Leah Brennan

Long-term outcomes after bariatric surgery : fifteen-year follow-up of adjustable gastric banding and a systematic review of the bariatric surgical literature

Objective:To describe the long-term outcomes after laparoscopic adjustable gastric banding (LAGB) and compare these with the published literature on bariatric surgery. Background:Because obesity is a chronic disease, any proposed obesity treatment should be expected to demonstrate long-term durability to be considered effective. Yet for bariatric surgery, few long-term weight loss data are available. We report our 15-year follow-up data after LAGB and provide a systematic review of the peer-reviewed literature for weight loss at 10 years or more after bariatric surgical procedures. Methods:We performed a prospective longitudinal cohort study of LAGB patients using an electronic database system (LapBase) to track progress, measure weight changes, and document revisional procedures. The evolution of the LAGB procedure was recognized, and revisional rates for 3 separate periods between September 1994 and December 2011 were described. In addition, we performed a systematic review of the peer-reviewed published literature collecting all reports that included weight loss data at or beyond 10 years. Results:A total of 3227 patients, with a mean age of 47 years and a mean body mass index of 43.8 kg/m2, were treated by laparoscopic adjustable gastric band placement between September 1994 and December 2011. Seven hundred fourteen patients had completed at least 10 years of follow-up. Follow-up was intact in 81% of patients overall and 78% of those beyond 10 years. There was no perioperative mortality for the primary placement or for any revisional procedures. There was 47.1% of excess weight loss (% EWL) at 15 years [n = 54; 95% confidence interval (CI) = 8.3] and 62% EWL at 16 years (n = 14; 95% CI = 13.6). There was a mean of 47.0% EWL (n = 714; 95% CI = 1.3) for all patients who were at or beyond 10 years follow-up. Revisional procedures were performed for proximal enlargement (26%), erosion (3.4%), and port and tubing problems (21%). The band was explanted in 5.6%. The need for revision decreased as the technique evolved, with 40% revision rate for proximal gastric enlargements in the first 10 years, reducing to 6.4% in the past 5 years. The revision group showed a similar weight loss to the overall group beyond 10 years. The systematic review of all bariatric procedures with 10 or more years of follow-up showed greater than 50% EWL for all current procedures. The weighted mean at maximum follow-up for LAGB was 54.2% EWL and for Roux-en-Y gastric bypass was 54.0% EWL. Conclusions:The LAGB study from 1 center demonstrates a durable weight loss with 47% EWL maintained to 15 years. This weight loss occurred regardless of whether any revisional procedures were needed. A systematic review shows substantial and similar long-term weight losses for LAGB and other bariatric procedures.

Predictors of dropout in weight loss interventions: a systematic review of the literature

Attendance and completion of weight loss intervention is associated with better weight loss outcomes; however, attrition is neither consistently reported nor comprehensively explored in the weight loss literature. A systematic review was undertaken to identify factors associated with attrition in weight loss interventions involving overweight or obese (body mass index ≥ 25) adults (18–65 years). Sixty‐one studies published before May 2011 and addressing factors associated with weight loss programme attrition were identified. Conclusions were limited by the large number of variables explored, the small number of studies exploring each variable, the large variety of study settings and methodologies used, the inconsistent reporting of results, and the conflicting findings across studies. A consistent set of predictors has not yet been identified. The majority of studies relied on pre‐treatment routinely collected data rather than variables selected because of their theoretical and/or empirical relationship with attrition. However, psychological and behavioural patient factors and processes associated with the treatment were more commonly associated with attrition than patient background characteristics. Future research should consider theoretically grounded social–psychological and behavioural processes as potential predictors of dropout. Identification of patients at risk of dropout will contribute to both the effectiveness and the cost‐effectiveness of weight loss interventions.

