Role of Adverse Childhood Experiences in the Onset of Overweight/Obesity.

PURPOSE OF REVIEW: The goal of this chapter was to summarize the literature on childhood adversity and obesity, discuss treatment implications with a case example, and provide recommendations for trauma-informed care for clinicians who work with individuals living with obesity. RECENT FINDINGS: Adversity in childhood is related directly and indirectly to obesity development. Upstream contributors like adverse childhood experiences (ACEs) and other factors can lead to experiences of toxic stress and increased allostatic load, resulting in downstream effects of obesity and other chronic health conditions. A well-established literature has linked ACEs and obesity suggesting complex interactions between genetic, biological, behavioral, mental health, social, and environmental factors and obesity. Trauma-informed care strategies can be used to optimize care for individuals living with obesity. Care pathways should include individual (clinician) and systemic (organizational) evidence-based interventions.

Bariatric surgery outcomes in patients with bipolar or schizoaffective disorders.

BACKGROUND: Obesity is associated with many co-morbidities and can cause harm to physical and mental well-being. While much has been studied in the general population about the outcomes of bariatric surgery, its implications in patients with bipolar/schizoaffective disorder (BSD) are less well understood. OBJECTIVE: We aimed to describe outcomes of bariatric surgery in patients with BSD. SETTING: Referral center for bariatric surgery. METHODS: We conducted a retrospective chart review analysis of bariatric surgical procedures in patients with BSD between 2008 and 2021 at Mayo Clinic. Patients with BSD (cases) were matched via propensity score matching (1:2) with non-BSD controls based on surgical procedure, age, sex, body mass index, and type 2 diabetes. Hierarchical logistic regression model was performed using SAS software. RESULTS: We matched 71 patients with BSD with 142 controls in a 1:2 ratio. After adjusting for baseline preoperative weight, patients with BSD had a 3.4% greater total weight loss compared with controls over 24 months (P = .02 [95% CI, .65-6.08]). Remission in obesity-related diseases, such as diabetes, hypertension, dyslipidemia, and sleep apnea, was similar in both groups. Perioperative complication rates were similar other than deep venous thrombosis, which showed a higher rate in patients with BSD (P = .04). Patients with long-term BSD were at increased risk of alcohol use compared with controls. CONCLUSIONS: When compared with the general bariatric population, weight loss was similar to slightly improved, with a comparable risk and complication profile. Patients with BSD have increased alcohol use after bariatric surgery, highlighting the need for psychological care before and after surgery in this population.

Phenotype tailored lifestyle intervention on weight loss and cardiometabolic risk factors in adults with obesity: a single-centre, non-randomised, proof-of-concept study.

Background: Lifestyle interventions for weight loss are currently not individualised to underlying pathophysiology and behavioral traits in obesity. We aim to compare the outcome of a standard lifestyle intervention (SLI) to phenotype-tailored lifestyle interventions (PLI) on weight loss, cardiometabolic risk factors and physiologic variables contributing to obesity. Methods: This 12-week, single-centre non-randomised proof-of-concept clinical trial including men and women aged 18-65 years with a body mass index (BMI) greater than 30 without history of any bariatric procedure, and current use of any medication known to affect weight. Participants lived anywhere in the United States, and underwent in-person testing in Rochester, MN at a teaching hospital. All participants completed in-person phenotype testing at baseline and after 12 weeks. Participants were assigned to their intervention based on their period of enrollment. In the first phase, participants were assigned to SLI with a low-calorie diet (LCD), moderate physical activity, and weekly behavioral therapy sessions. In the second phase, other participants were assigned to PLI according to phenotype: abnormal satiation (time-restricted volumetric LCD); abnormal postprandial satiety (LCD with pre-meal protein supplementation); emotional eating (LCD with intensive behavioral therapy); and abnormal resting energy expenditure (LCD with post-workout protein supplementation and high-intensity interval training). The primary outcome was total body weight loss in kg at 12 weeks using multiple imputation for missing data. Linear models estimated the association of study group allocation and study endpoints adjusting for age, sex, and baseline weight. This study was registered with ClinicalTrials.gov, NCT04073394. Findings: Between July 2020 and August 2021, 211 participants were screened, and 165 were assigned to one of the two treatments in the two phases: 81 SLI (mean [SD] age 42.9 [12] years; 79% women; BMI 38.0 [6.0]) and 84 PLI (age 44.8 [12.2] years; 83% women; BMI 38.7 [6.9]); 146 completed the 12-week programs. The weight loss was -7.4 kg (95%CI, -8.8, -6.0) with PLI vs. -4.3 kg (95%CI, -5.8, -2.7) with SLI (difference, -3.1 kg [95%CI, -5.1 to -1.1]; P = 0.004). No adverse events were reported in any group. Interpretation: Phenotype-tailored lifestyle interventions may result in significant weight loss, but a randomised controlled trial is required to confirm causality. Funding: Mayo Clinic; NIH (K23-DK114460).

