Bariatric surgery in adolescents: What's the rationale? What's rational?

Abstract

Rates of obesity in adolescents continue to rise, and available lifestyle and pharmacological interventions have had limited success in reducing excess weight and risk for comorbid health issues. However, ongoing health risks, psychosocial issues, and increased risk of mortality place these adolescents in jeopardy and warrant ongoing investigation for available treatments. Bariatric surgery for adults has had positive medical and psychological outcomes. However, bariatric surgery is a relatively new option for adolescents. Initial findings suggest positive results for excess weight loss and psychosocial improvements, but not without possible risks. Selection of appropriate candidates is essential in the process, specifically considering developmental maturity, family support, and resultant disease burden without surgery. Surgery is not a panacea for the obesity epidemic. Outcome studies are limited and long-term results are unknown, but for extremely obese adolescents, bariatric surgery is promising and should be considered a viable option for appropriate adolescent candidates.     

Bariatric surgery in adolescents: what's the rationale? what's rational?

Rates of obesity in adolescents continue to rise, and available lifestyle and pharmacological interventions have had limited success in reducing excess weight and risk for comorbid health issues. However, ongoing health risks, psychosocial issues, and increased risk of mortality place these adolescents in jeopardy and warrant ongoing investigation for available treatments. Bariatric surgery for adults has had positive medical and psychological outcomes. However, bariatric surgery is a relatively new option for adolescents. Initial findings suggest positive results for excess weight loss and psychosocial improvements, but not without possible risks. Selection of appropriate candidates is essential in the process, specifically considering developmental maturity, family support, and resultant disease burden without surgery. Surgery is not a panacea for the obesity epidemic. Outcome studies are limited and long-term results are unknown, but for extremely obese adolescents, bariatric surgery is promising and should be considered a viable option for appropriate adolescent candidates.     

Bariatric Surgery Induces White and Grey Matter Density Recovery in the Morbidly Obese: A Voxel‐Based Morphometric Study

Obesity is associated with lowered brain's grey (GM) and white matter (WM) density as measured by voxel‐based morphometry (VBM). Nevertheless, it remains unknown whether obesity has a causal influence on cerebral atrophy. We recruited 47 morbidly obese subjects (mean BMI = 42.2, SD = 4.0, 42 females and five males) eligible for bariatric surgery and 29 non‐obese subjects (mean BMI = 23.2, SD = 2.8, 23 females and six males) served as controls. Baseline scans were acquired with T1‐weighted magnetic resonance imaging (MRI) at 1.5 Tesla; obese participants were scanned again six months after the surgery. Local GM and WM densities were quantified using VBM. Full‐volume analyses were used for comparing baseline between‐group differences as well as the effects of surgery‐induced weight loss in the morbidly obese. Metabolic variables were used in linear models to predict WM and GM densities. Obese subjects had initially lower GM densities in widespread cortical areas including frontal, parietal, and temporal regions as well as insulae. Lower WM densities were observed throughout the WM. Bariatric surgery and concomitant weight loss resulted in global increase in WM density. Grey matter increase was limited to occipital and inferior temporal regions. Metabolic variables were associated with brain densities. We conclude that weight loss results in global recovery of WM as well as local recovery of grey matter densities. These changes likely reflect improved brain tissue integrity. Hum Brain Mapp 37:3745–3756, 2016. © 2016 Wiley Periodicals, Inc.     

Do psychosocial factors predict weight loss following gastric surgery for obesity?

This study was undertaken to determine whether psychosocial factors determined during a pre-operative semi-structured psychiatric interview were associated either with the amount of weight loss following obesity surgery or with dropping out from follow-up after surgery. Multiple regression and discriminant function analysis of weight loss at six, twelve, twenty four and thirty six months showed no correlation between psychosocial variables and the amount of weight lost or with dropping out from follow-up. It is concluded that the type of psychiatric interview performed in this study does not yield information which reliably predicts weight loss after surgery for obesity.     

Underweight, obesity and exercise among adults with intellectual disabilities in supported accommodation in Northern England

Background Significant deviation from normal weight (obesity and underweight) and lack of physical exercise have been identified as three of the most significant global behavioural risks to health. Methods Body mass index (BMI) and levels of physical activity were measured in a sample of 1542 adults with intellectual disabilities (ID) receiving supported accommodation in nine geographical localities in Northern England. Comparative population data were extracted from the Health Survey for England 1998 and 2001. Results Men and women with ID living in supported accommodation are at increased risk of being significantly underweight and physically inactive. Women with ID living in supported accommodation are at increased risk of obesity. Within the population of people with ID living in supported accommodation increased behavioural health risks are associated with gender, severity of ID, age and location. Conclusion Significant deviation from normal weight and lack of physical exercise are significant behavioural risks to health among people with ID.     

