Article

Weight loss and metabolic outcomes of bariatric surgery in men versus women — A matched comparative observational cohort study

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Abstract

Background: Despite the high prevalence of morbid obesity, the global frequency of bariatric surgery in men is significantly lower than in women. It is unclear if this is due to the perception of poorer outcomes in men. Objectives: Compare weight loss and metabolic outcomes in men vs. women after bariatric surgery. Setting: University teaching hospital in North West England. Methods: We performed an observational cohort analysis of 79 men matched to 79 women for baseline age (±5 years), body mass index (BMI; ±2 kg/m2), bariatric procedure (69 gastric bypass and 10 sleeve gastrectomy each), type 2 diabetes (33 each), and continuous positive airway pressure (CPAP) therapy for obstructive sleep apnoea (OSA; 40 each). Results: Overall mean (95% confidence interval) reduction in BMI was 17.5 (15.7–19.4) kg/m2 (P < 0.001) at 24 months. There was no significant difference between men and women in mean percentage excess BMI loss (65.8% vs. 72.9%) at 24 months. Likewise, there were significant reductions in blood pressure, glycosylated haemoglobin and total cholesterol-to-high density lipoprotein cholesterol overall but no significant gender differences. Postoperatively, 77.5% of men and 90.0% of women with OSA discontinued CPAP therapy (non-significant). Conclusions: Weight loss and metabolic outcomes after bariatric surgery are of similar magnitude in men compared to women. The use of bariatric surgery in eligible men should be encouraged.

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... The number of bariatric surgeries performed differed in men and women, and men had higher postoperative mortality and morbidity rates [24][25][26]. Several studies have described the reasons for these disparities [27][28][29]. Korner et al. [29] revealed a negative correlation between visceral adipose tissue and the degree of weight loss after bariatric surgery in women; however, the relationship was not significant in men. Additionally, females undergoing bariatric surgery had a significant decrease in inflammation, whereas no significant effect on inflammatory markers was observed in men with the same kind of weight loss [28]. ...
... Additionally, females undergoing bariatric surgery had a significant decrease in inflammation, whereas no significant effect on inflammatory markers was observed in men with the same kind of weight loss [28]. Another study pooled more subjects and showed no difference in weight loss or metabolic outcomes after bariatric surgery between men and women [27]. We also verified no differences in obesity or metabolic outcomes in patients with OSA. ...
... OSA is quite different from other diseases, as sex-specific differences exist in the relationship between OSA and cardiovascular disease [30]. Kennedy-Dalby et al. [27] focused on the same topic and enrolled more subjects, but the power analysis showed that even a smaller number of participants could detect a significant effect size. Several aspects differentiated their study from our study. ...
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Background: Roux-en-Y gastric bypass (RYGB) surgery is an effective therapy for obstructive sleep apnea (OSA). However, little attention has been paid to the treatment goals systematically stratified by sex. The objective of this study was to assess how sex differences affect obesity indices and metabolic outcomes after RYGB surgery. Methods: A sleep questionnaire was conducted and medical histories were taken. Full-night polysomnography (PSG), anthropometric variables, and blood samples were collected. Results: Thirty-five consecutive patients with OSA who underwent laparoscopic RYGB surgery were prospectively examined for at least 6 months were included in the study. Significant improvements (p < 0.01) in sleep parameters (except for micro-arousal), obesity indices, and metabolic outcomes [except low-density lipoprotein in men and high-density lipoprotein (HDL) in women] were obtained in men and women with OSA. Men had higher baseline triglyceride (TG) (p < 0.01) and lower HDL levels (p < 0.01) but a larger neck circumference (NC) (p = 0.03) at follow-up than did women. However, only TG in men improved more than in women (p = 0.02). Conclusions: Sleep parameters, obesity indices, and metabolic outcomes after RYGB surgery were of similar magnitude in women and men with OSA. Alleviating sleep and obesity problems was correlated with metabolic outcomes in men and women.
... However, there is evidence that highlights the absence of significant differences between men and women in the mean percentage of excess BMI loss after RYGB (Bekheit et al., 2014;Perrone et al., 2016), and also 24 months afterSG (65.8% kg/m² in men vs 72.9% kg/m² in women; Kennedy-Dalby et al., 2014). Although Tymitz, Kerlakian, Engel and Bollmer (2007) found no significant differences between men and women in their BMI after RYGB, male patients continued to weigh more and lost more pounds than females at 6 and 12 months post operation. ...
... When measuring improvements in comorbidities after SG and RYGB, studies showed great reductions but similar outcomes for both sexes (Kennedy-Dalby et al., 2014;Perrone et al., 2016). However, despite similar improvements in both sexes, remission rates of hypertension after AGB seem to be higher for female patients. ...
Chapter
Bariatric surgery has showed to be a successful weight loss treatment, which has been mainly performed on women. Sex entails differences on biological, behavioral and psychological features along with social-cultural factors that might be important in predicting outcomes after surgery, as well as on the (re)emergence of eating-related problems and psychopathology in the post-operative time. However, research addressing sex differences after bariatric surgery is scarce. The aim of this chapter is to summarize the existing literature on sex differences in obesity and bariatric surgery population. Men and women are biologically different in terms of body fat distribution and gonadal hormones. For example, male patients have higher body mass index and higher probability of developing medical complications following gastric bypass surgery in all weight ranges, whereas in women obesity-related risk factors, for instance pregnancy or menopause, may play a role in the physiological and behavioral consequences of appetite and weight regulation. These differences lead to diverse behaviors and attitudes towards food. Regarding eating behavior, although eating disorders, such as bulimia and anorexia nervosa, have been reported in men, they are usually more prevalent in women.. However, women tend to report higher levels of loss of control over eating, while men tend to report more overeating without loss of control. Women also tend to report more compensatory behavior such as vomiting or dieting. Likewise women tend to engage more often than man in body checking behaviors. In the psychological perspective, women are more likely to acknowledge a history of depression, social anxiety, psychological and psychiatric treatment. Furthermore women have more negative thoughts about themselves, and their weight has a greater influence on body image and self-esteem. Similarly, men and women differ on motivations for undergoing bariatric surgery. Considering all of these aspects, clinical practice and follow-up evaluation should be sex adjusted, and sex should be investigated as a predictor of adjustment to treatment, quality of live and psychological distress after surgery. Understanding such differences and their impact would allow the development of tailored assessment and interventions pre- and post-surgery.
... Both cohorts lost a significant amount of preoperative weight (Table 1). This was achieved within a median of 18 weeks (IQR [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28]. Weight loss at 1 year was for both procedures substantial (SG −12.6 kg/m 2 , GBP −13.7 kg/ m 2 ). ...
... Findings in the literature of gender on postoperative weight loss also remain controversial. Some studies found no difference [18,19], others found greater weight loss in men [20,21] and other authors suggested more benefit for females [22]. An explanation could be that predictors for weight loss are different for men and women [23]. ...
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PurposeWeight loss before bariatric surgery is not mandatory, but questions remain as to whether preoperative weight loss has an impact on weight loss after surgery. Most studies have small sample sizes. The objective was to evaluate the relationship between preoperative and successful postoperative weight loss defined as ≥25% total weight loss (TWL) at 1 and 2 years after primary bariatric surgery with regard to the obesity-related comorbidities.Materials and Methods Data were extracted from a large nationwide quality registry of patients who underwent a sleeve gastrectomy (SG) or gastric bypass (GBP) between January 2015 and January 2018. Patients with completed screening and preoperative and postoperative data were included. A multivariate logistic regression analysis was performed for each technique and follow-up years separately.ResultsIn total, 8751 were included in the analysis. Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL in both procedures. Patients with higher preoperative weight loss of 5–10% had an increased likelihood for achieving 25% TWL compared to 0–5%, OR 1.79 (CI (1.42–2.25), p < 0.001) vs 1.25 (CI (1.08–1.46), p < 0.004) for the GBP group for year 2 postoperative. This was the same for the SG group at year 2, OR 1.30 (CI (1.03–1.64), p < 0.029) vs 1.14 (CI (0.94–1.38), p < 0.198).Conclusion Patients with preoperative weight loss were more likely to achieve ≥25% postoperative TWL at 1 and 2 years after surgery in both procedures; moreover, the extent of preoperative weight loss contributes to the significance and odds of this success.Graphical abstract
... The main findings show that RYGB induced, in both sexes, an improvement in the nutritional profile and a reduction in risk factors for cardiovascular and metabolic diseases associated with obesity. The study portrayed a greater number of male patients who underwent bariatric and metabolic surgery for RYGB, which at least for this technique contradicts the overall frequency of predominance of bariatric and metabolic surgery by women as reported in the literature (19). ...
... Notably, the positive outcomes observed were similar between men and women undergoing RYGB bariatric and metabolic surgery when we consider the classic anthropometric parameters expected after the procedure such as rapid weight loss, reduced BMI and morbidities related to the degree of obesity, reduction cardiovascular risk is seen by the smaller abdominal perimeter and an increase in the %WL (19)(20)(21). ...
Article
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BACKGROUND: Roux-en-Y gastric bypass surgery (RYGB) is the most applied technique in the treatment of severe obesity worldwide. However, its impact on anthropometric parameters and the risk for cardiometabolic diseases in obese patients is uncertain. OBJECTIVE: To evaluate anthropometric clinical parameters and the evolution of risk factors for obesity-related diseases in individuals of both sexes undergoing RYGB. METHODOLOGY: Sixty-nine adults subjects from both sexes submitted to RYGB surgery treatment were divided into 3 groups: G1(<13 months, n=24); G2 (>13 and <25 months, n=21), and G3 (>25 and <37 months, n=24). Sociodemographic and anthropometric information before and after surgery were collected. The abdominal perimeter was used in the classification of cardiometabolic risk and the BMI was used for the risk of obesity-related diseases. Hypotheses were tested by Student's t-test and ANOVA, and the significance level adopted was 5%. RESULTS: The average age was 36.0±10.0 years, with 69.6% being male and 30.4% female. Anthropometric parameters (weight, BMI, and abdominal circumference) were higher among women, except for weight loss and percentage of weight loss. There was a difference in weight loss between the sexes in the moments before and after RYGB. There was a decrease in the risk of disease due to obesity and cardiovascular diseases after RYGB. Weight loss and %WL were greater years by year in the short term of 3 years after surgery. CONCLUSION: RYGB proved to be an effective strategy for both sexes in combating obesity, providing in the short term a significant improvement in clinicalanthropometric parameters and reduction of risk factors for obesity-related cardiometabolic diseases. keywords: Bariatric Surgery, Severe obesity, Nutritional and metabolic diseases
... A recent meta-analysis (48 studies, 6077 partic- ipants) showed a significant reduction in LDL-C by 1-month post-operatively (standardised mean difference -0.92, 95% CI: -1.31 to -0.52) with the effect being maintained in the longer-term [132]. Indeed, in addition to improvements in the lipid profile, bariatric surgery induced weight loss is also associated with significant improvements in systemic inflammation, insulin resistance, mediators of vascular inflammation, vascular function, perivascular adipose tissue inflammation and adipose tissue anticontractile properties [133][134][135]. Interestingly, obesity complicated by obstructive sleep apnoea (OSA) is associated with a more pronounced impairment of HDL function, systemic and adipose tissue inflammation [136]. ...
... Interestingly, obesity complicated by obstructive sleep apnoea (OSA) is associated with a more pronounced impairment of HDL function, systemic and adipose tissue inflammation [136]. Given the marked improvement seen in OSA itself after bariatric surgery [134,137,138], it may also improve the associated lipoprotein and inflammatory disturbance. ...
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Hypercholesterolaemia is amongst the most common conditions encountered in the medical profession. It remains one of the key modifiable cardio-vascular risk factors and there have been recent advances in the risk strati-fication methods and treatment options available. In this review, we provide a background into hypercholesterolaemia for non-specialists and consider the merits of the different risk assessment tools available. We also provide detailed considerations as to: i) when to start treatment, ii) what targets to aim for and iii) the role of low density lipoprotein cholesterol.
