Long-term changes in eating-related problems and quality of life in children with overweight and obesity attending a 10-week lifestyle camp.

BACKGROUND: Eating-related problems (e.g., binge eating (BE)) and impaired quality of life (QoL) is more prevalent in children with overweight and obesity. This study aimed to investigate changes in self-reported overeating (OE), BE, and QoL in children with overweight or obesity attending multicomponent 10-week lifestyle camps with a 52-weeks follow-up. Additionally, the study sought to investigate whether self-reported OE/BE before camp was associated with changes in QoL. METHODS: Children aged 7 to 14-years could attend camp if they had overweight/obesity, were lonely, unhappy, or had social or family-related problems. In this study only children with overweight and obesity were included (n:185). OE, BE, and QoL were measured using self-reported questionnaires. RESULTS: In total, 38 % of the children reported regular BE at baseline. Regular OE, occasional BE, and occasional OE was reported by 14 %, 13 %, and 11 %, respectively, while 24 % reported no eating-related problems. The relative risk of experiencing eating-related problems decreased at 10-weeks compared to baseline. Additionally, the probability of regular OE (RR 0.12 (95 % CI 0.04;0.38) (X2 = 8.44, p = 0.004)) and regular BE (RR 0.01 (95 % CI 0.00;0.11) (X2 = 9.91, p = 0.002)) remained lower at 52-weeks relative to baseline. All QoL dimensions improved after camp, and the presence of self-reported OE and regular BE at baseline was significantly associated with lower QoL at baseline, 10 and 52-weeks. CONCLUSION: Children self-reporting OE and BE may be a particular vulnerable group that needs more support from camp staff and healthcare professionals to improve QoL. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov with ID: NCT04522921.

Family screening for neurodevelopmental problems and its associations with child cognitive function enable tailored treatment for childhood obesity.

AIM: To identify neurodevelopmental disorders in children with obesity, and investigate associations to cognitive functions as well as parents' self-reported neurodevelopmental problems. METHODS: Eighty children were included at two outpatient obesity clinics in Sweden 2018-2019. Of these, 50 children without previously diagnosed neurodevelopmental disorders were screened, and so were their parents. Children who screened positive for neurodevelopmental problems were referred to a specialised psychiatry unit for further diagnosis. Test results of cognitive functioning were compared with the norm and between study groups by neurodevelopmental diagnoses. RESULTS: Of the screened families, 17/50 children were diagnosed by the psychiatric unit with attention deficit-hyperactivity disorder (ADHD) and 15/82 parents screened positive for neurodevelopmental problems. Having a mother who screened positive for neurodevelopmental problems was associated with child ADHD (p < 0.05). The children's full-scale intelligence quotient (92.86 ± 12.01, p < 0.001) and working memory index (90.62 ± 12.17, p < 0.001) were lower than the norm. Working memory index was lower in children with ADHD compared to without ADHD: 84.76 ± 9.58 versus 94.09 ± 12.29 (p ≤ 0.01). Executive constraints were associated with verbal deviances. CONCLUSION: Increased awareness is needed about the overlap between neurodevelopmental problems and obesity in obesity clinics.

Cognitive functioning in adolescents with severe obesity undergoing bariatric surgery or intensive non-surgical treatment in Sweden (AMOS2): a multicentre, open-label, randomised controlled trial.

