semi-structured interviews with parents whose children were identified as over-consuming sugar-sweetened beverages (SSB) and/or fruit juice (FJ). The first goal of these interviews was to understand, in a diverse real-world patient population, what parents viewed as the primary drivers of their family's beverage choices, and explore how these drivers might need to be addressed in order to make changes to beverage consumption. A second goal was to explore parental preferences for planned intervention components. An exploratory goal of the interviews was to examine whether knowledge, attitudes, and beliefs around family beverage choice differed across racial and ethnic groups in this sample., Design: Semi-structured phone interviews were conducted and interviews audio-recorded and transcribed., Participants: 39 parents/caregivers of children ages 1-8 who over-consumed sugary drinks as determined by screenings at pediatric visits., Phenomenon of Interest: Parents were interviewed about family beverage choices and preferences to inform development of a multi-component intervention., Analysis: Thematic analysis was performed, including comparison of themes across racial/ethnic groups., Results: Parents expressed that sugary drinks were unhealthy and water was a better alternative. Most were familiar with the health consequences of excess sugar consumption. They identified many reasons why sugary drinks are chosen over water despite this knowledge. One common reason was concern about tap water safety. Few differences were noted across racial and ethnic groups in our sample. Parents were enthusiastic about a technology-based intervention to be delivered through their child's doctor's office., Conclusions and Implications: Knowledge is not enough to change behavior. Beverage interventions need to be easy to access, make water more appealing, and elevate beverage choice above the "white noise" of everyday life. Delivering an intervention in a clinical setting could provide an extra level of care, while technology would reduce the amount of live contact and decrease the burden for clinicians and parents.

Beverages are the leading source of sugar in children's diets and a modifiable risk factor for adverse health conditions. Electronic health record-based screeners could facilitate health systems' efforts to reduce child consumption of sugary beverages. Before implementing a sugar-sweetened beverage screener in the electronic health record within academic healthcare system, 228 pediatric and family medicine clinic staff completed an online educational training to familiarize them with the screener and its rationale. Pretraining and posttraining surveys were used to examine the association between staff knowledge of sugar-sweetened beverages and the acceptability of the screening workflow. Respondents displayed high levels of pretraining knowledge about health consequences of added sugar intake, but lower levels of pediatric beverage guideline knowledge. Knowledge improved from pretraining to posttraining surveys, with high acceptability of the screening process. Staff compliance with sugar-sweetened beverage screening was examined using electronic health record data. During the 6 months after screener implementation, 47% of eligible pediatric patients were screened, with some variation in compliance by age group and practice type. This study demonstrated that engaging nursing and frontline staff to screen pediatric patients for behavioral determinants of health is feasible. Ongoing outreach and refreshers may improve sustainability., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Healthcare-based interventions to address sugary beverage intake could achieve broad reach, but intensive in-person interventions are unsustainable in clinical settings. Technology-based interventions may provide an alternative, scalable approach. Methods: Within an academic health system in the United States that already performs electronic health record-based sugary drink screening, we conducted a pilot randomized trial of a technology-driven family beverage choice intervention. The goal of the intervention was to reduce sugar-sweetened beverage (SSB) and fruit juice (FJ) consumption in 60 parent-child dyads, in which children were 1-8 years old. The pediatrician-initiated intervention consisted of a water promotion toolkit, a video, a mobile phone application, and 14 interactive voice-response phone calls to parents over 6 months. The study was conducted between June 2021 and May 2022. The aim of the pilot study was to assess the potential feasibility and efficacy of the newly developed intervention. Results: Intervention fidelity was excellent, and acceptability was high for all intervention components. Children in both the intervention and the control groups substantially decreased their consumption of SSB and FJ over follow-up (mean combined baseline 2.5 servings/day vs. 1.4/day at 6 months) and increased water consumption, but constrained linear mixed-effects models showed no differences between groups on these measures. Compared to parents in the control group, intervention parents had larger decreases in SSB intake at 3 months (-0.80 (95% CI: -1.54, -0.06, p = 0.03) servings daily), but these differences were not sustained at 6 months. Conclusion: These findings suggest that, though practical to implement in a clinical care setting and acceptable to a diverse participant group, our multicomponent intervention may not be universally necessary to achieve meaningful behavior changes around family beverage choice. A lower-intensity intervention, such as EHR-based clinical screening alone, might be a less resource-intense way for health systems to achieve similar behavioral outcomes. Future studies might therefore explore whether, instead of applying a full intervention to all families whose children overconsume SSB or FJ, a stepped approach, starting with clinical screening and brief counseling, could be a better use of health system resources.

Children of parents participating in weight management programs (WMPs) are more likely to adopt their parents' weight control practices. Little is known about the weight outcomes of children who have a parent participating in a WMP. This study aimed to assess this relationship. Children 2-17 years of age with a parent who participated in a WMP were included in the study. Multilevel linear mixed-effects regression models were used, stratified by child weight status at the time of parental WMP participation (healthy weight, overweight/obesity) to determine change in children's BMIz from before to after parents WMP participation, including covariates of parent BMI and parental feeding practices. Parents (N = 77) were mostly white (76%) and female (84%). Children (N = 114) had a mean age of 10.5 ± 4.6; 47% had overweight or obesity. Children with overweight or obesity prior to their parent's WMP had a decrease in BMIz (-0.68) after the WMP while children with a healthy weight had no significant change. Children with overweight or obesity had a decrease in BMIz from before to after parent's participation in a WMP. Further research is needed to understand changes in family eating practices that occur during and after parent WMP participation., (© 2023 The Authors. Clinical Obesity published by John Wiley & Sons Ltd on behalf of World Obesity Federation.)

Objective: To examine whether depression status before metabolic and bariatric surgery (MBS) influenced 5-year weight loss, diabetes, and safety/utilization outcomes in the PCORnet Bariatric Study., Summary of Background Data: Research on the impact of depression on MBS outcomes is inconsistent with few large, long-term studies., Methods: Data were extracted from 23 health systems on 36,871 patients who underwent sleeve gastrectomy (SG; n=16,158) or gastric bypass (RYGB; n=20,713) from 2005-2015. Patients with and without a depression diagnosis in the year before MBS were evaluated for % total weight loss (%TWL), diabetes outcomes, and postsurgical safety/utilization (reoperations, revisions, endoscopy, hospitalizations, mortality) at 1, 3, and 5 years after MBS., Results: 27.1% of SG and 33.0% of RYGB patients had preoperative depression, and they had more medical and psychiatric comorbidities than those without depression. At 5 years of follow-up, those with depression, versus those without depression, had slightly less %TWL after RYGB, but not after SG (between group difference = 0.42%TWL, P = 0.04). However, patients with depression had slightly larger HbA1c improvements after RYGB but not after SG (between group difference = - 0.19, P = 0.04). Baseline depression did not moderate diabetes remission or relapse, reoperations, revision, or mortality across operations; however, baseline depression did moderate the risk of endoscopy and repeat hospitalization across RYGB versus SG., Conclusions: Patients with depression undergoing RYGB and SG had similar weight loss, diabetes, and safety/utilization outcomes to those without depression. The effects of depression were clinically small compared to the choice of operation., Competing Interests: The other authors report no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This study examined the association between individual- and neighborhood-level sociodemographic factors and surgical weight loss at 1 year (short term) and 3 years (long term)., Methods: Data were obtained from the baseline survey of the BELONG (Bariatric Experience Long Term) prospective longitudinal cohort study. Individual-level self-reported data on sex, race and ethnicity, education, and household income were obtained by survey. Data from the 2010 US Census were used to calculate area Neighborhood Deprivation Index score and median value of owner-occupied housing units at the census tract level., Results: Patients (N = 1341) had a mean age of 43.4 (SD 11.3) years, were mostly female (86%), were mostly Black or Hispanic (52%), had some college education (83%), and had annual household incomes ≥$51,000 (55%). Percentage total weight loss was 25.8% (SD 9.0%) at year 1 and 22.2% (SD 10.5%) at year 3. Race and ethnicity and age were significant predictors of weight loss at 1 and 3 years with a small effect of self-reported household income at year 1. There were no significant associations between census tract-level Neighborhood Deprivation Index score or value of owner-occupied housing units and weight loss at either time point., Conclusions: Health systems could improve the chances of weight-loss maintenance after surgery by addressing factors related to racial and ethnic disparities and to income disparities., (© 2023 The Obesity Society.)