... This sex effect on CRC risk could be due to differences in dietary quality, sex hormones, fat deposition, or other factors [6][7][8]. In that regard, bariatric surgery offers a substantial, long-lasting weight reduction that appears to be similar in males and females with severe obesity [9][10][11][12]. As a result, bariatric surgery can serve as a critical tool to study the impact of weight loss on CRC risk and if that effect varies by sex. ...
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Purpose Sex differences exist in the associations between obesity and the risk of colorectal cancer (CRC). However, limited data exist on how sex affects CRC risk after bariatric surgery. Materials and Methods This retrospective cohort study used the 2012–2020 MarketScan database. We employed a propensity-score-matched analysis and precise coding to define CRC in this nationwide US study. Adjusted hazards ratio (HR) assessed CRC risk ≥ 6 months. In a restricted analysis, logistic regression with adjusted odds ratios (OR) examined CRC risk ≥ 3 years. Results Our sample included 327,734 controls with severe obesity and 88,630 patients with Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (VSG). The odds of cessation of diabetes mellitus medications, a surrogate for diabetes remission, were higher post-surgery vs. controls, especially in RYGB and males. In females, CRC risk decreased post-RYGB compared to controls (HR = 0.40, 95%CI: 0.18–0.87, p = 0.02). However, VSG was not associated with lower CRC risk in females. Paradoxically, in males compared to controls, CRC risk trended toward an almost significant increase, especially after 3 years or more from surgery (OR = 2.18, 95%CI: 0.97–4.89, p = 0.06). Males had a higher risk of CRC, particularly rectosigmoid cancer, than females after bariatric surgery (HR = 2.69, 95% CI: 1.35–5.38, p < 0.001). Furthermore, diabetes remission was not associated with a lower CRC risk post-surgery. Conclusion Our data suggest an increased risk of CRC in males compared to females after bariatric surgery. Compared to controls, there was a decrease in CRC risk in females’ post-RYGB but not VSG. Mechanistic studies are needed to explain these differences. Graphical abstract
... Outcomes at 5-year follow-up are also maintained [94]. For instance laparoscopic Roux-en-Y gastric bypass could be an effective treatment method in the management of OSAS patients reducing AHI and BMI [95]. A. Kennedy-Dalby and coworkers in 2014 report that postoperatively, 77.5% of men and 90.0% of women with OSAS stopped CPAP therapy [96]. 18 months after bariatric surgery 75% of patients had full resolution of OSAS [97]. ...
Article
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Obstructive sleep apnea/hypopnea syndrome (OSAS) is a relatively new disease which is proven to be a major cause of morbidity and mortality worldwide and a huge problem for public health. Type 2 diabetes (T2DM) is another disease which is worldwide seen as an epidemic. The link between these two conditions makes it more important to provide a proper treatment option for such patients in order to prevent life threatening complications. This article is an up-to-date review of the relationship between OSAS and T2DM, diagnostic procedures and treatment options for patients who have both of the diseases since every particular case may be adjusted differently and may benefit from a multiple line treatment.
... This eliminates practice variability as a cause of differences between the groups. In the matching of gender, many studies have shown variable results [8][9][10][11]. Our design of a matched cohort helps us eliminate this factor as we have the same ratio of females to males. The most consistent predictor of postoperative weight loss outcomes is preoperative BMI [9,10,[12][13][14]. ...
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Background: The Roux-en-Y gastric bypass (GBP) has been considered the gold standard for many years. The loop duodenal switch (LDS) is a relatively new procedure that simplifies the complexity of the duodenal switch (BPDDS) by making it a single anastomosis procedure while at the same time giving it more intestinal absorption to reduce the rates of malnutrition associated with traditional BPDDS. This paper seeks to compare the 18-month weight loss outcomes and complications of the more standard GBP with the newer LDS in a single US center. Methods: A retrospective matched cohort was analyzed on 108 patients who had either GBP (54 patients) or LDS (54 patients). Regression analysis was used to compare weight loss outcomes as measured by BMI and weight loss percentages. Complications gathered included bleeds, reoperations, diagnostic or therapeutic endoscopy (EGD), ulcers and chronic nausea. Results: GBP and LDS have statistically similar weight loss at 18 months (39.6 vs 41 % weight loss, respectively). However, there were significantly more nausea complaints (26 vs 5), diagnostic endoscopies (EGD) (21 vs 3) and ulcers (6 vs 0) with the GBP than the LDS. Conclusion: LDS has comparable weight loss results to GBP. However, LDS has fewer 30-day and 18-month complications and patients suffer from less nausea postoperatively.
... This observation refers to the discontinuation of OSA treatment due to authentic recovery. Regarding gender, a recent study by Kennedy-Dalby et al. [30] looked at potential differences in weight loss or metabolic improvement after bariatric surgery in 70 men and 70 matched women. Among them, 80 patients (40 men matched to 40 women) presented with OSA treated with CPAP preoperatively. ...
Article
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Background Uncontrolled studies looking at the discontinuation of obstructive sleep apnea (OSA) treatment after bariatric surgery (BS) have suggested that surgery improves OSA. However, this discontinuation of OSA treatment by BS patients has never been compared to a matched population without BS. The objectives of this study are to evaluate whether BS increases OSA treatment discontinuation compared to that in matched patients without BS and to identify predictive factors of OSA treatment discontinuation in BS patients. The study took place in an ambulatory, tertiary hospital. Methods We included 61 OSA patients who underwent BS in a retrospective controlled cohort study. The computerized matching procedure included age, sex, body mass index, year of starting OSA treatment, treatment type, and duration selected 59 controls matched to 28 patients with BS. The main outcome was OSA treatment discontinuation within 2 years after BS. Results Patients with BS stopped OSA treatment more often than controls, usually between 6 months and 1 year after BS: hazards ratio (HR (95 %, CI)) 15.93 (3.29, 77.00). Before 6 months or beyond 1 year after BS, treatment discontinuation was not different between BS patients and controls. In univariate analyses, female gender, absence of co-morbidities, greater weight loss, and lower baseline OSA severity were associated with stopping OSA treatment after BS. No factor remained independently associated in multivariate analysis. Conclusions Apneic patients having BS stop OSA treatment more than matched controls. Treatment discontinuation may be attributed to recovery or to abandonment. The effect of BS on OSA may have been overestimated in uncontrolled BS studies that ignored basal OSA treatment discontinuation in routine clinical practice.
... This eliminated practice variability as a cause of differences between the groups. [10][11][12][13]. The matched cohort based upon gender helped eliminate this is as a factor in differences in results. ...
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Background In bariatric surgery, the procedure with the highest average weight loss is the biliopancreatic diversion with duodenal switch (BPDDS). A new simplified duodenal switch called the stomach intestinal pylorus sparing (SIPS) surgery with less malabsorption and one fewer anastomosis claims to have similar outcomes when compared to the BPDDS. MethodsA retrospective matched cohort analysis of SIPS versus BPDDS patients in a single private practice was obtained by matching every BPDDS to a SIPS patient of the same gender and BMI. Excess weight loss percentage (EWL), BMI, and percentage total weight loss (%TWL) were compared. Additionally, comorbidity resolution, nutritional data, and complications were also compared. Data was analyzed using both descriptive and comparative statistics. ResultsOver 2 years, there was no statistical difference in weight loss between BPDDS and SIPS. There also was no difference in nutritional data between the two procedures pre- and post-op. Complication rates were lower in SIPS however, due to the small sample sizes this is not statistically significant. Conclusion Weight loss and nutritional results between SIPS and BPDDS are similar at 2 years. However, there are fewer complications with SIPS.
... Our results present poor eating and lifestyle behaviors among candidates for LSG. Similar to previous studies, we found a significant disparity between genders in the uptake of bariatric surgery with the majority of bariatric surgeries being performed in women [14,15]. In addition, we also found that the prevalence of pre-surgery comorbidities is higher in men compared to women, as was previously reported [14,16]. ...
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IntroductionIdentifying eating and lifestyle behaviors prior to bariatric surgery may assist in better selecting and preparing patients and might lead to improved success rate. The current study aimed to assess eating behaviors and lifestyle trends among laparoscopic sleeve gastrectomy (LSG) candidates and to compare those trends between genders. Methods This descriptive study was conducted in the bariatric clinic at the Haifa Assuta Medical Center. Data was gathered from medical records of LSG candidates that were evaluated before surgery in our institution between 2008 and 2011. The data included demographics, comorbidities, anthropometrics, weight management history, and lifestyle parameters. Eating pattern and eating habits were determined by eating habits questionnaires. ResultsA total of 266 LSG surgery candidates (71.4 % female) with an average age of 40.7 ± 10.9 years and pre-surgery BMI of 42.4 ± 4.8 kg/m2 were studied. More than half of the patients have family history of obesity and their onset of obesity was before the age of 18 years (54.5 and 57.9 %, respectively). Most of the patients reported on poor eating habits and sedentary lifestyle: 65.1 % do not eat regular meals, 70.3 % skip over breakfast, 61.9 % presented loss of control eating, 45 % frequently consume sweets, and 80.1 % were classified as none active. There were no differences in eating patterns or lifestyle parameters between genders. Conclusion High occurrence of unhealthy eating habits and a non-active lifestyle were detected in morbid obese candidates for LSG surgery. More efforts should be directed towards nutritional and lifestyle education prior to the surgery.
... It is only to this extent of physiology that most clinical studies have probed and they report similar responses to surgery between men and women. While some studies have observed similar clinical responses to bariatric surgery between men and women [27], exploration of the bariatric outcomes longitudinal database (BOLD) did find that sex contributed to the variability of surgical outcome [28]. However, a true physiological comparison of the responses to surgery in men vs. women is limited by the small number of male patients in addition to the need for the appropriate resources for these studies. ...
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Background Eighty percent of patients who receive bariatric surgery are women, yet the majority of preclinical studies are in male rodents. Because sex differences drive hepatic gene expression and overall lipid metabolism, we sought to determine whether sex differences were also apparent in these endpoints in response to bariatric surgery. Methods Two cohorts of age-matched virgin male and female Long-Evans rats were placed on a high fat diet for 3 weeks and then received either Sham or vertical sleeve gastrectomy (VSG), a surgery which resects 80% of the stomach with no intestinal rearrangement. ResultsEach sex exhibited significantly decreased body weight due to a reduction in fat mass relative to Sham controls (p < 0.05). Microarray and follow-up qPCR on liver revealed striking sex differences in gene expression after VSG that reflected a down-regulation of hepatic lipid metabolism and an up-regulation of hepatic inflammatory pathways in females vs. males after VSG. While the males had a significant reduction in hepatic lipids after VSG, there was no reduction in females. Ad lib-fed and fasting circulating triglycerides, and postprandial chylomicron production were significantly lower in VSG relative to Sham animals of both sexes (p < 0.01). However, hepatic VLDL production, highest in sham-operated females, was significantly reduced by VSG in females but not males. Conclusions Taken together, although both males and females lose weight and improve plasma lipids, there are large-scale sex differences in hepatic gene expression and consequently hepatic lipid metabolism after VSG.
... Males: 51% ± 12% Females: 71% ± 13% Fig. 1 Excess weight loss among nine couples by gender at the 1year postoperative visit. Among the nine couples where both partners underwent the same type of bariatric surgery, women lost significantly more excess weight than men at the 1-year mark Previous studies have described conflicting results regarding whether women lose more weight than men [2,10]. As partners in 34 of 35 couples reported the same residential address and likely had similar support networks associated with being married, our study offered a unique opportunity to assess weight loss by gender. ...
