Health care utilization in children and adolescents with psychiatric disorders.

OBJECTIVE: Mental illness is increasing among young people and likewise the request for health care services. At the same time, somatic comorbidity is common in children and adolescents with psychiatric disorders. There is a lack of studies on health care use in children and adolescents, and the hypothesis was that children and adolescents with psychiatric disorders use more primary-, and specialized somatic health care compared to children without psychiatric disorders. METHODS: In this retrospective population-based register study, all individuals aged 3-17 years living in Västra Götaland region in Sweden in 2017 were included (n = 298,877). Linear and Poisson regression were used to compare health care use during 2016-2018 between children with and without psychiatric diagnoses, controlling for age and gender. The results were reported as unstandardised beta coefficient (ß) and adjusted prevalence ratio (aPR) respectively. RESULTS: Having a psychiatric diagnosis was associated with more primary care visits (ß 2.35, 95% CI 2.30-2.40). This applied to most diagnoses investigated. Girls had more primary care visits than boys. Likewise, individuals with psychiatric diagnoses had more specialized somatic outpatient care (ß 1.70, 95% CI 1.67-1.73), both planned and unplanned (ß 1.23, 95% CI 1.21-1.25; ß 0.18, 95% CI 0.17-0.19). Somatic inpatient care was more common in those having a psychiatric diagnosis (aPR 1.65, 95% CI 1.58-1.72), with the diagnoses of psychosis and substance use exerting the greatest risk. CONCLUSIONS: Psychiatric diagnoses were associated with increased primary-, somatic outpatient- as well as somatic inpatient care. Increased awareness of comorbidity and easy access to relevant health care could be beneficial for patients and caregivers. The results call for a review of current health care systems with distinct division between medical disciplines and levels of health care.

The Swedish Youth with Obesity cohort: Profile of an ongoing prospective study.

OBJECTIVE: As there is a lack of studies on adolescents and young adults with obesity, the Swedish Youth with Obesity cohort was set up to describe the long-term results of medical, as well as surgical, obesity interventions in youth. This article describes the study protocol. METHODS: Since 2018, the study has continuously recruited patients aged between 16 and 25 years who have been admitted for obesity treatment at a specialist obesity clinic in Stockholm, Sweden. Participants provide data from blood tests, questionnaires, and anthropometric measurements. Data are collected longitudinally at enrollment and after 18 months and 3, 4, 5, and 10 years. RESULTS: In the first 500 participants (76% female), the mean age was 21 (SD 3.0) years and the mean BMI was 41.3 (SD 6.1) kg/m2 at enrollment. Almost half of the participants (44.4%) reported that both parents were born outside the Nordic countries. The proportion of participants who smoked at least sometimes was 28.4%. CONCLUSIONS: The longitudinally collected data from the Swedish Youth with Obesity cohort will become a valuable source for answering various research questions regarding long-term results of medical and surgical obesity treatment in adolescents and young adults with obesity.

Elevated pulse pressure and its associations with demographic and clinical parameters in a clinically representative sample of outpatients with psychotic disorders.

Elevated pulse pressure is associated with metabolic and neurocognitive diseases. Preliminary small-scale studies among patients with psychotic disorders have indicated that these patients had an increased pulse pressure compared with controls. However, it is unclear whether and how these associations are manifested among larger heterogenous samples of patients with psychotic disorders. We examined elevated pulse pressure and its associations with demographic and clinical characteristics in a clinically representative sample of outpatients with psychotic disorders (n = 1289). In a subsample (n = 343), we also examined associations with six domains of functioning. Controlling for age and cardiovascular disease, body mass index (BMI) and employment status independently predicted the odds ratio of having elevated pulse pressure. Elevated pulse pressure was also primarily associated with the physical domains of functioning. Outpatients with psychotic disorders that have high BMI and are unemployed thus seem to be at increased risk for elevated pulse pressure and should therefore be particularly considered for blood pressure screenings.

Clinical validity of the 12-item WHODAS-2.0 in a naturalistic sample of outpatients with psychotic disorders.