Background: Severe obesity during childhood is associated with cognitive deficits. Studies in adults have suggested improvements in executive functioning and memory after bariatric surgery. Our aim was to explore changes in cognitive function in adolescents over two years after bariatric surgery or intensive non-surgical treatment. Methods: The Adolescent Morbid Obesity Surgery 2 (AMOS2) is a multicentre, open-label, randomised controlled trial in which adolescents (aged 13-16 years) with severe obesity (defined as body mass index (BMI) ≥35 kg/m2) at three specialised obesity centres in Sweden, were randomly assigned to receive bariatric surgery or intensive non-surgical treatment. Herein we report the results of the prespecified exploratory endpoint of change in cognitive functioning. Inclusion in AMOS2 required Tanner pubertal stage ≥3, previous participation in lifestyle obesity treatment for at least one year, and passed assessment form a paediatrician and a paediatric psychologist. Adolescents with severe intellectual disability or other severe, pervasive developmental disorder were excluded. Participants underwent baseline assessment of general intellectual ability, executive functioning, and memory before randomisation. Tests were administrated by clinical psychologists and repeated at one- and two-year follow-up timepoints. Differences in means between groups during follow-up are provided with confidence intervals. The trial is registered at ClinicalTrials.gov, NCT02378259. Findings: Between October 28 2015 and June 7 2017, 46 adolescents (74% girls), with a mean age of 15.8 (±0.92) years and a mean BMI of 42.8 (±5.4) kg/m2, were included and randomised (23 to bariatric surgery and 23 to intensive non-surgical treatment). At baseline 23/46 (50%) of the adolescents had general intellectual functioning classified as borderline or below. For 15/18 (83%) aspects of cognitive functioning, no significant differences in change over two years were identified between groups; Immediate (average difference during follow-up 1.0 [95% CI: -2.6 to 4.6]) and Delayed (0.5 [95% CI: -0.6 to 1.6]) Verbal Recall, Category Fluency (1.1 [95% CI: -1.6 to 3.8]) and Switching (1.5 [95% CI: -0.0 to 2.9]), Number (-6.0 [95% CI: -12.3 to 0.3]) and Letter (0.1 [95% CI: -5.2 to 5.3]) Sequencing, Number-Letter Switching (-10.3 [95% CI: -26.4 to 5.8]), Motor Speed (-8.3 [95% CI: -17.5 to 0.9]), Colour Naming (-1.9 [95% CI: -4.2 to 0.3]), Inhibition (-3.6 [95% CI: -9.6 to 2.5]), Inhibition Switching (-6.7 [95% CI: -15.3 to 1.9]), Mazes (-0.5 [95% CI: -4.9 to 3.9]), Digit Span Forward (0.1 [95% CI: -0.6 to 0.9 ]) and Backward (0.6 [95% CI: -0.4 to 1.6 ]), and Estimated IQ (0.4 [95% CI: -3.9 to 4.8]; all p > 0.05). Three sub-tests assessing fundamental cognitive skills improved more over two years in operated adolescents than in intensive non-surgical treatment; Letter Fluency (average difference during follow-up 3.8 [95% CI: 0.1-7.5]; p = 0.046), Visual Scanning (-6.5 [95% CI: -11.6 to -1.5]; p = 0.011), and Word Reading (-1.9 [95% CI: -3.3 to -0.4]; p = 0.011). Interpretation: In contrast to non-randomised studies in adults, we could not demonstrate an association of bariatric surgery and its accompanying significant weight loss with overall greater improvement in executive functions and memory in adolescents over two years compared with a non-surgical group without weight loss. However, lack of statistical power is a potential limitation. The clinical relevance of greater improvements in basic cognitive skills needs to be explored. Funding: Sweden's innovation agency (VINNOVA), Swedish Research Council, Joanna Cocozza foundation for paediatric research, The Skane University Hospital Psychology Research and Development Grant, Tore Nilsson's Foundation, SUS Foundations and Donations, and Mary von Sydow's Foundation.

'My goal was to become normal'-A qualitative investigation of coping with stigma, body image and self-esteem long-term after bariatric surgery.

Improved self-esteem and body image, as well as reduced experiences of weight stigma are important patient-reported obesity treatment outcomes. However, more knowledge is needed about how individuals who have undergone metabolic and bariatric surgery (MBS) perceive themselves and their bodies and use different coping strategies in relation to body image and self-esteem long-term after MBS. In this qualitative study body image, self-esteem, weight stigma and coping strategies were explored among 18 individuals who underwent MBS more than 10 years ago when interviewed. Using reflexive thematic analysis, two primary themes were identified: 'Experiences of living with a stigmatised body' and 'Coping with weight stigma, body image and self-esteem', and eight sub-themes. Findings capture frequent experiences of weight stigma before bariatric surgery, the need for coping with stigma and body dissatisfaction before and after MBS, and how different coping strategies are related to participants' perceptions of their bodies and self-concepts. More adaptive coping strategies, such as confrontation and cognitive restructuring may facilitate more positive body image outcomes, than more ruminative and avoidant strategies. Understanding adaptive coping strategies can be useful to develop interventions to reduce negative consequences of weight stigma on body image and self-esteem.

Systematic Development of National Guidelines for Obesity Care: The Swedish Approach.

INTRODUCTION: With the rapid development of treatment modalities for obesity management, there is an increasing demand for guidance to facilitate the prioritization of interventions. In 2020, the Swedish National Board of Health and Welfare started the process of producing the first national guidelines for obesity care directed to decision makers who allocate resources to the best knowledge-based care. The main aim of this paper was to describe the systematic development of these guidelines, designed to guarantee uniformly high standards of care throughout the whole country. METHODS: The standardized procedures of the National Board of Health and Welfare were applied to construct guidelines in a systematic and transparent way, including priority setting of recommendations and quality indicators to evaluate the progress of implementation. The process involved independent expert committees including professionals and patient representatives, and the guidelines were reviewed through an open public consultation. RESULTS: National guidelines were issued in 2023, encompassing a broad scope, from identification and diagnosis to multiple treatment modalities, embedded in a life-course perspective from pregnancy to the elderly, as well as highlighting the need for improved knowledge and competence of health care providers. CONCLUSIONS: National guidelines for improved standard care and evidence-based and efficient use of health care resources for obesity treatment can be developed in a systematic way with professionals and patient representatives.

