Intensive Medical Weight Loss or Laparoscopic Adjustable Gastric Banding in the Treatment of Mild to Moderate Obesity: Long-Term Follow-up of a Prospective Randomised Trial Optimizing long-term weight control after bariatric surgery: a pilot study. Treatment of Mild to Moderate Obesity with Laparoscopic Adjustable Gastric Banding or an Intensive Medical Program Multicenter evaluation of an interdisciplinary 52-week weight loss program for obesity with regard to body weight, comorbidities and quality of life—a prospective study Bariatric Surgery versus Lifestyle Interventions for Morbid Obesity—Changes in Body Weight, Risk Factors and Comorbidities at 1 Year Preoperative Lifestyle Intervention in Bariatric Surgery: Initial Results from a Randomized, Controlled Trial Lifestyle, diabetes, and cardiovascular risk factors 10 years after bariatric surgery. Does cognitive behavioral therapy strengthen the effect of bariatric surgery for obesity? Design and methods of a randomized and controlled study. A randomised control trial assessing the impact of an investment based intervention on weight-loss, beliefs and behaviour after bariatric surgery: study protocol A bariatric surgery center of excellence: operative trends and long-term outcomes. Early U.S. outcomes after laparoscopic adjustable gastric banding in patients with a body mass index less than 35 kg/m2 Surgical vs conventional therapy for weight loss treatment of obstructive sleep apnea: a randomized controlled trial. Three-Year Outcomes of Bariatric Surgery vs Lifestyle Intervention for Type 2 Diabetes Mellitus Treatment: A Randomized Clinical Trial. What Is the Best Treatment before Bariatric Surgery? Exercise, Exercise and Group Therapy, or Conventional Waiting: a Randomized Controlled Trial Lifestyle intervention favorably affects weight loss and maintenance following obesity surgery. Gastric bypass surgery for severe obesity: what can be achieved? Evaluation of Current Eligibility Criteria for Bariatric Surgery
Background Proven short-term effectiveness of obesity therapy should be re-evaluated in the long-term . The objective of this paper is to determine the long-term ( 10 years ) outcome for patients from a r and omised controlled trial ( RCT ) . Methods A RCT in 2002 compared laparoscopic adjustable gastric b and ( LAGB ) for obesity  with non-surgical therapy . Follow-up has been conducted at 10 years . Eighty patients ( BMI 30–35 ) were r and omised to a non-surgical or a surgical program .  Outcome data are available on 37 ( 92.5 % ) of the surgical patients and 27 ( 62.5 % ) of the non-surgical patients at 10 years . Results Weight change , the metabolic syndrome , quality of life , adverse events and direct costs of the surgical cohort were the main results of the study . A durable weight loss is present in the surgical group with a mean ( SD ) 10-year weight loss of 14.1 ( 7.7 ) kg ( 63.4 % EWL ) , better than the non-surgical group ( mean ( SD ) = 0.4 ( 10.5 ) kg ; p < 0.001 ) . The metabolic syndrome was reduced from 14 to 4 of the 37 patients who completed 10 years within the LAGB groups . Proximal gastric enlargements occurred in 17 ( 30 % ) of the 57 who had LAGB and removal of the b and occurred in 7 ( 12 % ) . The annual maintenance costs including additional surgery was AUD $ 765 per patient per year . Conclusions Bariatric surgery with the LAGB can achieve long-term weight reduction which is better than a program of non-surgical therapy . There is also a sustained reduction of the metabolic syndrome . There is a significant maintenance requirement after LAGB BACKGROUND Although bariatric surgery is associated with significant overall weight loss , many patients experience suboptimal outcomes . Our objective was to document the preliminary efficacy of a behavioral intervention for bariatric surgery patients with relatively poor long-term weight loss and to explore the factors related to outcome at an academic medical center in the United States . METHODS Patients with a body mass index ( BMI ) ≥ 30 kg/m(2 ) who had undergone bariatric surgery ≥ 3 years before study entry and had < 50 % excess weight loss were enrolled . The participants were r and omly assigned to a 6-month behavioral intervention or wait list control group . The assessment s were conducted at baseline ( before intervention ) and 6 months ( after intervention ) and 12 months ( 6-mo follow-up ) . RESULTS On average , the participants ( n = 36 ) had undergone surgery 6.6 years before study entry . The average age was 52.5 ± 7.1 years , and the BMI was 43.1 ± 6.2 kg/m(2 ) ; most participants were women ( 75 % ) and white ( 88.9 % ) . The intervention patients had a greater percentage of excess weight loss than did the wait list control group at 6 ( 6.6 % ± 3.4 % versus 1.6 % ± 3.1 % ) and 12 ( 5.8 % ± 3.5 % versus .9 % ± 3.2 % ) months . However , the differences were not significant and the results varied . The intervention patients with more depressive symptoms ( P = .005 ) and less weight regain before study entry ( P = .05 ) experienced a greater percentage of excess weight loss . CONCLUSION Behavioral intervention holds promise in optimizing long-term weight control after bariatric surgery . More research is needed on when to initiate the intervention and to identify which patients will benefit from this type of approach Context Observational studies have shown sustained weight loss after surgery