Guiding Kidney Transplantation Candidates for Effective Weight Loss: A Clinical Cohort Study.

Background: Obesity is increasingly common in kidney transplant candidates and may limit access to transplantation. Obesity and diabetes are associated with a high risk for post-transplant complications. The best approach to weight loss to facilitate active transplant listing is unknown, but bariatric surgery is rarely considered due to patient- and physician-related apprehension, among other factors. Methods: We aimed to determine the magnitude of weight loss, listing, and transplant rates in 28 candidates with a mean BMI of 44.4±4.6 kg/m2 and diabetes treated conservatively for 1 year post weight-loss consultations (group 1). Additionally, we evaluated 15 patients (group 2) who met the inclusion criteria but received bariatric intervention within the same time frame. All patients completed a multidisciplinary weight management consultation with at least 1 year of follow-up. Results: In the conservatively managed group (group 1), the mean weight at the time of initial consultation was 126.5±18.5 kg, and the mean BMI was 44.4±4.6 kg/m2. At 1 year post weight-loss consultation, the mean weight decreased by 4.4±8.2 kg to 122.9±17 kg, and the mean BMI was 43±4.8 kg/m2, with a total mean body weight decrease of 3% (P=0.01). Eighteen patients (64%) did not progress to become candidates for active listing/transplantation during the follow-up time of 4±2.9 years, with 15 (54%) subsequently developing renal failure/diabetes-related comorbidities prohibitive for transplantation. In contrast, mean total body weight decreased by 19% at 6 months post bariatric surgery, and the mean BMI was 34.2±4 and 32.5±3.7 kg/m2 at 6 and 12 months, respectively. Bariatric surgery was strongly associated with subsequent kidney transplantation (HR=8.39 [95% CI 1.71 to 41.19]; P=0.009). Conclusions: A conservative weight-loss approach involving multidisciplinary consultation was ineffective in most kidney transplant candidates with diabetes, suggesting that a more proactive approach is needed.

Effectiveness of anti-obesity medications approved for long-term use in a multidisciplinary weight management program: a multi-center clinical experience.

BACKGROUND AND AIMS: Randomized clinical trials have proven the efficacy and safety of Food and Drug Administration (FDA) approved anti-obesity medications (AOMs) for long-term use. It is unclear whether these outcomes can be replicated in real-world clinical practice where clinical complexities arise. The aim of this study was to evaluate the effectiveness and side effects of these medications in real-world multidisciplinary clinical practice settings. METHODS: We reviewed the electronic medical records (EMR) of patients with obesity who were prescribed an FDA-approved AOM for long-term use in academic and community multidisciplinary weight loss programs between January 2016 and January 2020. INTERVENTION: We assessed percentage total body weight loss (%TBWL), metabolic outcomes, and side effect profile up to 24 months after AOM initiation. RESULTS: The full cohort consisted of 304 patients (76% women, 95.2% White, median age of 50 years old [IQR, 39-58]). The median follow-up time was 9.1 months [IQR, 4.2-14.1] with a median number of 3 visits [IQR, 2-4]. The most prescribed medication was phentermine/topiramate extended-release (ER) (51%), followed by liraglutide (26.3%), bupropion/naltrexone sustained-release (SR) (16.5%), and lorcaserin (6.2%). %TBWL was 5.0%, 6.8%, 9.3%, 10.3%, and 10.5% at 3, 6, 12, 18, and 24 months. 60.2% of the entire cohort achieved at least 5% TBWL. Overall, phentermine/topiramate-ER had the most robust weight loss response during follow-up, with the highest %TBWL at 12 months of 12.0%. Adverse events were reported in 22.4% of patients. Only 9% of patients discontinued the medication due to side effects. CONCLUSIONS: AOMs resulted in significant long-term weight loss, that was comparable to outcomes previously reported in clinical trials.