Objective: To compare acute care utilization and costs following sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB)., Summary Background Data: Comparing postbariatric emergency department (ED) and inpatient care use patterns could assist with procedure choice and provide insights about complication risk., Methods: We used a national insurance claims database to identify adults undergoing SG and RYGB between 2008 and 2016. Patients were matched on age, sex, calendar-time, diabetes, and baseline acute care use. We used adjusted Cox proportional hazards to compare acute care utilization and 2-part logistic regression models to compare annual associated costs (odds of any cost, and odds of high costs, defined as ≥80th percentile), between SG and RYGB, overall and within several clinical categories., Results: The matched cohort included 4263 SG and 4520 RYGB patients. Up to 4 years after surgery, SG patients had slightly lower risk of ED visits [adjusted hazard ratio (aHR): 0.90; 95% confidence interval (CI): 0.85,0.96] and inpatient stays (aHR: 0.80; 95% CI: 0.73,0.88), especially for events associated with digestive-system diagnoses (ED aHR: 0.68; 95% CI: 0.62,0.75; inpatient aHR: 0.61; 95% CI: 0.53,0.72). SG patients also had lower odds of high ED and high total acute costs (eg, year-1 acute costs adjusted odds ratio (aOR) 0.77; 95% CI: 0.66,0.90) in early follow-up. However, observed cost differences decreased by years 3 and 4 (eg, year-4 acute care costs aOR 1.10; 95% CI: 0.92,1.31)., Conclusions: SG may have fewer complications requiring emergency care and hospitalization, especially as related to digestive system disease. However, any acute care cost advantages of SG may wane over time., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: This study examined the association of weight loss following bariatric surgery with self-reported sleep quality after accounting for other sleep-related factors., Methods: Participants were from the Bariatric Experience Long Term (BELONG) study. Participants completed a survey up to 6 months before surgery and approximately 1 year after surgery. The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality. One-year percentage total weight loss (%TWL) was determined from electronic medical records. Covariates included demographics, Charlson Comorbidity Index, geocoded variables to assess neighborhood quality, and physical activity. The authors assessed the association between %TWL at 1 year and PSQI component scores with separate cumulative logit models., Results: There were 997 participants in the analytic cohort. Participants were 86.2% women, 37.0% Hispanic, and 13.7% Black adults. Mean one-year %TWL was 26.3 (SD 8.7). Each 1% increase in %TWL was associated with a 3% better daytime dysfunction score (odds ratio = 1.03; 95% CI: 1.02-1.05) and a 2% better sleep quality score (odds ratio = 1.02; 95% CI: 1.00-1.03). No significant differences were found for the other PSQI components., Conclusions: Weight loss from bariatric surgery was associated with better self-reported sleep at 1 year. For people undergoing bariatric surgery, there may be an added benefit of better sleep., (© 2022 The Obesity Society.)

Importance: Bariatric surgery is the most effective treatment for severe obesity; yet it is unclear whether the long-term safety and comparative effectiveness of these operations differ across racial and ethnic groups., Objective: To compare outcomes of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) across racial and ethnic groups in the National Patient-Centered Clinical Research Network (PCORnet) Bariatric Study., Design, Setting, and Participants: This was a retrospective, observational, comparative effectiveness cohort study that comprised 25 health care systems in the PCORnet Bariatric Study. Patients were adults and adolescents aged 12 to 79 years who underwent a primary (first nonrevisional) RYGB or SG operation between January 1, 2005, and September 30, 2015, at participating health systems. Patient race and ethnicity included Black, Hispanic, White, other, and unrecorded. Data were analyzed from July 1, 2021, to January 17, 2022., Exposure: RYGB or SG., Outcomes: Percentage total weight loss (%TWL); type 2 diabetes remission, relapse, and change in hemoglobin A1c (HbA1c) level; and postsurgical safety and utilization outcomes (operations, interventions, revisions/conversions, endoscopy, hospitalizations, mortality, 30-day major adverse events) at 1, 3, and 5 years after surgery., Results: A total of 36 871 patients (mean [SE] age, 45.0 [11.7] years; 29 746 female patients [81%]) were included in the weight analysis. Patients identified with the following race and ethnic categories: 6891 Black (19%), 8756 Hispanic (24%), 19 645 White (53%), 826 other (2%), and 783 unrecorded (2%). Weight loss and mean reductions in HbA1c level were larger for RYGB than SG in all years for Black, Hispanic, and White patients (difference in 5-year weight loss: Black, -7.6%; 95% CI, -8.0 to -7.1; P < .001; Hispanic, -6.2%; 95% CI, -6.6 to -5.9; P < .001; White, -5.9%; 95% CI, -6.3 to -5.7; P < .001; difference in change in year 5 HbA1c level: Black, -0.29; 95% CI, -0.51 to -0.08; P = .009; Hispanic, -0.45; 95% CI, -0.61 to -0.29; P < .001; and White, -0.25; 95% CI, -0.40 to -0.11; P = .001.) The magnitude of these differences was small among racial and ethnic groups (1%-3% of %TWL). Black and Hispanic patients had higher risk of hospitalization when they had RYGB compared with SG (hazard ratio [HR], 1.45; 95% CI, 1.17-1.79; P = .001 and 1.48; 95% CI, 1.22-1.79; P < .001, respectively). Hispanic patients had greater risk of all-cause mortality (HR, 2.41; 95% CI, 1.24-4.70; P = .01) and higher odds of a 30-day major adverse event (odds ratio, 1.92; 95% CI, 1.38-2.68; P < .001) for RYGB compared with SG. There was no interaction between race and ethnicity and operation type for diabetes remission and relapse., Conclusions and Relevance: Variability of the comparative effectiveness of operations for %TWL and HbA1c level across race and ethnicity was clinically small; however, differences in safety and utilization outcomes were clinically and statistically significant for Black and Hispanic patients who had RYGB compared with SG. These findings can inform shared decision-making regarding bariatric operation choice for different racial and ethnic groups of patients.

