A Prospective Cohort of Alcohol Use and Alcohol-related Problems Before and After Metabolic and Bariatric Surgery in Adolescents.

OBJECTIVE: To describe alcohol use, alcohol-related harm, and alcohol-related problems preoperatively and up to 8 years following metabolic and bariatric surgery (MBS) in adolescents. BACKGROUND: Risk for alcohol use and alcohol use disorders (AUD) increases post-Roux-en-Y gastric bypass and vertical sleeve gastrectomy in adults. However, data are lacking in adolescents who undergo MBS. METHODS: This study includes 217 adolescents (aged 13-19 y) enrolled in a 5-center prospective cohort study who underwent Roux-en-Y gastric bypass or vertical sleeve gastrectomy (2007-2011) and reported alcohol use preoperatively and annually postoperatively for up to 8 years. Time to elevated Alcohol Use Disorder Identification Test-Consumption (AUDIT-C) score, alcohol-related harm, and alcohol-related problems were analyzed with Kaplan-Meier estimates of cumulative incidence. RESULTS: Preoperatively, the median age was 17 years; the median body mass index was 51 kg/m 2 . Alcohol use frequency and average quantity of drinks per drinking day increased postoperatively (2% consumed alcohol 2-4 times/month 6 months versus 24% 8 years postoperatively, P <0.001; 2% consumed≥3 drinks per drinking day 6 months versus 35% 8 years postoperatively, P <0.001). Cumulative incidence of postoperative onset elevated AUDIT-C score, alcohol-related harm, and alcohol-related problems at year 8 were 45% (95% CI:37-53), 43% (95% CI:36-51), and 47% (95% CI:40-55), respectively. CONCLUSIONS: Nearly half of those who underwent MBS as adolescents screened positively for AUD, symptoms of alcohol-related harm, or alcohol-related problems 8 years post-MBS, highlighting the risk for alcohol use and AUD after MBS in adolescents. AUD evaluation and treatment should be integrated into routine long-term care for adolescents undergoing MBS.

Effect of Surgical Versus Medical Therapy on Diabetic Kidney Disease Over 5 Years in Severely Obese Adolescents With Type 2 Diabetes.

OBJECTIVE: To compare diabetic kidney disease (DKD) rates over 5 years of follow-up in two cohorts of severely obese adolescents with type 2 diabetes (T2D) undergoing medical or surgical treatment for T2D. RESEARCH DESIGN AND METHODS: A secondary analysis was performed of data collected from obese participants of similar age and racial distribution enrolled in the Teen-Longitudinal Assessment of Bariatric Surgery (Teen-LABS) and the Treatment Options of Type 2 Diabetes in Adolescents and Youth (TODAY) studies. Teen-LABS participants underwent metabolic bariatric surgery (MBS). TODAY participants were randomized to metformin alone or in combination with rosiglitazone or intensive lifestyle intervention, with insulin therapy given for glycemic progression. Glycemic control, BMI, estimated glomerular filtration rate (eGFR), urinary albumin excretion (UAE), and prevalence of hyperfiltration (eGFR ≥135 mL/min/1.73 m2) and elevated UAE (≥30 mg/g) were assessed annually. RESULTS: Participants with T2D from Teen-LABS (n = 30, mean ± SD age, 16.9 ± 1.3 years; 70% female; 60% white; BMI 54.4 ± 9.5 kg/m2) and TODAY (n = 63, age 15.3 ± 1.3 years; 56% female; 71% white; BMI 40.5 ± 4.9 kg/m2) were compared. During 5 years of follow-up, hyperfiltration decreased from 21% to 18% in Teen-LABS and increased from 7% to 48% in TODAY. Elevated UAE decreased from 27% to 5% in Teen-LABS and increased from 21% to 43% in TODAY. Adjusting for baseline age, sex, BMI, and HbA1c, TODAY participants had a greater odds of hyperfiltration (odds ratio 15.7 [95% CI 2.6, 94.3]) and elevated UAE (27.3 [4.9, 149.9]) at 5 years of follow-up. CONCLUSIONS: Compared with MBS, medical treatment of obese youth with T2D was associated with a higher odds of DKD over 5 years.

Insulin Sensitivity and ß-Cell Function Improve after Gastric Bypass in Severely Obese Adolescents.

OBJECTIVE: To test the hypothesis that insulin secretion and insulin sensitivity would be improved in adolescents after Roux-en-Y gastric bypass (RYGB). STUDY DESIGN: A longitudinal study of 22 adolescents and young adults without diabetes undergoing laparoscopic RYGB (mean age 17.1 ± 1.42 years; range 14.5-20.1; male/female 8/14; Non-Hispanic White/African American 17/5) was conducted. Intravenous glucose tolerance tests were done to obtain insulin sensitivity (insulin sensitivity index), insulin secretion (acute insulin response to glucose ), and the disposition index as primary outcome variables. These variables were compared over the 1 year of observation using linear mixed modeling. RESULTS: In the 1-year following surgery, body mass index fell by 38% from a mean of 61 ± 12.3 to 39 ± 8.0 kg/m(2) (P < .01). Over the year following surgery, fasting glucose and insulin values declined by 54% and 63%, respectively. Insulin sensitivity index increased 300% (P < .01), acute insulin response to glucose decreased 56% (P < .01), leading to a nearly 2-fold increase in the disposition index (P < .01). Consistent with improved ß-cell function, the proinsulin to C-peptide ratio decreased by 21% (P < .01). CONCLUSIONS: RYGB reduced body mass index and improved both insulin sensitivity and ß-cell function in severely obese teens and young adults. These findings demonstrate that RYGB is associated with marked metabolic improvements in obese young people even as significant obesity persists. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00360373.