for extreme obesity . No r and omized trial of contemporary surgical methods has been performed . Contribution The authors r and omly assigned 80 mildly to moderately obese ( body mass index , 30 to 35 kg/m2 ) adults to laparoscopic placement of an adjustable gastric b and or to an intensive nonsurgical weight loss program . After 2 years , the surgical group had lost 21.6 % of initial weight , and the nonsurgical group had lost 5.5 % of initial weight . Four patients required laparoscopic revision of the gastric b and . Caution s The study was not design ed to detect uncommon adverse events . Implication s Laparoscopic gastric b and ing is effective treatment for mild to moderate obesity . The Editors The development of a safe and effective treatment for obesity is a leading challenge in health care today . Obesity is an increasing health problem across the world with a prevalence of more than 20 % among the adult population in Western countries and more than 30 % in the United States ( 1 , 2 ) . The increasing prevalence is associated with a parallel increase of several obesity-related diseases , in particular , the diseases of the metabolic syndrome ( 3 , 4 ) , which include type 2 diabetes , hypertension , and dyslipidemia , and are linked to nonalcoholic steatohepatitis , obstructive sleep apnea , and the polycystic ovary syndrome . For obese individuals , the options are limited . Behavioral therapies of reduced energy intake , improved eating practice s , and increased exercise and activity , supplemented by pharmacotherapy , generally achieve only modest and often transient effects ( 5 , 6 ) . Observational studies have shown that bariatric surgical therapies involving gastric restriction by various forms of stapling with or without diversion of the gut to generate malabsorption of food are effective in achieving major weight loss and clinical ly significant improvements in health and quality of life ( 7 - 11 ) . Strong direct evidence from r and omized , controlled trials of the relative benefits of nonsurgical and surgical therapies is lacking . We are aware of only a single study , performed in the 1980s , in which 60 morbidly obese patients were r and omly assigned , without informed consent , to diet plus an early form of gastric stapling or to diet alone ( 12 ) . The maximum weight losses did not differ between the groups . However , the weight regain was greater in the diet-only group . The advent of the laparoscopic adjustable gastric b and has provided a new bariatric surgical option , which has proved to be safe , minimally invasive in its application , gentle in its use through its adjustability and easy reversibility , and similarly effective to the other bariatric procedures ( 10 , 13 , 14 ) . Figure 1 shows the LAP-B AND System ( INAMED Health , Santa Barbara , California ) and demonstrates the key feature of adjustability of the area within the b and through which it induces satiety ( 15 ) . Patients require no more than an overnight hospital stay , and the procedure has been shown to be markedly safer than gastric bypass surgery ( 13 ) . Figure 1 . The laparoscopic adjustable gastric b and ( LAP-B AND System , INAMED Health , Santa Barbara , California ) with no added fluid ( top ) and with 2 mL of fluid added ( bottom ) . We hypothesized that surgical therapy would induce more weight loss , health benefit , and improvement in quality of life than nonsurgical therapy and have conducted a r and omized , controlled trial comparing the effectiveness of current nonsurgical therapy with laparoscopic adjustable gastric b and ing in a group of mildly to moderately obese adults ( body mass index , 30 kg/m2 to 35 kg/m2 ) . We did not study patients with a body mass index greater than 35 kg/m2 because current observational data suggest that outcomes after nonsurgical treatment were unlikely to be equal to those after surgical care for these patients . The principal outcome measures were weight change , health , quality of life , and complications of therapy . Methods Patient Recruitment We recruited patients for the study through a newspaper advertisement . All patient assessment s and outpatient treatments were conducted at a community clinic dedicated to obesity management or in the clinics of a university department of surgery . Surgical procedures were conducted at a private community hospital experienced in the care of bariatric surgical patients . Patients in both groups did not pay any medical costs generated by the study . The human ethics committees of The Alfred Hospital and The Avenue Hospital approved the study in accordance with the guidelines of the National Health and Medical Research Council ( www.nhmrc.gov.au/publications/synopses/e35syn.htm ) and with the Helsinki Declaration of 1975 , as revised in 2000 ( www.wma.net/e/ethicsunit/pdf/draft_historical_contemporary_perspectives.pdf ) . Inclusion Criteria We considered patients to be eligible if they were between 20 and 50 years of age ; had a body mass index of 30 kg/m2 to 35 kg/m2 ; had identifiable problems , including an obesity-related comorbid condition ( such as hypertension , dyslipidemia , diabetes , obstructive sleep apnea , or gastroesophageal reflux disease ) , severe physical limitations , or clinical ly significant psychosocial problems associated with their obesity ; had attempted to reduce weight over at least the previous 5 years ; could