Maureen E. Dixon

The Laparoscopic Adjustable Gastric Band (Lap-Band®): A Prospective Study of Medium-Term Effects on Weight, Health and Quality of Life

Background: Obesity is now one of our major public health problems. Effective and acceptable treatment options are needed.The Lap-Band® system is placed laparoscopically and allows adjustment of the level of gastric restriction. Methods: A prospective study of 709 severely obese patients was conducted over a 6-year period at a university-based multidisciplinary referral center. After extensive preoperative evaluation, patients with a body mass index >35 were treated by LapBand® placement. Close follow-up with progressive adjustment of gastric restriction continued permanently. Medical co-morbidities were monitored as part of comprehensive prospective data collection. Results: There have been no deaths perioperatively or during follow-up. Significant perioperative adverse events occurred in 1.2% only. Reoperation has been needed for prolapse (slippage) in 12.5%, erosion of the band into the stomach in 2.8% and for tubing breaks in 3.6%. A steady progression of weight loss has occurred through the duration of the study with 52 ± 19 %EWL at 24 months (n=333), 53±22 %EWL at 36 months (n=264), 52 ± 24 %EWL at 48 months (n=108), 54 ± 24 %EWL at 60 months (n=30), and 57 ± 15% EWL at 72 months (n=10). Major improvements have occurred in diabetes, asthma, gastroesophageal reflux, dyslipidemia, sleep apnea and depression. Quality of life as measured by Rand SF-36 shows highly significant improvement. Conclusions: Placement of the Lap-Band® system provides safe and effective control of severe obesity. The effect on weight loss is durable and is associated with major improvement in health and quality of life. It has the potential to provide a broadly acceptable option for this common and serious disease.

Pre-operative Predictors of Weight Loss at 1-Year after Lap-Band® Surgery

Background: The authors studied a range of preoperative factors for their predictive value of effectivenes of Lap-Band® placement, using the percentage of excess weight loss at 1-year as the outcome measure (%EWL1). Methods: All factors were measured and recorded prior to surgery. Factors included: patient demographics, family, medical and weight history. Laboratory measures and the responses to the SF36 Health Survey were also assessed. Factors were assessed for correlation with %EWL1. Results: The group (N=440, F:M 383:57) had mean age 40.0 ± 9.5 years, weight of 126 ± 25 kg, and BMI 45.6 ± 7.5 kg/m2 pre-operatively. At 1-year follow-up, the group had mean weight 97.6 ± 20 kg, BMI 35.6 ± 6.3 kg/m2, and %EWL1 45.8 ± 17%. Increasing age (R=-0.13, p<0.01) and preoperative BMI (R=-0.22, p<0.001) were significantly associated with less %EWL1 and all other factors were controlled for these before assessing significance. Important factors associated with a lower %EWL1 included: hyperinsulinemia (R=-0.36, p<0.001), insulin resistance (R=-0.33, p<0.001) and disease associated with insulin resistance, poor physical ability, pain, and poor general health responses to the SF-36 Health Survey. Patients who consumed alcohol regularly had a better rate of weight loss (R= 0.23, p<0.005). Factors that had no influence included gender, a history of mental illness and measures of mental health, previous bariatric surgery, and a history of many medical conditions associated with obesity. Conclusion: Important physical factors have been found to influence the rate of weight loss.Those with increased age, pain, physical disability and insulin resistance have a great deal to gain from weight loss. Although this study has identified factors that are associated with less weight loss, we have not found any factor that predicts an unacceptably low weight loss and thus provides a contraindication to Lap-Band® placement. The findings of this study allow us to set more realistic goals for the rate of weight loss in specified sub-groups of our patients.

Pregnancy after Lap-Band Surgery: Management of the Band to Achieve Healthy Weight Outcomes

Background: Severely obese women have higher obstetric risks and poorer neonatal outcomes. Weight loss reduces obstetric risk. The introduction of a laparoscopically-placed adjustable gastric band, a safe and effective method of weight loss, has given us the ability and responsibility to adjust the band in relation to pregnancy. Objective: Our aim was to devise a safe management plan to achieve healthy maternal weight gain (Institute of Medicine 1990) during pregnancy. Methods: In a cohort group of 650 patients to have a Lap-Band® placement for severe obesity, we have reviewed the management of the band and pregnancy outcomes of all women (n=20) to complete a pregnancy (n=22) with a band in-situ. Results: All 22 pregnancies were singleton, with no primary caesarean sections (3 for recurring indications). The mean maternal weight gain was 8.3 kg compared with 15.2 kg for the 15 previous pregnancies of women in this group (p<0.05). There was no difference in birth weights. Obstetric complications were minimal, and there were no premature or low birth weight infants. 11 of 15 subjects with active management of the band achieved a maternal weight gain within the advised range compared with only 2 of 7 prior to this. Conclusion:The ability to adjust gastric restriction allows optimal control of maternal weight change in pregnancy and should help avoid the risks of excessive weight change.