Article
There exists marked variation in weight loss among the 200,000 annual bariatric patients, and many of these patients struggle with weight regain. Several studies have suggested that positive social support may significantly impact bariatric surgery outcomes, leading to more excess weight loss and maintenance of this weight loss through appropriate lifestyle changes. We sought to understand this by assessing clinical and behavioral outcomes among married couples whereby both spouses underwent bariatric surgery at our institution. In our case series, we found evidence that married couples meet or exceed postoperative weight loss milestones at 12, 18, and 24 months and did not show signs of weight regain as a group at 18 or 24 months. Among partners who underwent the same clinical pathway at our single institution, women tended to lose more weight than men at 12 months. Additionally, while there was significant variation in postoperative follow-up among patients, we found that partners within couples typically exhibited the same behavior with respect to postoperative visits when they had their surgeries within a year of each other. This case series suggests that partnered patients undergoing bariatric surgery can meet or exceed weight loss outcomes and may practice similar follow-up adherence.
... It has also been shown to be a cost-effective treatment for obesity [19,20]. Globally, more women than men undergo bariatric surgery [14,18,21], commonly in women of childbearing age [13,22,23]. Whilst bariatric surgery can improve fertility and maternal outcomes for obese women [24][25][26], patients may encounter complications during pregnancy attributable to bariatric surgery [27]. ...
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The widespread use of bariatric surgery for the treatment of morbid obesity has led to a dramatic increase in the numbers of women who become pregnant post-surgery. This can present new challenges, including a higher risk of protein and calorie malnutrition and micronutrient deficiencies in pregnancy due to increased maternal and fetal demand. We undertook a focused, narrative review of the literature and present pragmatic recommendations. It is advisable to delay pregnancy for at least 12 months following bariatric surgery. Comprehensive pre-conception and antenatal care is essential to achieving the best outcomes. Nutrition in pregnancy following bariatric surgery requires specialist monitoring and management. A multidisciplinary approach to care is desirable with close monitoring for deficiencies at each trimester.
... 4 The majority of individuals who use weight loss programmes, including bariatric surgery, are women. 5,6 Investigating whether outcomes differ between men and women is import in developing gender-specific treatment programmes, if required. [6][7][8][9][10][11][12] Differences in outcome after weight loss have been reported previously, with men commonly losing more body weight and fat than women. ...
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Aims: The PREVIEW lifestyle intervention study (ClinicalTrials.gov Identifier: NCT01777893) is, to date, the largest, multinational study concerning prevention of type-2 diabetes. We hypothesized that the initial, fixed low-energy diet (LED) would induce different metabolic outcomes in men vs women. Materials and methods: All participants followed a LED (3.4 MJ/810 kcal/daily) for 8 weeks (Cambridge Weight Plan). Participants were recruited from 8 sites in Europe, Australia and New Zealand. Those eligible for inclusion were overweight (BMI ≥ 25 kg/m2 ) individuals with pre-diabetes according to ADA-criteria. Outcomes of interest included changes in insulin resistance, fat mass (FM), fat-free mass (FFM) and metabolic syndrome Z-score. Results: In total, 2224 individuals (1504 women, 720 men) attended the baseline visit and 2020 (90.8%) completed the follow-up visit. Following the LED, weight loss was 16% greater in men than in women (11.8% vs 10.3%, respectively) but improvements in insulin resistance were similar. HOMA-IR decreased by 1.50 ± 0.15 in men and by 1.35 ± 0.15 in women (ns). After adjusting for differences in weight loss, men had larger reductions in metabolic syndrome Z-score, C-peptide, FM and heart rate, while women had larger reductions in HDL cholesterol, FFM, hip circumference and pulse pressure. Following the LED, 35% of participants of both genders had reverted to normo-glycaemia. Conclusions: An 8-week LED induced different effects in women than in men. These findings are clinically important and suggest gender-specific changes after weight loss. It is important to investigate whether the greater decreases in FFM, hip circumference and HDL cholesterol in women after rapid weight loss compromise weight loss maintenance and future cardiovascular health.
... Long-term data on diet or physical activity after surgery were not available, and the male sample size was smaller than the female sample size (mostly in the LRYGB group), reflecting that fewer men than women choose bariatric surgery [1,7]. In this regard, Kennedy-Dalby et al. [21] observed that the global frequency of bariatric surgery is significantly lower in men than in women, despite the high prevalence of morbid obesity. It is unclear whether this is due to the perception of poorer outcomes in men. ...
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Gender might be important in predicting outcomes after bariatric surgery. The aim of the study was to investigate the influence of gender on long-term weight loss and comorbidity improvement after laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB). A cohort of 304 consecutive patients underwent surgery in 2006-2009: 162 (98 women, 64 men) underwent LSG and 142 (112 women, 30 men) underwent LRYGB. The mean follow-up time was 75.8 ± 8.4 months (range, 60-96 months). Overall mean (95 % CI) reduction in BMI was 23.5 (24.3-22.7) kg/m(2) after 5 years, with no statistical difference between LSG and LRYGB groups (P = 0.94). The overall means ± standard deviations of %EBMIL after 5 years were 78.8 ± 23.5 and 81.6 ± 21.4 in the LSG and LRYGB groups, respectively. Only for LSG group %EBMIL after 24-36 and 60 months differed significantly between male and female patients (P = 0.003 versus P = 0.06 in LRYGB), and 89 versus 90 % of patients showed improvements in comorbidities in the LSG and LRYGB groups, respectively. Only two patients (women) were lost to follow-up: 1/162 (0.6 %) for LSG at the 4th year and 1/142 (0.7 %) for LRYGB to the 5th year. LSG was more effective in obese male than in female patients in terms of %EBMIL, with no difference in comorbidities. LRYGB elicited similar results in both genders in terms of %EBMIL and comorbidities.
... Benaiges et al. showed that the number of the anti-hypertension drugs taken prior to surgery and a slower weight loss, but not age or sex, were associated with lower hypertension remission rates after 12 months and a higher disease recurrence rate 36 months after surgery 16 . In a single-center study on 79 men and 79 women matched for age, preoperative BMI, diabetes mellitus, the type of bariatric procedure, and obstructive sleep apnea, no significant sex differences were noted comparing EBMIL%, blood pressure, and HbA1C reduction at 24-month postoperatively 17 www.nature.com/scientificreports/ In this study, we noted no sex differences regarding the length of postoperative hospital stay. ...
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Men have been historically considered to be higher-risk patients for bariatric surgery compared to women, the perception of which is suggested to be a barrier to bariatric surgery in men. The purpose of this study is to conduct a matched-pair analysis to evaluate sex disparities in laparoscopic bariatric surgery outcomes. Data on patients who underwent laparoscopic bariatric surgery from March 2013 to 2017 was collected prospectively. Then, 707 men and 707 women pair-matched for age, preoperative body mass index (BMI) and the procedure type (i.e., sleeve gastrectomy, Roux-en-Y, or one-anastomosis gastric bypass) were compared in terms of weight loss, remission of obesity-related comorbidities, and postoperative complications classified according to the Clavien–Dindo classification. There was no difference between the two sexes regarding the operation time, bleeding during surgery and length of postoperative hospital stay. We observed similar total weight loss, BMI loss, and percentage of excess BMI loss at 12, 24, and 36 months postoperatively between men and women, with no difference in remission of diabetes mellitus, hypertension and dyslipidemia at 12 months. The rate of in-hospital, 30-day and late complications according to Clavien–Dindo classification grades was similar between men and women. Our matched-pair cohort analysis demonstrated that bariatric surgery results in comparable short- and mid-term efficacy in men and women, and is associated with similar rate and severity of postoperative complications between sexes. These findings suggest bariatric surgeons not to consider sex for patient selection in bariatric surgery.
... Similar to the knowledge gap about the safety of weight loss surgery, differential referral for and utilization of bariatric surgery by men and women may also be founded in a lack of knowledge, on the part of both providers and patients, surrounding the effectiveness of weight loss and health risk reduction with surgery. Kennedy-Dalby et al. [35] sought to compare sex-based outcomes in an observational cohort analysis of 79 men matched to 79 women for age, BMI, bariatric procedure, and comorbidities including type 2 diabetes and obstructive sleep apnea. At 24 months postoperatively, significant reductions in excess BMI loss were identified for both women and men (72.9% and 65.8%, respectively). ...
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Obesity is a growing epidemic affecting more than one third of the United States’ population. It has detrimental effects on an individual’s health and is associated with myriad negative outcomes including increased mortality. It also poses a substantial financial burden on the healthcare system. Weight loss surgery is an effective way of treating obesity with tremendous positive outcomes. Most patients who undergo bariatric surgery lose a significant amount of weight, reverse most of their comorbidities, and enjoy an improved quality of life. However, fewer than one percent of patients eligible for bariatric surgery actually undergo treatment. Furthermore, there exists a considerable gender disparity, with women comprising 80% of those patients who undergo bariatric surgery, despite equal obesity rates across genders. Many barriers exist between obese patients and weight loss surgery including misconceptions among patients and primary care providers regarding the perceived risk of surgery. This is in addition to numerous other psychosocial and cultural factors that may have contributed to and precipitated the existing gender imbalance. This review aims to highlight barriers to patients undergoing bariatric surgery and examine factors leading to the gender disparity that exists.
... Taken together, it seems that the impact of preoperative eGFR on weight loss response to bariatric surgery is independent of the type of procedure. Finally, our findings regarding the impact of gender on post-bariatric weight loss were in contrast with those of previous studies reporting either gender as ineffective or male gender as a predictor of lower postbariatric weight loss [9,11,28]. ...
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IntroductionSevere obesity can lead to progressive kidney injury and chronic kidney disease (CKD). The current study aimed at determining whether preoperative kidney function level in patients with estimated glomerular filtration rate (eGFR) ≥30 mL/min affects weight loss after bariatric surgery.MethodsA total of 1958 bariatric patients underwent laparoscopic sleeve gastrectomy and gastric bypass from March 2013 to March 2017. The patients were categorized according to preoperative eGFR (30–59, 60–89, 90–124, and ≥ 125 mL/min). Changes in body mass index (BMI), percentage of total weight loss (TWL%), and percentage of excess weight loss (EWL%) were compared across the eGFR categories. Moreover, multivariable logistic regression analysis was used to evaluate the relationship between eGFR and insufficient weight loss (defined as not achieving 50% EWL at 12 months after surgery).ResultsPreoperative eGFR was positively associated with unadjusted ΔBMI (P trend < 0.001), TWL% (P trend < 0.001), and EWL% (P trend = 0.007) after 12 months of surgery. However, these associations were no longer significant after multivariable adjustment. Further, univariate analysis demonstrated a positive relationship between preoperative eGFR and insufficient weight loss (odds ratio [OR] 1.38; 95% confidence interval [CI] 1.11–1.71; P = 0.004). By contrast, preoperative eGFR was not a predictor of insufficient weight loss in multivariable logistic regression analysis (OR 0.98; 95% CI 0.46–1.24; P = 0.886).Conclusion Although patients with lower preoperative eGFR experience less weight loss after bariatric surgery, preoperative kidney function does not appear to have an independent impact on postoperative weight loss in patients with eGFR ≥ 30 mL/min.
... An English survey analyzed the outcome of bariatric surgery in men and women. After matching the patients for age, BMI, diabetes, insulin, and continuous positive airway pressure (CPAP) treatment, there were no significant differences in outcome regarding weight loss and improvement of obesity-related comorbidities [131]. ...
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This systematic literature review aims to point out sex-specific special features that are important in the bariatric treatment of women suffering from severe obesity. A systematic literature search was carried out according to Cochrane and Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) guidelines. After the literature selection, the following categories were determined: sexuality and sexual function; contraception; fertility; sex hormones and polycystic ovary syndrome; menopause and osteoporosis; pregnancy and breastfeeding; pelvic floor disorders and urinary incontinence; female-specific cancer; and metabolism, outcome, and quality of life. For each category, the current status of research is illuminated and implications for bariatric treatment are determined. A summary that includes key messages is given for each subsection. An overall result of this paper is an understanding that sex-specific risks that follow or result from bariatric surgery should be considered more in aftercare. In order to increase the evidence, further research focusing on sex-specific differences in the outcome of bariatric surgery and promising treatment approaches to female-specific diseases is needed. Nevertheless, bariatric surgery shows good potential in the treatment of sex-specific aspects for severely obese women that goes far beyond mere weight loss and reduction of metabolic risks.