Mental health from 5 years before to 10 years after bariatric surgery in adolescents with severe obesity: a Swedish nationwide cohort study with matched population controls.

BACKGROUND: The long-term effects of bariatric surgery on the mental health of adolescents with severe obesity remain uncertain. We aimed to describe the prevalence of psychiatric health-care visits and filled prescription psychiatric drugs among adolescents with severe obesity undergoing bariatric surgery in the 5 years preceding surgery and throughout the first 10 years after surgery, and to draw comparisons with matched adolescents in the general population. METHODS: Adolescents with severe obesity and who underwent bariatric surgery were identified through the Scandinavian Obesity Surgery Registry. We included adolescents who had bariatric surgery between 2007 and 2017 and were younger than 21 years at time of surgery. Each adolescent patient was matched with ten adolescents from the general population by age, sex, and county of residence. Specialist psychiatric care and filled psychiatric prescriptions were retrieved from nationwide data registers. FINDINGS: 1554 adolescents (<21 years) with severe obesity underwent bariatric surgery between 2007 and 2017, 1169 (75%) of whom were female. At time of surgery, the mean age was 19·0 years [SD 1·0], and the mean BMI was 43·7 kg/m2 (SD 5·5). 15 540 adolescents from the general population were matched with adolescents in the surgery group. 5 years before the matched index date, 95 (6·2%) of 1535 surgery patients and 370 (2·5%) of 14 643 matched adolescents had a psychiatric health-care visit (prevalence difference 3·7%; 95% CI 2·4-4·9), whereas 127 (9·8%) of 1295 surgery patients and 445 (3·6%) of 12 211 matched adolescents filled a psychiatric drug prescription (prevalence difference 6·2%; 95% CI 4·5-7·8). The year before the matched index date, 208 (13·4%) of 1551 surgery patients and 844 (5·5%) of 15 308 matched adolescents had a psychiatric health-care visit (prevalence difference 7·9%; 95% CI 6·2-9·6), whereas 319 (20·6%) of 1551 surgery patients and 1306 (8·5%) of 15 308 matched adolescents filled a psychiatric drug prescription (prevalence difference 12·0%; 10·0-14·1). The prevalence difference in psychiatric health-care visits peaked 9 years after the matched index date (12·0%; 95% CI 9·0-14·9), when 119 (17·6%) of 675 surgery patients and 377 (5·7%) of 6669 matched adolescents had a psychiatric health-care visit. The prevalence difference in filled psychiatric drug prescription was highest 10 years after the matched index date (20·4%; 15·9-24·9), when 171 (36·5%) of 469 surgery patients and 739 (16·0%) of 4607 matched adolescents filled a psychiatric drug prescription. The year before the matched index date, 19 (1·2%) of 1551 surgery patients and 155 (1·0%) of 15304 matched adolescents had a health-care visit associated with a substance use disorder diagnosis (mean difference 0·2%, 95% CI -0·4 to 0·8). 10 years after the matched index date, the prevalence difference had increased to 4·3% (95% CI 2·3-6·4), when 24 (5·1%) of 467 surgery patients and 37 (0·8%) of 4582 matched adolescents had a health-care visit associated with a substance use disorder diagnosis. INTERPRETATION: Psychiatric diagnoses and psychiatric drug prescriptions were more common among adolescents with severe obesity who would later undergo bariatric surgery than among matched adolescents from the general population. Both groups showed an increase in prevalence in psychiatric diagnoses and psychiatric drug prescriptions leading up to the time of surgery, but the rate of increase in the prevalence was higher among adolescents with severe obesity than among matched adolescents. With the exception of health-care visits for substance use disorders, these prevalence trajectories continued in the 10 years of follow-up. Realistic expectations regarding mental health outcomes should be set preoperatively. FUNDING: Swedish Research Council, Swedish Research Council for Health, Working Life and Welfare.

Long-term Outcomes Following Adolescent Metabolic and Bariatric Surgery.

Severe obesity in adolescence negatively impacts upon health and wellbeing. Lifestyle modifications do not usually achieve a sufficient degree or durability of weight loss to mitigate the risk of medical complications. In recent years, metabolic and bariatric surgery (MBS), already a well-established treatment for adults with severe obesity, has emerged as an option in adolescents. Controlled studies in this age group have demonstrated substantial and sustained weight loss, improvements in associated health parameters, and a safety profile surpassing that observed in adult patients. This review aims to present published data on the results of MBS in adolescents with a focus on long-term outcomes. Indications for bariatric surgery and aspects of timing in the young person's life are also presented, along with safety considerations and factors influencing patient selection for surgery. We conclude, predominantly from short- to medium-term outcomes data, that MBS is a safe and valuable therapeutic option for adolescents with severe obesity. Considering the poor health and social wellbeing prognosis in this group, MBS appears to be underutilized. The need for continued research, multiprofessional specialist provision, coherent contemporary clinical guidelines, and routine long-term follow-up in adolescents undergoing MBS is highlighted.