Inflammation in obese children and adolescents: Association with psychosocial stress variables and effects of a lifestyle intervention

Obesity in childhood and adolescence is a complex health issue that has detrimental effects on the physical and psychological health of the youngster, both in the short and long term. A characteristic of obesity is the associated chronic low-grade inflammation which can result in insulin resistance. Previous research suggested that biomarkers referring to such increased inflammation may help in understanding resistance to weight loss. Whether and how psychosocial factors are related with inflammation remains to be proven. The current study consisted of 594 children and adolescents (7–19 years), of whom 480 had follow-up data, who enrolled for a ten-month inpatient multidisciplinary obesity treatment consisting of healthy food routines, physical activities and psychological treatment. The purpose of the study was to explore (1) the relationship between inflammation and psychosocial stress variables (i.e., depressive symptoms, eating behavior, concerns about eating/shape/weight, insecure parent-child attachment) (correlational and multiple regression analysis), (2) whether a lifestyle intervention for obese youngsters results in decreased C-reactive protein (CRP) values (paired t-test) and (3) which psychosocial variables influence this CRP change as indication of treatment success (multiple regression analysis with change in BMI as control variable). Results showed that the psychosocial stress variables emotional eating, external eating and attachment anxiety are related to higher CRP values. Our data further suggested that a lifestyle intervention decreases the CRP values. This significant reduction in blood inflammatory marker was besides being influenced by weight loss also dependent on psychosocial variables, more specific on self-reported attachment avoidance, as this latter was related to less CRP decrease.     

Psychological and social aspects of the surgical treatment of obesity

New surgical procedures have revolutionized the treatment of morbid obesity (more than 100% overweight), a condition associated with serious medical complications and for which conservative treatment has been largely ineffective. These procedures, which are surprisingly safe, produce large weight losses and marked improvement in hypertension, diabetes, and other disorders influenced by obesity. Striking changes also occur in vocational and psychosocial functioning, including marital and sexual relations, in eating behavior, in food preferences, and in body image. The emotional state of patients during weight loss following surgery is far superior to that during attempts at weight reduction by other methods. The surgical procedures appear to produce a major biological change, perhaps lowering a body weight set point.     

Mechanisms for the metabolic success of bariatric surgery

To date, bariatric surgery remains the most effective strategy for the treatment of obesity and its comorbidities. However, given the enormity of the obesity epidemic, and sometimes variable results, it is not a feasible strategy for the treatment of all obese patients. A simple PubMed search for ‘bariatric surgery' reveals over 28 000 papers that have been published since the 1940s when the first bariatric surgeries were performed. However, there is still an incomplete understanding of the mechanisms for the weight loss and metabolic success of surgery. An understanding of the mechanisms is important because it may lead to greater understanding of the pathophysiology of obesity and thus surgery‐alternative strategies for the treatment of all obese patients. In this review, the potential mechanisms that underlie the success of surgery are discussed, with a focus on the potential endocrine, neural and other circulatory factors (eg, bile acids) that have been proposed to play a role.     

Plasticity of gastrointestinal vagal afferent satiety signals

The vagal link between the gastrointestinal tract and the central nervous system (CNS) has numerous vital functions for maintaining homeostasis. The regulation of energy balance is one which is attracting more and more attention due to the potential for exploiting peripheral hormonal targets as treatments for conditions such as obesity. While physiologically, this system is well tuned and demonstrated to be effective in the regulation of both local function and promoting/terminating food intake the neural connection represents a susceptible pathway for disruption in various disease states. Numerous studies have revealed that obesity in particularly is associated with an array of modifications in vagal afferent function from changes in expression of signaling molecules to altered activation mechanics. In general, these changes in vagal afferent function in obesity further promote food intake instead of the more desirable reduction in food intake. It is essential to gain a comprehensive understanding of the mechanisms responsible for these detrimental effects before we can establish more effective pharmacotherapies or lifestyle strategies for the treatment of obesity and the maintenance of weight loss.     

Psychotherapie und Adipositas

One fifth of the German population is obese with increasing prevalence. Psychotherapy plays an important role in weight loss programmes. Cognitive behaviour therapy, targeting lifestyle changes, including exercise and eating behaviour, is the evidence-based treatment of choice. Especially the lack of motivation or absence of weight loss, further weight gain or psychosocial burden makes psychotherapy essential. The treatment of a comorbid binge eating disorder should be initiated prior to focusing on weight loss. Remarkably difficult stages in the treatment of obesity are the initiation of changes as well as the maintenance of the achieved weight loss. Internet-based attempts will become increasingly important.