Association between anxiety and eating behaviors in patients with obesity.

Background: Given the link between eating behavior and obesity, it is critical to identify individuals who have eating behaviors which contribute to obesity etiology. This study aimed to investigate the potential relationship between symptoms of anxiety and eating behaviors in patients with obesity. Methods: This was a cross-sectional study analyzing baseline characteristics of 438 patients with obesity (BMI>30). Patients completed the Hospital Anxiety and Depression Scale (HADS) questionnaire, the Three-Factor Eating Questionnaire R21 (TFEQ-R21), and the Weight Efficacy Lifestyle Questionnaire (WEL). Pearson correlation coefficients were used to evaluate the association between questionnaires. Two-sample independent t-test were conducted to examine differences in the TFEQ-R21 and WEL between low and moderate to severe levels of symptoms of anxiety. Results: Anxiety scores (HADS-A) positively correlated with two factors of the TFEQ, emotional eating (r = 0.36) and uncontrolled eating (r = 0.27). The HADS-A score was negatively correlated with self-efficacy to resist eating in all five situational factors on the WEL (p < 0.01). Patients with symptoms of anxiety additionally showed higher mean scores for emotional eating and uncontrolled eating (p < 0.001, respectively),and lower levels of cognitive restraint (p = 0.04)) on the TFEQ-R21. Conclusion: Patients with obesity who reported having anxiety symptoms had lower self-confidence to manage their eating and more emotional eating than patients with low anxiety symptoms. Clearly more needs to be learned about symtoms of anxiety and eating behaviors.

Liver Transplantation After Bariatric Surgery: a Clinical Cohort Study.

PURPOSE: Individuals that undergo bariatric surgery are at higher risk for problematic alcohol use via pharmacokinetic changes in alcohol metabolism and cross addictions. Little data exists regarding post-bariatric surgery patients with alcohol-related liver disease (ALD) who ultimately require liver transplantation. The aim of this project was to better understand demographic, medical, and psychological characteristics of post-bariatric surgery patients who undergo liver transplantation due to ALD. METHODS: This retrospective clinical cohort identified 1416 patients who underwent ALD liver transplantation over a 10-year timespan at three academic medical centers. Electronic medical records were reviewed for patient characteristics, including sex, age, body mass index, surgery dates, Model for End Stage Liver Disease (MELD) scores, medical history, psychiatric history, and mortality rates. RESULTS: Within the sample of liver transplantation patients, 1.3% had undergone bariatric surgery prior to transplantation. Fifty percent of the post-bariatric surgery sample was female. The MELD score was higher and the median age at transplantation was younger in the post-bariatric surgery subgroup in comparison to that in the non-bariatric surgery patients. Mood and anxiety disorders were more common among those with a history of having bariatric surgery, with major depressive disorder having the largest difference between subgroups. CONCLUSIONS: Among patients who require a liver transplantation due to ALD, those with a history of bariatric surgery are more likely to be female, younger, and diagnosed with mood disorders. Further studies with larger and more diverse samples are necessary to better understand how to prevent development of alcohol use disorder in the bariatric surgery population.

Efficacy and Safety of Endoscopic Balloon Placement for Weight Loss in Patients With Cirrhosis Awaiting Liver Transplantation.