Purpose: The Bariatric Experience Long Term (BELONG) prospective study cohort was created to address limitations in the literature regarding the relationship between surgical weight loss and psychosocial, health, behaviour and environmental factors. The BELONG cohort is unique because it contains 70% gastric sleeve and 64% patients with non-white race/ethnicity and was developed with strong stakeholder engagement including patients and providers., Participants: The BELONG cohort study included 1975 patients preparing to have bariatric surgery who completed a baseline survey in a large integrated health system in Southern California. Patients were primarily women (84%), either black or Hispanic (59%), with a body mass index (BMI) of 45.1±7.4 kg/m 2 , age 43.3±11.5 years old, and 32% had at least one comorbidity., Findings to Date: A total of 5552 patients were approached before surgery between February 2016 and May 2017, and 1975 (42%) completed a baseline survey. A total of 1203 (73%) patients completed the year 1 and 1033 (74%) patients completed the year 3 postoperative survey. Of these survey respondents, 1341 at baseline, 999 at year 1, and 951 at year 3 were included in the analyses of all survey and weight outcome data. A total of 803 (60% of eligible patients) had survey data for all time points. Data collected were self-reported constructs to support the proposed theoretical model. Height, weight and BMI were abstracted from the electronic medical record to obtain the main outcomes of the study: weight loss and regain., Future Plans: We will collect self-reported constructs and obtain height, weight and BMI from the electronic medical record 5 years after bariatric surgery between April 2022 and January 2023. We will also collect patient experiences using focus groups of 8-12 patients each throughout 2022., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: Studies comparing contemporary bariatric surgical types could facilitate procedure selection for patients interested in reducing their frequency of health care visits and reliance on prescription drugs., Objective: To compare the association of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) with ambulatory health care costs and use for as long as 4 years after surgery., Design, Setting, and Participants: This comparative effectiveness study, which included patients undergoing bariatric surgery who were aged 18 to 64 years with at least 24 months of enrollment data before surgery and 12 months of enrollment data after surgery, used a retrospective interrupted time series with a comparison group. Data represent insurance claims dated January 2006 to June 2017, with analyses completed in September 2021. Data were collected from US commercial and Medicare Advantage claims database. Cohorts were matched on characteristics including baseline body mass index category, diabetes status, baseline ambulatory care costs, region of the United States, and year of surgery., Exposures: SG or RYGB, based on procedure codes., Main Outcomes and Measures: Annual ambulatory health care costs, and subtypes of cost and use including prescriptions, office visits, laboratory encounters, and radiology., Results: Matched cohorts included 3049 patients who underwent SG and 3251 patients who underwent RYGB, with a mean (SD) age of 45.2 (10.0) years; 4820 (77%) were women. Full follow-up was 37% for SG (514 patients) and 38% for RYGB (643 patients) among those eligible for 4-year follow-up. There were no significant differences between SG and RYGB in total ambulatory costs, office visit costs, or radiology costs in all follow-up years. Patients who underwent SG had significantly higher prescription costs than those who underwent RYGB bypass in year 4 ($852.8 per patient per year; 95% CI: $395.6-$1310.0 per patient per year) with more cardiometabolic medication fills in each year (eg, year 4: 42.5%; 95% CI, 13.7%-71.2%). In contrast, early after surgery, patients who underwent SG had relatively fewer specialist visits (eg, year 1: -7.2%; 95% CI, -14.3% to -0.2%) and lower laboratory costs (eg, year 1: -$118.9 per patient per year; 95% CI, -$220.2 to -$17.5 per patient per year)., Conclusions and Relevance: Despite clinical studies showing greater weight loss and comorbidity improvement with RYGB vs SG, this study found no difference in total ambulatory costs for as long as 4 years after SG and RYGB. These findings may reflect the trade-off between greater improvements in cardiometabolic health and additional surgery-related care among patients undergoing RYGB. Studies with longer follow-up time could determine whether greater sustained weight loss from RYGB eventually results in lower costs compared with SG.

Importance: There is limited evidence on whether the Affordable Care Act Medicaid expansion beginning in 2014 improved access to elective procedures. Uninsured individuals are at higher risk of obesity and may have experienced improved uptake of bariatric surgery following Medicaid expansion., Objective: To examine the association between Medicaid expansion and the receipt of inpatient elective bariatric surgery among Medicaid-covered and uninsured individuals aged 26 to 64 years., Design Setting and Participants: This cohort study used difference-in-differences analysis of all-payer data (2010-2017) of 637 557 elective bariatric surgeries for patients aged 26 to 74 years from 11 Medicaid expansion states and 6 nonexpansion states. Nonexpansion states and individuals aged 65 to 74 years were control cohorts. Data analysis was performed from July 6, 2020, to July 23, 2021., Exposure: Living in a Medicaid expansion state., Main Outcomes and Measures: The main outcomes were the (1) number of elective bariatric surgeries, (2) population count, and (3) rate of bariatric surgery (number of surgeries per 10 000 population) among Medicaid-covered and uninsured individuals., Results: Of the 600 798 elective bariatric surgeries in adults aged 26 to 64 years between 2010 and 2017 from the 17 study states, Medicaid-covered and uninsured individuals accounted for 18.3% of the total surgery volume in expansion states and 14.5% in nonexpansion states. A total of 296 798 patients (78.9%) in expansion states were women vs 177 386 (78.9%) in nonexpansion states. Among individuals aged 26 to 64 years, the median age was 44 (IQR, 37-52) years. Racial and ethnic distribution was non-Hispanic White, 60.2%; non-Hispanic Black, 17.7%; Hispanic, 16.6%; and other, 5.5%. Between 2013 and 2017, the volume of bariatric surgeries for Medicaid-covered and uninsured patients increased annually by 30.3% in expansion states and 16.5% in nonexpansion states. Medicaid expansion was associated with a 36.6% annual increase (95% CI, 8.2% to 72.5%) in surgery volume, a 9.0% annual increase (95% CI, 3.8% to 14.5%) in the population, and a 25.5% change (95% CI, -1.3% to 59.4%) in the rate of bariatric surgery. By race and ethnicity, Medicaid expansion was associated with an increase in the rate of bariatric surgery among non-Hispanic White individuals (31.6%; 95% CI, 6.1% to 63.0%) but no significant change among non-Hispanic Black (5.9%; 95% CI, -19.8% to 39.9%) and Hispanic (28.9%; 95% CI, -24.4% to 119.8%) individuals., Conclusions and Relevance: This cohort study found that Medicaid expansion was associated with increased rates of bariatric surgery among lower-income non-Hispanic White individuals, but not among Hispanic and non-Hispanic Black individuals., Competing Interests: Conflict of Interest Disclosures: Dr Lewis reported receiving an honorarium for serving as a faculty member on a continuing medical education activity on the diagnosis and treatment of obesity for the National Committee for Quality Assurance. No other disclosures were reported., (Copyright 2021 Hanchate AD et al. JAMA Health Forum.)