BACKGROUND: The World Health Organization Disability Assessment Schedule 2.0 (WHODAS-2.0) is a self-administered instrument to assess functional impairment. It is used in the general population as well as different patient groups. However, its application to patients with psychotic disorders may be hampered by disease-specific difficulties of self-estimation. This study aimed to examine the psychometric properties of the short (12-item) WHODAS-2.0 in a naturalistic sample of outpatients attending a psychosis clinic in Gothenburg, Sweden. METHODS: Annual data from two outpatient clinics registered 2016-2019 were analyzed retrospectively. The assessment of the short WHODAS-2.0 was based on the first questionnaire completed by 881 patients. Confirmatory factor analysis evaluated previously validated models. Item convergent and discriminant validity as well as internal reliability were computed. Construct validity was assessed by comparing mean differences in accord with previous research regarding patients' characteristics associated with functioning such as advanced age, diagnosed comorbidities, antipsychotic treatment status, and symptom severity measured with PANSS-8 remission items. RESULTS: A heterogeneous sample was obtained in terms of age (range: 20-92), various living situations, and different geographic areas of birth. Most patients (75%) had been diagnosed with psychotic disorders more than 10 years ago and the majority (89%) were on antipsychotic medication. We confirmed an adjusted two-level factor model with a single second-order disability factor and six first-order factors representing the six IFC dimensions. The WHODAS-2.0 sum score measuring general disability showed good reliability (Cronbach's alpha = 0.89). Construct validity was confirmed as older patients, patients with comorbidities, and patients in assisted living had higher WHODAS-2.0 scores. Patients with no or mild psychotic symptoms had significantly lower WHODAS-2.0 sum scores than patients with more severe symptoms. CONCLUSIONS: The findings further validate the 12-item WHODAS-2.0 in a naturalistic sample of outpatients with psychotic disorders. This study corroborates the clinical significance of the short, 12-item WHODAS-2.0 by demonstrating consistent associations between patients' age, medical comorbidities, living situation, antipsychotic treatment status, and psychotic symptom severity.

Attitudes and beliefs in Swedish midwives and obstetricians towards obesity and gestational weight management.

BACKGROUND: Gestational weight interventions are important in maternity care to counteract adverse pregnancy events. However, qualitative findings indicate potential obstacles in the implementation of interventions due to the sensitivity of the subject and existing obesity stigma. Pregnant women have reported disrespectful or unhelpful communication, while some midwives seem to avoid the topic, as not to upset women. This descriptive study aimed to provide knowledge about maternity care providers' beliefs about obesity, and their attitudes towards gestational weight management. METHOD: A web survey was emailed to Swedish maternity care clinics. Existing questionnaires, "Beliefs About Obese People" (BAOP), "Perceived weight bias in health care" and "Attitudes toward obese patients" was used, supplemented with questions formulated for this study. An open free-text question allowed participants to provide a deeper and more nuanced picture of the topic. RESULTS: 274 respondents (75% midwives and 25% obstetricians) participated. One third of respondents found obesity to be a more sensitive topic than smoking or alcohol habits, and 17% of midwives agreed to the statement: "I sometimes avoid talking about weight so as not to make the pregnant woman worried or ashamed". Having had training in motivational interviewing seemed positively associated with midwives' inclination to talk about body weight, especially with women with obesity (p = .001), whereas years of working experience were not associated. Having received obesity education increased confidence in providing adequate information, but still only 46% felt they had enough knowledge to provide diet and exercise advice to pregnant women with obesity. Qualitative data revealed great empathy for women with obesity, and a wish to have more obesity education and access to other professionals. CONCLUSION: Swedish maternity care staff displayed empathy for women with obesity and found gestational weight interventions important, but almost one fifth of midwives sometimes avoid the subject of body weight for fear of upsetting women. Education about obesity facts, training in person-centered communication, i.e. motivational interviewing, and access to dieticians may facilitate gestational weight management implementation.

Injuries in children and adolescents with psychiatric disorders.