A systematic review of variables associated with the relationship between obesity and depression

Obesity is one of the leading causes of preventable diseases and disability worldwide, and depression is among the leading causes of burden of disease. Both disorders are increasingly prevalent and comorbid. This comorbidity compounds associated health. While there is consistent evidence of a bidirectional obesity depression relationship, little is known about the biopsychosocial variables associated with this relationship. A systematic review was undertaken to identify variables associated with the relationship between obesity (Body mass index > 30 kg m−2) and depression. Forty‐six studies were identified. Obesity, educational attainment, body image, binge eating, physical health, psychological characteristics and interpersonal effectiveness were consistently associated with the relationship between obesity and depression. The current review identified potential biopsychosocial variables associated with the relationship between obesity and depression. This knowledge can inform future research examining moderators, mediators and mechanisms of the relationship between obesity and depression. Improved understanding of this relationship will inform identification, prevention and intervention efforts.

Parental use of restrictive feeding practices and child BMI z-score. A 3-year prospective cohort study

This study examines associations between parental feeding restriction at baseline and child body mass index (BMI) z-score at 3-year follow-up. Parents of 204 5-6-year-old and 188 10-12-year-old children completed the Child Feeding Questionnaire at baseline (2002/3). In 2002/3 and 2005/6, childrens BMI z-score was calculated from measured height and weight. Analyses were stratified by age-group. The association of follow-up zBMI and baseline feeding restriction score was explored using (i) linear regression with adjustment for baseline zBMI and (ii) with further adjustments for baseline maternal BMI, maternal education level and child sex. Baseline restriction was associated with follow-up zBMI at 3 years in 5-6-year-old children and was largely unchanged when adjusting for child sex, maternal BMI and education. Restriction was not associated with follow-up zBMI in 10-12-year-old children. This longitudinal study adds important depth to our understanding of associations between restrictive feeding and change in zBMI, suggesting that restriction of energy-dense foods and drinks may be protective of unhealthy weight gain in younger children but may have no effect among older children. These findings support a reconsideration of the notion that restriction is likely to result in increased child weight.

Examining the relationship between obesity and cognitive function: A systematic literature review

The increasing prevalence of both obesity and dementia is a significant public health concern, especially as recent research demonstrates a significant relationship between these conditions. However, while there is evidence of an obesity-dementia relationship, the effect of obesity on cognitive function in adults, independent of obesity related comorbidities, remains ambiguous. Furthermore, research is yet to systematically compare evidence for domain specific cognitive deficits in obese adults. A systematic literature review was conducted to assess evidence for domain specific cognitive deficits in obese (BMI>30 kg/m(2)) adults (18-65 years of age) and whether these studies have been able to determine an independent relationship between obesity and cognition over and above relevant comorbidities. Seventeen articles were identified. The literature revealed impairments in obese adults across almost all cognitive domains investigated (e.g. complex attention, verbal and visual memory, decision making). However, numerous methodological limitations were identified which need to be considered in interpretations and conclusions regarding an independent effect. While cognitive impairments in obese adults are evident, as a result of these methodological limitations there is currently insufficient evidence to indicate a reliable and valid independent association between obesity and cognitive impairment in mid-life adults. Further research addressing key methodological limitations (e.g. application of relevant exclusions and control variables, use of appropriate comparison groups and measures) is recommended in order to improve understanding of the relationship between mid-life obesity and cognition. Such research will inform the development of appropriate approaches to identification, prevention and treatment of cognitive decline in obese adults.

Correlates of weight stigma in adults with overweight and obesity: A systematic literature review

While evidence regarding associations between weight stigma and biopsychosocial outcomes is accumulating, outcomes are considered in isolation. Thus, little is known about their complex relationships. This article extends existing work by systematically reviewing the biopsychosocial consequences of stigma in adults with overweight/obesity.

Maternal psychosocial predictors of controlling parental feeding styles and practices

The aim of the current study was to explore the relative contribution of parental depression, anxiety and stress and parenting satisfaction and efficacy to the explanation of variance in controlling parental feeding styles and practices. The sample comprised 124 mothers (M=36.80 years, SD=4.62 years) who reported on both themselves and a selected child (59 male, 65 female; M=6.46 years, SD=0.95 years). Mothers completed several questionnaires examining demographic information, parental feeding styles, parental feeding practices, parental depression, anxiety and stress and parenting satisfaction and efficacy. Parenting satisfaction contributed significantly to the prediction of the parental feeding practice pressure to eat. Parenting satisfaction and parental anxiety contributed significantly to the prediction of the parental feeding practice restriction. The results of this study provide important insight into maternal characteristics associated with the use of controlling parental feeding styles and practices.