underst and the options offered and the r and omization process ; and were willing to comply with the requirements of each program . Exclusion Criteria We excluded c and i date s with a history of bariatric surgery or medical problems that contraindicated treatment in either study group , such as impaired mental status , drug or alcohol addiction , or portal hypertension . In addition , we excluded participants if they had undergone an intensive , physician-supervised program that used very-low-calorie diets or pharmacotherapy or if they did not attend the 2 initial patient information visits . Assessment We provided detailed information about the problems of obesity and about the 2 study groups through at least 2 discussion periods and a patient information booklet . Initial assessment included anthropometric measures ; identification of medical , physical , or psychosocial problems ( both weight-related and other ) ; and a discussion of previous weight loss efforts . The assessment included a detailed dietary history by the trial dietitian and a review by a specialist physician to determine the presence and severity of associated medical conditions . Initial investigations included measurements of fasting blood glucose level ; serum insulin level ; and a lipid profile , including HDL cholesterol and LDL cholesterol levels . After initial assessment , we instituted a program of advice on appropriate eating patterns and exercise and followed each patient on a monthly basis for 3 months . During this time , we assessed the patients ' fulfillment of tasks , such as completion of a food diary , and overall adherence to appointments . R and omization Process We r and omly allocated eligible patients to receive a conventional , intensive , nonsurgical program or laparoscopic adjustable gastric b and ing .  A computer-derived r and om allocation sequence , without blocking or stratification , performed the r and omization . This was prepared at the trial office . The trial coordinator enrolled participants and informed them of the trial allocation . After assessment had confirmed a participant 's suitability for r and omization , the coordinator contacted the trial office by telephone for allocation . The study was not blinded . Description of Nonsurgical and Surgical Interventions Common Program We instructed and encouraged all patients to follow appropriate lifestyle behavior of good eating practice s and increased exercise and activity . We also encouraged them to exercise for at least 200 minutes per week . Nonsurgical Program This program centered on the use of behavioral modification , very-low-calorie diet , and pharmacotherapy with education and professional support on appropriate eating and exercise behavior . During the 2-year period , 3 trained physicians developed a program using all the available modalities for each individual on the basis of guidelines prepared and continually review ed by a panel of experienced bariatric physicians . The program began with an intensive 6-month period of very-low-calorie diet ( 500 to 550 kcal/d ) using 1 to 3 packets of Optifast ( Novartis , Fremont , Michigan ) daily for 12 weeks , followed by a transition phase over 4 weeks combining some very-low-calorie meals with 120 mg of orlistat before nonvery-low-calorie diet meals , and then 120 mg of orlistat before all meals until the completion of the intensive phase . This intensive 6-month program was followed by further courses of very-low-calorie diets or orlistat as tolerated , as well as continual behavioral , dietary , and exercise advice to assist the participant in maintaining weight loss over a prolonged period . Sibutramine was not approved for use in Australia during the first 12 months of the study and , therefore , was not incorporated into the medical program . The management program for each individual was design ed to reflect good clinical practice . A physician saw each patient every 2 weeks during the very-low-calorie diet program and every 4 to 6 weeks during the rest of the study . All patients were seen at least every 6 weeks . Surgical Program Two experienced surgeons performed the laparoscopic adjustable gastric b and ( LAP-B AND System ) procedure , by a st and ardized method ( 14 ) , within 1 month of r and omization . The b and was placed along the perigastric pathway in all cases ( 16 ) . The treating surgeon review ed patient progress every 4 to 6 weeks during the study period and made adjustments to the volume of saline within the b and in the office by using st and ard clinical criteria ( 17 ) . Adverse Events All patients in the study were question ed about the occurrence of adverse events at each consultation , and physicians recorded the Objectives : To determine the effectiveness of a structured multidisciplinary non-surgical obesity therapy program on the basis of a temporary low-calorie-diet for 12 weeks , and additional intervention modules to enhance nutritional education , to increase physical activity and to modify eating behavior . Design : Prospect i ve multicenter observational study in obese individuals undergoing a medically supervised outpatient-based 52-week treatment in 37 centers in Germany . Subjects : A total of 8296 participants with a body mass index ( BMI ) of > 30 kg m−2 included within 8.5 years . Measurements : Main outcome measures were body weight loss , waist circumference ( WC ) , blood