BACKGROUND: Unintentional injuries are a leading cause of morbidity and mortality in children of all ages. Prevention strategies require knowledge of risk factors, and behavior and psychiatric disorders have been suggested to influence the risk of injury during childhood. While externalizing disorders have been found to increase the risk for injuries, results are mixed regarding internalizing disorders, such as affective and anxiety conditions, and Autism Spectrum Disorders (ASD). There is a need for large scale studies relying on robust data sources. The aim of the present study was to examine the association between psychiatric disorders and injuries requiring medical attention, in a large population-based cohort of 350,000 children and adolescents in Sweden. METHODS: Data were obtained from the regional health care database Vega. Psychiatric diagnoses and injury diagnoses obtained during 2014-2018 for individuals aged 0-17 years in 2016 were extracted. Descriptive statistics were used to examine differences in 5-year injury prevalence between children with and without different psychiatric diagnoses. Logistic regression was used in age-stratified models to test the association between psychiatric diagnoses and injuries requiring medical attention. RESULTS: The results show an increased risk for concurrent injuries in general, but the patterns vary by age and psychiatric disorder. Externalizing disorders and anxiety conditions were associated with concurrent injuries, while individuals with ASD had a lower risk for most injuries included. Affective disorders were associated with an increased risk for wounds, concussion, complications and poisoning, while the risk for fractures was decreased. Self-inflicted injury was more common in all psychiatric conditions investigated during adolescence, except for ASD. Children and adolescents with many types of psychiatric disorders were also at increased risk for a concurrent maltreatment diagnosis. CONCLUSIONS: A general pattern of increased risk for concurrent injuries in children and adolescents with most psychiatric diagnoses was found, but the associations vary by age and type of psychiatric disorder. The results add to the literature on risk factors for injuries in children and adolescents, supporting diagnosis specific patterns. Several psychiatric diagnoses were associated with a marked increase in injury risk, indicating a high burden of disease for affected individuals.

Long-term incidence of gallstone disease after bariatric surgery: results from the nonrandomized controlled Swedish Obese Subjects study.

BACKGROUND: Gallstone disease is a known short-term complication of bariatric surgery; little is known of the long-term incidence. OBJECTIVES: The aim of this study was to investigate the association between bariatric surgery and long-term incidence of gallstone disease. SETTINGS: A total of 25 surgery departments and 480 primary healthcare centers in Sweden. METHODS: The Swedish Obese Subjects study is a prospective, controlled study comparing the effects of bariatric surgery with usual care with a follow-up of 20 years, including 4047 individuals. The current report includes all participants without previous or concomitant cholecystectomy (n = 3597). Operative techniques used in the surgery group (n = 1755) were gastric bypass (n = 236), vertical banded gastroplasty (n = 1202), and gastric banding (n = 317). The control group (n = 1842) received customary treatment for obesity. Gallstone disease was a predefined secondary endpoint in the Swedish Obese Subjects study and the primary endpoint of this report. Data were obtained by cross-checking our study database with the Swedish National Patient Register of diagnosis and procedures. RESULTS: In the surgery and control groups, respectively, there were 307 and 252 first-time events of symptomatic gallstone disease and 230 and 170 cholecystectomies (log-rank P < .001, both outcomes). Bariatric surgery was associated with an increased risk of symptomatic gallstone disease, with a more pronounced risk during the first years of follow-up (P = .002) and an increased risk for cholecystectomy but with no time-varying effect (P = .213). CONCLUSIONS: Bariatric surgery increases the risk for symptomatic gallstone disease and cholecystectomy, especially during the first years following treatment.

" or else I close my ears" How women with obesity want to be approached and treated regarding gestational weight management: A qualitative interview study.

INTRODUCTION: The importance of helping pregnant women maintain a healthy lifestyle and prevent excessive gestational weight gain is well recognized, but pregnant women do not always perceive communication about body weight as respectful or helpful. Furthermore, fear of inducing shame or guilt can prohibit some midwives from talking about body weight, especially if the woman has obesity. We aimed to explore what women of reproductive age with obesity regard to be the most important and relevant aspects when discussing gestational weight management. METHODS: Qualitative interview study using focus groups and individual semi-structured interviews with 17 women of reproductive age (19-39 y) with obesity. Thematic analysis was used to analyze the data. RESULTS: We identified three themes: 1) Importance of obtaining vital medical information; 2) A wish to feel understood and treated with respect; 3) Midwives' approach is crucial in sensitive key situations, which include bringing up the subject of body weight, weighing, providing weight-related information, coaching lifestyle modification, dealing with emotional reactions and ending a conversation. CONCLUSIONS: A majority of the interviewed women wished to receive information about risks about obesity and gestational weight gain, and recommendations on weight management. However, the risk of midwives offending someone by raising the topic may be increased if the pregnant woman believe that gestational weight gain is uncontrollable by the individual. Also, several situations during maternity care meetings can be stigmatizing and make women less receptive to advice or support. Women suggest that a good working alliance is likely to be achieved if midwives have knowledge about the causes of obesity, take interest in the patients' background, have a non-judgmental approach and refrain from giving unsolicited advice.