Severe obesity and comorbid condition impact on the weight-related quality of life of the adolescent patient.

OBJECTIVES: To assess links between comorbid health status, severe excess weight, and weight-related quality of life (WRQOL) in adolescents with severe obesity and undergoing weight-loss surgery (WLS) to inform clinical care. STUDY DESIGN: Baseline (preoperative) data from Teen Longitudinal Assessment of Bariatric Surgery, a prospective multicenter observational study of 242 adolescents with severe obesity (MedianBMI = 50.5 kg/m(2); Meanage = 17.1; 75.6% female; 71.9% white) undergoing WLS, were used to examine the impact of demographics, body mass index (BMI), presence/absence of 16 comorbid conditions, and a cumulative comorbidity load (CLoad) index on WRQOL scores (Impact of Weight on Quality of Life-Kids). RESULTS: WRQOL was significantly lower than reference samples of healthy weight, overweight, and obese samples. Of 16 comorbid conditions, the most prevalent were dyslipidemia (74.4%), chronic pain (58.3%), and obstructive sleep apnea (56.6%). Male subjects had a greater CLoad (P = .01) and BMI (P = .01), yet less impairment in total WRQOL (P < .01) than females. CLoad was a significant predictor of male WRQOL. For females, psychosocial (vs physical) comorbidities, BMI, and white race were significant predictors of WRQOL impairment. Less prevalent conditions (eg, stress urinary incontinence) also emerged as contributors to lower WRQOL. CONCLUSIONS: WRQOL impairment is substantial for adolescents with severe obesity undergoing WLS, with predictors varying by sex. These patient-data highlight targets for education, support, and adjunctive care referrals before WLS. Furthermore, they provide a comprehensive empirical base for understanding heterogeneity in adolescent WRQOL outcomes after WLS, as weight and comorbidity profiles change over time.

Baseline BMI is a strong predictor of nadir BMI after adolescent gastric bypass.

OBJECTIVE: Surgical treatment of extreme obesity may be appropriate for some adolescents. We hypothesized that surgical weight loss outcomes may differ by preoperative level of extreme obesity (body mass index [BMI] > or=99th percentile). STUDY DESIGN: A longitudinal assessment of clinical characteristics from 61 adolescents who underwent laparoscopic Roux-en-Y gastric bypass at a single pediatric center from 2002 until 2007 was performed. Patients were categorized into 1 of 3 preoperative BMI groups: group 1, BMI = 40.0 to 54.9 (n = 23); group 2, BMI = 55.0 to 64.9 (n = 21); group 3, BMI = 65.0 to 95.0 (n = 17). Changes in BMI and cardiovascular risk factors between baseline and year 1 were evaluated using repeated-measures mixed linear modeling. RESULTS: BMI in the overall cohort at baseline (60.2 +/- 11 kg/m(2)) decreased by 37.4% at 1 year after surgery (P < .001). Percent BMI change varied little by preoperative BMI groups (-37.2%, -36.8%, and -37.7% for groups 1, 2, and 3 respectively; P = .8762). The rate of change in absolute BMI units significantly varied by preoperative BMI class (group x time interaction, P < .0001), with 1-year nadir BMI values for groups 1, 2, and 3 falling to 31 +/- 4 kg/m(2), 38 +/- 5 kg/m(2), and 47 +/- 9 kg/m(2), respectively. One year after surgery, only 17% of patients achieved a nonobese BMI (<30 kg/m(2)). Significant improvements in systolic and diastolic blood pressure (P < .0001), fasting insulin (P < .0001), total cholesterol (P = .0007), and triglyceride levels (P < .0001) were seen after surgery irrespective of baseline BMI class. Mean albumin levels remained normal despite significant caloric restriction and weight loss. CONCLUSIONS: Laparoscopic gastric bypass resulted in improvement or reversal of cardiovascular risk factors and resulted in a decrease in BMI of approximately 37% in all patients, regardless of starting BMI, 1 year after surgery. The timing of surgery for adolescent extreme obesity is an important consideration, because "late" referral for bariatric surgery at the highest of BMI values may preclude reversal of obesity.

Obesity identified by discharge ICD-9 codes underestimates the true prevalence of obesity in hospitalized children.

OBJECTIVES: To define inpatient care of obese children with or without an obesity diagnosis. STUDY DESIGN: A total of 29,352 inpatient discharges (18,459 unique inpatients) from a tertiary children's hospital were analyzed. Body mass index (BMI) was calculated from measured height and weight. "Obesity" was defined as BMI >or=95th percentile by using Centers for Disease Control and Prevention 2000 growth charts. "Diagnosed obesity" was defined by primary, secondary or tertiary International Classification of Diseases, Ninth Revision codes for "obesity" or "overweight." Analyses controlled for multiple inpatient records per individual. RESULTS: A total of 5989 discharges from the hospital (20.4%) were associated with obesity, but only 512 discharges (1.7%) indicated obesity as a diagnosis. An obesity diagnosis identified only 5.5% of inpatient days for obese inpatients. Obese patients with an obesity diagnosis (Ob/Dx) had fewer hospital discharges per person and shorter lengths of stay than obese patients without an obesity diagnosis (Ob/No Dx). Patients with Ob/Dx had higher odds of mental health, endocrine, and musculoskeletal disorders than non-obese inpatients, but Ob/No Dx patients generally did not. CONCLUSIONS: Inpatient obesity diagnoses underestimate inpatient utilization and misidentify patterns of care for obese children. Extreme caution is warranted when using obesity diagnoses to study healthcare utilization by obese children.

Beriberi after gastric bypass surgery in adolescence.

We report three cases of dry beriberi in adolescents who underwent gastric bypass surgery for clinically severe obesity. The key to successful treatment of this problem lies in prompt recognition and thiamine supplementation.