Bariatric surgery is associated with changing food preferences, but it is not known whether these changes differ by type of operation or are associated with weight loss. The current study presents validation results for a new 27-item scale, Bariatric Surgical Alterations in Tolerability, Enjoyment and Cravings in the Diet (BSATED). This scale measured enjoyment, craving, and intolerance changes for nine food and beverage categories common to dietary habits in the Southern California region of the U.S. one year following bariatric surgery in the Bariatric Experience Long Term (BELONG) study. Validation of BSATED was done using exploratory factor analyses, construct validity with other conceptually related survey instruments, and criterion validity using hypothesized differences for operation type and percent total weight loss (%TWL) at 12-18 months after surgery. Participants (n = 999) were 86% female, 41% non-Hispanic White, with a mean age of 43.1 ± 11.3 years and a body mass index (BMI) of 43.4 ± 6.8 kg/m 2 at the time of surgery. Participants reported less enjoyment and craving for high-fat meats (62%), grains (54%), candy and other desserts (e.g. candy bars, chocolate, ice cream) (52%), and sweet baked goods (48%) 12 months after surgery. These changes were more common among participants undergoing Roux-en-Y gastric bypass (RYGB) compared to those receiving sleeve gastrectomy (SG). Participants who reported decreased enjoyment and craving for foods and beverages that post-bariatric patients are counseled to reduce or avoid had greater %TWL at 12-18 months following surgery (p < .001 and p = .003 respectively). The foods and beverages in BSATED that post-bariatric patients are counseled to reduce or avoid could be used to understand how changes in enjoyment, craving and tolerability of these foods/beverages contribute to weight loss following surgery., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Objective: The aim of the study was to compare diabetes outcomes following vertical sleeve gastrectomy (VSG) and Roux-en-Y gastric bypass (RYGB)., Background: There are few comparative studies on diabetes outcomes after VSG and RYGB., Methods: We used a US-wide commercial insurance claims database to identify adults with diabetes undergoing VSG or RYGB in 2010 to 2016. We matched patients on baseline insulin use, total diabetes medication burden, age, presence of diabetes complications, and follow-up duration, and used adjusted Cox proportional hazards models to compare diabetes medication discontinuation between procedures. We used difference-in-differences analyses to compare changes in medication use intensity up to 2 years after surgery., Results: The matched cohort included 1111 VSG and 922 RYGB patients: 16% were younger than 40 years, 11% were 60 years or older, 67% were women, 67% had a body mass index of 40 kg/m2 or higher, and 23% were on insulin at the time of surgery. Thirteen percent were lost to follow-up at 1 year, and 30% at 2 years after surgery. Patients with VSG were less likely than matched RYGB patients to discontinue all diabetes medications (hazard ratio 0.80, 95% confidence interval 0.72-0.88). Although both groups had substantial decreases in medication use after surgery, RYGB patients had an 86% (32%, 140%) lower total diabetes medication dose than VSG by the second half of postoperative year 2., Conclusions: In a large claims-based, nationwide cohort of bariatric patients with diabetes, those undergoing RYGB were more likely to come off all medications than those undergoing VSG. Patients with diabetes should consider this potential benefit of RYGB when making informed decisions about obesity treatments., Competing Interests: The authors report no conflicts of interest., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Obesity is highly prevalent and associated with several adverse outcomes including health-related quality-of-life (HRQoL), work productivity, and activity impairment. The objective of this study is to examine group differences in HRQoL and labor-related health outcomes among participants in the OPTIWIN program, which compared the effectiveness of two intensive behavioral weight loss interventions. Participants ( n = 273) were randomized to OPTIFAST ® (OP) or food-based (FB) dietary interventions for 52 weeks. HRQoL and labor-related health outcomes were measured at baseline, week 26, and week 52, using two questionnaires. At baseline, there were no differences between groups on the Impact of Weight on Quality-of-Life Questionnaire (IWQOL-Lite). At week 26, the OP group had statistically significant differences towards better HRQoL for Physical Function, Self-Esteem, and the total score compared with the FB group. At week 52, the OP group showed better HRQoL in the total score ( p = 0.0012) and in all but one domain. Moreover, the adjusted change-from-baseline normalized total score at week 52 was -5.9 points ( p = 0.0001). Finally, the mean IWQOL-Lite normalized score showed that HRQoL improves by 0.4442 units ( p < 0.0001) per kg lost, and that greater weight reduction was positively associated with better HRQoL. No statistically significant group differences were found with the Work Productivity and Activity Impairment (General Health) (WPAI-GH) Questionnaire. HRQoL improves with highly intensive, well-structured weight loss interventions. Greater weight loss lead to larger improvements. The lack of negative effect on productivity and activity suggests that these interventions may be compatible with an active work lifestyle.

Purpose: Bariatric surgery is the most effective treatment for severe obesity, but currently, only 1-2% of all eligible patients undergo surgery each year. This study examined which factors were associated with a patient receiving bariatric surgery after referral in a real-world healthcare setting., Materials and Methods: The current study used the baseline survey and electronic medical record (EMR) data from the Bariatric Experience Long Term (BELONG) study (n = 1975). Predictors of who did (n = 1680) and who did not (n = 295) have surgery were analyzed using multivariate logistic regression., Results: Participants (n = 1975; 42.4% response rate) were primarily women (84%) and either non-Hispanic Black or Hispanic (60%). In the fully adjusted multivariate model, the strongest predictors of having surgery were being a woman (OR = 3.17; 95% CI = 2.15, 4.68; p < .001) and losing at least 5% of their body weight in the year before surgery (OR = 3.16; 95% CI = 2.28, 4.38; p < .001). The strongest predictors of not having surgery were a ≥ BMI 50 kg/m 2 (OR = .39; 95% CI = .27, .56; p < .001) and having a higher physical comorbidity burden (OR = .84; 95% CI = .75, .94; p = .004)., Conclusions: Practices such as 5-10% total weight loss before surgery and selection of patients with safer operative risk profiles (younger with lower comorbidity burden) may inadvertently contribute to under-utilization of bariatric surgery among some demographic subpopulations who could most benefit from this intervention.