pressure , quality of life and adverse events . Results : In females , initial body weight was reduced after the 1-year-intervention by 19.6 kg ( 95 % confidence intervals 19.2–19.9 kg ) and in males by 26.0 kg ( 25.2–26.8 ) according to per protocol analysis of 4850 individuals . Intention-to-treat ( ITT ) analysis revealed a weight reduction of 15.2 kg ( 14.9–15.6 ) in females and 19.4 kg ( 18.7–20.1 ) in males . Overall , the intervention result ed in mean reduction in WC of 11 cm ; it reduced the prevalence of the metabolic syndrome by 50 % and the frequency of hypertension from 47 to 29 % of all participants ( ITT , all P<0.001 ) . The beneficial effects could be documented for up to 3 years and comprised significant improvement of health-related quality of life . The incidence of adverse effects was low ; the only event repeatedly observed and possibly related to either the intervention or the underlying disease was biliary disorders . Conclusion : The present non-surgical intervention program is a highly effective treatment of obesity grade s I – III and obesity-related diseases , and therefore , could be a valuable basis for future weight maintenance strategies required for sustained success Background Few studies have looked at non-surgical alternatives for morbid obese patients . This study aims to compare 1-year weight loss and changes in risk factors and comorbidities after bariatric surgery and three conservative treatments . Methods Patients with morbid obesity ( BMI > 40 or BMI > 35 kg/m2 plus comorbidities ) on waiting list for bariatric surgery  , were non-r and omly allocated to ( A ) bariatric surgery or to one of three conservative treatments ; ( B ) residential intermittent program ; ( C ) commercial weight loss camp and ( D ) hospital outpatient program . Body weight , risk factors and comorbidities were assessed at baseline and 1 year . Results Of 206 participants , 179 completed the study . All treatments result ed in significant weight loss , but bariatric surgery ( 40 ± 14 kg , 31 ± 9 % ) led to the largest weight loss ( P < 0.0001 ) . There were no differences in weight loss between B and C ( 22 ± 13 kg , 15 ± 8 % vs. 18 ± 12 kg , 13 ± 8 % ) , but these result ed in larger weight loss compared with D ( 7 ± 10 kg , 5 ± 8 % ) . There were no differences in changes in total or LDL cholesterol , triacylglycerols or glucose between groups ; however , the increase in HDL cholesterol was significantly larger in groups A and C. There were no differences in comorbidities resolution between groups A and B , C and D combined ( except hypertension , which was better in group A ) . Conclusion In conclusion , although bariatric surgery leads to a greater weight loss at 1 year compared with conservative treatment , in patients with morbid obesity , clinical significant weight loss and similar improvements in risk factors and comorbidities resolution can also be achieved with lifestyle interventions OBJECTIVE To document preoperative outcomes of a behavioral lifestyle intervention delivered to patients prior to bariatric surgery in comparison to treatment as usual ( insurance-m and ated physician supervised diet ) . DESIGN AND METHODS After completing a baseline assessment , c and i date s for surgery were r and omized to a 6-month , evidence -informed , manualized lifestyle intervention ( LIFESTYLE , n = 121 ) or to preoperative care as usual ( USUAL CARE , n = 119 ) . At 6 months , 187 participants remained c and i date s for bariatric surgery and were included in the analyses . RESULTS LIFESTYLE participants  lost significantly more weight than those receiving USUAL CARE [ 8.3 ± 7.8 kg vs. 3.3 ± 5.5 kg , F(1,183 ) = 23.6 , P < 0.0001 ] , with an effect size of 0.72 . Additionally , logistic regression modeling indicated that LIFESTYLE patients were significantly more likely to lose at least 5 % of initial body weight than those in USUAL CARE [ OR ( 95 % CI ) = 2.94 ( 1.253 , 6.903 ) ] , as were participants who were heavier [ OR ( 95 % CI ) = 1.07 ( 1.001 - 1.14 ) for each unit increase in BMI ] or with larger improvements in eating behaviors [ OR ( 95 % CI ) = 1.1 ( 1.049 , 1.145 ) for each unit increase on the Eating Behavior Inventory ) . CONCLUSIONS A behavioral lifestyle intervention for severely overweight individuals leads to clinical ly significant weight loss prior to bariatric surgery . Post-surgery follow-up will allow us to examine the impact of the preoperative intervention on postoperative outcomes BACKGROUND Weight loss is associated with short-term amelioration and prevention of metabolic and cardiovascular risk , but whether these benefits persist over time is unknown . METHODS The prospect i ve , controlled Swedish Obese Subjects Study involved obese subjects who underwent gastric surgery and contemporaneously matched , conventionally treated obese control subjects . We now report follow-up data for subjects ( mean age , 48 years ; mean body-mass index , 41 ) who had been enrolled for at least 2 years ( 4047 subjects ) or 10 years ( 1703 subjects ) before the analysis ( January 1 , 2004 ) . The follow-up rate for laboratory examinations was 86.6 percent at 2 years and 74.5 percent at 10 years . RESULTS After two years , the weight had increased by 0.1 percent in the control group and had decreased by 23.4 percent in the surgery group ( P<0.001 ) . After 10 years , the weight had increased by 1.6 percent