The efficacy and safety of a fluid-filled intragastric balloon (IGB) for weight loss in patients with cirrhosis on the liver transplantation (LT) waiting list is unknown. We enrolled stable compensated patients with body mass index >35 kg/m2 and on the waiting list for IGB placement endoscopically for a maximum of 6 months. A total of 8 patients (7 men) aged mean ± SD, 56 ± 4.6 years with Model for End-Stage Liver Disease-sodium (MELD-Na) scores 14.1 ± 3.4 experienced weight reduction (146 ± 22.2 kg versus 127 ± 21.6 kg [P = 0.005] with IGB in place and 130 ± 24.6 kg [P = 0.014] at 6 months), with a total body weight loss of 12.2% ± 8.8% with IGBs in place and 10.9% ± 8.9% at 6 months. Body fat decreased from 48.6% ± 5.8% to 40.6% ± 6.4% (P = 0.001) and lean mass increased from 51.3% ± 6% to 59.4% ± 6.4% (P = 0.001). No change in MELD-Na scores occurred (P = 0.770). Early balloon retrieval was attributed to accommodative symptoms (n = 2) and liver decompensation (n = 1). Mallory Weiss tears (n = 3), but no portal hypertensive bleeding, occurred. Liver decompensation and/or hepatocellular carcinoma (HCC) developed in 3 patients. A total of 4 patients with LT ± sleeve gastrectomy maintained overall weight loss. Of 4 patients who did not receive transplants, 2 experienced weight regain. IGB results in short-term weight loss in patients with cirrhosis awaiting LT, with body fat loss without lean mass loss. Adverse effects were common. Decompensation and HCC did occur, with uncertainty of the relation to weight loss, and thus careful patient selection and close follow-up are required.

Cannabis use and bariatric surgery psychology practice: survey and insights.

BACKGROUND: Cannabis is second only to alcohol as a substance of abuse and dependence in the United States. While there is extensive research examining alcohol use and bariatric surgery, there is currently little research and there are no published guidelines specific to cannabis use and bariatric surgery. OBJECTIVES: To identify major themes and general guidelines applied by bariatric surgery psychology clinicians. SETTING: This practice survey was disseminated to bariatric surgery psychologists at various U.S. academic medical centers, hospitals, and private practices. METHODS: An electronic, 35-question survey was sent to 47 bariatric surgery psychologists to collect information on current clinical practice guidelines regarding cannabis use before and after bariatric surgery. RESULTS: The survey questionnaire was completed by 34 (72.34%) bariatric surgery psychologists. The major identified themes included: (1) the lack of a standardized assessment of cannabis use; (2) a requirement for 3 months of abstinence from cannabis before bariatric surgery; (3) recommended lifetime abstinence from cannabis after bariatric surgery; and (4) discussion of cannabis use risks following bariatric surgery, including appetite stimulation, addiction potential, and possible negative impacts on judgment. CONCLUSION: Cannabis use will likely further increase in the United States. This survey highlighted common bariatric surgery psychology practices in the absence of extensive research and published guidelines. These findings suggest a preliminary framework with which to address cannabis use in patients seeking bariatric surgery. It is recommended that professional organizations and societies build on these initial survey findings to develop guidelines for more consistent, evidence-based practice regarding cannabis use and bariatric surgery.

Validation of the Yale Food Addiction Scale 2.0 in Patients Seeking Bariatric Surgery.