Background: Hiatal hernias are often repaired concurrently with bariatric surgery to reduce risk of gastroesophageal reflux disease-related complications., Objectives: To examine the association between concurrent hiatal hernia repair (HHR) and bariatric outcomes., Setting: A 2010-2017 U.S. commercial insurance claims data set., Methods: We conducted a retrospective cohort study. We identified adults who underwent sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) alone or had bariatric surgery concurrently with HHR. We matched patients with and without HHR and followed patients up to 3 years for incident abdominal operative interventions, bariatric revisions/conversions, and endoscopy. Time to first event for each outcome was compared using multivariable Cox proportional hazards modeling., Results: We matched 1546 SG patients with HHR to 3170 SG patients without HHR, and we matched 457 RYGB patients with HHR to 1156 RYGB patients without HHR. A total of 73% had a full year of postoperative enrollment. Patients who underwent concurrent SG and HHR were more likely to have additional abdominal operations (adjusted hazard ratio [aHR], 2.1; 95% CI, 1.5-3.1) and endoscopies (aHR, 1.5; 95% CI, 1.2-1.8) but not bariatric revisions/conversions (aHR, 1.7; 95% CI, .6-4.6) by 1 year after surgery, a pattern maintained at 3 years of follow-up. Among RYGB patients, concurrent HHR was associated only with an increased risk of endoscopy (aHR, 1.4; 95% CI, 1.1-1.8)) at 1 year of follow-up, persisting at 3 years., Conclusions: Concurrent SG/HHR was associated with increased risk of some subsequent operative and nonoperative interventions, a pattern that was not consistently observed for RYGB. Additional studies could examine whether changes to concurrent HHR technique could reduce risk., (Copyright © 2020 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Identifying areas with higher sugar-sweetened beverage intake could help tailor policy and public health efforts intended to reduce sugary beverage consumption., Objective: Demonstrate the feasibility of using health system data to examine the geographic distribution of sugar-sweetened beverage intake and evaluate neighbourhood characteristics associated with intake., Methods: We extracted electronic health record data from a sugar-sweetened beverage and 100% fruit juice screener used for children ages 1 to 17 years in eight pediatric practices in North Carolina (March 2017-2018) and dichotomized intake to high (≥3 sugar-sweetened beverages/day) vs not. We geocoded address and mapped the proportion of consumers in each census tract. We combined electronic health record data with US census data and evaluated associations of census tract income and race/ethnicity with intake. We used multivariable models to evaluate the association between geographic concentrations of income and race/ethnicity and sugar-sweetened beverage intake, controlling for demographics extracted from the electronic health record and clustering by tract., Results: Of 19 451 patients, 4579 (23.5%) reported consuming ≥3 sugar-sweetened beverages/day. In multivariable models, children living in tracts with high concentrations of low-income (OR: 1.45, 95% CI: 1.26, 1.68) and non-white residents (OR: 1.44, 95% CI: 1.21, 1.71) were more likely to consume ≥3 sugar-sweetened beverages/day than children in tracts with a high concentration of high-income and white residents., Conclusion: We demonstrate how health system data could be used to characterize geographic variation in sugar-sweetened beverage and 100% fruit juice consumption. This approach could help target public health efforts and monitor the effects of community-level interventions., (© 2020 World Obesity Federation.)

Background: Claims databases are generally considered inadequate for obesity research due to suboptimal capture of body mass index (BMI) measurements. This might not be true for bariatric surgery because of reimbursement requirements and changes in coding systems. We assessed the availability and validity of claims-based weight-related diagnosis codes among bariatric surgery patients., Methods: We identified three nested retrospective cohorts of adult bariatric surgery patients who underwent adjusted gastric banding, Roux-en-Y gastric bypass, or sleeve gastrectomy between January 1, 2011 and June 30, 2018 using different components of OptumLabs® Data Warehouse, which contains linked de-identified claims and electronic health records (EHRs). We measured the availability of claims-based weight-related diagnosis codes in the 6-month preoperative and 1-year postoperative periods in the main cohort identified in the claims data. We created two claims-based algorithms to classify the presence of severe obesity (a commonly used cohort selection criterion) and categorize BMI (a commonly used baseline confounder or postoperative outcome). We evaluated their performance by estimating sensitivity, specificity, positive predictive value, negative predictive value, and weighted kappa in two sub-cohorts using EHR-based BMI measurements as the reference., Results: Among the 29,357 eligible patients identified using claims only, 28,828 (98.2%) had preoperative weight-related diagnosis codes, either granular indicating BMI ranges or nonspecific denoting obesity status. Among the 27,407 patients with granular preoperative codes, 12,346 (45.0%) had granular codes and 9355 (34.1%) had nonspecific codes in the 1-year postoperative period. Among the 3045 patients with both preoperative claims-based diagnosis codes and EHR-based BMI measurements, the severe obesity classification algorithm had a sensitivity 100%, specificity 71%, positive predictive value 100%, and negative predictive value 78%. The BMI categorization algorithm had good validity categorizing the last available preoperative or postoperative BMI measurements (weighted kappa [95% confidence interval]: preoperative 0.78, [0.76, 0.79]; postoperative 0.84, [0.80, 0.87])., Conclusions: Claims-based weight-related diagnosis codes had excellent validity before and after bariatric surgical operation but suboptimal availability after operation. Claims databases can be used for bariatric surgery studies of non-weight-related effectiveness and safety outcomes that are well-captured.

Objective: For every weight loss treatment, there are usually groups of people who lose less than expected. This study sought to determine if response rates to a total diet replacement (TDR) differed from those of a calorie-restricted, food-based (FB) diet., Methods: Data from OPTIWIN, a 12-month multicenter trial in adults with a BMI of 30-55 kg/m 2 , with 26-week weight-loss and weight-maintenance phases, were utilized. Participants ( n = 330) were randomized to the OPTIFAST programme (OP) or to a reduced-energy FB diet. Treatment non-responders were defined as those who lost <3% of initial weight at months 6 or 12., Results: There were 103 (76%) responders in the OP compared with 78 (57%) in the FB group at 12 months. The odds of treatment response at 12 months among participants who were non-responders at 3 months was not significantly different between the OP and FB groups ( p = 0.64). Race, type 2 diabetes status and previous weight loss attempts were significantly associated with responder status. OP responders had higher meal plan adherence and non-caloric fluid intake compared with FB responders., Conclusion: Early treatment response is more likely and better sustained with TDR compared with an FB diet. Individual and treatment level factors appear to influence early treatment response to behavioural interventions for weight reduction., Competing Interests: JDA and JL are consultants for Nestlé Healthcare Nutrition; JDA, KHL, AER and LM receive grant funding from Nestlé Health Science; and SP is an employee of Nestlé Health Science. All remaining authors have no relevant disclosures. Nestlé Healthcare Nutrition owns the OPTIFAST programme., (© 2020 The Authors. Obesity Science & Practice published by World Obesity and The Obesity Society and John Wiley & Sons Ltd.)