and decreased by 16.1 percent , respectively ( P<0.001 ) . Energy intake was lower and the proportion of physically active subjects higher in the surgery group than in the control group throughout the observation period . Two- and 10-year rates of recovery from diabetes , hypertriglyceridemia , low levels of high-density lipoprotein cholesterol , hypertension , and hyperuricemia were more favorable in the surgery group than in the control group , whereas recovery from hypercholesterolemia did not differ between the groups . The surgery group had lower 2- and 10-year incidence rates of diabetes , hypertriglyceridemia , and hyperuricemia than the control group ; differences between the groups in the incidence of hypercholesterolemia and hypertension were undetectable . CONCLUSIONS As compared with conventional therapy , bariatric surgery appears to be a viable option for the treatment of severe obesity , result ing in long-term weight loss , improved lifestyle , and , except for hypercholesterolemia , amelioration in risk factors that were elevated at baseline BACKGROUND ( Extreme ) obesity is a chronic harmful condition with high risk of medical comorbidities and negative social and emotional consequences . Bariatric surgery is an effective intervention for obesity , but approximately 20 to 30 % of the patients experience adverse outcomes after surgery and there is a need for augmentation of current treatment strategies . This study examines the added value of pre-operative cognitive behavioral therapy ( CBT ) focused on modification of thoughts and behaviors in terms of eating behavior and physical exercise as well as preparation for surgery and postoperative life style . We hypothesize that pre-operative CBT will result in better weight loss maintenance , reduction of maladaptive eating behavior and better adherence to postoperative lifestyle on the long term as compared to bariatric surgery alone . METHODS One hundred and twenty eight patients that are on a waiting list for bariatric surgery are r and omly assigned to the control or treatment condition . Patients in the treatment condition receive 10 sessions of CBT before surgery aim ed at modifying dysfunctional eating habits and behaviors and developing more rational weight and body-related beliefs in order to enable long term maintenance of a healthier lifestyle after surgery . Weight loss , eating behavior , eating disorders , depression , quality of life and psychological distress are assessed before and after treatment , as well as 1 , 3 , and 5 year following surgery Background Although obesity surgery is currently the most effective method for achieving weight loss , not all patients lose the desired amount of weight and some show weight regain . Previous research shows that successful weight loss may be associated with the amount of investment the patient feels that they have made in their operation . For example , those who feel that it has taken more time and effort to organise , has cost more money , has been more disruptive to their lives and has caused pain are more likely to lose weight after their operation . Therefore , it seems as if the greater the sense of investment , the greater the motivation to make the operation a success . The present study aims to build on these findings by encouraging weight loss surgery patients to focus on the investment they have made , thus making their investment more salient to them and a means to improve weight loss outcomes . Methods The study involves an open r and omised parallel group control trial with patients allocated either to the control or investment intervention group . Using third party blinded r and omization , half the patients will be asked to rate and describe the investment they have made in their operation just before surgery then 3 and 6 months after surgery . All patients will record their weight , beliefs about food , intentions to change and actual eating and exercise behaviour at baseline then 3 , 6 and 12 months follow up . Patients will be recruited from the bariatric surgery pre- assessment clinic at University College Hospital , London . The primary outcome is to explore the impact of the investment based intervention on patient ’s weight and BMI , with secondary outcomes of patients ’ beliefs about foods , behavioural intentions and diet and exercise behaviours . Discussion It is predicted that the investment intervention will improve excess weight loss post-surgery , together with beliefs about food , intentions to change and actual change in diet and exercise behaviour . This has cost implication s for the NHS and other healthcare providers as improved effectiveness of bariatric surgery reduces the health costs of obese patients in the longer term and this simple , easy to administer and low cost intervention could become routine practice for bariatric patients .Trial registration Clinical Trials.gov identifier NCT02045628 ; December 2 , 2013 BACKGROUND Surgery remains the most effective intervention for obesity and its comorbidities . However , the long-term efficacy of bariatric procedures is rarely reported . This study addresses operative trends , efficiency , and long-term outcomes from a large bariatric program . STUDY DESIGN Data were prospect ively collected on 3,460 patients undergoing 3,503 operations from January 2004 to March 2013 . Primary procedures included  Roux-en-Y gastric bypass  ( RY ; n = 2,966 ) , adjustable b and ( AB ; n = 352 ) , and sleeve gastrectomy ( SG ; n = 118 ) . There were 67 revisional procedures ( RP ) . Mean operative time , hospital length of stay , major 30-day morbidity/mortality , follow-up compliance , and weight loss per procedure at follow-up were recorded . RESULTS Mean operative times decreased to the following : RY , 53 minutes ; AB , 35 minutes ; SG , 46 minutes ; and RP , 71 minutes . Mean length of stay was reduced to the following : RY , 1.53 days ; AB , 0.97 days ; SG , 2.12 days ; and RP , 2.68 days . Major complications were mortality , 0.09 % ; leak , 0.51 % ; bleed , 2.37 % ; pneumonia , 0.63 % ; venous thromboembolism , 0.40 % ; and reoperation , 2.34 % . The complication rate was lowest for AB and highest for SG ( p < 0.05 ) . Adjustable b and was the initial procedure in 73 % of cases requiring RP . Follow-up compliance was 93 % at 1 year , 79 % at 3 years , 71 % at 5 years , and 33 % at 9 years . Adjustable b and offered significant weight loss at 1 and 3 years ( p < 0.0001 ) , but less than RY or SG ( p < 0.0001 ) . Excess weight loss was not significantly different between RY and SG at 1 year . Significant weight loss with RY persisted at 7 to 9 years ( p < 0.0001 ) . CONCLUSIONS Our bariatric program experienced an increase in SG and RP and a decrease in AB . Optimization of care reduced operative time and length of stay . All procedures achieved significant weight loss in the first year . Adjusted b and had the lowest morbidity , but inferior weight loss and greater need for revision . Long-term weight-loss data are only available for RY Background Many mildly to moderately obese individuals with a body mass index ( BMI ) lower than 35 kg/m2 have serious diseases related to their obesity . Nonsurgical therapy is ineffective in the long term , yet surgery has never been made widely available to this population . Methods Between 2002 and 2007 , 53 patients with a BMI lower than 35 kg/m2 underwent laparoscopic adjustable gastric b and ing at our institution . Data on all these patients were collected prospect ively and entered into an institutional review board – approved electronic registry . The study parameters included preoperative age , gender , BMI , presence of comorbidities , percentage of excess weight loss ( % EWL ) , and resolution of comorbidities . Results The mean preoperative age of the patients was 46.9 years ( range , 16–68 years ) , and the mean preoperative BMI was 33.1 kg/m2 ( range , 28.2–35.0 kg/m2 ) . Of the 53 patients , 49 ( 92 % ) had at least one obesity-related comorbidity . The mean BMI decreased to 28.1 ± 2.4 kg/m2 , 25.8 ± 2.9 kg/m2 , and 25.8 ± 3.1 kg/m2 and mean % EWL was 48.3 ± 17.6 , 69.9 ± 28.0 , and 69.7 ± 31.7 at 0.5 , 1 , and 2 years , respectively . Substantial improvement occurred for the following comorbidities evaluated : hypertension , depression , diabetes , asthma , hypertriglyceridemia , obstructive sleep apnea , hypercholesterolemia , and osteoarthritis . There was one slip , two cases of b and obstruction ( from food ) , two cases of esophagitis , and two port leaks , but no mortality . Conclusion The authors are very encouraged by this series of low- BMI patients who underwent laparoscopic adjustable gastric b and ing .  Their weight loss has been excellent , and their complications have been acceptable . Their comorbidities have partially or wholly resolved . With further study , it is reasonable to expect alteration of the weight guidelines for bariatric surgery to include patients with a BMI lower than 35 kg/m2 CONTEXT Obstructive sleep apnea ( OSA ) is strongly related to obesity . Weight loss is recommended as part of the overall management plan for obese patients diagnosed with OSA . OBJECTIVE To determine whether surgically induced weight loss is more effective than conventional weight loss therapy in the management of OSA . DESIGN , SETTING , AND PATIENTS A r and omized controlled trial of 60 obese patients ( body mass index : > 35 and < 55 ) with recently diagnosed ( < 6 months ) OSA and an apnea-hypopnea index ( AHI ) of 20 events/hour or more . These patients had been prescribed continuous positive airway pressure ( CPAP )  therapy to manage OSA and were identified via accredited community sleep clinics . The trial was conducted between September 2006 and March 2009 by university- and teaching hospital-based clinical research ers in Melbourne , Australia . Patients with obesity hypoventilation syndrome , previous bariatric surgery , contraindications to bariatric surgery , or significant cardiopulmonary , neurological , vascular , gastrointestinal , or neoplastic disease were excluded . INTERVENTIONS Patients were r and omized to a conventional weight loss program that included regular consultations with a dietitian and physician , and the use of very low-calorie diets as necessary ( n = 30 ) or to bariatric surgery ( laparoscopic adjustable gastric b and ing ; n = 30 ) . MAIN OUTCOME MEASURES The primary outcome was baseline to 2-year change in AHI on diagnostic polysomnography scored by staff blinded to r and omization . Secondary outcomes were changes in weight , CPAP adherence , and functional status . RESULTS Patients lost a mean of 5.1 kg ( 95 % CI , 0.8 to 9.3 kg ) in the conventional weight loss program compared with 27.8 kg ( 95 % CI , 20.9 to 34.7 kg ) in the bariatric surgery group ( P < .001 ) . The