... This potentially indicates a significant role of obesity as a cardiometabolic risk, mediated via compromising HDL properties. We also show, in keeping with our previous studies, marked improvements in BMI, insulin resistance, hyperglycaemia, inflammation and the lipid profile [25,[35][36][37]. ...
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Purpose Autoantibodies against apolipoprotein A-1 have been associated with cardiovascular disease, poorer CV outcomes and all-cause mortality in obese individuals. The impact of bariatric surgery (BS) on the presence of circulating anti-apoA-1 IgG antibodies is unknown. This study aimed to determine the effect of bariatric surgery on auto-antibodies titres against Apolipoprotein A-1 (anti-apoA-1 IgG), looking for changes associated with lipid parameters, insulin resistance, inflammatory profile and percentage of excess body mass index loss (%EBMIL). Materials and Methods We assessed 55 patients (40 women) before, 6 and 12 months post-operatively. Baseline and post-operative clinical history and measurements of body mass index (BMI), serum cholesterol, triglycerides, high- and low-density lipoprotein cholesterol (HDL-C and LDL-C), apoA-1, highly sensitive C-reactive protein (hsCRP), fasting glucose (FG), glycated haemoglobin (HbA1c) and HOMA-IR were taken at each point. Human anti-apoA-1 IgG were measured by ELISA. Results The mean age of participants was 50 years. BS significantly improved BMI, %EBMIL triglycerides, HDL-C, apoA-1, hsCRP, HBA1c, FG and HOMA-IR. Baseline anti-apoA-1 IgG seropositivity was 25% and was associated with lower apoA-1 and higher hsCRP levels. One year after BS, anti-apoA-1 IgG seropositivity decreased to 15% (p = 0.007) and median anti-apoA-1 IgG values decreased from 0.70 (0.56–0.84) to 0.47 (0.37–0.61) AU (p < 0.001). Post-operative anti-apoA-1 IgG levels were significantly associated with a decreased post-surgical %EBMIL at 1 year. Conclusion Bariatric surgery results in significant reduction in anti-apoA-1 IgG levels, which may adversely influence weight loss. The exact mechanisms underpinning these results are elusive and require further study before defining any clinical recommendations. Graphical abstract
... Despite similar obesity rates in men and women, women comprise 80% of bariatric surgical patients [77]. In an observational cohort study comparing outcomes of bariatric surgery in men and women, of those with OSA preoperatively, 77.5% (31/40) men and 90% (36/40) women were able to discontinue CPAP postoperatively [78]. ...
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... A systematic review comprising 79 women matched to 79 men showed no difference in sustained reduction of BMI and metabolic markers (BP, HbA1c, cholesterol:HDL) at 2 years following bariatric surgery. 132 Interestingly, a significantly greater proportion of women undergo bariatric surgery than men. Data from the US showed that out of more than 800,000 people undergoing bariatric surgery over a 10-year period, around 80% were women. ...
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Diabetes mellitus represents a global health concern affecting 463 million adults and is projected to rapidly rise to 700 million people by 2045. Amongst those with type 2 diabetes (T2D), there are recognised differences in the impact of the disease on different sex and ethnic groups. The relative risk of cardiovascular complications between individuals with and without T2D is higher in females than males. People of South Asian heritage are two to four times more likely to develop T2D than white people, but conversely not more likely to experience cardiovascular complications. Differences in the pathophysiological responses in these groups may identify potential areas for intervention beyond glycaemic control. In this review, we highlight key differences of diabetes-associated cardiovascular complications by sex and ethnic background, with a particular emphasis on South Asians. Evidence assessing therapeutic efficacy of new glucose lowering drugs in minority groups is limited and many major cardiovascular outcomes trials do not report ethnic specific data. Conversely, lifestyle intervention and bariatric surgery appear to have similar benefits regardless of sex and ethnic groups. We encourage future studies with better representation of women and ethnic minorities that will provide valuable data to allow better risk stratification and tailored prevention and management strategies to improve cardiovascular outcomes in T2D.
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Background: Bariatric surgery has come out as an effective treatment for morbid obesity due to its effects as stabilized weight loss and remission of obesity related comorbidities like type 2 diabetes. Postoperative weight loss is affected by many factors and predictors of weight loss after bariatric surgery are controversial.This study has been performed to evaluate the impact of gender and age on the short-term outcomes of laparoscopic sleeve gastrectomy (LSG) in type 2 diabetic(T2D) obese patients. Material and Methods: In this retrospective study, the records of morbidly obese patients with a body mass index(BMI)≥40 kg/m2, aged between 18-65 years old who underwent LSG and were followed-up for at least 6 months postoperatively were reviewed.Patients were subdivided into two groups according to age(≥50 y
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Background Emerging evidence suggests an association between impaired high-density lipoprotein (HDL) functionality and cardiovascular disease (CVD). HDL is essential for reverse cholesterol transport (RCT) and reduces inflammation and oxidative stress principally via paraoxonase-1 (PON1). RCT depends on HDL’s capacity to accept cholesterol (cholesterol efflux capacity [CEC]) and active transport through ATP-binding cassette (ABC) A1, G1, and scavenger receptor-B1 (SR-B1). We have studied the impact of Roux-en-Y gastric bypass (RYGB) in morbidly obese subjects on RCT and HDL functionality. Methods Biomarkers associated with increased CVD risk including tumour necrosis factor-α (TNF-α), high-sensitivity C-reactive protein (hsCRP), myeloperoxidase mass (MPO), PON1 activity, and CEC in vitro were measured in 44 patients before and 6 and 12 months after RYGB. Overweight but otherwise healthy (mean body mass index [BMI] 28 kg/m2) subjects acted as controls. Twelve participants also underwent gluteal subcutaneous adipose tissue biopsies before and 6 months after RYGB for targeted gene expression (ABCA1, ABCG1, SR-B1, TNF-α) and histological analysis (adipocyte size, macrophage density, TNF-α immunostaining). Results Significant (P < 0.05) improvements in BMI, HDL-cholesterol, hsCRP, TNF-α, MPO mass, PON1 activity, and CEC in vitro were observed after RYGB. ABCG1 (fold-change, 2.24; P = 0.005) and ABCA1 gene expression increased significantly (fold-change, 1.34; P = 0.05). Gluteal fat adipocyte size (P < 0.0001), macrophage density (P = 0.0067), and TNF-α immunostaining (P = 0.0425) were reduced after RYBG and ABCG1 expression correlated inversely with TNF-α immunostaining (r = -0.71; P = 0.03). Conclusion RYGB enhances HDL functionality in association with a reduction in adipose tissue and systemic inflammation.
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Binge eating disorder (BED) is the most common eating disorder and an important public health problem. Lifetime prevalence of BED in the United States is 2.6%. In contrast to other eating disorders, the female to male ratio in BED is more balanced. BED co-occurs with a plethora of psychiatric disorders, most commonly mood and anxiety disorders. BED is also associated with obesity and its numerous complications. Although BED is similar in men and women in presentation and treatment outcomes, there are some key neurobiological differences that should be taken in consideration when personalizing treatment.
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Introduction: Obstructive sleep apnea is an important and common disorder with associated health risks. Assuring successful longitudinal management is vital to patient health and sleep-related quality of life. This paper establishes the positions of the American Academy of Sleep Medicine (AASM) regarding the use of polysomnography (PSG) and home sleep apnea tests (HSATs) after a diagnosis of obstructive sleep apnea has been established and, in most cases, treatment implemented. Methods: The AASM commissioned a task force of five sleep medicine experts. A literature search was conducted to identify studies that included adult patients with OSA who underwent follow-up PSG or an HSAT. The task force developed position statements based on a review of these studies and expert opinion. The AASM Board of Directors approved the final position statements.
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Background: Bariatric surgery is a safe and effective treatment for clinically severe obesity, but inequity in male and female utilization is well recognized. Approximately 20% of patients undergoing bariatric surgery are male. This paper aims to describe differences in outcomes by gender and to understand the physiologic and psychological differences that may explain this gender gap. Methods: We examined 61,708 patients from the Michigan Bariatric Surgery Collaborative (MBSC) undergoing primary bariatric surgery between 2006 and 2016. Clinical data regarding demographics, comorbidities, and outcomes were compared by gender. Preoperative and 1-year postoperative surveys gathered psychological outcomes. Results: This cohort was consistent with the national population with approximately 22% male patients. There were several significant differences between males and females at the time of surgery. Males tended to be older, have a higher BMI, be married, have lower self-reported depression scores, and have more comorbidities (all p < 0.05). Postoperatively, males suffered more serious complications than women (2.67 vs. 2.12, respectively, p < 0.05). At 1 year postoperatively, males were significantly more satisfied with their operation despite increased complications, decreased weight loss, and decreased rates of comorbidity resolution as compared to females (all p < 0.05). Conclusions: Despite significantly lower weight loss and increased complication rates, males tend to have markedly higher satisfaction and psychological well-being scores than females. To improve outcomes in males, earlier referral to surgery may help to significantly reduce their risk. Conversely, increased attention to psychological support in the perioperative period for females may lead to improved psychological outcomes (i.e., body image, depression, psychological well-being).
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Nearly 80% of patients that receive bariatric surgery are women, yet mechanistic pre-clinical studies have focused on males. The goal of this study was to determine the metabolic impact of diet- and surgery-induced weight loss in males, females, and ovariectomized females. Male and female mice were fed a 60% high-fat (HFD) diet before undergoing either vertical sleeve gastrectomy (VSG) or sham surgery. Mice either remained on HFD or were switched to a standard chow diet post-surgically. When maintained on HFD, both males and females decreased fat mass and improved oral glucose tolerance after VSG. After dietary intervention, additional adiposity was lost in both surgical groups. Ovariectomized females had a blunted decrease in fat mass on a HFD, but lost significant adiposity after dietary intervention. Energy expenditure was only impacted by dietary but not surgical intervention across all groups. Males decreased hepatic triglyceride levels after VSG, which was further decreased after dietary intervention. Intact and ovariectomized females had a blunted decrease in hepatic triglycerides after surgical intervention but a significant decrease after dietary intervention. The more pronounced effect of surgery on hepatic lipids in males was strongly associated with changes in expression of hepatic microRNAs and genes that have previously been linked to hepatic lipid regulation and systemic energy homeostasis. These data highlight the importance of post-surgical diet on metabolic outcomes across sexes and hormone levels. Furthermore, these data suggest the impact of VSG on hepatic triglycerides is diet-dependent in females and support that hypothesis that males and females achieve a similar metabolic outcome, at least within the liver, via distinct mechanisms.
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Context: Obstructive sleep apnea (OSA) complicates morbid obesity and is associated with increased cardiovascular disease incidence. An increase in the circulating markers of chronic inflammation and dysfunctional high-density lipoprotein (HDL) occur in severe obesity. Objective: The objective of the study was to establish whether the effects of obesity on inflammation and HDL dysfunction are more marked when complicated by OSA. Design and patients: Morbidly obese patients (n = 41) were divided into those whose apnea-hypoapnea index (AHI) was more or less than the median value and on the presence of OSA [OSA and no OSA (nOSA) groups]. We studied the antioxidant function of HDL and measured serum paraoxonase 1 (PON1) activity, TNFα, and intercellular adhesion molecule 1 (ICAM-1) levels in these patients. In a subset of 19 patients, we immunostained gluteal sc adipose tissue (SAT) for TNFα, macrophages, and measured adipocyte size. Results: HDL lipid peroxide levels were higher and serum PON1 activity was lower in the high AHI group vs the low AHI group (P < .05 and P < .0001, respectively) and in the OSA group vs the nOSA group (P = .005 and P < .05, respectively). Serum TNFα and ICAM-1 levels and TNFα immunostaining in SAT increased with the severity of OSA. Serum PON1 activity was inversely correlated with AHI (r = -0.41, P < .03) in the OSA group. TNFα expression in SAT directly correlated with AHI (r = 0.53, P < .03) in the subset of 19 patients from whom a biopsy was obtained. Conclusion: Increased serum TNFα, ICAM-1, and TNFα expression in SAT provide a mechanistic basis for enhanced inflammation in patients with OSA. Decreased serum PON1 activity, impaired HDL antioxidant function, and increased adipose tissue inflammation in these patients could be a mechanism for HDL and endothelial dysfunction.