Background: Sugar-sweetened beverages (SSBs) and, to some extent, fruit juice are modifiable risk factors for childhood obesity. Data on consumption have not been previously systematically collected in the electronic health record (EHR) in a way that could facilitate observational research and population health management., Methods: In 2017 to 2018, we used data from an EHR-based SSB and fruit juice screener to study the association between consumption and weight status among children 6 months through 17 years of age. We used linear models to examine the cross-sectional association between sugary drinks and BMIz, adjusting for sex, age, race/ethnicity, clinic site, and encounter type. We also used separate mixed-effects models to examine the association of baseline consumption with ∆BMIz., Results: Our dataset included 22,291 children (15% <2 years; 23% 2-5 years; 34% 6-11 years; 28% 12-17 years) of diverse race/ethnicity (27% African American, 30% Hispanic). Sugary drink consumption was very common; 43% reported ≥2 per day. For children 6 to 17 years, greater consumption was associated cross sectionally with higher BMIz (eg, 6-11 years old children consuming ≥3/day had 0.27 (95% CI, 0.18, 0.36) higher BMIz vs those consuming <1/week). In longitudinal models, sugary drink consumption was related to ∆BMIz for children 2 to 5 at the highest reported levels of consumption (∆0.35 (0.04, 0.65) BMIz/year more for children consuming ≥3/day versus <1x/week). Larger increases in BMIz were seen for 6 to 17 year olds reporting consumption at or above 1x/day, versus <1x/week. No consistent cross-sectional or longitudinal associations were observed among children under 2., Conclusions: In our EHR-derived data, sugary drink consumption was most associated with high BMIz in school-aged children. Early childhood may be a critical period for intervening on sugary beverage consumption in obesity prevention efforts., (Copyright © 2019 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To identify predictors associated with specific family meal practices and weight talk among patients participating in weight management programs (WMPs) and weight loss surgery (WLS) and their children., Design: Cross-sectional survey., Setting: Two US weight management centers., Participants: 259 patients (aged ≥ 18 years) in either WMP (n = 101) or WLS (n = 158) and residing with a child (aged 2-18 years) MAIN OUTCOME MEASURE(S): Dependent variables: family meal practices (Project EAT) and weight talk (investigator-created). Covariates: family communication (Family Communication Scale), family discouragement for making eating habit change (Social Support for Eating Habits Survey), child age, sex, and perceived weight status, and WMP or WLS participation., Analysis: Binomial and ordinal regression models determined the odds of engaging in specific family meal practices and weight talk, including covariates., Results: Patients had increased odds of engaging in family dinners if they reported lower family discouragement (P = .003) and had younger children (P < .001), and increased odds of engaging in family breakfast if they had higher family communication (P = .002) and younger children (P = .020). Patients had increased odds of talking about their child's weight if their child was perceived to have an overweight/obese weight status (P < .001). Patients with older children had increased odds of talking about their weight with their child (P = .021)., Conclusions and Implications: Additional research assessing the family meal practices and weight talk in the families of adults pursuing weight loss could yield important evidence that could lead to improved patient outcomes, and safely promote healthy behaviors and prevention of obesity in children., (Published by Elsevier Inc.)

Objective: Spouses are known to influence the outcomes of an individual's attempt at weight loss, but little is known about the broader influence of, and on, the family. The objectives were to explore: (a) the effects of an adult weight management program on the family and (b) family factors that help or hinder patient weight loss., Methods: A qualitative design was employed to explore triadic family members' experiences of patient participation in a weight management program. Semi-structured interviews were conducted with patients, partners and children (ages 7-18). Questions included support for patient participation and weight loss, dietary choices, meal preparation, physical activity routines, the home-food environment, communication about health and family dynamics. Thematic analysis was used, where codes and categories of codes were then grouped together to create themes and subthemes., Results: Nineteen triadic interviews were conducted (57 total). Seven themes emerged, including four related to Outcomes (objective 1): (a) shift in family dynamics, (b) family behaviour change, (c) child observations of family change, (d) indirect benefit to partner; and three related to Process (objective 2): (e) level of accountability, (f) patient perception of support and (g) support is essential and flexible., Conclusions: Future research and clinical applications from these themes should seek to determine the positive behaviour change that was evident in the families that were interviewed, where the culmination of family interactions, expectations and concurrent partner weight loss indicates the potential longevity of weight management programs beyond patients' own participation., (© 2020 World Obesity Federation.)

Objective: Deposit contracts, where participants "bet" on achieving a goal and get their money back only if successful, have been shown to be effective for short-term weight-loss. This pilot study examined their effect on weight-loss maintenance., Methods: From 2016 to 2018, we conducted a pilot, 50-week randomized controlled trial among 42 hospital employees (19 intervention and 23 control), in Boston, Massachusetts, who lost ≥10 lb (4.5 kg) in the two years prior to enrollment. Participants were recruited primarily in-person. Both control and intervention participants were asked to attend a weigh in weekly and received weekly email communication. Intervention participants also entered into a deposit contract to maintain baseline weight within ≤2 lb (0.9 kg). We examined weight change from baseline to 50 weeks (primary outcome) and maintenance of baseline weight at 50 weeks (secondary outcome; binary - yes v. no). Participants completed baseline and follow-up surveys and received incentives for completion., Results: At baseline, mean (SD) weight was 83.2 (15.5 kg) among intervention and 80.7 (14.5 kg) among control participants. After 50 weeks, intervention participants had slightly less but non-significant weight gain (adjusted β -1.12 kg; 95% CI -5.28, 3.05) than control participants; 73.7% of intervention v. 39.1% of control participants met their weight-loss maintenance goal by study end (adjusted OR 4.78; 95% CI 1.01, 22.71)., Conclusions: A deposit contract was not associated with differences in weight but led to more participants meeting their weight-loss maintenance goals; a deposit contract for weight-loss maintenance should be tested in a full-scale intervention. Most intervention participants viewed the deposit contract as acceptable., (© 2020 Published by Elsevier Inc.)

Importance: There are few nationwide studies comparing the risk of reintervention after contemporary bariatric procedures., Objective: To compare the risk of intervention after Roux-en-Y gastric bypass (RYGB) vs vertical sleeve gastrectomy (VSG)., Design, Setting, and Participants: This cohort study used a nationwide US commercial insurance claims database. Adults aged 18 to 64 years who underwent a first RYGB or VSG procedure between January 1, 2010, and June 30, 2017, were matched on US region, year of surgery, most recent presurgery body mass index (BMI) category (based on diagnosis codes), and baseline type 2 diabetes. The prematch pool included 4496 patients undergoing RYGB and 8627 patients undergoing VSG, and the final weighted matched sample included 4476 patients undergoing RYGB and 8551 patients undergoing VSG., Exposures: Bariatric surgery procedure type (RYGB vs VSG)., Main Outcomes and Measures: The primary outcome was any abdominal operative intervention after the index procedure. Secondary outcomes included the following subtypes of operative intervention: biliary procedures, abdominal wall hernia repair, bariatric conversion or revision, and other abdominal operations. Nonoperative outcomes included endoscopy and enteral access. Time to first event was compared using multivariable Cox proportional hazards regression modeling., Results: Among 13 027 patients, the mean (SD) age was 44.4 (10.3) years, and 74.1% were female; 13.7% had a preoperative BMI between 30 and 39.9, 45.8% had a preoperative BMI between 40 and 49.9, and 24.2% had a preoperative BMI of at least 50. Patients were followed up for up to 4 years after surgery (median, 1.6 years; interquartile range, 0.7-3.2 years), with 41.9% having at least 2 years of follow-up and 16.3% having at least 4 years of follow-up. Patients undergoing VSG were less likely to have any subsequent operative intervention than matched patients undergoing RYGB (adjusted hazard ratio [aHR], 0.80; 95% CI, 0.72-0.89) and similarly were less likely to undergo biliary procedures (aHR, 0.77; 95% CI, 0.67-0.90), abdominal wall hernia repair (aHR, 0.60; 95% CI, 0.47-0.75), other abdominal operations (aHR, 0.71; 95% CI, 0.61-0.82), and endoscopy (aHR, 0.54; 95% CI, 0.49-0.59) or have enteral access placed (aHR, 0.58; 95% CI, 0.39-0.86). Patients undergoing VSG were more likely to undergo bariatric conversion or revision (aHR, 1.83; 95% CI, 1.19-2.80)., Conclusions and Relevance: In this nationwide study, patients undergoing VSG appeared to be less likely than matched patients undergoing RYGB to experience subsequent abdominal operative interventions, except for bariatric conversion or revision procedures. Patients considering bariatric surgery should be aware of the increased risk of subsequent procedures associated with RYGB vs VSG as part of shared decision-making around procedure choice.