BACKGROUND: The Yale Food Addiction Scale (YFAS) was developed in 2009 to assess food addiction (FA); a revised version was released in 2016 (YFAS 2.0). The objective of this study was to determine the statistical and clinical validity of the YFAS 2.0 in adults seeking bariatric surgery. METHODS: Patients who underwent a preoperative psychological evaluation in preparation for bariatric surgery from 2015 to 2018 were included. The YFAS 2.0 was administered as part of routine clinical care and validated against an assessment battery of standardized clinical measures. Statistical analyses included chi-square and Wilcoxon rank sum tests and calculation of Spearman's rank correlation coefficients. RESULTS: Overall, 1061 patients were included. Mean age and BMI were 47.5 ± 12.9 years and 46.9 ± 13.4 kg/m2, respectively. There were 196 (18%) patients who screened positive on the YFAS 2.0 (21% mild, 23% moderate, and 56% severe FA). The YFAS 2.0 demonstrated strong convergent validity where patients who met criteria for FA had significantly increased levels of binge eating (p < 0.001), emotional eating (p < 0.001), and lower self-efficacy (p < 0.001). Discriminant validity was demonstrated by lack of association with alcohol use (p = 0.319). The YFAS 2.0 was significantly correlated with total scores for depression (p < 0.001), anxiety (p < 0.001), bipolar disorder symptoms (p < 0.001), and trauma history (p < 0.001). CONCLUSIONS: The prevalence of FA in a large sample of patients seeking bariatric surgery was consistent with previous literature. These data suggest that the YFAS 2.0 is psychometrically valid, demonstrating strong construct validity, and is a clinically useful measure of FA severity in patients pursuing bariatric surgery.

Intragastric Balloon Placement Induces Significant Metabolic and Histologic Improvement in Patients With Nonalcoholic Steatohepatitis.

BACKGROUND & AIMS: Obese patients with nonalcoholic steatohepatitis (NASH) are at risk for cirrhosis if significant weight loss is not achieved. The single fluid-filled intragastric balloon (IGB) induces meaningful weight loss and might be used in NASH treatment. We performed an open-label prospective study to evaluate the effects of IGB placement on metabolic and histologic features of NASH. METHODS: Twenty-one patients with early hepatic fibrosis (81% female; mean age, 54 years; average body mass index, 44 kg/m2) underwent magnetic resonance elastography (MRE) and endoscopic ultrasound with core liver biopsy collection at time IGB placement and removal at a single center from October 2016 through March 2018. The primary outcome measure was the changes in liver histology parameters after IGB, including change in nonalcoholic fatty liver disease activity score (NAS) and fibrosis score. We also evaluated changes in weight, body mass index, waist to hip ratio, aminotransaminases, fasting levels of lipids, fasting glucose, glycosylated hemoglobin, and MRE-detected liver stiffness. RESULTS: Six months after IGB, patients' mean total body weight loss was 11.7% ± 7.7%, with significant reductions in HbA1c (1.3% ± 0.5%) (P = .02). Waist circumference decreased by 14.4 ± 2.2 cm (P = .001). NAS improved in 18 of 20 patients (90%), with a median decrease of 3 points (range, 1-4 points); 16 of 20 patients (80%) had improvements of 2 points or more. Fibrosis improved by 1.17 stages in 15% of patients, and MRE-detected fibrosis improved by 1.5 stages in 10 of 20 patients (50%). Half of patients reached endpoints approved by the Food and Drug Administration of for NASH resolution and fibrosis improvement. Percent total body weight loss did not correlate with reductions in NAS or fibrosis. Other than post-procedural pain (in 5% of patients), no serious adverse events were reported. CONCLUSION: In a prospective study, IGB facilitated significant metabolic and histologic improvements in NASH. IGB appears to be safe and effective for NASH management when combined with a prescribed diet and exercise program. ClinicalTrials.gov no: NCT02880189.

Symptoms of bipolar disorder are associated with lower bariatric surgery completion rates and higher food addiction.

BACKGROUND: Bipolar disorder (BP) is highly comorbid with obesity, however, little is known about how BP might be associated with bariatric surgery outcomes. METHODS: In this retrospective clinical cohort study, 1034 patients completed a psychological evaluation, and screening positive for possible BP was defined as a score ≥7 and moderate disability on the Mood Disorders Questionnaire. Food addiction (FA), subthreshold binge eating disorder (BED), and illegal drug use were also assessed using standardized questionnaires. RESULTS: The 54 (5.2%) patients screening positive for BP were less likely to have bariatric surgery compared to 980 (94.8%) patients who screened negative for BP (5 patients or 9.3% vs 273 patients, or 27.9%). Patients with possible BP also had significantly higher prevalence of FA (37% vs 13.2%), subthreshold BED (29.6% vs 8.3%) and illegal drug use (7.4% vs 2.1%). CONCLUSIONS: In this retrospective clinical cohort study, patients who screened positive for BP had a higher prevalence of food addiction, subthreshold binge eating disorder and recent illegal drug use. They also demonstrated lower completion rates for having bariatric surgery. Clearly, more needs to be learned about how to help patients with symptoms of bipolar disorder manage their obesity and behavioral challenges.