Practicalities and Research Considerations for Conducting Childhood Obesity Prevention Interventions with Families

Internationally, childhood obesity is a major public health concern. Given the established difficulties in treating obesity, designing and evaluating effective obesity prevention interventions are research priorities. As parents play a crucial role in establishing positive health behaviours in children, they are a key target for child obesity prevention programs. However, recruiting and engaging parents in such interventions can be a considerable challenge for researchers and practitioners. Members of the ‘Parenting, Child Behaviour and Well-being’ stream of the Australasian Child and Adolescent Obesity Research Network (ACAORN) have considerable and varied expertise in conducting such interventions and can provide insights into addressing these challenges. This paper aims to highlight considerations regarding the design, implementation, and evaluation of obesity prevention interventions with families and provide practical insights and recommendations for researchers and practitioners conducting family-based research in this area. Case studies of three family-based interventions conducted by ACAORN members are highlighted to provide examples and contextualise the recommendations proposed.

Parent- and Adolescent-Reported Barriers to Participation in an Adolescent Overweight and Obesity Intervention

This study explored reported barriers to treatment completion in a sample of adolescents and their parents who either completed or did not complete family‐based cognitive behavioral lifestyle intervention for overweight and obese adolescents. The sample comprises 56 overweight or obese adolescents (52% female) aged 11.5–18.9 years (mean = 14.5, s.d. = 1.8) and a parent. 57% of families did not complete treatment and maintenance phases of the intervention. A telephone‐administered questionnaire assessing barriers to participation was completed by 96% of adolescents and 91% of parent completers and 100% of adolescents and 94% of parent noncompleters. Adolescents and parents most commonly reported barriers to participation related to research demands, treatment approach, program components/strategies, practical barriers, and other individual/family demands. Parents also noted adolescent effort, parent‐adolescent conflict, and adolescent unhappiness as barriers to participation. While both completers and noncompleters experienced barriers to participation, families who discontinued treatment reported experiencing more treatment barriers. Findings of the current study suggest that adolescents and parents may find it easier to participate in adolescent overweight and obesity interventions if research and out‐of‐session program demands are minimized, efforts are made to enhance adolescent motivation, and treatment is offered in a convenient location and scheduled around school holidays and other family demands. Results also suggest that targeting adolescent unhappiness, family stressors, and parent‐adolescent conflict in treatment may improve retention. Future research should explore the impact of these modifications on treatment completion and outcomes.

Measuring and reporting attrition from obesity treatment programs: A call to action!

The high attrition rates in obesity interventions are associated with poorer weight loss and maintenance for the individual and poorer overall treatment effectiveness and cost-effectiveness for the treatment provider. Increased knowledge about factors associated with attrition can facilitate the identification of individuals at risk of drop-out and inform treatment program improvements with the aim of maximising treatment retention. To date, a relatively small body of literature has explored attrition from weight-loss interventions using two methods of attrition assessment: identification of pre-treatment predictors of attrition and eliciting post-treatment reasons for attrition. A range of attrition rates have been reported and no reliable or consistent predictors of attrition have been found. It is unknown whether the lack of consistent findings reflects population or treatment differences, or if the discrepant findings simply reflect differences in definition and measurement of attrition. Further research is required to address these limitations. There is a need for a recognised definition of obesity treatment attrition, the consideration of predictors that are theoretically and empirically associated with attrition, the development of a well-validated and standardised measure of barriers to attendance, and assessment of both treatment completers and drop-outs. Understanding the factors that influence attrition can be used to inform the modification of treatment programs and to target those most at risk of drop-out so as to maximise the success of obesity interventions.