Metabolic and bariatric surgery versus intensive non-surgical treatment for adolescents with severe obesity (AMOS2): a multicentre, randomised, controlled trial in Sweden.

BACKGROUND: Severe obesity in adolescents has a profound impact on current and future health. Metabolic and bariatric surgery (MBS) is increasingly used in adolescents internationally. However, to our knowledge, there are no randomised trials examining the currently most used surgical techniques. Our aim was to evaluate changes in BMI and secondary health and safety outcomes after MBS. METHODS: The Adolescent Morbid Obesity Surgery 2 (AMOS2) study is a randomised, open-label, multicentre trial done at three university hospitals in Sweden (located in Stockholm, Gothenburg, and Malmö). Adolescents aged 13-16 years with a BMI of at least 35 kg/m2, who had attended treatment for obesity for at least 1 year, passed assessments from a paediatric psychologist and a paediatrician, and had a Tanner pubertal stage of at least 3, were randomly assigned (1:1) to MBS or intensive non-surgical treatment. Exclusion criteria included monogenic or syndromic obesity, major psychiatric illness, and regular self-induced vomiting. Computerised randomisation was stratified for sex and recruitment site. Allocation was concealed for both staff and participants until the end of the inclusion day, and then all participants were unmasked to treatment intervention. One group underwent MBS (primarily gastric bypass), while the other group received intensive non-surgical treatment starting with 8 weeks of low-calorie diet. The primary outcome was 2-year change in BMI, analysed as intention-to-treat. The trial is registered at ClinicalTrials.gov, NCT02378259. FINDINGS: 500 people were assessed for eligibility between Aug 27, 2014, and June 7, 2017. 450 participants were excluded (397 did not meet inclusion criteria, 39 declined to participate, and 14 were excluded for various other reasons). Of the 50 remaining participants, 25 (19 females and six males) were randomly assigned to receive MBS and 25 (18 females and seven males) were assigned to intensive non-surgical treatment. Three participants (6%; one in the MBS group and two in the intensive non-surgical treatment group) did not participate in the 2-year follow-up, and in total 47 (94%) participants were assessed for the primary endpoint. Mean age of participants was 15·8 years (SD 0·9) and mean BMI at baseline was 42·6 kg/m2 (SD 5·2). After 2 years, BMI change was -12·6 kg/m2 (-35·9 kg; n=24) among adolescents undergoing MBS (Roux-en-Y gastric bypass [n=23], sleeve gastrectomy [n=2]) and -0·2 kg/m2 (0·4 kg; [n=23]) among participants in the intensive non-surgical treatment group (mean difference -12·4 kg/m2 [95% CI -15·5 to -9·3]; p<0·0001). Five (20%) patients in the intensive non-surgical group crossed over to MBS during the second year. Adverse events (n=4) after MBS were mild but included one cholecystectomy. Regarding safety outcomes, surgical patients had a reduction in bone mineral density, while controls were unchanged after 2 years (z-score change mean difference -0·9 [95% CI -1·2 to -0·6]). There were no significant differences between the groups in vitamin and mineral levels, gastrointestinal symptoms (except less reflux in the surgical group), or in mental health at the 2-year follow-up. INTERPRETATION: MBS is an effective and well tolerated treatment for adolescents with severe obesity resulting in substantial weight loss and improvements in several aspects of metabolic health and physical quality of life over 2 years, and should be considered in adolescents with severe obesity. FUNDING: Sweden's Innovation Agency, Swedish Research Council Health.

Metabolic and Bariatric Surgery in Adolescents: For Whom, When, and How?

Severe obesity in adolescence profoundly impacts health and social well-being. Lifestyle modifications are seldom successful in maintaining sufficient weight loss to mitigate the risk of complications. Metabolic and bariatric surgery (MBS) is a standard treatment for adult patients and has emerged as an option for adolescent patients. Several high-quality studies of adolescent MBS show substantial and sustained improvements both in weight and cardiometabolic parameters, as well as a safety profile similar to that seen in adult patients. Patients report improvements in health- and weight-related quality of life. Concerns around adolescent MBS can be attributed to a fear of side effects on growth and puberty, risk of nutritional deficiencies and osteoporosis, alcohol abuse, psychosocial vulnerability, and the ability to consent in the decision process. Guidelines give somewhat different recommendations, but the most comprehensive guidelines from the American Society for Metabolic and Bariatric Surgery recommend MBS for class III obesity or class II obesity with comorbidity. This mini-review aimed to pre-sent published data on MBS in adolescents. We discuss indications for MBS and the optimal timing in the young person's life, the choice of surgical method, and MBS in relation to the new anti-obesity medications. Based on data primarily from the USA and Sweden, we conclude that MBS is a valuable treatment option for adolescents with severe obesity that appears underutilized against the backdrop of the poor prognosis of severe obesity. We argue for continued research, development of guidelines, multi-professional teamwork, long-term follow-up, and centralization of adolescent MBS.