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Gastric bypass surgery induces early remission or significant improvement in type 2 diabetes (T2D). To assess effectiveness of stopping glucose lowering treatment at the time of surgery. Observational cohort analysis. We identified 101 patients (62 women) with T2D who had undergone gastric bypass surgery at a mean (SD, standard deviation) age of 51.4 (9.0) years. We recorded weight, body mass index (BMI), glycosylated haemoglobin (HbA1c), blood pressure (BP), total and high-density lipoprotein (HDL) cholesterol preoperatively and at a median 4, 12 and 24 months postoperatively, and changes to glucose-lowering therapy. Mean (SD) baseline BMI was 50.3 (6.3) kg/m(2), HbA1c 65.3 (18.5) mmol/mol, systolic BP 146.0 (18.0) mmHg, diastolic BP 87.0 (10.8) mmHg and total cholesterol-to-HDL cholesterol ratio 4.0 (1.2). Mean (95% confidence interval) reduction in BMI was 16.4 (14.09-18.70) kg/m(2), HbA1c 23.6 (17.6-29.6) mmol/mol, systolic BP 12.9 (5.9-19.8) mm Hg, diastolic BP 6.1 (1.8-10.5) mmHg and total cholesterol-to-HDL cholesterol ratio 1.1 (0.6-1.5) at 24 months (P < 0.001 for all measures). Whereas 91% of patients were receiving glucose-lowering therapies preoperatively, complete (HbA1c < 42 mmol/mol) and partial (HbA1c 42-48 mmol/mol) remissions of T2D were seen in 62.1% and 5.2% at two years postoperatively. Cessation of glucose-lowering therapies in people with type 2 diabetes at the time of gastric bypass surgery was clinically effective. The majority of patients remained in complete or partial remission of diabetes up to two years postoperatively.
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To quantify the overall effects of bariatric surgery compared with non-surgical treatment for obesity. Systematic review and meta-analysis based on a random effects model. Searches of Medline, Embase, and the Cochrane Library from their inception to December 2012 regardless of language or publication status. Eligible studies were randomised controlled trials with ≥6 months of follow-up that included individuals with a body mass index ≥30, compared current bariatric surgery techniques with non-surgical treatment, and reported on body weight, cardiovascular risk factors, quality of life, or adverse events. The meta-analysis included 11 studies with 796 individuals (range of mean body mass index at baseline 30-52). Individuals allocated to bariatric surgery lost more body weight (mean difference -26 kg (95% confidence interval -31 to -21)) compared with non-surgical treatment, had a higher remission rate of type 2 diabetes (relative risk 22.1 (3.2 to 154.3) in a complete case analysis; 5.3 (1.8 to 15.8) in a conservative analysis assuming diabetes remission in all non-surgically treated individuals with missing data) and metabolic syndrome (relative risk 2.4 (1.6 to 3.6) in complete case analysis; 1.5 (0.9 to 2.3) in conservative analysis), greater improvements in quality of life and reductions in medicine use (no pooled data). Plasma triglyceride concentrations decreased more (mean difference -0.7 mmol/L (-1.0 to -0.4) and high density lipoprotein cholesterol concentrations increased more (mean difference 0.21 mmol/L (0.1 to 0.3)). Changes in blood pressure and total or low density lipoprotein cholesterol concentrations were not significantly different. There were no cardiovascular events or deaths reported after bariatric surgery. The most common adverse events after bariatric surgery were iron deficiency anaemia (15% of individuals undergoing malabsorptive bariatric surgery) and reoperations (8%). Compared with non-surgical treatment of obesity, bariatric surgery leads to greater body weight loss and higher remission rates of type 2 diabetes and metabolic syndrome. However, results are limited to two years of follow-up and based on a small number of studies and individuals. PROSPERO CRD42012003317 (www.crd.york.ac.uk/PROSPERO).
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Importance Current eligibility criteria for bariatric surgery use arbitrarily chosen body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) thresholds, an approach that has been criticized as arbitrary and lacking evidence. Objectives To verify the importance of BMI as a mortality predictor, to identify other important mortality predictors, and to construct a mortality prediction rule in a population eligible for bariatric surgery.Design We studied individuals from a population-representative register who met contemporary eligibility criteria for bariatric surgery (BMI, ≥35.0 alone or 30.0-34.9 with an obesity-related comorbidity) from January 1, 1988, through December 31, 1998. We used binary logistic regression to construct a parsimonious model and a clinical prediction rule for 10-year all-cause mortality.Setting The United Kingdom General Practice Research Database, a population-representative primary care registry.Participants Fifteen thousand three hundred ninety-four patients aged 18 to 65 years.Exposure Bariatric surgery.Main Outcome and Measure Ten-year all-cause mortality.Results Mean (SD) age was 46.9 (11.9) years, BMI was 36.2 (5.5), and 63.2% of the patients were women. All-cause mortality was 2.1%, and mean follow-up duration was 9.9 years. The final model, which included age (odds ratio, 1.09 per year [95% CI, 1.07-1.10]), type 2 diabetes mellitus (2.25 [1.76-2.87]), current smoking (1.62 [1.28-2.06]), and male sex (1.50 [1.20-1.87]), had a C statistic of 0.768. Although BMI significantly predicted mortality (odds ratio, 1.03 per unit [95% CI, 1.01-1.05]), it did not improve model discrimination or calibration. We divided clinical prediction rule scoring into 4 tiers. All-cause mortality was 0.2% in tier 1, 0.9% in tier 2, 2.0% in tier 3, and 5.2% in tier 4.Conclusions and Relevance All-cause 10-year mortality in obese individuals eligible for bariatric surgery can be estimated using a simple 4-variable prediction rule based on age, sex, smoking, and diabetes mellitus. Body mass index was not an important mortality predictor. Further work is needed to define low, moderate, and high absolute risk thresholds and to provide external validation.
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Background: Although bariatric surgery in women of childbearing age reduces the risks of pregnancy complications associated with maternal obesity, little is known of the effect of gestation on weight loss outcomes. Aim: To study weight loss and pregnancy outcomes after bariatric surgery in women of childbearing age. Design and methods: We performed a retrospective, observational cohort analysis of women aged 18-45 years in a university teaching hospital. The results shown represent mean ± standard deviation where appropriate. Results: A total of 232 women aged 34.0 ± 5.9 years with pre-operative weight 137.7 ± 21.3 kg and body mass index (BMI) 50.6 ± 7.2 kg/m(2) underwent bariatric surgery that included 197 (84.9%) gastric bypass, 19 (8.2%) gastric banding, 8 (3.4%) sleeve gastrectomy and 8 other procedures. Twenty-one women had 28 pregnancies following bariatric surgery, of which 24 (85.7%) resulted in live births, 3 (10.7%) terminations of pregnancy and 1 (3.6%) spontaneous miscarriage. The pregnancy group was younger compared with the non-pregnancy group (28.0 ± 5.4 vs. 34.6 ± 5.6 years; P < 0.001) but well matched for pre-operative weight (136.5 ± 18.5 vs. 137.8 ± 21.6 kg), BMI (49.2 ± 7.4 vs. 50.7 ± 7.2 kg/m(2)) and bariatric procedure. The interval between bariatric surgery and first pregnancy was a median 11 months. The pregnancy group lost 70.4% of excess weight compared with 70.0% in the non-pregnancy group at median 30 months of follow-up. Conclusion: Pregnancy after bariatric surgery is safe and does not adversely affect weight loss outcomes.
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Studies have shown that mortality was reduced by 31.6% in patients that underwent bariatric surgery compared with the non-operative control group. However, in most surgical series the majority of patients were women, and men had higher post-operative mortality rates and a higher postoperative morbidity, regardless of weight. Our primary end point was to study gender effects on vascular inflammation following bariatric surgery for weight loss. Methods. A prospective study evaluated vascular inflammation in obese patients before and three months after bariatric surgery. Markers of vascular inflammation were measured - before surgery and three months afterwards. Results. One hundred and two patients (73 women and 29 men, 40.5 ± 12.3 years old) underwent bariatric surgery. Correlation was found between BMI change and waist circumference change (r = 0.658, P<0.001). Three months post-surgery, BMI was significantly decreased (p<0.001) (a decrease of 8.82), waist circumference was reduced (p<0.001) (a decrease of 17.33 cm). ICAM-1 levels and hs-CRP levels were decreased (both P = 0.0001). Gender differences seem to be borderline significant with respect to the prevalence of type II diabetes mellitus (men > women; P = 0.05) and hypertension (men > women; P = 0.06). In women, following bariatric surgery, BMI was decreased (p<0.001) (a decrease of 9.25), waist circumference was reduced (p<0.001) (a decrease of 18.8cm). ICAM-1 levels were decreased (p = 0.002) and hs-CRP levels were also decreased (P = 0.0001). In men, following bariatric surgery, BMI was decreased (p = 0.001) (a decrease of 8.1), waist circumference was reduced (p<0.005) (a decrease of 14.6cm); however, although ICAM-1 levels and hs-CRP levels were decreased the decreases were non-significant (both P = 0.09). Discussion. Our study examined gender effects of bariatric surgery on vascular inflammation. Bariatric surgery had no significant effect on biochemical inflammatory markers in male patients, while females undergoing the same kind of bariatric surgery for weight loss showed a significant decrease in these markers of inflammation. These results may explain the epidemiological data that described higher morbidity and mortality among obese men undergoing bariatric operation for weight loss. This is the first study that has demonstrated a gender difference in the inflammatory responses that may affect clinical outcome, and cardiovascular morbidity and mortality.
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Observational studies have shown improvement in patients with type 2 diabetes mellitus after bariatric surgery. In this randomized, nonblinded, single-center trial, we evaluated the efficacy of intensive medical therapy alone versus medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy in 150 obese patients with uncontrolled type 2 diabetes. The mean (±SD) age of the patients was 49±8 years, and 66% were women. The average glycated hemoglobin level was 9.2±1.5%. The primary end point was the proportion of patients with a glycated hemoglobin level of 6.0% or less 12 months after treatment. Of the 150 patients, 93% completed 12 months of follow-up. The proportion of patients with the primary end point was 12% (5 of 41 patients) in the medical-therapy group versus 42% (21 of 50 patients) in the gastric-bypass group (P=0.002) and 37% (18 of 49 patients) in the sleeve-gastrectomy group (P=0.008). Glycemic control improved in all three groups, with a mean glycated hemoglobin level of 7.5±1.8% in the medical-therapy group, 6.4±0.9% in the gastric-bypass group (P<0.001), and 6.6±1.0% in the sleeve-gastrectomy group (P=0.003). Weight loss was greater in the gastric-bypass group and sleeve-gastrectomy group (-29.4±9.0 kg and -25.1±8.5 kg, respectively) than in the medical-therapy group (-5.4±8.0 kg) (P<0.001 for both comparisons). The use of drugs to lower glucose, lipid, and blood-pressure levels decreased significantly after both surgical procedures but increased in patients receiving medical therapy only. The index for homeostasis model assessment of insulin resistance (HOMA-IR) improved significantly after bariatric surgery. Four patients underwent reoperation. There were no deaths or life-threatening complications. In obese patients with uncontrolled type 2 diabetes, 12 months of medical therapy plus bariatric surgery achieved glycemic control in significantly more patients than medical therapy alone. Further study will be necessary to assess the durability of these results. (Funded by Ethicon Endo-Surgery and others; ClinicalTrials.gov number, NCT00432809.).