AHI decreased by 14.0 events/hour ( 95 % CI , 3.3 to 24.6 events/hour ) in the conventional weight loss group and by 25.5 events/hour ( 95 % CI , 14.2 to 36.7 events/hour ) in the bariatric surgery group . The between-group difference was -11.5 events/hour ( 95 % CI , -28.3 to 5.3 events/hour ; P = .18 ) . CPAP adherence did not differ between the groups . The bariatric surgery group had greater improvement in the Short Form 36 physical component summary score ( mean , 9.3 [ 95 % CI , 0.5 to 18.0 ] ; P = .04 ) . CONCLUSION Among a group of obese patients with OSA , the use of bariatric surgery compared with conventional weight loss therapy did not result in a statistically greater reduction in AHI despite major differences in weight loss . TRIAL REGISTRATION anzctr.org Identifier : 12605000161628 IMPORTANCE Questions remain about the role and durability of bariatric surgery for type 2 diabetes mellitus ( T2DM ) . OBJECTIVE To compare the remission of T2DM following surgical and nonsurgical treatments . DESIGN , SETTING , AND PARTICIPANTS In this 3-arm r and omized clinical trial conducted at the University of Pittsburgh Medical Center from October 1 , 2009 , to June 26 , 2014 , in Pittsburgh , Pennsylvania , outcomes were assessed 3 years after treating 61 obese participants aged 25 to 55 years with T2DM . Analysis was conducted with an intent-to-treat population . INTERVENTIONS Participants were r and omized to either an intensive lifestyle weight loss intervention for 1 year followed by a low-level lifestyle intervention for 2 years or surgical treatments ( Roux-en-Y gastric bypass [ RYGB ] or laparoscopic adjustable gastric b and ing [ LAGB ] ) followed by low-level lifestyle intervention in years 2 and 3 . MAIN OUTCOMES AND MEASURES Primary end points were partial and complete T2DM remission and secondary end points included diabetes medications and weight change . RESULTS Body mass index ( calculated as weight in kilograms divided by height in meters squared ) was less than 35 for 26 participants ( 43 % ) , 50 ( 82 % ) were women , and 13 ( 21 % ) were African American .  Mean ( SD ) values were 100.5 ( 13.7 ) kg for weight , 47.3 ( 6.6 ) years for age , 7.8 % ( 1.9 % ) for hemoglobin A1c level , and 171.3 ( 72.5 ) mg/dL for fasting plasma glucose level . Partial or complete T2DM remission was achieved by 40 % ( n = 8) of RYGB , 29 % ( n = 6 ) of LAGB , and no intensive lifestyle weight loss intervention participants ( P = .004 ) . The use of diabetes medications was reduced more in the surgical groups than the lifestyle intervention-alone group , with 65 % of RYGB , 33 % of LAGB , and none of the intensive lifestyle weight loss intervention participants going from using insulin or oral medication at baseline to no medication at year 3 ( P < .001 ) . Mean ( SE ) reductions in percentage of body weight at 3 years were the greatest after RYGB at 25.0 % ( 2.0 % ) , followed by LAGB at 15.0 % ( 2.0 % ) and lifestyle treatment at 5.7 % ( 2.4 % ) ( P < .01 ) . CONCLUSIONS AND RELEVANCE Among obese participants with T2DM , bariatric surgery with 2 years of an adjunctive low-level lifestyle intervention result ed in more disease remission than did lifestyle intervention alone . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01047735 Objective This trial ’s objective was to investigate the effect of an exercise program with and without cognitive-behavioral therapy ( CBT ) , compared by a control group , on weight , functional capacity , and cardiometabolic profile of morbidly obese individuals while waiting for bariatric surgery . Material s and Methods This r and omized controlled trial investigated the effect of a 4-month low-intensity exercise program ( two weekly sessions of 25 min each ) on 66 morbidly obese individuals awaiting bariatric surgery . Participants were r and omly divided into three groups : EXER , exercise program ; EXER + CBT , exercise program plus support group sessions for lifestyle modification , with a CBT ; and CONTROL , routine treatment . They were compared on weight , functional capacity , and cardiometabolic profile . Results The weight change ( Kg ) was −7.4 ( −9.6 to 5,1 ) ; −4,2 ( −6,8 to −1.6 ) and 2.9 ( 0.4 to 5.3 ) and the BMI change ( kg/m2 ) was −2.7 ( −3.6 to −1.8 ) ; −1.4 ( −2.4 to −0.4 ) and 1.1 ( 0.1 to 2.1 ) for groups EXER , EXER + CBT , and CONTROL , respectively . Changes were significant when compared to the control group ( p < 0.001 ) , but there were no differences between the two intervention arms ( p = 0.2 ) . Functional capacity and cardiometabolic parameters significantly improved in the intervention arms and worsened in the control group . The adherence to the exercise program in both groups was above 78 % . Conclusion A 4-month , twice-weekly supervised program of low-intensity physical activity that encourages individuals to adopt a more active lifestyle can positively interfere with weight loss and improvement in functional capacity and cardiometabolic parameters of morbidly obese individuals with and without the aid of support group sessions The present study was design ed to evaluate the 3 year effects of a lifestyle intervention on weight loss and maintenance , dietary , and physical activity habits and eating behavior of patients following vertical b and ed gastroplasty ( VBG ) . Thirty severely obese female volunteers were included in the study and they were r and omly assigned