Rethinking Patient and Medical Professional Perspectives on Bariatric Surgery as a Medically Necessary Treatment.

The prevalence of class 3 obesity (body mass index ≥40 kg/m2) is 7.7% of the United States adult population; thus, more than 25 million people may be medically appropriate for consideration of bariatric surgery as therapy for severe obesity. Although bariatric surgery is the most effective therapy for patients with severe obesity, the surgery is performed in less than 1% of patients annually for whom it may be appropriate. Patients' and medical professionals' misperceptions about obesity and bariatric surgery create barriers to accessing bariatric surgery that are not given adequate attention and clinical consideration. Commonly cited patient barriers are lack of knowledge about the severity of obesity, the perception that obesity is a lifestyle problem rather than a chronic disease, and fear that bariatric surgery is dangerous. Medical professional barriers include failing to recognize causes of obesity and weight gain, providing recommendations that are inconsistent with current obesity treatment guidelines, and being uncomfortable counseling patients about treatment options for severe obesity. Previous research has revealed that medical professional counseling and accurate perception of the health risks associated with severe obesity are strong predictors of patients' willingness to consider bariatric surgery. This article reviews patient and medical professional barriers to acceptance of bariatric surgery as a treatment of medical necessity and offers practical advice for medical professionals to rethink perspectives about bariatric surgery when it is medically and psychologically appropriate.

Development and initial validation of the Support for Healthy Lifestyle (SHeL) questionnaire for adolescents.

This study developed and provided initial validation for the Support for Healthy Lifestyle (SHeL), a set of scales designed to measure adolescent-perceived social support of healthy eating and physical activity. Item pool development utilized a prior focus group study of adolescents' perceptions of socially supportive behavior and a review of the literature on social support for health behavior change in adolescents. Exploratory factor analysis of the item pool completed by 220 adolescents, internal consistency estimates, and expert review of items and consensus resulted in 9 scales for the SHeL: Family Healthy Eating Support, Family Physical Activity Support, Family Hypocritical Control, Peer Health Eating Support, Peer Physical Activity Support, Peer Undermining, Professional Healthy Eating Support, Professional Physical Activity Support, and Professional General Support. Scale internal reliability estimates were α = 0.73-0.96. Supporting construct validity, the SHeL showed a pattern of stronger correlations between measures of the same source (parent/peer) and target behavior (healthy eating/physical activity) and stronger correlations with corresponding Sallis scales vis-à-vis other Sallis scales, with exceptions related to peer support for healthy eating. Divergent validity was somewhat limited, including in two instances, the SHeL scale was more strongly correlated with another SHeL scale. Supporting criterion validity, often the SHeL scales were correlated with related health behaviors. This study provided important psychometric information for a new measurement of social support for health behavior for adolescents. Further research with larger, more diverse, and treatment-seeking populations is needed to provide further validation of the SHeL and to begin to establish normative scores.

Effectiveness of Online Aftercare Programs Following Intragastric Balloon Placement for Obesity Is Similar to Traditional Follow-up: a Large Propensity Matched US Multicenter Study.