Somatic comorbidity in children and adolescents with psychiatric disorders.

In the adult population, psychiatric disorders are associated with somatic illness. Explanatory life style factors have been found, but also a failure to recognize somatic illness in this group. Another factor is side effects from long-term use of antipsychotic drugs. Given the psychiatric-somatic comorbidity in the adult population, it is of interest to investigate whether an association exists already during childhood. The aim of the present study was to investigate the frequency of somatic illness in children and adolescents with a psychiatric diagnose. Data were obtained from the regional health care database Vega, Sweden. Psychiatric and somatic diagnoses obtained during 2011-2013 for individuals aged 3-18 years were extracted. Descriptive statistics were used to examine difference in somatic morbidity between children with and without psychiatric diagnoses. Logistic regression was used in age-stratified models to test the association between psychiatric and somatic diagnoses. Anxiety and behavioral disorders were associated with all somatic conditions investigated at nearly all ages. The same applied to substance use, investigated at age 9-18 years. Affective disorders were associated with all somatic conditions at age 12-18 years. Psychotic conditions were associated with asthma, bowel disorders and myalgia in adolescents. Children with psychiatric disorders are at remarkably high risk for concurrent somatic illness. The associations span across many types of conditions and across all ages. The results support the need for awareness of somatic morbidity in child and adolescent psychiatric clinical settings, and the need for coordinated health care for children with comorbid states.

[Increased somatic morbidity in patients with severe mental illness]. / Markant somatisk översjuklighet vid allvarlig psykisk sjukdom.

Patients with severe mental illness suffer an increased somatic mortality and morbidity from cardiovascular disease, diabetes and cancer. Furthermore, they are less likely to have adequate diagnostic and therapeutic procedures for somatic disorders. Life style issues, side effects of pharmacotherapy, cognitive impairment and suboptimal organization of the health care system all contribute. In total, a challenging situation that has to be addressed by the health care system. In Region Västra Götaland, Sweden, new medical routines for psychiatric patients are currently implemented. All patients should be offered an annual medical somatic checkup, including blood tests and ECG, and be advised about their life style, i.e. diet, exercise, smoking and alcohol. At the Department of psychosis, Sahlgrenska University Hospital, Göteborg, Sweden, a new permanent position as senior consultant in internal medicine/liaison physician has been established.

Weight loss, adverse events, and loss to follow-up after gastric bypass in young versus older adults: A Scandinavian Obesity Surgery Registry study.

BACKGROUND: Young adults display particularly poor weight loss in behavioral obesity treatment; nonetheless, they have seldom been included in bariatric research. OBJECTIVES: To compare weight loss, adverse events, and loss to follow-up in young (18-25 yr) versus older (≥26 yr) adults up to 5 years after Roux-en-Y gastric bypass. SETTING: Nationwide, register-based study, Sweden. METHODS: Prospective registry data (Scandinavian Obesity Surgery Register) were analyzed in young (22.2 yr [standard deviation (SD): 2.1], 81.6% women, mean body mass index 43.7 kg/m2 [SD: 5.4]) and older (42.6 years [SD: 9.6], 82.0% women, mean body mass index 43.4 kg/m2 [SD: 5.0]) adults undergoing Roux-en-Y gastric bypass. Groups were matched for body mass index, sex, and year of surgery. Regression analyses and mixed models were used to compare outcomes between groups. RESULTS: A total of 369 young (37.0% of eligible) and 2210 older (46.1%) adults attended the 5-year follow-up. At this time, weight loss was 31.8% in young and 28.2% in older adults (P < .001), with a serious adverse event (Clavien-Dindo ≥3b) being reported in 52 (14.1%) young and 153 (6.9%) older adults (odds ratio = 2.06, 95% confidence interval: 1.45-2.92, P < .001). Loss to follow-up was higher in young versus older adults throughout the study period (range of relative risk = 1.16-1.89, P < .001). CONCLUSIONS: While young adults displayed at least equal weight loss as older adults, rates of adverse events were approximately doubled, and loss to follow-up rates were higher. Future studies on the significance of and the etiology behind the higher incidence of serious adverse events are needed. Intensified clinical contact post Roux-en-Y gastric bypass should have the potential to further improve outcomes in young adults.