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OBJECTIVE AND METHODS: Given the profound weight loss after gastric banding and bypass we compared fat compartmentalization by whole body magnetic resonance imaging in women and men after these procedures to two groups of non-surgical controls who were either matched for age, weight and height or were of lower body mass index (BMI). RESULT: In women post-surgery (n=17; BMI 31.7 kg/m(2)) there was lower visceral adipose tissue (VAT) (1.4 vs 2.5 kg; P<0.01) compared with matched controls (n=59; BMI 32.1 kg/m(2)). In contrast, VAT (5.3 vs 5.4 kg) was nearly identical in men post-surgery (n=10; BMI 34.1 kg/m(2)) compared with matched controls (n=10; BMI 32.1 kg/m(2)) even though the degree of weight reduction was not significantly different from women (27.4 vs 32.6%). Furthermore, VAT when adjusted for total adipose tissue (TAT) was 43% less in women post-surgery (1.2 vs 2.1 kg; P=0.03) than in controls with lower BMI (25.1 kg/m(2)). After adjustment for TAT, subcutaneous adipose tissue in women post-surgery was significantly greater than matched controls (35.1 vs 34.2 kg; P=0.03). There was a significant negative correlation of VAT and the degree of weight loss in women (r=-0.57; P=0.018) but this relationship was not significant in men (r=-0.39; P=0.27). Skeletal muscle was lower in both sexes compared with matched controls (women, 21.8 vs 23.1 kg; men, 32.5 vs 35.5 kg). CONCLUSION: Prospective studies are necessary to confirm if there is a sexual dimorphism in the effects of bariatric surgery on body composition.
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To assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity. Seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references. Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) > or = 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI > or = 40; BMI > or = 30 and < 40 with Type 2 diabetes at baseline; and BMI > or = 30 and < 35. Models were applied with assumptions on costs and comorbidity. A total of 5386 references were identified of which 26 were included in the clinical effectiveness review: three randomised controlled trials (RCTs) and three cohort studies compared surgery with non-surgical interventions and 20 RCTs compared different surgical procedures. Bariatric surgery was a more effective intervention for weight loss than non-surgical options. In one large cohort study weight loss was still apparent 10 years after surgery, whereas patients receiving conventional treatment had gained weight. Some measures of QoL improved after surgery, but not others. After surgery statistically fewer people had metabolic syndrome and there was higher remission of Type 2 diabetes than in non-surgical groups. In one large cohort study the incidence of three out of six comorbidities assessed 10 years after surgery was significantly reduced compared with conventional therapy. Gastric bypass (GBP) was more effective for weight loss than vertical banded gastroplasty (VBG) and adjustable gastric banding (AGB). Laparoscopic isolated sleeve gastrectomy (LISG) was more effective than AGB in one study. GBP and banded GBP led to similar weight loss and results for GBP versus LISG and VBG versus AGB were equivocal. All comparisons of open versus laparoscopic surgeries found similar weight losses in each group. Comorbidities after surgery improved in all groups, but with no significant differences between different surgical interventions. Adverse event reporting varied; mortality ranged from none to 10%. Adverse events from conventional therapy included intolerance to medication, acute cholecystitis and gastrointestinal problems. Major adverse events following surgery, some necessitating reoperation, included anastomosis leakage, pneumonia, pulmonary embolism, band slippage and band erosion. Bariatric surgery was cost-effective in comparison to non-surgical treatment in the reviewed published estimates of cost-effectiveness. However, these estimates are likely to be unreliable and not generalisable because of methodological shortcomings and the modelling assumptions made. Therefore a new economic model was developed. Surgical management was more costly than non-surgical management in each of the three patient populations analysed, but gave improved outcomes. For morbid obesity, incremental cost-effectiveness ratios (ICERs) (base case) ranged between 2000 pounds and 4000 pounds per QALY gained. They remained within the range regarded as cost-effective from an NHS decision-making perspective when assumptions for deterministic sensitivity analysis were changed. For BMI > or = 30 and 40, ICERs were 18,930 pounds at two years and 1397 pounds at 20 years, and for BMI > or = 30 and < 35, ICERs were 60,754 pounds at two years and 12,763 pounds at 20 years. Deterministic and probabilistic sensitivity analyses produced ICERs which were generally within the range considered cost-effective, particularly at the long twenty year time horizons, although for the BMI 30-35 group some ICERs were above the acceptable range. Bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required to provide detailed data on patient QoL; impact of surgeon experience on outcome; late complications leading to reoperation; duration of comorbidity remission; resource use. Good-quality RCTs will provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.
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To improve decision making in the treatment of extreme obesity, the risks of bariatric surgical procedures require further characterization. We performed a prospective, multicenter, observational study of 30-day outcomes in consecutive patients undergoing bariatric surgical procedures at 10 clinical sites in the United States from 2005 through 2007. A composite end point of 30-day major adverse outcomes (including death; venous thromboembolism; percutaneous, endoscopic, or operative reintervention; and failure to be discharged from the hospital) was evaluated among patients undergoing first-time bariatric surgery. There were 4776 patients who had a first-time bariatric procedure (mean age, 44.5 years; 21.1% men; 10.9% nonwhite; median body-mass index [the weight in kilograms divided by the square of the height in meters], 46.5). More than half had at least two coexisting conditions. A Roux-en-Y gastric bypass was performed in 3412 patients (with 87.2% of the procedures performed laparoscopically), and laparoscopic adjustable gastric banding was performed in 1198 patients; 166 patients underwent other procedures and were not included in the analysis. The 30-day rate of death among patients who underwent a Roux-en-Y gastric bypass or laparoscopic adjustable gastric banding was 0.3%; a total of 4.3% of patients had at least one major adverse outcome. A history of deep-vein thrombosis or pulmonary embolus, a diagnosis of obstructive sleep apnea, and impaired functional status were each independently associated with an increased risk of the composite end point. Extreme values of body-mass index were significantly associated with an increased risk of the composite end point, whereas age, sex, race, ethnic group, and other coexisting conditions were not. The overall risk of death and other adverse outcomes after bariatric surgery was low and varied considerably according to patient characteristics. In helping patients make appropriate choices, short-term safety should be considered in conjunction with both the long-term effects of bariatric surgery and the risks associated with being extremely obese. (ClinicalTrials.gov number, NCT00433810.)
Article
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Gastric bypass surgery (GBP) results in rapid weight loss, improvement of type 2 diabetes (T2DM), and increase in incretins levels. Diet-induced weight loss also improves T2DM and may increase incretin levels. Our objective was to determine whether the magnitude of the change of the incretin levels and effect is greater after GBP compared with a low caloric diet, after equivalent weight loss. Obese women with T2DM studied before and 1 month after GBP (n = 9), or after a diet-induced equivalent weight loss (n = 10), were included in the study. Patients from both groups were matched for age, body weight, body mass index, diabetes duration and control, and amount of weight loss. This outpatient study was conducted at the General Clinical Research Center. Glucose, insulin, proinsulin, glucagon, gastric inhibitory peptide (GIP), and glucagon-like peptide (GLP)-1 levels were measured after 50-g oral glucose. The incretin effect was measured as the difference in insulin levels in response to oral and to an isoglycemic iv glucose load. At baseline, none of the outcome variables (fasting and stimulated values) were different between the GBP and diet groups. Total GLP-1 levels after oral glucose markedly increased six times (peak:17 +/- 6 to 112 +/- 54 pmol/liter; P < 0.001), and the incretin effect increased five times (9.4 +/- 27.5 to 44.8 +/- 12.7%; P < 0.001) after GBP, but not after diet. Postprandial glucose levels (P = 0.001) decreased more after GBP. These data suggest that early after GBP, the greater GLP-1 and GIP release and improvement of incretin effect are related not to weight loss but rather to the surgical procedure. This could be responsible for better diabetes outcome after GBP.
Article
OBJECTIVES To assess the clinical effectiveness and cost-effectiveness of bariatric surgery for obesity. DATA SOURCES Seventeen electronic databases were searched [MEDLINE; EMBASE; PreMedline In-Process & Other Non-Indexed Citations; The Cochrane Library including the Cochrane Systematic Reviews Database, Cochrane Controlled Trials Register, DARE, NHS EED and HTA databases; Web of Knowledge Science Citation Index (SCI); Web of Knowledge ISI Proceedings; PsycInfo; CRD databases; BIOSIS; and databases listing ongoing clinical trials] from inception to August 2008. Bibliographies of related papers were assessed and experts were contacted to identify additional published and unpublished references. REVIEW METHODS Two reviewers independently screened titles and abstracts for eligibility. Inclusion criteria were applied to the full text using a standard form. Interventions investigated were open and laparoscopic bariatric surgical procedures in widespread current use compared with one another and with non-surgical interventions. Population comprised adult patients with body mass index (BMI) > or = 30 and young obese people. Main outcomes were at least one of the following after at least 12 months follow-up: measures of weight change; quality of life (QoL); perioperative and postoperative mortality and morbidity; change in obesity-related comorbidities; cost-effectiveness. Studies eligible for inclusion in the systematic review for comparisons of Surgery versus Surgery were RCTs. For comparisons of Surgery versus Non-surgical procedures eligible studies were RCTs, controlled clinical trials and prospective cohort studies (with a control cohort). Studies eligible for inclusion in the systematic review of cost-effectiveness were full cost-effectiveness analyses, cost-utility analyses, cost-benefit analyses and cost-consequence analyses. One reviewer performed data extraction, which was checked by two reviewers independently. Two reviewers independently applied quality assessment criteria and differences in opinion were resolved at each stage. Studies were synthesised through a narrative review with full tabulation of the results of all included studies. In the economic model the analysis was developed for three patient populations, those with BMI > or = 40; BMI > or = 30 and or = 30 and or = 30 and 40, ICERs were 18,930 pounds at two years and 1397 pounds at 20 years, and for BMI > or = 30 and < 35, ICERs were 60,754 pounds at two years and 12,763 pounds at 20 years. Deterministic and probabilistic sensitivity analyses produced ICERs which were generally within the range considered cost-effective, particularly at the long twenty year time horizons, although for the BMI 30-35 group some ICERs were above the acceptable range. CONCLUSIONS Bariatric surgery appears to be a clinically effective and cost-effective intervention for moderately to severely obese people compared with non-surgical interventions. Uncertainties remain and further research is required to provide detailed data on patient QoL; impact of surgeon experience on outcome; late complications leading to reoperation; duration of comorbidity remission; resource use. Good-quality RCTs will provide evidence on bariatric surgery for young people and for adults with class I or class II obesity. New research must report on the resolution and/or development of comorbidities such as Type 2 diabetes and hypertension so that the potential benefits of early intervention can be assessed.
Article
This review summarizes recent evidence related to the safety, efficacy, and metabolic outcomes of bariatric surgery to guide clinical decision making. Several short term randomized controlled trials have demonstrated the effectiveness of bariatric procedures for inducing weight loss and initial remission of type 2 diabetes. Observational studies have linked bariatric procedures with long term improvements in body weight, type 2 diabetes, survival, cardiovascular events, incident cancer, and quality of life. Perioperative mortality for the average patient is low but varies greatly across subgroups. The incidence of major complications after surgery also varies widely, and emerging data show that some procedures are associated with a greater risk of substance misuse disorders, suicide, and nutritional deficiencies. More research is needed to enable long term outcomes to be compared across various procedures and subpopulations, and to identify those most likely to benefit from surgical intervention. Given uncertainties about the balance between the risks and benefits of bariatric surgery in the long term, the decision to undergo surgery should be based on a high quality shared decision making process.
