[Evidence-based therapy guideline of the German Working Group on Obesity in Childhood and Adolescence]. / Evidenzbasierte Leitlinie der Arbeitsgemeinschaft Adipositas im Kindes- und Jugendalter zur Therapie der Adipositas im Kindes- und Jugendalter.

Obesity in childhood and adolescence has increased worldwide in recent years. A consensus guideline (S2) for treating obesity in childhood and adolescence in Germany was first published by the German Working Group on Obesity in Childhood and Adolescence (AGA) in 2000. The intention is to gradually replace this consensus-based (S2) guideline with an evidence-based (S3) guideline. Following a systematic literature search, 21 recommendations were predominantly approved with "strong consensus" (agreement >95%). Body weight and body fat mass can be significantly influenced by conventional behavior-based measures and also by the currently available drug therapies. However, the extent of the achieved weight reduction is small. Surgical measures (unproven, experimental therapy) to reduce body weight, in contrast, are very successful. In addition to the long version of this evidence-based guideline, an abbreviated version exists and a practice guideline is planned. This guideline should be further developed within the competence network on obesity of the German Federal Ministry of Education and Research. The guideline will be published in the scholarly journals of the professional associations concerned, will be available via the Internet, and will also be distributed through periodicals, congress events, and information at facilities.

[Practical implementation of treatment guidelines concerning obesity in children and adolescents]. / Praktische Umsetzungen von Therapieempfehlungen zur Adipositas bei Kindern und Jugendlichen.

Guidelines recommend a long-term outpatient lifestyle intervention in obese children and adolescents that also addresses the children's parents. However, lifestyle interventions are performed only in 1% of the 1,000,000 obese children and adolescents in Germany, suggesting a large gap between guidelines and medical care in real life. Possible reasons are a lacking awareness of the consequences of overweight, no time resources, and the lack of motivation to change lifestyle habits in some obese children and their families. Furthermore, there is no treatment option throughout Germany. The long-term success rate varies widely between outpatient treatment centers (<50% up to >70%), while the long-term effectiveness of short-term, inpatient intervention (rehabilitation) is unknown. However, many more obese children are treated by short-term rehabilitation compared to long-term outpatient intervention. Older and extreme obese children and adolescents are treated by lifestyle intervention, although this kind of intervention is more effective in younger and not so obese children. Some subgroups (extreme obese adolescents, obese disabled children) have no meaningful and effective treatment options.

[Evaluation of obesity treatment in children and adolescents (EvAKuJ Study). Role of therapeutic concept, certification, and quality indicators]. / Evaluation von Therapieangeboten für adipöse Kinder und Jugendliche (EvAKuJ-Projekt). Welche Rolle spielen Behandlungskonzept, AGA-Zertifizierung und initiale Qualitätsangaben?

AIM: Different providers of obesity treatment in children and adolescents in Germany were compared using the following criteria: outpatient/inpatient; with/without AGA certification; good/less good quality. METHODS: A total of 1,916 patients (8-16.9 years) from 48 study centers were examined before (t0), after (t1), and at least 1 year after therapy (t2/3). Body mass index (BMI), blood pressure, blood lipids, and psychosocial data were measured. RESULTS: Patients from inpatient rehabilitation centers were older and more obese. Patients from AGA-certified centers were more obese, and the completeness of comorbidity screening was higher. There were no differences in short- or long-term BMI reduction. "Good" treatment centers (classified after the UKE study 2004) did not differ from those centers not rated as "good" in weight reduction. Patients treated in "good" centers were more obese, and screening for comorbidity was better. No differences in drop out and loss to follow-up were found. CONCLUSION: There were only small differences between the different groups. Pronounced differences were found between the individual treatment centers. In order to improve therapy processes and outcomes, benchmarking and quality management have to be extended.

Standardization of Bariatric Metabolic Procedures: World Consensus Meeting Statement.

BACKGROUND: Standardization of the key measurements of a procedure's finished anatomic configuration strengthens surgical practice, research, and patient outcomes. A consensus meeting was organized to define standard versions of 25 bariatric metabolic procedures. METHODS: A panel of experts in bariatric metabolic surgery from multiple continents was invited to present technique descriptions and outcomes for 4 classic, or conventional, and 21 variant and emerging procedures. Expert panel and audience discussion was followed by electronic voting on proposed standard dimensions and volumes for each procedure's key anatomic alterations. Consensus was defined as ≥ 70% agreement. RESULTS: The Bariatric Metabolic Surgery Standardization World Consensus Meeting (BMSS-WOCOM) was convened March 22-24, 2018, in New Delhi, India. Discussion confirmed heterogeneity in procedure measurements in the literature. A set of anatomic measurements to serve as the standard version of each procedure was proposed. After two voting rounds, 22/25 (88.0%) configurations posed for consideration as procedure standards achieved voting consensus by the expert panel, 1 did not attain consensus, and 2 were not voted on. All configurations were voted on by ≥ 50% of 50 expert panelists. The Consensus Statement was developed from scientific evidence collated from presenters' slides and a separate literature review, meeting video, and transcripts. Review and input was provided by consensus panel members. CONCLUSIONS: Standard versions of the finished anatomic configurations of 22 surgical procedures were established by expert consensus. The BMSS process was undertaken as a first step in developing evidence-based standard bariatric metabolic surgical procedures with the aim of improving consistency in surgery, data collection, comparison of procedures, and outcome reporting.