Shame and avoidance as barriers in midwives' communication about body weight with pregnant women: A qualitative interview study.

INTRODUCTION: Excessive gestational weight gain, regardless of initial BMI, is associated with perinatal risks for both mother and offspring and contributes to obesity in women. Studies report that healthcare professionals find it difficult to communicate about weight and pregnant women perceive healthcare professionals as unconcerned, leaving many women uninformed about weight recommendations and risks. We aimed to explore how midwives approach communication about gestational weight gain recommendations, and to characterize communication barriers and facilitators. METHODS: Seventeen midwives from different areas in Sweden were interviewed by a therapist using semi-structured interviews. Interviews were transcribed verbatim and analysed by three researchers using latent content analysis. Recurrent themes were identified and formulated. RESULTS: The main theme identified in the latent part of the analysis was "midwives use avoidant behaviours to cope with fear of inflicting worries, shame or feelings of guilt in pregnant women". Avoidant behaviours include: adjusting weight recommendations, toning down risks and avoid talking about weight. Subthemes identified were (I) Conflicting responsibilities in midwives' professional identity (II) Perceived deficiencies in the working situation. CONCLUSION: Midwives' empathy and awareness of weight stigma strongly affects communication about weight with pregnant women, and midwives' use of avoidant behaviours constitutes salient information barriers. More research is needed on whether gestational weight guidelines and weighing routines for all women, resources for extra visits, training in specific communication skills and backup access to other professions can facilitate for midwives to initiate and communicate about healthy gestational weight development, enabling more pregnant women to make well-informed lifestyle choices.

Access to primary and specialized somatic health care for persons with severe mental illness: a qualitative study of perceived barriers and facilitators in Swedish health care.

BACKGROUND: Persons with severe mental illness (e.g. schizophrenia, bipolar disorder) have a high prevalence of somatic conditions compared to the general population. Mortality data in the Nordic countries reveal that these persons die 15-20 years earlier than the general population. Some factors explaining this high prevalence may be related to the individuals in question; others arise from the health care system's difficulty in offering somatic health care to these patient groups. The aim of the present study was therefore to explore the experiences and views of patients, relatives and clinicians regarding individual and organizational factors which facilitate or hinder access to somatic health care for persons with severe mental illness. METHODS: Flexible qualitative design. Data was collected by means of semi-structured individual interviews with patients with severe mental illness, relatives and clinicians representing primary and specialized health care. In all, 50 participants participated. RESULTS: The main barrier to accessing somatic care is the gap between the organization of the health care system and the patients' individual health care needs. This is observed at both individual and organizational level. The health care system seems unable to support patients with severe mental illness and their psychiatric-somatic comorbidity. The main facilitators are the links between severe mental illness patients and medical departments. These links take the form of functions (i.e. systems which ensure that patients receive regular reminders), or persons (i.e. professional contacts who facilitate patients' access the health care). CONCLUSIONS: Health care services for patients with severe mental illness need reorganization. Organizational structures and systems that facilitate cooperation between different departments must be put in place, along with training for health care professionals about somatic disease among psychiatric patients. The links between individual and organizational levels could be strengthened by introducing professional contacts, such as liaison physicians and case managers. This is also important to reduce stress and responsibility among relatives.

Women's Perceived Reasons for Their Excessive Postpartum Weight Retention: A Qualitative Interview Study.

INTRODUCTION: Obesity in Sweden has doubled to 14% over the last 20 years. New strategies for treatment and prevention are needed. Excessive gestational weight gain has been found to contribute substantially to obesity, and there is a consistent association between postpartum weight retention and obesity later in life. We aimed to explore what factors women perceive as reasons for having substantial postpartum weight retention, to identify areas for new and improved interventions. METHODS: Qualitative interview study (semi-structured) using an emergent design. Fifteen women, with a postpartum weight retention ≥ 10 kg, were interviewed by a trained cognitive therapist. Eight women had pre-pregnancy BMI below 30 kg/m2. Interviews were transcribed verbatim and data analysed using inductive manifest content analysis. Salient text passages were extracted, shortened, coded and clustered into categories. RESULTS: Participants reported no knowledge of current gestational weight gain recommendations or of risks for adverse pregnancy outcomes with excessive weight gain or postpartum weight retention. Excessive eating emerged as a common strategy to provide relief of psychological, emotional and physical discomfort, such as depression and morning sickness. Women perceived medical staff as being unconcerned about weight, and postpartum weight loss support was scarce or absent. Some women reported eating more due to a belief that breastfeeding would automatically lead to weight loss. CONCLUSION: There is a need to raise awareness about risks with unhealthy gestational weight development and postpartum weight retention in women of childbearing age. The common strategy to cope with psychological, emotional or physical discomfort by eating is an important factor to target with intervention. The postpartum year is a neglected period where additional follow-up on weight and weight loss support is strongly indicated.