Body image: appearance orientation and evaluation in the severely obese. Changes with weight loss.

Background: The severely obese experience discrimination and embarrassment regarding their appearance, causing psychosocial distress. We assessed the importance of appearance, presentation and self-evaluation of appearance before and after weight loss, in severely obese subjects (BMI >35 kg/m2). Methods: Appearance orientation (AO) and appearance evaluation (AE) sections of the Multidimentional Body Self Relations Questionnaire were completed by preoperative patients and those attending an annual follow-up after Lap-Band® gastric restrictive surgery over a 2-year period. AO is a measure of the importance one places in appearance. AE is a self-evaluation of ones appearance. Results: Before surgery 322 consecutive patients (48 men and 274 women) completed the survey. AO was similar to that of community norms (mean scores 3.76 ± SD 0.6 vs 3.84 ± 0.6), with the exception of the super obese (BMI >50 kg/m2) who placed significantly less importance on their appearance (3.34, ± 0.8, p=0.001). There was no change in AO at 1-4 years after surgery, with the exception of the super obese whose mean values rose to normal by 1 year. AE was very low before surgery compared with community normal values (1.6 ± 0.6 vs 3.4 ± 0.8, p<0.001). Major improvement in mean AE was seen at 1 year after surgery (n=209, 2.6 ± 0.8, p<0.001) and the improvement was maintained out to 4 years.The change in AE from pre-surgery to 1 year (n=122 paired) correlated positively with the percentage of excess weight lost (r=0.32, p<0.01) and positively with measures of quality of life and psychological disturbance. Conclusion: Major improvements in appearance evaluation occur with weight loss after surgery and this is associated with psychological benefit.

Confirmatory factor analysis of the Beck Depression Inventory in obese individuals seeking surgery.

BackgroundThe Beck Depression Inventory (BDI) is frequently employed as measure of depression in studies of obesity. The aim of the study was to assess the factorial structure of the BDI in obese patients prior to bariatric surgery.MethodsConfirmatory factor analysis was conducted on the current published factor analyses of the BDI. Three published models were initially analysed with two additional modified models subsequently included. A sample of 285 patients presenting for Lap-Band® surgery was used.ResultsThe published bariatric model by Munoz et al. was not an adequate fit to the data. The general model by Shafer et al. was a good fit to the data but had substantial limitations. The weight loss item did not significantly load on any factor in either model. A modified Shafer model and a proposed model were tested, and both were found to be a good fit to the data with minimal differences between the two. A proposed model, in which two items, weight loss and appetite, were omitted, was suggested to be the better model with good reliability.ConclusionsThe previously published factor analysis in bariatric candidates by Munoz et al. was a poor fit to the data, and use of this factor structure should be seriously reconsidered within the obese population. The hypothesised model was the best fit to the data. The findings of the study suggest that the existing published models are not adequate for investigating depression in obese patients seeking surgery.

Reduced plasma homocysteine in obese red wine consumers: a potential contributor to reduced cardiovascular risk status.

Background: Moderate alcohol consumption is associated with improved vascular risk profile and decreased mortality in the middle aged. An elevated homocysteine concentration is an independent risk factor for cardiovascular disease.Objective: To examine the relationship between alcohol consumption and homocysteine concentrations in severely obese patients (body mass index (BMI)>35).Design: A careful alcohol history was obtained from 350 (male:female 1:5) consecutive patients as part of preoperative assessment for surgical treatment of obesity. Data were obtained concerning amount, frequency, timing and type of alcohol consumption. Fasting homocysteine, serum folate and vitamin B12 concentrations were measured. Differences between groups were assessed using Student t-test, and ANOVA. Linear regression was used to assess factors influencing homocysteine concentration.Results: There is a U-shaped relationship between alcohol consumption and homocysteine concentrations, with light to moderate consumption being associated with lower concentrations. Those consuming <100 g/week (n=165) of alcohol had geometric mean (95% CI of mean) serum homocysteine concentrations of 8.5 (8.2–8.9) μmol/l compared with 9.5 (9.1–9.9) μmol/l for non or rare consumers (n=153; P=0.001). The lower concentrations of homocysteine in regular consumers were associated with higher folate concentrations of 9.4 (8.6–10.2) ng/ml when compared with non-consumers 7.5 (7.1–7.8) ng/ml (P=0.001). Red wine consumers (n=42) had lower fasting concentrations of homocysteine 7.8 (7.5–8.1) μmol/l compared with 153 non-consumers 9.4 (9.0–9.8) μmol/l (P<0.001), 82 beer and spirit consumers 9.0 (8.4–9.7) μmol/l (P=0.005) and 73 white wine consumers 8.8 (8.2–9.4) μmol/l (P=0.013). Red wine consumption was an independent predictor for lower homocysteine concentrations.Conclusion: Mild to moderate alcohol consumption, especially red wine consumption, in obese subjects is associated with lower fasting homocysteine concentrations. This may reduce cardiovascular risk and help explain the ‘French paradox’.