Attitude Isn't the Only Thing, It's Everything: Humanistic Care of the Bariatric Patient Using Donabedian's Perspective on Quality of Care.

Comprehensive care of bariatric patients is challenging. Although structural knowledge exists about safe care given correct equipment and supplies, care processes also must be humane. The literature suggests morbidly obese patients may fear the health system because of past negative experiences. The purpose of this literature review was to examine quality issues in the care of bariatric patients in light of Donabedian's structure-process-outcomes model, emphasizing process components. Using the Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, and PsycINFO; the criteria English language and years 2005 to 2017; and the search terms morbid obesity, obesity, bariatric, attitudes, health professionals, health clinicians, and patient care yielded 150 articles. Of those, 35 were pertinent to the review. A subsequent search using the terms Donabedian, care, and quality in MEDLINE and CINAHL resulted in 68 and 36 citations, respectively; 4 were used. When the searches were combined, no articles were identified. Findings show care providers generally understand structure aspects (knowledge or what to do) but need increased understanding of optimal care interventions (process issues or how to perform an intervention), including physical and psychological aspects. Organizations have a responsibility to ensure appropriate equipment and supportive services are available to achieve desired outcomes. Structure components will not overcome barriers or prevent complications if uncaring attitudes (processes) interfere with interpersonal interactions. Implications for clinical practice include requisite reflection on personal belief systems and empathetic understanding of precursors to morbid obesity development. Research needs to analyze what process issues are hampering quality care delivery and how to eradicate deficiencies. Health professionals can promote optimal bariatric patient outcomes by developing necessary insight and clinical wisdom. Obesity is a worldwide epidemic and those affected deserve improved care now.

The history of metabolic and bariatric surgery: Development of standards for patient safety and efficacy.

Weight loss surgery, also referred to as bariatric surgery, has been in existence since the 1950's. Over the decades, it has been demonstrated to successfully achieve meaningful and sustainable weight loss in a large number of patients who undergo these procedures. Additionally, the benefits observed across a number of metabolic disorders such as type 2 diabetes mellitus and hyperlipidemia, are often to a degree, independent of the weight loss, thus the term "metabolic bariatric surgery (MBS)" has become a better descriptor. Throughout its long history, MBS has evolved from an era of high morbidity and mortality to one of laudable safety despite the high-risk nature of the patients undergoing these major gastrointestinal procedures. This article will describe the historic evolution of MBS and concentrate on those events that were instrumental in reducing the morbidity of these operations.

Bariatric operative reporting: Quality assessment and perceptions among bariatric surgeons.

BACKGROUND: The quality of narrative operative notes is poor. No investigation has previously addressed operative reporting specifically in bariatric surgery. OBJECTIVES: To evaluate surgeons' perceptions of the quality of operative reporting in bariatric surgery and compare this to an audit of Roux-en-Y gastric bypass (RYGB) narrative reports using validated quality indicators. SETTING: University hospital, Canada. METHODS: A Web-based survey was distributed to bariatric surgeons across Canada. Perceptions regarding the quality of reporting were gathered using a Likert scale (modified Structured Assessment Format for Evaluating Operative Reports) and free text fields. Forty RYGB narrative reports were analyzed against established quality indicators and compared to respondent's perceptions based on themes. RESULTS: Twenty-four of 34 bariatric surgeons (71%) completed the survey. The most commonly performed procedures were RYGB and sleeve gastrectomy (96% and 100%, respectively). Currently, 70.8% perform a traditional narrative report. The average Structured Assessment Format for Evaluating Operative Reports score for narrative dictations by bariatric surgeons was neutral (27.9/40). The lowest scoring items were the "description of indications" (2.9/5) and "succinctness" (3.3/5). Opinions reflected a need for an immediately generated, standardized, template-based report to improve the quality and accessibility of operative documentation. The quality audit reinforced respondents' perceptions. Reports included only 62.0%±6.6% of quality indicators, with the lowest scoring areas being "patient details," "preoperative events," and "postoperative details" (41.1%, 32.4%, and 31.7%, respectively). CONCLUSION: This survey revealed a perception of mediocre quality of narrative dictations. This was reinforced by an audit of RYGB operative reports. Future investigations should focus on improving this form of operative communication.