["Active health management" can provide support for vulnerable patients. New model for the prevention of unplanned healthcare]. / ¼Aktiv hälsostyrning« kan ge utsatta patienter stöd - Ny modell för prevention av oplanerad sjukvård.

A small group of frequent emergency department visitors account for a disproportionally large fraction of health care consumption, including unplanned hospitalizations and overall healthcare costs. In response, case and disease management programs aimed at reducing health care consumption in this group have been tested, however results vary widely. In this study, we aimed to investigate if a telephone-based, nurse led case management intervention can reduce health care consumption for frequent emergency department visitors in a large-scale set-up. A total of 12,181 frequent emergency department users in three counties in Sweden were randomized either using Zelen's design or a traditional randomized design to receive a nurse led case management intervention or no intervention. Patients were followed for health care consumption for up to 2 years. The results of the study with traditional design showed an overall 12% (95% confidence interval [CI], 4-19%) decreased rate of hospitalization, which was mostly driven by effects among patients included in the last year. Similar results were achieved in the Zelen studies, with significant reduction of hospitalization, again in the last year, but mixed results in the early development of the project. Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized set-up can lead to significant decreases in health care consumption and costs. However, we also demonstrate that the effects are sensitive to the delivery model chosen.

A case management intervention targeted to reduce healthcare consumption for frequent Emergency Department visitors: results from an adaptive randomized trial.

BACKGROUND: A small group of frequent visitors to Emergency Departments accounts for a disproportionally large fraction of healthcare consumption including unplanned hospitalizations and overall healthcare costs. In response, several case and disease management programs aimed at reducing healthcare consumption in this group have been tested; however, results vary widely. OBJECTIVES: To investigate whether a telephone-based, nurse-led case management intervention can reduce healthcare consumption for frequent Emergency Department visitors in a large-scale setup. METHODS: A total of 12 181 frequent Emergency Department users in three counties in Sweden were randomized using Zelen's design or a traditional randomized design to receive either a nurse-led case management intervention or no intervention, and were followed for healthcare consumption for up to 2 years. RESULTS: The traditional design showed an overall 12% (95% confidence interval 4-19%) decreased rate of hospitalization, which was mostly driven by effects in the last year. Similar results were achieved in the Zelen studies, with a significant reduction in hospitalization in the last year, but mixed results in the early development of the project. CONCLUSION: Our study provides evidence that a carefully designed telephone-based intervention with accurate and systematic patient selection and appropriate staff training in a centralized setup can lead to significant decreases in healthcare consumption and costs. Further, our results also show that the effects are sensitive to the delivery model chosen.

Incidence and remission of type 2 diabetes in relation to degree of obesity at baseline and 2 year weight change: the Swedish Obese Subjects (SOS) study.

