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Concept: Bariatrics

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Background Long-term results from randomized, controlled trials that compare medical therapy with surgical therapy in patients with type 2 diabetes are limited. Methods We assessed outcomes 5 years after 150 patients who had type 2 diabetes and a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of 27 to 43 were randomly assigned to receive intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary outcome was a glycated hemoglobin level of 6.0% or less with or without the use of diabetes medications. Results Of the 150 patients who underwent randomization, 1 patient died during the 5-year follow-up period; 134 of the remaining 149 patients (90%) completed 5 years of follow-up. At baseline, the mean (±SD) age of the 134 patients was 49±8 years, 66% were women, the mean glycated hemoglobin level was 9.2±1.5%, and the mean BMI was 37±3.5. At 5 years, the criterion for the primary end point was met by 2 of 38 patients (5%) who received medical therapy alone, as compared with 14 of 49 patients (29%) who underwent gastric bypass (unadjusted P=0.01, adjusted P=0.03, P=0.08 in the intention-to-treat analysis) and 11 of 47 patients (23%) who underwent sleeve gastrectomy (unadjusted P=0.03, adjusted P=0.07, P=0.17 in the intention-to-treat analysis). Patients who underwent surgical procedures had a greater mean percentage reduction from baseline in glycated hemoglobin level than did patients who received medical therapy alone (2.1% vs. 0.3%, P=0.003). At 5 years, changes from baseline observed in the gastric-bypass and sleeve-gastrectomy groups were superior to the changes seen in the medical-therapy group with respect to body weight (-23%, -19%, and -5% in the gastric-bypass, sleeve-gastrectomy, and medical-therapy groups, respectively), triglyceride level (-40%, -29%, and -8%), high-density lipoprotein cholesterol level (32%, 30%, and 7%), use of insulin (-35%, -34%, and -13%), and quality-of-life measures (general health score increases of 17, 16, and 0.3; scores on the RAND 36-Item Health Survey ranged from 0 to 100, with higher scores indicating better health) (P<0.05 for all comparisons). No major late surgical complications were reported except for one reoperation. Conclusions Five-year outcome data showed that, among patients with type 2 diabetes and a BMI of 27 to 43, bariatric surgery plus intensive medical therapy was more effective than intensive medical therapy alone in decreasing, or in some cases resolving, hyperglycemia. (Funded by Ethicon Endo-Surgery and others; STAMPEDE ClinicalTrials.gov number, NCT00432809 .).

Concepts: Medicine, Diabetes mellitus, Obesity, Surgery, Body mass index, Bariatric surgery, Gastric bypass surgery, Bariatrics

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Roux-en-Y gastric bypass (RYGB) has greater efficacy for weight loss in obese patients than gastric banding (BAND) surgery. We hypothesise that this may result from different effects on food hedonics via physiological changes secondary to distinct gut anatomy manipulations.

Concepts: Obesity, Bariatric surgery, Gastric bypass surgery, Bariatrics, Duodenum, Surgical procedures, Beriberi, The Band