Article
Full text available from http://dx.doi.org/10.1016/S2213-8587(14)70089-0
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Obstructive sleep apnoea (OSA) is associated with obesity and frequently remits with significant weight loss.We report that bariatric surgery induces an immediate reduction in continuous positive airway pressure requirement.This implicates weight-independent mechanisms in resolution of OSA after bariatric surgery.
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Background: Despite similar rates of obesity among American men and women, population-based studies suggest that bariatric surgery patients are disproportionately female. We sought to assess this observation quantitatively. Methods: Data were prospectively collected from 1,368 consecutive patients evaluated for bariatric surgery over a 4-year period. The prevalence of diabetes mellitus (DM), hypertension (HTN), dyslipidemia (DYS), obstructive sleep apnea (OSA), gastroesophageal reflux disease, depression, back pain (BKP), and musculoskeletal peripheral disease was assessed. A severity score from 1 to 5 had been assigned to each comorbidity based on the Assessment of Obesity Related Comorbidities Scale (AORC). Metabolic syndrome (MetS) was defined as the concurrent presence of DM, HTN, and DYS. Results: The majority of patients were female (n = 1,115, 81.5%). Male patients were older (44.5 ± 9.5 vs. 42.6 ± 9.6 years, p = 0.0044) and had higher body mass index (48.7 ± 7.8 vs. 46.6 ± 7.4 kg/m(2), p < 0.0001). On average, men presented with 4.54 serious comorbidities and 3.7 complicated comorbidities (AORC score ≥3), whereas women presented with 4.15 serious comorbidities and 3.08 complicated comorbidities. More men presented with DM (36.4 vs. 28.9%, p = 0.0154), HTN (68.8 vs. 55.3%, p = 0.0001), OSA (71.9 vs. 45.7%, p < 0.0001), and MetS (20.9 vs. 15.2%, p = 0.0301). Men also presented with more complicated DM (33.2 vs. 23.9%, p = 0.0031), DYS (36.8 vs. 23.5%, p < 0.0001), HTN (58.9 vs. 44.6%, p < 0.0001), BKP (25.3 vs. 19.3%, p = 0.0378), OSA (56.9 vs. 30.1%, p < 0.0001), and MetS (17.8 vs. 10.0%, p = 0.001). Conclusions: Although men typically comprise less than 20% of bariatric surgery patients, they potentially have more to gain from these operations. Men present later in life, with more advanced obesity, and with more complicated comorbidities. Such findings mandate more research and resources to investigate this barrier to treatment and to provide the morbidly obese male with the surgical care he clearly needs.
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Conventional primary care won’t get the job doneThe European Commission’s recently published report, The State of Men’s Health in Europe, shows marked differences in health outcomes between men,1 which are strongly related to their biology, culture, and socioeconomic realities.The report is a huge undertaking: an attempt to describe the salient health issues of the 290 million men and boys of the 27 member states of the European Union, the four states of the European Free Trade Association, and three EU candidate countries.Included in its findings are that: working age men have significantly higher mortality rates than working age women (210% higher mortality rate in the 15-64 age range; 630 000 men per year versus 300 000 women); public health activity that benefits men’s health is patchy across the EU; and working men underuse health services compared with women and unemployed men. A key conclusion of the report is that “Gender equality initiatives will have a positive impact on the way men’s needs are taken into account within government health strategies and at the more local practitioner level.”1Health ministers should be reminded by their treasury counterparts that because of lower birth rates, rising life expectancy, and the higher death rate in men in the 15-64 age group, by 2060 there will be …
Article
Bariatric (weight loss) surgery for obesity is considered when other treatments have failed. The effects of the available bariatric procedures compared with medical management and with each other are uncertain. This is an update of a Cochrane review first published in 2003 and previously updated in 2005. To assess the effects of bariatric surgery for obesity. Studies were obtained from computerized searches of multiple electronic bibliographic databases, supplemented with searches of reference lists and consultation with experts in obesity research. Randomised controlled trials (RCTs) comparing different surgical procedures, and RCTs, controlled clinical trials and prospective cohort studies comparing surgery with non-surgical management for obesity. Data were extracted by one reviewer and checked independently by two reviewers. Two reviewers independently assessed trial quality. Twenty six studies were included. Three RCTs and three prospective cohort studies compared surgery with non-surgical management, and 20 RCTs compared different bariatric procedures. The risk of bias of many trials was uncertain; just five had adequate allocation concealment. A meta-analysis was not appropriate.Surgery results in greater weight loss than conventional treatment in moderate (body mass index greater than 30) as well as severe obesity. Reductions in comorbidities, such as diabetes and hypertension, also occur. Improvements in health-related quality of life occurred after two years, but effects at ten years are less clear.Surgery is associated with complications, such as pulmonary embolism, and some postoperative deaths occurred.Five different bariatric procedures were assessed, but some comparisons were assessed by just one trial. The limited evidence suggests that weight loss following gastric bypass is greater than vertical banded gastroplasty or adjustable gastric banding, but similar to isolated sleeve gastrectomy and banded gastric bypass. Isolated sleeve gastrectomy appears to result in greater weight loss than adjustable gastric banding. Evidence comparing vertical banded gastroplasty with adjustable gastric banding is inconclusive. Data on the comparative safety of the bariatric procedures was limited.Weight loss and quality of life were similar between open and laparoscopic surgery. Conversion from laparoscopic to open surgery may occur. Surgery is more effective than conventional management. Certain procedures produce greater weight loss, but data are limited. The evidence on safety is even less clear. Due to limited evidence and poor quality of the trials, caution is required when interpreting comparative safety and effectiveness.
Article
The prevalence of obesity-induced type 2 diabetes mellitus is increasing worldwide. The objective of this review and meta-analysis is to determine the impact of bariatric surgery on type 2 diabetes in association with the procedure performed and the weight reduction achieved. The review includes all articles published in English from January 1, 1990, to April 30, 2006. The dataset includes 621 studies with 888 treatment arms and 135,246 patients; 103 treatment arms with 3188 patients reported on resolution of diabetes, that is, the resolution of the clinical and laboratory manifestations of type 2 diabetes. Nineteen studies with 43 treatment arms and 11,175 patients reported both weight loss and diabetes resolution separately for the 4070 diabetic patients in these studies. At baseline, the mean age was 40.2 years, body mass index was 47.9 kg/m2, 80% were female, and 10.5% had previous bariatric procedures. Meta-analysis of weight loss overall was 38.5 kg or 55.9% excess body weight loss. Overall, 78.1% of diabetic patients had complete resolution, and diabetes was improved or resolved in 86.6% of patients. Weight loss and diabetes resolution were greatest for patients undergoing biliopancreatic diversion/duodenal switch, followed by gastric bypass, and least for banding procedures. Insulin levels declined significantly postoperatively, as did hemoglobin A1c and fasting glucose values. Weight and diabetes parameters showed little difference at less than 2 years and at 2 years or more. The clinical and laboratory manifestations of type 2 diabetes are resolved or improved in the greater majority of patients after bariatric surgery; these responses are more pronounced in procedures associated with a greater percentage of excess body weight loss and is maintained for 2 years or more.
Article
Obesity is associated with increased morbidity and mortality. Intentional weight loss results in improvement of cardiovascular risk factors, but most observational studies suggest that weight reduction is associated with increased overall and cardiovascular mortality. No prospective intervention studies on mortality have earlier been reported in obese subjects. The prospective, controlled Swedish Obese Subjects Study enrolled obese subjects who either underwent bariatric surgery (n=2010) or were allocated to a contemporaneously matched, conventionally treated obese control group (n=2037). This review sums up effects on morbidity and mortality over an average of 10 years. The mean weight change of the control group was less than +/-2% over up to 15 years of weight recording. Maximum weight losses in the surgical subgroups were observed after 1-2 years. After 10 years, the weight losses from baseline were stabilized at 25, 16 and 14%, respectively. Bariatric surgery improved all traditional cardiovascular risk states except hypercholesterolemia over 10 years. There were 129 deaths in the control group compared with 101 in the surgery group. The unadjusted overall mortality was reduced by 23.7% (P=0.0419) in the surgery group (relative to controls), whereas the gender-, age- and risk factor-adjusted mortality reduction was 30.7% (P=0.0102). The most common causes of death were myocardial infarction (controls n=25, surgery n=13) and cancer (47/29). Bariatric surgery for severe obesity is associated with long-term weight loss, improved risk factors and decreased overall mortality.
Article
This report examines prospectively, in the Framingham cohort, the relation of diabetes and impaired glucose tolerance to each of the cardiovascular sequelae, taking into account age, sex, and associated cardiovascular risk factors. The incidence of cardiovascular disease, as well as the levels of cardiovascular risk factors, were found to be higher in diabetic than in nondiabetic men and women. The relative impact of diabetes on coronary heart disease, peripheral vascular disease, or stroke incidence was the same in men and women, but for cardiovascular mortality and cardiac failure the impact is greater for women. Present evidence suggests that alleviation of associated cardiovascular risk factors is the most promising course in reducing cardiovascular sequelae in diabetic patients.
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Obesity is associated with a number of medical conditions that lead to increased morbidity and increased mortality. Both the National Institutes of Health and the World Health Organization define obesity as a body mass index (BMI) > or = 30 kg/m2 and overweight as a BMI 25-30. The most common conditions associated with obesity are insulin resistance, diabetes mellitus, hypertension, dyslipidemia, cardiovascular disease, gallstones and cholecystitis, sleep apnea and other respiratory dysfunction, and the increased incidence of certain cancers. These are discussed below.
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To determine preoperative risk factors predictive of adverse outcomes after gastric bypass surgery. Gastric bypass results in sustained weight loss for seriously obese patients, but perioperative complications can be formidable. Preoperative risk assessment is important to establish the risk-benefit ratio for patients undergoing these operations. Data for 10 risk factors predictive of adverse outcomes were collected on 1,067 consecutive patients undergoing gastric bypass surgery at the UCLA Medical Center from December 1993 until June 2000. Univariate analyses were performed for individual risk factors to determine their potential significance as predictors for complications. All 10 risk factors were entered into a logistic regression model to determine their significance as predictors for complications. Sensitivity analysis was performed. Univariate analysis revealed that male gender and weight were predictive of severe life-threatening adverse outcomes. Multistep logistic regression yielded only male gender as a risk factor. Male patients were heavier than female patients on entry to the study, accounting for weight as a potential risk factor. Patients older than 55 years had a threefold higher mortality from surgery than younger patients, although the complication rate, 5.8%, was the same in both groups. Sensitivity analysis demonstrated that the risk for severe life-threatening adverse outcomes in women increased from 4% for a 200-lb female patient to 7.5% for a 600-lb patient. The risk increased from 7% for a 200-lb male patient to 13% for a 600-lb patient. Large male patients are at greater risk for severe life-threatening complications than smaller and/or female patients. Risk factors thought to be predictive of adverse outcomes, such as a history of smoking or diabetes, proved not to be significant in this analysis. Older patients had the same complication rate but a threefold higher mortality, suggesting that they lack the reserve to recover from complications when they occur.