BACKGROUND: The combination of intragastric balloons (IGB) with comprehensive lifestyle and behavioral changes is critical for ongoing weight loss. Many community and rural practices do not have access to robust obesity resources, limiting the use of IGBs. Online aftercare programs were developed in response to this need, delivering lifestyle coaching to maximize effectiveness. How these programs compare to traditional follow-up is currently unknown. METHODS: Using propensity scoring (PS) methods, two large prospective databases of patients undergoing IGB therapy were compared to estimate the difference in percent total body weight loss (%TBWL) between groups while identifying predictors of response. RESULTS: Seven hundred fifty-eight unique patients across 78 different participating practices (online n = 437; clinical registry n = 321) was analyzed. The mean %TBWL at balloon removal was 11% ± 6.9 with an estimated treatment difference (ETD) between online and traditional follow-up of - 1.5% TBWL (95% CI - 3-0.4%; p = 0.125). Three months post-balloon removal, the combined %TBWL was 12.2% ± 8.3 with an ETD of only 1% TBWL (95%CI - 3-3%; p = 0.08). On multivariable linear regression, each incremental follow-up was associated with increased %TBWL (ß = 0.6% p = 0.002). CONCLUSION: Online IGB aftercare programs provide similar weight loss compared with traditional programs. Increased lifestyle coaching whether in person or remotely is associated with more %TBWL at removal and during follow-up. Close follow-up for clinical symptoms is still warranted.

Weight Regain After Bariatric Surgery: Prevalence, Etiology, and Treatment.

PURPOSE OF REVIEW: Obesity is a life-limiting disease that is associated with a number of co-morbidities. Bariatric surgery remains the most efficacious and durable weight loss method available to patients. However, a significant percentage of patients can regain weight resulting in frustration, depression, and return of obesity-related co-morbidities. The present review provides an overview of the most common therapeutic modalities available to combat weigh regain after weight loss surgery. RECENT FINDINGS: Given the high percentage of patients with weight regain after surgery, significant effort has been placed on developing treatment options in the last few years. Tremendous work has taken place in the realm of cognitive behavior therapy, appetite suppressants, and endoscopic procedures with the hope of reducing the need for revision surgery which can be associated with significant complications. Weight regain is unfortunately a common phenomenon associated with all weight loss modalities including bariatric surgery. We now have a number of treatment options that can reverse the weight loss trend.

Association of Adverse Childhood Experiences and Food Addiction to Bariatric Surgery Completion and Weight Loss Outcome.

INTRODUCTION/PURPOSE: Adverse childhood experiences (ACEs) are known risk factors for obesity and poor outcomes following weight loss interventions. ACEs are also associated with addictive behaviors and, potentially, food addiction (FA). This study examined the relationship between ACEs and FA, and their association to undergoing bariatric surgery and post-surgical weight loss outcomes. MATERIALS AND METHODS: Between June 2013 and January 2016, 1586 bariatric-surgery-seeking patients completed a psychological evaluation. During their evaluation, the patients were administered measures including the ACE questionnaire and the Yale Food Addiction Scale. RESULTS: 19.2% of those seeking bariatric surgery reported being the victim of childhood sexual abuse, and 22.1% reported being the victim of childhood physical abuse. An elevated ACE score corresponded to increased likelihood of screening positive for FA and more severe FA. When the type of ACE was analyzed separately, ACE was not associated with bariatric surgery completion or percent total weight loss (%TWL). Screening positive for FA corresponded to less %TWL 1 year post-surgery as the total number of ACEs increased, yet there was no association with %TWL 2 years post-surgery. The participants were classified into two groups, those positive for an ACE or FA versus those negative for both. Those who screened positive were significantly less likely to undergo bariatric surgery. CONCLUSION: Screening positive for experiencing ACEs was related to severity of FA, and screening positive for being the victim of either childhood abuse or FA reduced the likelihood of completing bariatric surgery. More research is needed to determine how these psychosocial factors might influence bariatric surgery outcomes.

Methodology of a multispecialty outpatient Obesity Treatment Research Program.