Objective: This study aimed to investigate the association of metabolically healthy obesity (MHO) and other obesity phenotypes with electrocardiographic (ECG) markers to understand the pathophysiological basis of increased cardiovascular disease (CVD) risk associated with these phenotypes., Methods: A total of 3,700 participants (58.7 ± 13.6 years, 52% women) without CVD from the third National Health and Nutrition Examination Survey (NHANES III) were included. Logistic regression was used to examine the cross-sectional association between obesity phenotypes (metabolically healthy without obesity [MHNO; reference], metabolically unhealthy without obesity, MHO, and metabolically unhealthy obesity) with ECG markers (PR interval, P-wave duration, QRS duration, and QT interval)., Results: Higher odds of prolonged PR interval, P-wave duration, and QRS duration were observed among all phenotypes compared with MHNO, with the highest in participants with obesity with or without metabolic syndrome. However, for QT interval, the trend of association with obesity phenotypes was as follows, from the strongest to the least strong: metabolically unhealthy obesity, metabolically healthy without obesity, and then MHO, compared with MHNO., Conclusions: An association of obesity phenotypes with ECG abnormalities further raises doubt about the concept of MHO as a healthy state. Variations in associations with ECG markers may suggest that metabolic syndrome and obesity have a different relationship with different CVD outcomes and may explain some of the inconsistent CVD estimates for MHO., (© 2019 The Obesity Society.)

Background: Low-grade chronic inflammation, characterized by elevations in plasma Interleukin-6 (IL-6), is an independent risk factor of impaired mobility in older persons. Angiotensin receptor blockers and omega-3 polyunsaturated fatty acids (ω-3) may reduce IL-6 and may potentially improve physical function. To assess the main effects of the angiotensin receptor blocker losartan and ω-3 as fish oil on IL-6 and 400 m walking speed, we conducted the ENRGISE Pilot multicenter randomized clinical trial., Methods: The ENRGISE Pilot enrolled participants between April 2016 and June 2017, who participated for 12 months. Participants were aged ≥70 years with mobility impairment, had IL-6 between 2.5 and 30 pg/mL, and were able to walk 400 m at baseline. Participants were randomized in three strata 2 × 2 factorial to: (i) losartan 50-100 mg/d or placebo (n = 43), (ii) fish oil 1,400-2,800 mg/d or placebo (n = 180), and (iii) with both (n = 66)., Results: Two hundred eighty-nine participants were randomized (mean age 78.3 years, 47.4% women, 17.0% black). There was no effect of losartan (difference of means = -0.065 ± 0.116 [SE], 95% confidence interval [CI]: -0.293-0.163, p = .58) or fish oil (-0.020 ± 0.077, 95% CI: -0.171-0.132, p = .80) on the log of IL-6. Similarly, there was no effect of losartan (-0.025 ± 0.026, 95% CI: -0.076-0.026, p = .34) or fish oil (0.010 ± 0.017, 95% CI: -0.025-0.044, p = .58) on walking speed (m/s)., Conclusions: These results do not support the use of these interventions to prevent mobility loss in older adults at risk of disability with low-grade chronic inflammation., Registration: Clinicaltrials.gov NCT02676466., (© The Author(s) 2018. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: The aim of this work was to study weight loss and risk of cardiovascular disease (CVD) or death associated with longer-term phentermine use., Methods: Using electronic health record data, 13,972 adults were identified with a first phentermine fill in 2010 to 2015, creating exposure categories according to a patient's duration of use (referent: ≤ 3 months). Multivariable linear models were used to compare percent weight loss across categories at 6, 12, and 24 months, and Cox proportional hazards models were used to compare risk of composite CVD or death, up to 3 years after starting phentermine., Results: The cohort was 84% female and 45% white, with a mean (SD) baseline age 43.5 (10.7) years and BMI of 37.8 (7.2) kg/m 2 . In multivariable models, longer-term users of phentermine experienced more weight loss; patients using continuously for > 12 months lost 7.4% more than the referent group at 24 months (P < 0.001). The composite CVD or death outcome was rare (0.3%, 41 events), with no significant difference in hazard ratios between groups., Conclusions: Greater weight loss without increased risk of incident CVD or death was observed in patients using phentermine monotherapy for longer than 3 months. Despite the limitations of the observational design, this study supports the effectiveness and safety of longer-term phentermine use for low-risk individuals., (© 2019 The Obesity Society.)

Objective: The aim of this study was to test the effectiveness of the OPTIFAST program (OP), a total meal replacement dietary intervention, compared with a food-based (FB) dietary plan for weight loss., Methods: Participants with BMI 30 to 55 kg/m 2 , age 18 to 70 years old, were randomized to OP or FB dietary and lifestyle interventions for 26 weeks, followed by a weight-maintenance phase. Outcomes were percent change in body weight (%WL) from baseline to weeks 26 and 52, associated changes in body composition (using dual energy x-ray absorptiometry), and adverse events. Primary analysis used repeated-measures multivariable linear mixed models to compare outcomes between groups in a modified intention-to-treat fashion (mITT)., Results: A total of 273 participants (83% of randomized; 135 OP, 138 FB) made up the mITT population. Mean age was 47.1 ± 11.2 years; 82% were female and 71% non-Hispanic white. Baseline BMI was 38.8 ± 5.9 kg/m 2 . At 26 weeks, OP %WL was 12.4% ± 0.6% versus 6.0% ± 0.6% in FB (P < 0.001). At 52 weeks, OP %WL was 10.5% ± 0.6% versus 5.5% ± 0.6% in FB (P < 0.001). Fat mass loss was greater for OP; lean mass loss was proportional to total weight loss. There was no difference in serious adverse event rates between groups., Conclusions: Compared with an FB approach, OP was more effective with greater sustained weight loss., (© 2018 The Obesity Society.)