The prevention and treatment of obesity.

BACKGROUND: The high prevalence of obesity (24% of the adult population) and its adverse effects on health call for effective prevention and treatment. METHOD: Pertinent articles were retrieved by a systematic literature search for the period 2005 to 2012. A total of 4495 abstracts were examined. 119 publications were analyzed, and recommendations were issued in a structured consensus procedure by an interdisciplinary committee with the participation of ten medical specialty societies. RESULTS: Obesity (body-mass index [BMI] ge;30 kg/m2) is considered to be a chronic disease. Its prevention is especially important. For obese persons, it is recommended that a diet with an energy deficit of 500 kcal/day and a low energy density should be instituted for the purpose of weight loss and stabilization of a lower weight. The relative proportion of macronutrients is of secondary importance for weight loss. If the BMI exceeds 30 kg/m2, formula products can be used for a limited time. More physical exercise in everyday life and during leisure time promotes weight loss and improves risk factors and obesity-associated diseases. Behavior modification and behavioral therapy support changes in nutrition and exercise in everyday life. With respect to changes in lifestyle, there is no scientific evidence to support any particular order of the measures to be taken. Weight-loss programs whose efficacy has been scientifically evaluated are recommended. Surgical intervention is more effective than conservative treatment with respect to reduction of bodily fat, improvement of obesity-associated diseases, and lowering mortality. Controlled studies indicate that, within 1 to 2 years, a weight loss of ca. 4 to 6 kg can be achieved by dietary therapy, 2 to 3 kg by exercise therapy, and 20 to 40 kg by bariatric surgery. CONCLUSION: There is good scientific evidence for effective measures for the prevention and treatment of obesity.

Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient--2013 update: cosponsored by American Association of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery.

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re-evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type-2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE-TOS-ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.

Use of individual surgeon versus surgical team approach: surgical outcomes of laparoscopic Roux-en-Y gastric bypass in an Asian Medical Center.

BACKGROUND: Laparoscopic Roux-en-Y gastric bypass (LRYGB) has been shown to improve both the health and the quality of life of morbidly obese patients. We compared the efficacy and safety of using a team approach to LRYGB versus an individual surgeon at a medical center. METHODS: Data were collected from 200 consecutive patients undergoing LRYGB for morbid obesity from August 2005 to February 2008. Groups 1 and 2 included 50 patients each who underwent surgery and were cared for by the same surgeon. Group 3 included the next 100 consecutive patients, who underwent LRYGB by the same surgeon but who were cared for by a dedicated bariatric team. RESULTS: For the 76 men (38%) and 124 women (62%) in the study, the excess weight loss at 1 and 3 months of follow-up did not differ; however, it was significantly different at 6 and 12 months. At the mean follow-up period, 30% of group 1, 6% of group 2, and 8% of group 3 had experienced complications. Most complications in group 1 occurred early and were related to the surgical technique; however, in groups 2 and 3, the complications related to the technique were markedly reduced. Men were 4.57 times as likely as women to experience complications related to bariatric surgery. CONCLUSION: A team-based approach is a better option for patients undergoing LRYGB than care by a single surgeon. With an experienced bariatric surgeon, the team approach resulted in shorter operative times and shorter hospital stays, with the same rate of complications.

Creating a credential for bariatric behavioral health professionals: potential benefits, pitfalls, and provider opinion.

BACKGROUND: Since the 1991 recommendation by the National Institutes of Health-sponsored consensus development conference, preoperative psychosocial evaluation of weight loss surgery patients has been adopted by >80% of weight loss surgery programs. Although some published suggestions for conducting evaluations exist, no formal guidelines have been published specifying the qualifications, content knowledge, or clinical experience for the behavioral health professionals who conduct them. As a result, the backgrounds of behavioral health professionals working with bariatric surgery patients are varied, and no mechanism exists to ensure consistent quality of care. To obtain expert opinion on this issue, a survey of the American Society for Metabolic and Bariatric Surgery membership was conducted using an Internet-based survey. METHODS: American Society for Metabolic and Bariatric Surgery members of all disciplines were invited by electronic mail to complete an Internet-based survey. Separate forms were created for behavioral health providers and for members of other disciplines. RESULTS: A total of 409 American Society for Metabolic and Bariatric Surgery members responded (60 behavioral health and 349 nonbehavioral health). Of the 409 respondents, 95% indicated a belief that it is important for behavioral health providers to have specialty knowledge; 87% indicated a belief that specialty experience is important; and 70.6% favored the development of a specialty credential for bariatric behavioral health providers to regulate the quality of patient care. However, the respondents also reported concerns about creating such a credential. CONCLUSION: Our results reflect widespread opinion that the provision of bariatric behavioral health services requires specialty knowledge and experience and that a credentialing system would help regulate the standard of care in the field. However, some concerns about credential development remain.