AIMS/HYPOTHESIS: The aim of this work was to analyse the rates of incidence and remission of type 2 diabetes in relation to baseline BMI and weight change in the prospective, controlled Swedish Obese Subjects (SOS) study. METHODS: Three-thousand four-hundred and eighty-five obese individuals receiving bariatric surgery or conventional treatment were grouped into four baseline BMI categories (<35, 35-40, 40-45 or ≥ 45 kg/m(2)) and five weight-change categories according to their BMI at 2 years (increase [≥ 1 BMI unit increase], no change [less than 1 BMI unit change], minor reduction [-1 to -9 BMI units], medium reduction [-10 to -14 BMI units] and major reduction [< -15 BMI units]). The incidence and remission of diabetes at 2 years was assessed. RESULTS: Among individuals with no weight change, diabetes incidence rates were 5.5%, 7.4%, 8.3% and 5.2%, in the four baseline BMI categories, respectively. In those with an initial BMI of 35-40, 40-45 and ≥ 45 kg/m(2) who attained a minor reduction in weight, the corresponding rates were 1.3%, 1.2% and 3.4%, respectively. In both the medium- and major-weight-reduction groups, diabetes incidence was ≤ 0.5%. Among individuals with diabetes at baseline, the remission rates were 15.3-26.9% in the no-weight-change groups, and 48.1-70% for individuals who attained a minor weight reduction. In the medium- and major-weight-reduction groups, the remission rate was 77-97%. There were no differences in 2 year incidence and remission rates between different baseline BMI groups that achieved the same degree of weight reduction. CONCLUSIONS/INTERPRETATION: In obese individuals, the favourable effect of weight reduction on type 2 diabetes incidence and remission is independent of initial BMI. Trial registration ClinicalTrials.gov number NCT01479452.

Long-term effect of bariatric surgery on liver enzymes in the Swedish Obese Subjects (SOS) study.

BACKGROUND AND AIM: Obesity is associated with elevated serum transaminase levels and non-alcoholic fatty liver disease and weight loss is a recommended therapeutic strategy. Bariatric surgery is effective in obtaining and maintaining weight loss. Aim of the present study was to examine the long-term effects of bariatric surgery on transaminase levels in obese individuals. METHODS: The Swedish Obese Subjects (SOS) study is a prospective controlled intervention study designed to compare the long-term effects of bariatric surgery and usual care in obese subjects. A total of 3,570 obese participants with no excess of alcohol consumption at baseline (1,795 and 1,775 in the control and surgery group, respectively) were included in the analyses. Changes in transaminase levels during follow-up were compared in the surgery and control groups. RESULTS: Compared to usual care, bariatric surgery was associated with lower serum ALT and AST levels at 2- and 10- year follow up. The reduction in ALT levels was proportional to the degree of weight loss. Both the incidence of and the remission from high transaminase levels were more favorable in the surgery group compared to the control group. Similarly, the prevalence of ALT/AST ratio <1 was lower in the surgery compared to the control group at both 2- and 10-year follow up. CONCLUSIONS: Bariatric surgery results in a sustained reduction in transaminase levels and a long-term benefit in obese individuals.

Growth differentiation factor 15 predicts future insulin resistance and impaired glucose control in obese nondiabetic individuals: results from the XENDOS trial.

OBJECTIVE: Growth differentiation factor-15 (GDF-15) is a stress-responsive cytokine that is increased in obesity and established type 2 diabetes. We assessed whether GDF-15 can predict future insulin resistance and impaired glucose control in obese nondiabetic individuals. DESIGN AND METHODS: Plasma GDF-15 concentrations were measured with an automated electrochemiluminescent immunoassay at baseline and after 4 years in 496 obese nondiabetic individuals (52% men, median age 48 years, median body mass index (BMI) 37.6 kg/m(2)) enrolled in the XENical in the prevention of Diabetes in Obese subjects (XENDOS) trial. RESULTS: The median GDF-15 concentration at baseline was 869 ng/l (interquartile range 723-1064 ng/l). GDF-15 was related to body weight, BMI, waist-to-hip ratio, and insulin resistance (homeostasis model assessment of insulin resistance (HOMA-IR)) (all P < 0.01). Changes in GDF-15 from baseline to 4 years were related to changes in body weight, BMI, waist-to-hip ratio, and HOMA-IR (all P < 0.05). Baseline GDF-15 was associated with the risk to have prediabetes or diabetes at 4 years by univariate analysis (odds ratio (OR) FOR 1 unit increase in ln GDF-15, 3.2; 95% confidence interval (CI): 1.7-6.1; P<0.001), and after multivariate adjustment for age, gender, treatment allocation (orlistat vs placebo), BMI, waist-to-hip ratio, and glucose control at baseline (OR 2.2; 95% CI: 1.1-4.7; P=0.026). Similarly, baseline GDF-15 was independently associated with HOMA-IR at 4 years (P=0.024). CONCLUSIONS: This first longitudinal study of GDF-15 in a large cohort of obese individuals indicates that GDF-15 is related to abdominal obesity and insulin resistance and independently associated with future insulin resistance and abnormal glucose control.