Long-term changes in dietary intake and its association with eating-related problems after gastric bypass in adolescents.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) surgery is an established, effective treatment for severe adolescent obesity. Long-term dietary intake and the relationship to eating-related problems are scarcely evaluated in this population. OBJECTIVES: Assess changes in dietary intake in adolescents after RYGB and explore associations between dietary intake and eating-related problems. SETTING: Multicenter study in Swedish university hospitals. METHOD: Diet history, binge eating scale (BES), and Three-Factor Eating Questionnaire were assessed preoperatively and 1, 2, and 5 years after RYGB in 85 adolescents (67% female) aged 16.5 ± 1.2 years with a body mass index (BMI) of 45.5 ± 6.0 kg/m2 and compared with control individuals at 5 years. RESULTS: Five-year BMI change was -28.6% ± 12.7% versus +9.9% ± 18.9% in RYGB patients versus control individuals (P < .001). Through 5 years, RYGB adolescents reported reduced energy intake, portion size of cooked meals at dinner, and milk/yoghurt consumption (P < .01). The BES scores were 9.3 ± 8.3 versus 13.4 ± 10.5 in RYGB patients versus control individuals (P = .04). Association between BES score and energy intake was stronger in control individuals (r = .27 versus r = .62 in RYGB patients versus control individuals, P < .001). At 5 years, lower energy intake was associated with greater BMI loss in all adolescents (r = .33, P < .001). Higher scores in BES and uncontrolled and emotional eating were associated with higher energy intake, cooked meals, candies/chocolates, cakes/cookies, desserts, and sugary drinks (r > .23, P < .04) and lower intake of fruits/berries (r = -.32, P = .044). A higher score in cognitive restraint was associated with a higher intake of cereals and fruits/berries (r > .22, P < .05) and a lower intake of sugary drinks (r = -.24, P < .03). CONCLUSION: To support optimization of long-term outcomes in adolescent RYGB patients, it is important to provide management strategies to reduce energy intake. Monitoring eating-related problems could identify potential individuals at risk of poor weight loss and to initiate treatment interventions.

Patients' views of long-term results of bariatric surgery for super-obesity: sustained effects, but continuing struggles.

BACKGROUND: Bariatric surgery is a standard treatment for severe obesity, but little is known about patients' perceptions about the long-term impact of such surgery. OBJECTIVE: The aim of this study was to explore patients' experiences of living with a bariatric procedure for more than a decade. SETTING: University hospital. METHODS: At the 10-year follow-up after undergoing Roux-en-Y gastric bypass (RYGB) or biliopancreatic diversion with duodenal switch (BPD/DS), 18 consecutive patients from a previous randomized controlled trial were assessed with a semi-structured interview. Data were analyzed using thematic analysis. RESULTS: When asked to reflect broadly on their experiences of living with bariatric surgery for over a decade, the participants rarely mentioned procedure-specific issues and complications. Instead, their accounts revealed 2 broad themes: sustained effects after surgery, incorporating subthemes of better health, brighter futures, and better eating and weight regulation, and continuing struggles, including difficulties with physical activity, finding support, helping their children with overweight, and self-criticism. Many positive changes were sustained, but continuing personal struggles were similar to those presurgery. CONCLUSIONS: Participants expressed overall satisfaction with their bariatric surgery and related outcomes. Most participants acknowledged a continued effect on their appetite, which could be important information for patients who worry about a diminished effect after the first year postsurgery. Participants were prone to self-blame when things did not turn out the way they wanted. Therefore, healthcare providers must build a trustful relationship with their patients, so they will not hesitate to return when they face problems such as weight gain.

High prevalence of neurodevelopmental problems in adolescents eligible for bariatric surgery for severe obesity.