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Background Bariatric surgery is increasingly considered for the treatment of adolescents with severe obesity, but few prospective adolescent-specific studies examining the efficacy and safety of weight-loss surgery are available to support clinical decision making. Methods We prospectively enrolled 242 adolescents undergoing weight-loss surgery at five U.S. centers. Patients undergoing Roux-en-Y gastric bypass (161 participants) or sleeve gastrectomy (67) were included in the analysis. Changes in body weight, coexisting conditions, cardiometabolic risk factors, and weight-related quality of life and postoperative complications were evaluated through 3 years after the procedure. Results The mean (±SD) baseline age of the participants was 17±1.6 years, and the mean body-mass index (the weight in kilograms divided by the square of the height in meters) was 53; 75% of the participants were female, and 72% were white. At 3 years after the procedure, the mean weight had decreased by 27% (95% confidence interval [CI], 25 to 29) in the total cohort, by 28% (95% CI, 25 to 30) among participants who underwent gastric bypass, and by 26% (95% CI, 22 to 30) among those who underwent sleeve gastrectomy. By 3 years after the procedure, remission of type 2 diabetes occurred in 95% (95% CI, 85 to 100) of participants who had had the condition at baseline, remission of abnormal kidney function occurred in 86% (95% CI, 72 to 100), remission of prediabetes in 76% (95% CI, 56 to 97), remission of elevated blood pressure in 74% (95% CI, 64 to 84), and remission of dyslipidemia in 66% (95% CI, 57 to 74). Weight-related quality of life also improved significantly. However, at 3 years after the bariatric procedure, hypoferritinemia was found in 57% (95% CI, 50 to 65) of the participants, and 13% (95% CI, 9 to 18) of the participants had undergone one or more additional intraabdominal procedures. Conclusions In this multicenter, prospective study of bariatric surgery in adolescents, we found significant improvements in weight, cardiometabolic health, and weight-related quality of life at 3 years after the procedure. Risks associated with surgery included specific micronutrient deficiencies and the need for additional abdominal procedures. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; Teen-LABS ClinicalTrials.gov number, NCT00474318 .).

Concepts: Kidney, Nutrition, Hypertension, Obesity, Weight loss, Bariatric surgery, Gastric bypass surgery, Bariatrics

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Laparoscopic Roux-en-Y gastric bypass (LRYGB) is an effective treatment for morbid obesity, but might aggravate gastrointestinal complaints and food intolerance. The long-term prevalence of these symptoms has not been well studied.

Concepts: Nutrition, Obesity, Malnutrition, Bariatric surgery, Gastric bypass surgery, Bariatrics, Duodenum, Beriberi

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Bariatric surgery is currently the most effective procedure for the treatment of obesity. Given the role of the gut microbiota in regulating host metabolism and adiposity, we investigated the long-term effects of bariatric surgery on the microbiome of patients randomized to Roux-en-Y gastric bypass or vertical banded gastroplasty and matched for weight and fat mass loss. The two surgical procedures induced similar and durable changes on the gut microbiome that were not dependent on body mass index and resulted in altered levels of fecal and circulating metabolites compared with obese controls. By colonizing germ-free mice with stools from the patients, we demonstrated that the surgically altered microbiota promoted reduced fat deposition in recipient mice. These mice also had a lower respiratory quotient, indicating decreased utilization of carbohydrates as fuel. Our results suggest that the gut microbiota may play a direct role in the reduction of adiposity observed after bariatric surgery.

Concepts: Gut flora, Nutrition, Obesity, Surgery, Weight loss, Bariatric surgery, Gastric bypass surgery, Bariatrics

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Background In short-term randomized trials (duration, 1 to 2 years), bariatric surgery has been associated with improvement in type 2 diabetes mellitus. Methods We assessed outcomes 3 years after the randomization of 150 obese patients with uncontrolled type 2 diabetes to receive either intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy. The primary end point was a glycated hemoglobin level of 6.0% or less. Results The mean (±SD) age of the patients at baseline was 48±8 years, 68% were women, the mean baseline glycated hemoglobin level was 9.3±1.5%, and the mean baseline body-mass index (the weight in kilograms divided by the square of the height in meters) was 36.0±3.5. A total of 91% of the patients completed 36 months of follow-up. At 3 years, the criterion for the primary end point was met by 5% of the patients in the medical-therapy group, as compared with 38% of those in the gastric-bypass group (P<0.001) and 24% of those in the sleeve-gastrectomy group (P=0.01). The use of glucose-lowering medications, including insulin, was lower in the surgical groups than in the medical-therapy group. Patients in the surgical groups had greater mean percentage reductions in weight from baseline, with reductions of 24.5±9.1% in the gastric-bypass group and 21.1±8.9% in the sleeve-gastrectomy group, as compared with a reduction of 4.2±8.3% in the medical-therapy group (P<0.001 for both comparisons). Quality-of-life measures were significantly better in the two surgical groups than in the medical-therapy group. There were no major late surgical complications. Conclusions Among obese patients with uncontrolled type 2 diabetes, 3 years of intensive medical therapy plus bariatric surgery resulted in glycemic control in significantly more patients than did medical therapy alone. Analyses of secondary end points, including body weight, use of glucose-lowering medications, and quality of life, also showed favorable results at 3 years in the surgical groups, as compared with the group receiving medical therapy alone. (Funded by Ethicon and others; STAMPEDE ClinicalTrials.gov number, NCT00432809 .).