Background: Students live outside of their family homes for the first time in college and are expected to make their own decisions regarding dietary choices. College food environment could be a major determinant of dietary intake and is of importance in relation to obesity. This research determines the impact of removing cafeteria trays on student's food choice., Method: A quasi experimental pre-post research with control treatment was conducted in university dining halls. The participants were the dining hall patrons at a large public university in Southern US, spring 2015. The dining hall trays were removed from the intervened dining hall for five consecutive days during regular university session. Outcome measures of food choice were collected by observing tray waste before and after the tray removal in the intervened dining hall with parallel observation in the control dining hall. Difference-in-difference analysis was done to find the intervention effect., Results: A total of 3153 trays were observed ( N  = 1564 in control and N  = 1589 in intervention dining). Removal of trays resulted in a significant decrease in the total number of lunch plates (1.76 vs 1.66 servings, p  < .006), drink glasses (1.32 vs 1.02 servings, p  < .0001), dishes with leftovers (0.56 vs 0.39 serving, P  < .001), and lunch plates with leftovers (0.51 vs 0.35 servings, p  < .005)., Conclusions: Student food choices can be affected by removing trays from dining halls, specifically favoring fewer beverages, and without sacrificing salad consumption. Studies with more precise measures of tray waste are needed to understand the direct effect on energy and nutrient consumption., Competing Interests: The University’s IRB determined that this study did not represent research involving human subjects, because the research took place in a public setting without the collection of any individually-identifying information. Acknowledgements.Not applicable.The authors declare that they have no competing interest.Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Sugar-sweetened beverage (SSB) consumption is a risk factor for childhood obesity. Including this measure in electronic health records (EHR) could enhance clinical care and facilitate research on this topic. We implemented a single-item, EHR screening question for SSB and 100% fruit juice at 8 pediatric practices affiliated with a North Carolina academic medical center. From March-December 2017, we evaluated SSB screening of children 6 months-17 years of age. In a sub-sample of screened patients, we also conducted a telephone-based validation survey, comparing EHR-based responses to a lengthier beverage questionnaire, using Spearman rank coefficients and Kappa statistic. 22,626 children (91% of all seen) were screened for SSB intake. The screened population was diverse - 35% non-Hispanic White, 26% African-American, and 30% Hispanic. Consistent with national estimates, reported intake was typically higher than recommended: 41% (n = 9220) reported consuming SSB or fruit juice >1×/day in the past month, and consumption was higher among race/ethnic minorities. Of 201 validation survey respondents, direct correlation between their beverage survey and EHR screener responses was moderate, with a Spearman's rank correlation coefficient of 0.41 (p < 0.001) and Kappa statistic of 0.42 (95% CI 0.24-0.60). EHR-based screening for SSBs and fruit juice was successfully implemented, generating a large volume of SSB consumption data in a diverse patient population. Inclusion of patient-reported dietary measures in the EHR is feasible and could be useful for clinical care and research. Planned modifications may improve the correlation of such a screener with lengthier dietary instruments.

Objectives: To test two interventions to reduce interleukin (IL)-6 levels, an indicator of low-grade chronic inflammation and an independent risk factor for impaired mobility and slow walking speed in older adults., Design: The ENabling Reduction of low-Grade Inflammation in SEniors (ENRGISE) Pilot Study was a multicenter, double-blind, placebo-controlled randomized pilot trial of two interventions to reduce IL-6 levels., Setting: Five university-based research centers., Participants: Target enrollment was 300 men and women aged 70 and older with an average plasma IL-6 level between 2.5 and 30 pg/mL measured twice at least 1 week apart. Participants had low to moderate physical function, defined as self-reported difficulty walking one-quarter of a mile or climbing a flight of stairs and usual walk speed of less than 1 m/s on a 4-m usual-pace walk., Intervention: Participants were randomized to losartan, omega-3 fish oil (ω-3), combined losartan and ω-3, or placebo. Randomization was stratified depending on eligibility for each group. A titration schedule was implemented to reach a dose that was safe and effective for IL-6 reduction. Maximal doses were 100 mg/d for losartan and 2.8 g/d for ω-3., Measurements: IL-6, walking speed over 400 m, physical function (Short Physical Performance Battery), other inflammatory markers, safety, tolerability, frailty domains, and maximal leg strength were measured., Results: Results from the ENRGISE Pilot Study will provide recruitment yields, feasibility, medication tolerance and adherence, and preliminary data to help justify a sample size for a more definitive randomized trial., Conclusion: The ENRGISE Pilot Study will inform a larger subsequent trial that is expected to have important clinical and public health implications for the growing population of older adults with low-grade chronic inflammation and mobility limitations., (© 2017, Copyright the Authors Journal compilation © 2017, The American Geriatrics Society.)

Objective: To determine whether insurance coverage for medical weight loss treatment was associated with different program engagement and weight loss outcomes compared to those who paid out of pocket., Methods: One-year outcomes from an academic medical weight management program were used to compare two groups: employees (n = 480) with insurance coverage ("covered") versus nonemployees (n = 463) who paid out of pocket ("self-pay"). Demographics and weight were abstracted from medical records. Socioeconomic status was estimated using neighborhood demographics. Group differences in weight were analyzed using generalized linear modeling adjusted for age, baseline BMI, sex, program type, and neighborhood socioeconomic status., Results: Covered patients were younger (46.5 ± 10.6 vs. 51.6 ± 12.5) with a lower BMI (38.5 ± 7.5 vs. 41.3 ± 9.9) compared to self-pay (P < 0.001). Self-pay patients resided in higher annual per capita income neighborhoods (+$4,545, P < 0.001). Program dropout was lower for covered patients (12.7% vs. 17.6%, P = 0.03). There was no significant difference in 12-month weight loss between groups in adjusted models; covered patients lost 13.4%, compared to 13.6% for self-pay., Conclusions: Data from an academic medical weight management program suggest that individuals with access to insurance coverage for nonsurgical obesity treatment have lower levels of attrition and similar levels of participation and outcomes as those who pay out of pocket., (© 2017 The Obesity Society.)

Objective: To compare bariatric surgery outcomes according to preoperative mental illness category., Methods: Electronic health record data from several US healthcare systems were used to compare outcomes of four groups of patients who underwent bariatric surgery in 2012 and 2013. These included the following: people with (1) no mental illness, (2) mild-to-moderate depression or anxiety, (3) severe depression or anxiety, and (4) bipolar, psychosis, or schizophrenia spectrum disorders. Groups were compared on weight loss trajectory using generalized estimating equations using B-spline bases and on all-cause emergency department visits and hospital days using zero-inflated Poisson and negative binomial regression up to 2 years after surgery. Models were adjusted for demographic and health covariates, including baseline healthcare use., Results: Among 8,192 patients, mean age was 44.3 (10.7) years, 79.9% were female, and 45.6% were white. Fifty-seven percent had preoperative mental illness. There were no differences between groups for weight loss, but patients with preoperative severe depression or anxiety or bipolar, psychosis, or schizophrenia spectrum disorders had higher follow-up levels of emergency department visits and hospital days compared to those with no mental illness., Conclusions: In this multicenter study, mental illness was not associated with differential weight loss after bariatric surgery, but additional research could focus on reducing acute care use among these patients., (© 2017 The Obesity Society.)

Our objective was to compare patients' health care experiences, related to their weight, across racial and ethnic groups. In Summer 2015, we distributed a written survey with telephone follow-up to a random sample of 5400 racially/ethnically and geographically diverse U.S. adult health plan members with overweight or obesity. The survey assessed members' perceptions of their weight-related healthcare experiences, including their perception of their primary care provider, and the type of weight management services they had been offered, or were interested in. We used multivariable multinomial logistic regression to examine the relationship between race/ethnicity and responses to questions about care experience. Overall, 2811 members (53%) responded to the survey and we included 2725 with complete data in the analysis. Mean age was 52.7 years (SD 15.0), with 61.7% female and 48.3% from minority racial/ethnic groups. Mean BMI was 37.1 kg/m(2) (SD 8.0). Most (68.2%) respondents reported having previous discussions of weight with their provider, but interest in such counseling varied by race/ethnicity. Non-Hispanic blacks were significantly less likely to frequently avoid care (for fear of discussing weight/being weighed) than whites (OR 0.49, 95% CI 0.26-0.90). Relative to whites, respondents of other race/ethnicities were more likely to want weight-related discussions with their providers. Race/ethnicity correlates with patients' perception of discussions of weight in healthcare encounters. Clinicians should capitalize on opportunities to discuss weight loss with high-risk minority patients who may desire these conversations.