to one of two intervention groups : usual care ( UC ) or lifestyle intervention ( LS ) group . Patients were followed for 3 years postoperatively . Outcome measures included weight loss , dietary habits , physical activity level ( PAL ) , and eating behavior changes . Weight was significantly lower in the LS group after 12 months ( 84.4 + /- 3.9 kg vs. 98.4 + /- 4.4 kg , P < 0.05 ) , 24 months ( 83.0 + /- 3.3 vs. 101.9 + /- 5.3 kg , P < 0.05 ) , and 36 months following surgery ( 84.2 + /- 3.3 vs. 102.5 + /- 3.5 kg , P < 0.05 ) . Repeated measures ANOVA revealed significant differences between the two groups overall and at specific time points for the PAL and TV viewing . With regard to eating behavior , the LS group scored significantly better in total Dutch Eating Behavior Question naire ( DEBQ ) , Restraint Eating and External Eating scales at all postoperative time points . Similarly , significant differences were found between the two groups in dietary intake . These findings outline the importance of lifestyle intervention on weight loss and maintenance following bariatric surgery . The favorable effects of lifestyle intervention may be through adoption of healthier eating behaviors and increased physical activity BACKGROUND As severe obesity becomes an increasing problem , it is important that the role of surgery in the management of the condition becomes better understood and recognised . This study reports the outcome of a large series of gastric bypass operations performed for severe obesity by a single surgeon . METHODS AND RESULTS Between 1990 - 2002 , 310 patients underwent gastric bypass surgery with all data being collected prospect ively and recorded on a computerised data base .  Mean preoperative weight and percentage excess weight were 132 kg and 119 % , respectively . There was no 30-day mortality and only one life threatening complication . Re-operations were required in 43 patients , most of which were related to ring removal or staple line disruption seen in the earlier form of gastric bypass . These problems are largely overcome with the currently performed technique . Percentage excess weight loss at 1 , 2 , 3 , 4 and 5 years was 73 % , 73 % , 66 % , 64 % , and 59 % respectively . Forty-nine of the 52 patients with type 2 diabetes were cured following surgery and 87 % of those with hypertension resolved or improved their condition . Dyslipidaemia resolved or improved in 87 % and asthma was cured or improved in 89 % of those affected . 61 patients had symptoms of obstructive sleep apnoea prior to surgery and in 51 of these symptoms resolved following surgery . CONCLUSION This study confirms that gastric bypass is a very effective treatment for severe obesity  and can be performed with a high level of safety . Gastric transection is an important component of the operation . The majority of important comorbidities seen before surgery either resolve or improve following surgery . Bariatric surgery is establishing itself as a very important and satisfying branch of upper gastrointestinal ( GI ) surgery OBJECTIVE Patients with a BMI < 35 kg/m2 and patients with a BMI between 35 and 40 kg/m2 without comorbidities are noneligible by current eligibility criteria for bariatric surgery .  We used Swedish obese subjects ( SOS ) to explore long-term outcomes in noneligible versus eligible patients . RESEARCH DESIGN AND METHODS The SOS study involved 2,010 obese patients who underwent bariatric surgery ( 68 % vertical-b and ed gastroplasty , 19 % b and ing , and 13 % gastric bypass ) and 2,037 contemporaneously matched obese controls receiving usual care .  At inclusion , the participant age was 37–60 years and BMI was ≥34 kg/m2 in men and ≥38 kg/m2 in women . The effect of surgery was assessed in patients that do ( n = 3,814 ) and do not ( n = 233 ) meet current eligibility criteria . The date of analysis was 1 January 2012 . The follow-up time was up to 20 years , with a median of 10 years . RESULTS Cardiovascular risk factors were significantly improved both in noneligible and eligible individuals after 10 years of follow-up . Surgery reduced the diabetes incidence in both the noneligible ( adjusted hazard ratio 0.33 [ 95 % CI 0.13–0.82 ] , P = 0.017 ) and eligible ( 0.27 [ 0.22–0.33 ] , P < 0.001 ) groups . We could not detect a difference in the effect of surgery between the groups ( adjusted interaction P value = 0.713 ) . CONCLUSIONS Bariatric surgery drastically reduced the incidence of type 2 diabetes both in noneligible and eligible patients and improved cardiovascular risk factors in both groups . Our results show that strict BMI cutoffs are of limited use for bariatric surgery prioritization if the aim is to prevent diabetes and improve cardiovascular risk factors
Behavioural interventions appear to improve weight loss at 12 months after bariatric surgery .
Background Significant , sustained weight loss through conventional , non-surgical interventions is often unattainable for people with severe obesity ( e.g. BMI ≥40 or ≥35 kg/m2 with co-morbidities ) .
Bariatric surgery is effective in treating severe obesity , but surgery alone without additional behaviour change management may not result in optimum long-term weight loss and maintenance .
This systematic review and meta- analysis of r and omised controlled trials evaluated the effectiveness of lifestyle interventions before and /or after bariatric surgery .