Raised CRP Levels in Obese Patients: Symptoms of Depression Have an Independent Positive Association

Background: Depression and obesity, the two common ailments of modern society, are associated with increased risk of coronary artery disease and raised C‐reactive protein (CRP) levels. Are the effects of depression and obesity related or do they influence CRP levels independently?

Perceived discrimination and stigmatisation against severely obese women : age and weight loss make a difference

Aims: Patients’ perceptions about weight-related stigma and discrimination were assessed in 2 groups of patients, obese and laparoscopic adjustable gastric banding (LAGB). Methods: Seven focus group sessions were held including a total of 32 women, 8 obese (body mass index 35+) and 24 who had lost 50% of excess weight following bariatric surgery. During the sessions, participants were asked to consider their experiences in situations including general, family, friends, work place, medical, and educational settings. Results: Whilst perceptions of discrimination and stigmatisation were common and affected many life situations, they were less prevalent than previous reports. It appeared that it was not the frequency or number of events which affected an individual but the intensity of the experience. Younger women reported greater discrimination than older women and felt the social consequences of obesity to a greater extent. Older women were more concerned about the consequences of being overweight on their health. Conclusions: Women who had lost weight considered that aspects of their own behaviours when obese contributed to their experiences of discrimination and stigmatisation. Perceptions of discrimination and stigmatisation appear to be influenced by age and current weight status.

GPs, families and children's perceptions of childhood obesity

BACKGROUND Childhood obesity has a high risk of becoming a chronic disease requiring life-long weight management. Evidence based guidelines were developed and distributed to GPs throughout Australia by the NHMRC, but current application falls short. Measuring height and weight, and calculating BMI for children appears to be rare. Some general practitioners (GPs) perceive significant barriers to managing this patient cohort, and patients report not having confidence in their GPs. AIM To explore perceptions and experiences of treating childhood obesity of (i) GPs, (ii) families involved in a childhood obesity study in general practiceâ?? and (iii) families not involved in the project, but who had concerns about childhood obesity. METHODOLOGY Supported by the literature, a semi-structured schedule was developed to address the aims. Ten GPs and eight families involved, and four families previously not involved in the project participated in interviews in 2009. All family interviews were audio-taped and transcribed verbatim. Data were thematically analyzed. FINDINGS Five themes emerged: (1) raising the topic, (2) frustrations experienced by GPs and families, (3) support available for GPs to provide to families and/or anticipated by families, (4) successes from involvement in the project and (5) sustaining improvements â?? the GPsâ?? and familys perspectives. DISCUSSION AND CONCLUSION All acknowledged that childhood obesity is a sensitive issue with both GPs and parents preferring the other to raise the topic. GPs reported successes in practice and patient management such as improved patient records. For families, the GPs dedication and support were major factors sought.

Medical versus surgical interventions for the metabolic complications of obesity in children.

The global epidemic of obesity has not spared children. Although prevention of obesity is commendable, we cannot hide from the pressing need to identify, assess, and actively manage children seriously afflicted by obesity and its associated conditions. Sustained weight loss (or, for children, lowering of body mass index standard deviation score) delivers major health benefit, but in children has been difficult to achieve. In adults, the success of the diabetes prevention programs using practical lifestyle interventions is indisputable. Medical therapy, although currently limited in it scope, provides some promise for older children. There is now accumulating evidence, generally of poor quality that surgical interventions (laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass) provide excellent sustained weight loss and improvement in comorbidity and quality of life in selected older children. Their benefits in adults are well demonstrated. Surgery comes with risk, both immediate and in the future, as does severe obesity. Carefully weighing risk and benefit is challenging for the individual and for health service providers. Careful health outcomes research with registries and well-conducted trials will provide better direction in the future. In the meantime, we should move forward ethically and cautiously in providing more intensive obesity management in children.