Thomas H. Inge

From adolescence to young adulthood: trajectories of psychosocial health following Roux-en-Y gastric bypass ☆

BACKGROUNDnRoux-en-Y gastric bypass (RYGB) in adolescence results in substantial bodyweight reduction and cardiometabolic benefits into young adulthood. Knowledge gaps remain in understanding psychosocial health.nnnOBJECTIVEnDescribe trajectories of weight and psychosocial health in adolescents who underwent RYGB into young adulthood.nnnSETTINGnAcademic Pediatric Medical Center.nnnMETHODSnFourteen adolescents (presurgery: mean body mass index = 59.2±8.9; mean age = 16.0±1.3 yr; 64.3% female) participated in 2 sequential observational studies. Height and weight were measured, and participants completed measures of weight-related quality of life (WRQOL), mental health, and adaptive functioning at presurgery and 6, 12, 18, 24, and 72+months postsurgery. Substance use behaviors were assessed at 72+months.nnnRESULTSnModeling demonstrated rapid improvement in body mass index and WROQL across postoperative year 1, followed by stabilization and modest weight regain/WRQOL decline (P<.001), with 50% remaining severely obese. Presurgery, 11 adolescents presented with symptoms outside of the normal range for≥1 mental health domain. Postoperative profiles indicated either remittance (n = 5) or persistent symptomatology (n = 6: anxious/depressed, withdrawn/depressed, and/or thought problems) in young adulthood. No new incidence of mental health vulnerability occurred in young adults not already identified preoperatively. Adaptive functioning and substance use were within normal range.nnnCONCLUSIONSnAlthough adolescent RYGB resulted in improvement in weight and WRQOL into young adulthood, mental health trajectories were more variable, with some experiencing positive change while others experienced persistent mental health vulnerability. Research focused on larger contemporary samples using a controlled design is critical to inform targets for prevention and intervention to optimize both physical and psychosocial health outcomes in this younger patient population.

Roux-en-Y gastric bypass surgery in youth with severe obesity: 1-year longitudinal changes in spexin

BACKGROUNDnSpexin is a novel peptide predominantly produced in human white adipose tissue and has recently been implicated as a potential signal in the regulation of body weight, energy homeostasis, and satiety. The effect of bariatric surgery on spexin is unknown.nnnOBJECTIVESnTo study the effect of Roux-en-Y gastric bypass (RYGB) surgery on endogenous spexin concentration and various risk factors of type 2 diabetes and cardiovascular disease in youth with severe obesity.nnnSETTINGnUniversity hospital, United States METHODS: Spexin, body mass index (BMI), insulin, glucose, total and high molecular weight adiponectin, leptin, and high sensitivity C- reactive protein were measured longitudinally (baseline, 6 mo, and 12 mo) after RYGB surgery in girls with severe obesity (nu202f=u202f12; ageu202f=u202f16.7 ± 1.5 years; BMIu202f=u202f51.6 ± 2.9 kg/m2).nnnRESULTSnSerum spexin concentration increased (Pu202f=u202f.01) at 6 months after surgery and stabilized afterward. Spexin level correlated negatively with homeostatic model assessment insulin resistance, HOMA-IR (Spearman correlation ru202f=u202f-.796, P < .001) and positively with high molecular weight adiponectin (Spearman correlation ru202f=u202f.691, Pu202f=u202f.011). The change in spexin concentration, from baseline to 6 months after surgery, was inversely correlated with the corresponding change in BMI (Spearman correlation ru202f=u202f-.573, Pu202f=u202f.051). Furthermore, the 6-month changes in spexin and HOMA-IR were inversely correlated (slope [standard error, SE]u202f=u202f-.0084 (.0019), Pu202f=u202f.001)], even after adjusting for the change in BMI.nnnCONCLUSIONSnThe enhancement of circulating spexin concentration in response to RYGB and correlations with beneficial postoperative changes in various adipokines in youth are novel findings that require further validation.

Assessing and Selecting Patients for Bariatric Surgery

The use of bariatric procedures in general appears to be steeply increasing in pediatric age groups over recent years, suggesting a need for appropriate assessment criteria prior to surgery and for prospectively and rigorously collected adolescent outcome data. As of yet, the scientific evidence base is not sufficiently robust to allow a precise discrimination of which procedures are optimal for adolescents. Indeed, experts have broadly characterized the quality of evidence for effectiveness and safety of adolescent bariatric surgery as fair to poor for all procedures that have been reported. Despite limitations in the evidence base, clinicians are faced with a need to manage myriad health problems in adolescents with extreme obesity and more recently, higher quality prospectively collected data have emerged documenting efficacy and safety of adolescent bariatric procedures. Recommendations for assessment and selection of adolescent patients that are thoughtfully derived from our knowledge of obesity and bariatric surgery provide useful tools for those faced with sometimes difficult treatment decisions.

Effect of bariatric surgery on urinary sphingolipids in adolescents with severe obesity

BACKGROUNDnUntreated severe obesity of adolescents is associated with abnormal kidney function and development of chronic kidney disease. Lipotoxicity due to lipid accumulation in glomeruli might be an important mechanism in the progression of kidney disease in obesity.nnnOBJECTIVEnTo assess subclinical glomerular injury by measuring urinary sphingolipids in adolescents with severe obesity before and after weight loss surgery. We hypothesized that the levels of urinary sphingolipids would be elevated at baseline and improve after weight reduction.nnnSETTINGnCincinnati Childrens Hospital Medical Center, University of Cincinnati.nnnMETHODSnTen adolescents undergoing bariatric surgery with no microalbuminuria and normal kidney function were selected. Urinary sphingolipids (ceramides, glycosphingolipids, and sphingomyelins) were quantified using ultra performance liquid chromatography electrospray ionization tandem mass spectrometry at baseline and 1 year postoperatively. The levels of sphingolipids were compared with lean and moderately obese controls.nnnRESULTSnParticipants with severe obesity had a mean baseline body mass index of 50 kg/m2 that decreased to 36 kg/m2 at 1 year postsurgery (28% reduction). Almost all urinary ceramides, glycosphingolipids, and sphingomyelin species were significantly elevated in participants with severe obesity compared with controls at baseline (P<.01). One year after weight loss surgery, levels of urinary sphingolipids improved but were still significantly elevated compared with controls.nnnCONCLUSIONSnOur study indicates that severe obesity is associated with increased urinary excretion of sphingolipids despite the absence of microalbuminuria or decreased kidney function. Urinary sphingolipids may therefore represent a marker of early (subclinical) glomerular injury in adolescents with severe obesity.

42 Bariatric Surgery in Adolescents

Recent data demonstrates that the prevalence and incidence of childhood obesity in the United States parallels the increasing trends of adult obesity. The immediate and long-term health consequences of obesity in childhood, coupled with the psychosocial and economic effects, continue to provide compelling arguments to perform bariatric surgery on adolescents to achieve aggressive weight loss. These consequences can have lasting effects into adulthood. In limited studies to date, most significant comorbidities of adolescent obesity, including sleep apnea, hypertension, type 2 diabetes, nonalcoholic steatohepatitis, dyslipidemias, cardiomyopathy, and psychosocial impairment, have been shown to be greatly improved or resolved following bariatric surgery. Surgery has also been shown to be safe with similar expected weight loss to their adult counterparts. The benefits of a multidisciplinary approach in adolescent weight management and bariatric surgery are the key to success. Ongoing long-term studies will help to shape the role of bariatric surgery and better define its use in the adolescent population.