Article
About 5% of the US population is morbidly obese. This disease remains largely refractory to diet and drug therapy, but generally responds well to bariatric surgery. To determine the impact of bariatric surgery on weight loss, operative mortality outcome, and 4 obesity comorbidities (diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea). Electronic literature search of MEDLINE, Current Contents, and the Cochrane Library databases plus manual reference checks of all articles on bariatric surgery published in the English language between 1990 and 2003. Two levels of screening were used on 2738 citations. A total of 136 fully extracted studies, which included 91 overlapping patient populations (kin studies), were included for a total of 22,094 patients. Nineteen percent of the patients were men and 72.6% were women, with a mean age of 39 years (range, 16-64 years). Sex was not reported for 1537 patients (8%). The baseline mean body mass index for 16 944 patients was 46.9 (range, 32.3-68.8). A random effects model was used in the meta-analysis. The mean (95% confidence interval) percentage of excess weight loss was 61.2% (58.1%-64.4%) for all patients; 47.5% (40.7%-54.2%) for patients who underwent gastric banding; 61.6% (56.7%-66.5%), gastric bypass; 68.2% (61.5%-74.8%), gastroplasty; and 70.1% (66.3%-73.9%), biliopancreatic diversion or duodenal switch. Operative mortality (< or =30 days) in the extracted studies was 0.1% for the purely restrictive procedures, 0.5% for gastric bypass, and 1.1% for biliopancreatic diversion or duodenal switch. Diabetes was completely resolved in 76.8% of patients and resolved or improved in 86.0%. Hyperlipidemia improved in 70% or more of patients. Hypertension was resolved in 61.7% of patients and resolved or improved in 78.5%. Obstructive sleep apnea was resolved in 85.7% of patients and was resolved or improved in 83.6% of patients. Effective weight loss was achieved in morbidly obese patients after undergoing bariatric surgery. A substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete resolution or improvement.
Article
This paper reviews the key research literature regarding men's health-related help seeking behaviour. There is a growing body of research in the United States to suggest that men are less likely than women to seek help from health professionals for problems as diverse as depression, substance abuse, physical disabilities and stressful life events. Previous research has revealed that the principle health related issue facing men in the UK is their reluctance to seek access to health services. The investigation of men's health-related help seeking behaviour has great potential for improving both men and women's lives and reducing national health costs through the development of responsive and effective interventions. A search of the literature was conducted using CINAHL, MEDLINE, EMBASE, PsychINFO and the Cochrane Library databases. Studies comparing men and women are inadequate in explaining the processes involved in men's help seeking behaviour. However, the growing body of gender-specific studies highlights a trend of delayed help seeking when they become ill. A prominent theme among white middle class men implicates "traditional masculine behaviour" as an explanation for delays in seeking help among men who experience illness. The reasons and processes behind this issue, however, have received limited attention. Principally, the role of masculine beliefs and the similarities and differences between men of differing background requires further attention, particularly given the health inequalities that exist between men of differing socio-economic status and ethnicity. Further research using heterogeneous samples is required in order to gain a greater understanding of the triggers and barriers associated with the decision making process of help seeking behaviour in men who experience illness.
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Adjustable gastric banding for weight reduction in severely obese persons allows reversible individualized restriction during postoperative follow-up. It is unknown whether preoperative age, sex and BMI might modulate treatment outcome. 404 severely obese patients (79% women; age 42 +/- 0.5 years [mean +/- SEM]; BMI 42.1 +/- 0.2 kg/m2) completed 4-year follow-up after banding. Weight loss, complications, and Bariatric Analysis and Reporting Outcome System (BAROS) scores were recorded prospectively. 4 years after banding, younger (<50 years) women lost more weight than older (50 years) men (28.2 +/- 0.7% vs 19.4+/- 1.6%; P=0.001); older women and younger men lost similar weight. Patients with preoperative BMI >50 lost more weight than patients with BMI <35 (30.5 +/- 2.3% vs 22.8 +/- 2.6%; P=0.03). 22.3% of patients (n=90) had band system-related complications. Compared to women, men had more band leaks (7.0% vs 1.9%; P=0.007), and older men had more band slippages than younger men (8.4% vs 0.0%; P=0.035). Patients with preoperative BMI >50 were less likely than patients with BMI 35-40 or 40-50 to experience gastric complications (10.6%, 18.8%, 23.0%, respectively), but more likely to experience port/tube complications (15.8%, 2.4%, 7.9%, respectively; P<0.055). BAROS scores were different between men and women (P=0.05), and between younger and older people (P=0.001). Women and younger people were more likely than men and older people to score "very good" (P=0.03, P=0.001, respectively). Adjustable gastric banding is an effective intermediate-term treatment for severe obesity. Preoperative age, sex, and BMI are important modulators of outcome and should be considered during preoperative evaluation.
Article
The prevalence of obesity in the United States and the surgical treatment of obesity have increased since 1999. An important measure of outcome following surgical treatment is survival. This study began with data prospectively collected from Jan 1, 1986 to Dec 31, 1999 by 55 data collection sites, representing 77 surgeons who used standardized data collection software developed by the International Bariatric Surgery Registry (IBSR). A subset of 18,972 subjects was submitted to the National Death Index (NDI) for search of death occurring from Jan 1, 1986 to Dec 31, 2001. The univariate survival analysis included Kaplan-Meier plots and log-rank tests. Cox proportional-hazards (PH) frailty model was used to identify risk factors and estimate hazard ratios in a multi-factor survival analysis. Covariates included gender, operative age, body mass index, operation category (simple and complex), operation year, diabetes, smoking and hypertension as recorded prior to operation. Deaths were found for 3.45% of the patients (654/18,972). Average follow-up was 8.3 years. Age, gender, BMI, history of smoking, diabetes, and hypertension were significant predictors of survival. Operation category (P=0.13) and operation year (P=0.89) were not significant predictors of survival. Simple and complex operations were equally effective in keeping patients alive in this cohort of patients operated on for severe obesity from 1986 to 1999. Young, female, non-smoking patients with low BMI at operation and no history of diabetes or hypertension had the longest survival. Longer follow-up for death is needed before any recommendations can be made for operation category based on survival.
Article
Case series demonstrate that bariatric surgery can be performed with a low rate of perioperative mortality (0.5%), but the rate among high-risk patients and the community at large is unknown. To evaluate the risk of early mortality among Medicare beneficiaries and to determine the relative risk of death among older patients. Retrospective cohort study. All fee-for-service Medicare beneficiaries, 1997-2002. Thirty-day, 90-day, and 1-year postsurgical all-cause mortality among patients undergoing bariatric procedures. A total of 16 155 patients underwent bariatric procedures (mean age, 47.7 years [SD, 11.3 years]; 75.8% women). The rates of 30-day, 90-day, and 1-year mortality were 2.0%, 2.8%, and 4.6%, respectively. Men had higher rates of early death than women (3.7% vs 1.5%, 4.8% vs 2.1%, and 7.5% vs 3.7% at 30 days, 90 days, and 1 year, respectively; P<.001). Mortality rates were greater for those aged 65 years or older compared with younger patients (4.8% vs 1.7% at 30 days, 6.9% vs 2.3% at 90 days, and 11.1% vs 3.9% at 1 year; P<.001). After adjustment for sex and comorbidity index, the odds of death within 90 days were 5-fold greater for older Medicare beneficiaries (aged > or =75 years; n = 136) than for those aged 65 to 74 years (n = 1381; odds ratio, 5.0; 95% confidence interval, 3.1-8.0). The odds of death at 90 days were 1.6 times higher (95% confidence interval, 1.3-2.0) for patients of surgeons with less than the median surgical volume of bariatric procedures (among Medicare beneficiaries during the study period) after adjusting for age, sex, and comorbidity index. Among Medicare beneficiaries, the risk of early death after bariatric surgery is considerably higher than previously suggested and associated with advancing age, male sex, and lower surgeon volume of bariatric procedures. Patients aged 65 years or older had a substantially higher risk of death within the early postoperative period than younger patients.
Article
Men seek help and use health services less frequently than women do. Men's help-seeking practices and health service use are complex issues involving biological, psychological and sociological considerations. Most discussion on men's help-seeking positions them as reluctant consumers or "behaving badly" with respect to their health. Few studies have explored whether health service providers are equipped to deal with men's health issues appropriately. The current health system appears not to be tailored to meet the health needs of men. Better collaboration is required across disciplines, to further investigate men's health using both qualitative and quantitative research methods.
Article
To identify sociodemographic and clinical predictors of patient selection in bariatric surgery. Population-based studies suggest that bariatric surgery patients are disproportionately privately insured, middle-aged white women. It is uncertain whether such disparities are due to surgeon decisions to operate, differences among morbidly obese individuals in access to surgery, or patients' personal preferences regarding surgical treatment. We conducted a national survey of 1343 U.S. bariatric surgeons. The questionnaire contained clinical vignettes generated using a balanced fractional factorial design. For each of 3 hypothetical patients unique in age, race, gender, body mass index (BMI), comorbidities, social support, functional status, and insurance, respondents were asked if they would operate. Logistic regression was used to determine the odds of selection for each characteristic while controlling for the other 7 characteristics. Subset analyses were also performed using combinations of BMI and comorbidities. A total of 62.5% of eligible surgeons responded (n = 820). Patient race did not influence surgeon decisions to operate. Hypothetical patient age, BMI, and social support were most influential. In the subgroup of patients who did not meet current NIH BMI and comorbidity criteria for bariatric surgery, male sex (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.14-0.76) was associated with decreased odds of selection. Overall, younger age (OR, 0.09; 95% CI, 0.07-0.11), older age (OR, 0.70; 95% CI, 0.56-0.90), limited functional status (OR, 0.66; 95% CI, 0.52-0.82), poor social support (OR, 0.37; 95% CI, 0.30-0.47), self-pay (OR, 0.72; 95% CI, 0.57-0.91), and public insurance (OR, 0.54; 95% CI, 0.43-0.67) were associated with decreased odds of selection. BMI and comorbidity criteria influenced the magnitude of these effects. Patient race did not play a role in surgeon decisions to operate. Further research should examine the roles of unequal access to bariatric surgery and differing socio-cultural perceptions of morbid obesity on racial disparities. The influence of patient age, gender, insurance status, social support, and functional status on decisions to operate was mitigated by BMI and comorbidities. Policy-makers currently debating BMI and comorbidity criteria for bariatric surgery should also consider guidelines pertaining to these sociodemographic issues that influence patient selection in bariatric surgery.
Article
This is the first systematic review and meta-analysis of published mortality data after bariatric surgery. The review includes all papers published in English from January 1, 1990 to April 30, 2006, identified through electronic searches in MEDLINE, Current Contents, and the Cochrane Library, supplemented by manual reference checks. All accepted studies were assigned a level of evidence (Centre for Evidence-Based Medicine, Oxford, UK), and randomized controlled trials were rated for quality using the Jadad scoring method. Random effects meta-analyses were performed. Mortality was analyzed at either <or=30 days or 30 days to 2 years. The data set includes 361 studies with 478 treatment arms and 85,048 patients. At baseline, the mean age was 40.0 years, body mass index was 47.4 kg/m2, 85% were female, and 11.5% had previous bariatric procedures. Meta-analysis of total mortality at <or=30 days was 0.28% (95% confidence interval [CI], 0.22-0.34) in 475 treatment arms (n = 84,931); total mortality at >30 days to 2 years was 0.35% (95% CI, 0.12-0.58) in 140 treatment arms (n = 19,928). Mortality at <or=30 day for all restrictive procedures was 0.30% (95% CI, 0.15-0.46) for open and 0.07% (95% CI, 0.02-0.12) for laparoscopic procedures; restrictive/malabsorptive (gastric bypass) was 0.41% (95% CI, 0.24-0.58] for open and 0.16% (95% CI, 0.09-0.23) for laparoscopic; and malabsorptive was 0.76% (95% CI, 0.29-1.23) for open and 1.11% (95% CI, 0.00-2.70) for laparoscopic. Subgroup analyses of <or=30-day mortality show a male:female ratio of 4.74:0.13, with 1.25% (95% CI, 0.56-1.94) incidence in the superobese and 0.34% (95% CI, 0.00-1.29) in the elderly (>or=65 years). The early and late mortality rates after bariatric surgery are low and can be subjected to risk stratification for comparative analyses and prospective risk assessments.
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The gender and access to health services study: final report. London: Department of Health Predictors of patient selection in bariatric surgery Annals of surgery Impact of age, sex and body mass index on outcomes at four years after gastric banding
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