Concepts: Medicine, Insulin, Diabetes mellitus, Obesity, Surgery, Bariatric surgery, Gastric bypass surgery, Bariatrics

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This study aimed to use primary care electronic health records to evaluate the prevalence of overweight and obesity in 2-15-year-old children in England and compare trends over the last two decades.

Concepts: Cohort study, Epidemiology, Clinical trial, Nutrition, Obesity, Childhood, Body shape, Bariatrics

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Roux-en-Y gastric bypass and biliopancreatic diversion can markedly ameliorate diabetes in morbidly obese patients, often resulting in disease remission. Prospective, randomized trials comparing these procedures with medical therapy for the treatment of diabetes are needed.

Concepts: Medicine, Diabetes mellitus type 2, Diabetes mellitus, Obesity, Bariatric surgery, Gastric bypass surgery, Bariatrics, Duodenum

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An estimate of the lifetime medical costs of an obese child provides a benchmark of the potential per capita savings that could accrue from successful childhood obesity prevention efforts. We reviewed the literature to identify the best current estimate of the incremental lifetime per capita medical cost of an obese child in the United States today relative to a normal weight child.

Concepts: Nutrition, Diabetes mellitus, Obesity, United States, Childhood, Force, Bariatrics, Childhood obesity

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OBJECTIVES To analyze the effect of laparoscopic sleeve gastrectomy (LSG) on patients with gastroesophageal reflux disease (GERD) and to compare the results of LSG vs gastric bypass (GB) among patients with known GERD. DESIGN, SETTING, AND PATIENTS We performed a retrospective review of the Bariatric Outcomes Longitudinal Database from January 1, 2007, through December 31, 2010, including inpatient and all outpatient follow-up data. We compared patients undergoing LSG with a concurrent cohort undergoing GB. MAIN OUTCOMES AND MEASURES Rates of improvement or worsening of GERD symptoms, development of new-onset GERD, and weight loss and complications. RESULTS A total of 4832 patients underwent LSG and 33 867 underwent GB, with preexisting GERD present in 44.5% of the LSG cohort and 50.4% of the GB cohort. Most LSG patients (84.1%) continued to have GERD symptoms postoperatively, with only 15.9% demonstrating GERD resolution. Of LSG patients who did not demonstrate preoperative GERD, 8.6% developed GERD postoperatively. In comparison, GB resolved GERD in most patients (62.8%) within 6 months postoperatively (P < .001). Among the LSG cohort, the presence of preoperative GERD was associated with increased postoperative complications (15.1% vs 10.6%), gastrointestinal adverse events (6.9% vs 3.6%), and increased need for revisional surgery (0.6% vs 0.3%) (all P < .05). The presence of GERD had no effect on weight loss for the GB cohort but was associated with decreased weight loss in the LSG group. CONCLUSIONS AND RELEVANCE Laparoscopic sleeve gastrectomy did not reliably relieve or improve GERD symptoms and induced GERD in some previously asymptomatic patients. Preoperative GERD was associated with worse outcomes and decreased weight loss with LSG and may represent a relative contraindication.

Concepts: Obesity, Gastroesophageal reflux disease, Bariatric surgery, Bariatrics