AIM: To assess the prevalence of neurodevelopmental problems in adolescents with severe obesity and their associations with binge eating and depression. METHODS: Data were collected at inclusion in a randomised study of bariatric surgery in 48 adolescents (73% girls; mean age 15.7 ± 1.0 years; mean body mass index 42.6 ± 5.2 kg/m2 ). Parents completed questionnaires assessing their adolescents' symptoms of attention-deficit/hyperactivity disorder and autism spectrum disorder and reported earlier diagnoses. Patients answered self-report questionnaires on binge eating and depressive symptoms. RESULTS: The parents of 26/48 adolescents (54%) reported scores above cut-off for symptoms of the targeted disorders in their adolescents, but only 15% reported a diagnosis, 32% of adolescents reported binge eating, and 20% reported symptoms of clinical depression. No significant associations were found between neurodevelopmental problems and binge eating or depressive symptoms. Only a third of the adolescents reported no problems in either area. CONCLUSION: Two thirds of adolescents seeking surgical weight loss presented with substantial mental health problems (reported by themselves or their parents). This illustrates the importance of a multi-professional approach and the need to screen for and treat mental health disorders in adolescents with obesity.

Depression, anxiety, and suicidal ideation in young adults 5 years after undergoing bariatric surgery as adolescents.

PURPOSE: Metabolic and bariatric surgery (MBS) is increasingly used in adolescents. The aim was to explore symptoms of depression and anxiety in young adults over 5 years' follow-up after undergoing MBS. METHODS: Beck Depression Inventory-2 and the Beck Anxiety Inventory were used to assess symptoms of depression and anxiety in 62 patients 1, 2, and 5 years after having Roux-en-Y gastric bypass at 13-18 years of age. Mental health, eating-related problems, and weight outcomes were tested for association with suicidal ideation at the 5-year follow-up. RESULTS: At the 5-year follow-up, the mean score for depression was 11.4 (± 12.4), indicating minimal symptoms of depression. The mean score for anxiety was 12.82 (± 11.50), indicating mild anxiety symptoms. Still, several participants reported moderate or severe symptoms of depression (26%) and anxiety (32%). Women reported more symptoms than men (P = 0.03 and 0.04). No significant changes were found in self-reported symptoms of depression and anxiety between the 1-year and the 5-year follow-up (P = 0.367 and 0.934). Suicidal ideation was reported by 16% at the 5-year follow-up. Participants reporting suicidal ideation had lost significantly less excess weight than participants without suicidal ideation (P = 0.009). CONCLUSION: Five years after adolescent MBS, a substantial minority still struggles with mental health issues, and women are more burdened than men. Our results indicate an association between less optimal weight loss and suicidal ideation 5 years after MBS. The findings emphasize the importance of offering long-term follow-up and mental health treatment several years after MBS. LEVEL OF EVIDENCE: Level III, cohort study. CLINICAL TRIAL REGISTRATION: The study is registered with ClinicalTrials.gov (NCT00289705). First posted February 10, 2006.

A randomized controlled trial comparing intensive non-surgical treatment with bariatric surgery in adolescents aged 13-16 years (AMOS2): Rationale, study design, and patient recruitment.

BACKGROUND: Previous non-randomized studies show similar outcomes in adolescents and adults after bariatric surgery. We describe the study protocol, recruitment, and selected baseline data of patients in a randomized multi-center study, the Adolescent Morbid Obesity Surgery 2 (AMOS2). METHODS: Three clinics in Sweden collaborated in designing the study and recruitment of patients from August 1, 2014 to June 30, 2017. Patients were selected among adolescents 13-16 years of age attending third-level obesity care for at least one year. Patients were randomized 1:1 to bariatric surgery (predominantly Roux-en-Y gastric bypass) or intensive non-surgical treatment starting with an eight-week low-calorie-diet. RESULTS: Fifty adolescents (37 girls) were randomized, 25 (19 girls) to bariatric surgery. Mean age was 15.7 years (range 13.3-16.9), weight 122.6 kg (range 95-183.3), Body Mass Index (BMI) 42.6 kg/m2 (range 35.7-54.9) and BMI-SDS 3.45 (range 2.9-4.1). One patient had type 2 diabetes mellitus, and 12/45 (27%) had elevated liver enzymes. There were no significant differences between the groups. For the 39 eligible patients who were offered but declined inclusion, BMI was not different from included patients. However, patients who declined were younger, 15.2 years (p = 0.021). A sex difference was also noted with more of eligible girls, 37/53 (69.8%), than boys, 13/36 (36.1%), wanting to participate in the study (p = 0.002). CONCLUSIONS: This clinical trial, randomizing adolescents with severe obesity to bariatric surgery or intensive non-surgical treatment, aims at informing about whether it is beneficial to undergo bariatric surgery in early adolescence. It will also enlighten the outcome of comprehensive non-surgical treatment. The study was registered at www.clinicalTrials.gov number NCT02378259.

Three decades of increase in health anxiety: Systematic review and meta-analysis of birth cohort changes in university student samples from 1985 to 2017.