Despite the large number of U.S. adults who overweight or obese, few providers have ready access to comprehensive lifestyle interventions, the cornerstone of medical obesity management. Our goal was to establish a research infrastructure embedded in a comprehensive lifestyle intervention treatment for obesity. The Obesity Treatment Research Program (OTRP) is a multi-specialty project at Mayo Clinic in Rochester, Minnesota designed to provide a high intensity, year-long, comprehensive lifestyle obesity treatment. The program includes a nutritional intervention designed to reduce energy intake, a physical activity program and a cognitive behavioral approach to increase the likelihood of long-term adherence. The behavioral intervention template incorporated the Diabetes Prevention Program and the Look AHEAD trial materials. The OTRP is consistent with national recommendations for the management of overweight and obesity in adults, but with embedded features designed to identify patient characteristics that might help predict outcomes, assure long-term follow up and support various research initiatives. Our goal was to develop approaches to understand whether there are patient characteristics that predict treatment outcomes.

Transoral outlet reduction with full thickness endoscopic suturing for weight regain after gastric bypass: a large multicenter international experience and meta-analysis.

BACKGROUND AND AIMS: Many patients who undergo bariatric surgery will experience weight regain and effective strategies are needed to help these patients. A dilated gastrojejunal anastomosis (GJA) has been associated with weight recidivism after Roux-en-Y gastric bypass surgery (RYGB). Endoscopic transoral outlet reduction (TORe) with a full thickness endoscopic suturing device (Overstitch, Apollo Endosurgery, Austin, TX) is a minimally invasive therapeutic option. The primary aim of this project was to examine the safety and long-term efficacy data from three bariatric surgery centers and to conduct a systematic review and meta-analysis of the existing literature. METHODS: Patients who underwent TORe with the Overstitch device from Jan 2013 to Nov 2016 at 3 participating bariatric surgery centers were included in the multicenter analysis. For the systematic review and meta-analysis, a comprehensive search of multiple English databases was conducted. Random effects model was used. RESULTS: 130 consecutive patients across three centers underwent TORe with an endolumenal suturing device. These patients (mean age 47; mean BMI 36.8) had experienced 24.6% weight regain from nadir weight after RYGB. Average weight lost at 6, 12, and 18 months after TORe was 9.31 ± 6.7 kg (N = 84), 7.75 ± 8.4  kg (N = 70), 8 ± 8.8 kg (N = 46) (p < 0.01 for all three time points), respectively. The meta-analysis included 330 patients. The pooled weight lost at 12 months was 8.4 kg (95% CI 6.5-10.3) with no significant heterogeneity across included studies (p = 0.07). Overall, 14% of patients experienced nausea, 18% had pain and 8% required a repeat EGD. No serious adverse events reported. CONCLUSION: When implemented as part of a multidisciplinary intervention, TORe using endolumenal suturing is safe, reproducible, and effective approach to manage weight recidivism after RYGB and should be utilized early in the management algorithm of these patients.

Crucial conversations about weight management with healthcare providers: patients' perspectives and experiences.

PURPOSE: To elicit patient experiences of weight management discussions with providers and provide recommendations for future weight-related discussions. METHODS: 1000 patients who recently saw their provider for non-weight specific appointments were mailed measures of demographics, self-reported height and weight, activity level, adherence, perceptions of and recommendations for weight-related discussions, and internalized weight bias. This study was primarily descriptive and utilized a mixed method design including collection of quantitative and qualitative data. RESULTS: 242 patients responded (24 % response rate); 32.4 % overweight (N = 72), 41.9 % obese (N = 93). 47 % of overweight and 71 % of obese patients recalled that their provider discussed weight; 92 % were motivated to follow recommendations and 89 % felt confident doing so. Most patients (75 %) would like their provider to be "very direct/straightforward" when discussing weight, and 52 % would be "not at all offended" if they were diagnosed as "overweight/obese." Most patients (63 %) reported being "extremely comfortable" discussing weight with providers. Patients with higher BMI had higher levels of internalized weight bias (p < .001) and wanted their provider to "discuss weight sensitively" (p < .05). CONCLUSION: This study suggests that patients have important preferences that providers should be mindful of when discussing weight. While these discussions can be challenging, most patients report that they would be comfortable having these conversations directly and most would have enhanced motivation and confidence following these conversations. Communicating about weight is needed and desired by patients; doing so sensitively with those at higher weight is essential.