Health anxiety can be defined as a multifaceted trait that is primarily characterised by a fear of, or preoccupation with, serious illness. Whereas low levels of health anxiety can be helpful, clinically significant levels are associated with personal suffering and substantial societal costs. As general anxiety is probably on the rise, and the Internet has increased access to health-related information, it is commonly speculated that health anxiety has increased over the past decades. We tested this hypothesis based on a systematic review and meta-analysis of birth cohort mean health anxiety in Western university student samples from 1985 to 2017. Sixty-eight studies with 22 413 student participants were included. The primary analysis indicated that the mean score on the Illness Attitudes Scales had increased by 4.61 points (95 % CI: 1.02, 8.20) from 1985 to 2017. The percentage of general population Internet users in the study year of data collection was not predictive of student mean health anxiety. In conclusion, this study corroborates the hypothesis of an increase in health anxiety, at least in the student population, over the past decades. However, this increase could not be linked to the introduction of the Internet.

5-year mental health and eating pattern outcomes following bariatric surgery in adolescents: a prospective cohort study.

BACKGROUND: Mental health problems are prevalent among adolescents with severe obesity, but long-term mental health outcomes after adolescent bariatric surgery are not well known. We aimed to assess mental health outcomes over 5 years of follow-up after Roux-en-Y gastric bypass surgery in adolescents who participated in the Adolescent Morbid Obesity Surgery (AMOS) study. METHODS: This was a non-randomised matched-control study in adolescents aged 13-18 years who had a BMI of 40 kg/m2 or higher, or 35 kg/m2 or higher in addition to obesity-related comorbidity; who had previously undergone failed comprehensive conservative treatment; and were of pubertal Tanner stage III or higher, with height growth velocity beyond peak. A contemporary control group, matched for BMI, age, and sex, who underwent conventional obesity treatment, was obtained from the Swedish Childhood Obesity Treatment Register. Data on dispensed psychiatric drugs and specialist treatment for mental disorders were retrieved from national registers with complete coverage. In the surgical group only, questionnaires were used to assess self-esteem (Rosenberg Self-Esteem [RSE] score), mood (Mood Adjective Checklist [MACL]), and eating patterns (Binge Eating Scale [BES] and Three-Factor Eating Questionnaire-R21 [TFEQ]). This study is registered with ClinicalTrials.gov (NCT00289705). FINDINGS: Between April 10, 2006, and May 20, 2009, 81 adolescents (53 [65%] female) underwent Roux-en-Y gastric bypass surgery, and 80 control participants received conventional treatment. The proportion of participants prescribed psychiatric drugs did not differ between groups in the years before study inclusion (pre-baseline; absolute risk difference 5% [95% CI -7 to 16], p=0·4263) or after intervention (10% [-6 to 24], p=0·2175). Treatment for mental and behavioural disorders did not differ between groups before baseline (2% [-10 to 14], p=0·7135); however, adolescents in the surgical group had more specialised psychiatric treatment in the 5 years after obesity treatment than did the control group (15% [1 to 28], p=0·0410). There were few patients who discontinued psychiatric treatment post-surgery (three [4%] receiving psychiatric drug treatment and six [7%] receiving specialised care for a mental disorder before surgery). In the surgical group, self-esteem (RSE score) was improved after 5 years (mixed model mean 21·6 [95% CI 19·9 to 23·4]) relative to baseline (18·9 [17·4 to 20·4], p=0·0059), but overall mood (MACL score) was not (2·8 [2·7 to 2·9] at 5 years vs 2·7 [2·6 to 2·8] at baseline, p=0·0737). Binge eating was improved at 5 years (9·3 [7·4 to 11·2]) relative to baseline (15·0 [13·5 to 16·5], p<0·0001). Relative changes in BMI were not associated with the presence or absence of binge eating at baseline. INTERPRETATION: Mental health problems persist in adolescents 5 years after bariatric surgery despite substantial weight loss. Although bariatric surgery can improve many aspects of health, alleviation of mental health problems should not be expected, and a multidisciplinary bariatric team should offer long-term mental health support after surgery. FUNDING: Swedish Research Council, VINNOVA, Västra Götalandsregionen, ALF VG-region, Region Stockholm, Swedish Child Diabetes Foundation, Swedish Heart and Lung Foundation, Tore Nilsson's Foundation, SUS Foundations and Donations, Capio Research Foundation, and Mary von Sydow's Foundation.

Binge eating and other eating-related problems in adolescents undergoing gastric bypass: results from a Swedish nationwide study (AMOS).

Bariatric surgery is established as a treatment option for adolescents with severe obesity. Little is known about binge eating (BE) and other eating-related problems in adolescents undergoing bariatric surgery. BE, emotional eating, uncontrolled eating, and cognitive restraint were assessed at baseline, and one and two years after gastric bypass using questionnaires in 82 adolescents (mean age 16.9 years, 67% girls). BE was assessed with the Binge Eating Scale (BES) and other eating-related problems with the Three Factor Eating Questionnaire. Change in eating-related problems over time, along with the relationship between eating behaviors and other aspects of mental health and weight outcome, were analyzed. At baseline, 37% of the adolescents reported BE (defined as a BES score >17). Two years after gastric bypass, adolescents reported less problems related to BE, emotional eating, and uncontrolled eating. Improvements were moderate to large. Adolescents reporting BE at baseline also reported more general mental health and psychosocial weight-related problems before and/or two years after surgery, compared to adolescents with no BE. After surgery adolescents with BE before surgery reported more suicidal ideation than those with no BE at baseline. None of the eating-related problems assessed at baseline was associated with weight outcome after surgery. More binge eating, emotional eating, and uncontrolled eating two years after surgery were associated with less weight loss. In conclusion, eating-related problems were substantially reduced in adolescents after undergoing gastric bypass. However, pre-operative BE seem to be associated with general mental health problems before and two years after surgery, including suicidal ideation. Pre-operative eating-related problems did not affect weight outcome, and our results support existing guidance that BE should not be considered an exclusion criterion for bariatric surgery in adolescents.

Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study.

BACKGROUND: Severe obesity in adolescence is associated with reduced life expectancy and impaired quality of life. Long-term benefits of conservative treatments in adolescents are known to be modest, whereas short-term outcomes of adolescent bariatric surgery are promising. We aimed to compare 5-year outcomes of adolescent surgical patients after Roux-en-Y gastric bypass with those of conservatively treated adolescents and of adults undergoing Roux-en-Y gastric bypass, in the Adolescent Morbid Obesity Surgery (AMOS) study. METHODS: We did a nationwide, prospective, non-randomised controlled study of adolescents (aged 13-18 years) with severe obesity undergoing Roux-en-Y gastric bypass at three specialised paediatric obesity treatment centres in Sweden. We compared clinical outcomes in adolescent surgical patients with those of matched adolescent controls undergoing conservative treatment and of adult controls undergoing Roux-en-Y gastric bypass. The primary outcome measure was change in BMI over 5 years. We used multilevel mixed-effect regression models to assess longitudinal changes. This trial is registered with ClinicalTrials.gov, number NCT00289705. FINDINGS: Between April, 2006, and May, 2009, 100 adolescents were recruited to the study, of whom 81 underwent Roux-en-Y gastric bypass (mean age 16·5 years [SD 1·2], bodyweight 132·8 kg [22·1], and BMI 45·5 kg/m2 [SD 6·1]). 80 matched adolescent controls and 81 matched adult controls were enrolled for comparison of outcomes. The change in bodyweight in adolescent surgical patients over 5 years was -36·8 kg (95% CI -40·9 to -32·8), resulting in a reduction in BMI of -13·1 kg/m2 (95% CI -14·5 to -11·8), although weight loss less than 10% occurred in nine (11%). Mean BMI rose in adolescent controls (3·3 kg/m2, 95% CI 1·1-4·8) over the 5-year study period, whereas the BMI change in adult controls was similar to that in adolescent surgical patients (mean change -12·3 kg/m2, 95% CI -13·7 to -10·9). Comorbidities and cardiovascular risk factors in adolescent surgical patients showed improvement over 5 years and compared favourably with those in adolescent controls. 20 (25%) of 81 adolescent surgical patients underwent additional abdominal surgery for complications of surgery or rapid weight loss and 58 (72%) showed some type of nutritional deficiency; health-care consumption (hospital attendances and admissions) was higher in adolescent surgical patients compared with adolescent controls. 20 (25%) of 81 adolescent controls underwent bariatric surgery during the 5-year follow-up. INTERPRETATION: Adolescents with severe obesity undergoing Roux-en-Y gastric bypass had substantial weight loss over 5 years, alongside improvements in comorbidities and risk factors. However, gastric bypass was associated with additional surgical interventions and nutritional deficiencies. Conventional non-surgical treatment was associated with weight gain and a quarter of patients had bariatric surgery within 5 years. FUNDING: Swedish Research Council; Swedish Governmental Agency for Innovation Systems; National Board of Health and Welfare; Swedish Heart and Lung Foundation; Swedish Childhood Diabetes Foundation; Swedish Order of Freemasons Children's Foundation; Stockholm County Council; Västra Götaland Region; Mrs Mary von Sydow Foundation; Stiftelsen Göteborgs Barnhus; Stiftelsen Allmänna Barnhuset; and the US National Institute of Diabetes, Digestive, and Kidney Diseases (National Institutes of Health).