Severe obesity during childhood is associated with cognitive deficits. Studies in adults have suggested improvements in executive functioning and memory after bariatric surgery. Our aim was to explore changes in cognitive function in adolescents over two years after bariatric surgery or intensive non-surgical treatment.
International and national guidelines recommend metabolic and bariatric surgery (MBS) as a treatment option for adolescents with severe obesity, but few countries offer MBS to adolescents in routine clinical care. This narrative review summarizes existing adolescent MBS guidelines and the available underpinning evidence. Two randomized trials and additional prospective studies have demonstrated efficacy and safety in adolescent MBS, and the health benefits appear to be similar or superior to outcomes in adults. However, there are specific challenges regarding the intervention during adolescence related to decision-making capacity and a peak in risk-taking behavior. Adolescents with severe obesity have—as a group—a mental health vulnerability, and specific nutritional concerns need to be addressed in relation to MBS. This review also describes how study findings can be translated into clinical care. We use Sweden as an example, where the National Board of Health and Welfare recommends MBS for selected adolescents with severe obesity aged 15 years or older. We present practical advice for implementing and integrating MBS in adolescents in the framework of multidisciplinary pediatric and adolescent care for obesity.
<b><i>Introduction:</i></b> With the rapid development of treatment modalities for obesity management, there is an increasing demand for guidance to facilitate the prioritization of interventions. In 2020, the Swedish National Board of Health and Welfare started the process of producing the first national guidelines for obesity care directed to decision makers who allocate resources to the best knowledge-based care. The main aim of this paper was to describe the systematic development of these guidelines, designed to guarantee uniformly high standards of care throughout the whole country. <b><i>Methods:</i></b> The standardized procedures of the National Board of Health and Welfare were applied to construct guidelines in a systematic and transparent way, including priority setting of recommendations and quality indicators to evaluate the progress of implementation. The process involved independent expert committees including professionals and patient representatives, and the guidelines were reviewed through an open public consultation. <b><i>Results:</i></b> National guidelines were issued in 2023, encompassing a broad scope, from identification and diagnosis to multiple treatment modalities, embedded in a life-course perspective from pregnancy to the elderly, as well as highlighting the need for improved knowledge and competence of health care providers. <b><i>Conclusions:</i></b> National guidelines for improved standard care and evidence-based and efficient use of health care resources for obesity treatment can be developed in a systematic way with professionals and patient representatives.
To assess the prevalence of neurodevelopmental problems in adolescents with severe obesity and their associations with binge eating and depression.Data were collected at inclusion in a randomised study of bariatric surgery in 48 adolescents (73% girls; mean age 15.7 ± 1.0 years; mean body mass index 42.6 ± 5.2 kg/m2 ). Parents completed questionnaires assessing their adolescents' symptoms of attention-deficit/hyperactivity disorder and autism spectrum disorder and reported earlier diagnoses. Patients answered self-report questionnaires on binge eating and depressive symptoms.The parents of 26/48 adolescents (54%) reported scores above cut-off for symptoms of the targeted disorders in their adolescents, but only 15% reported a diagnosis, 32% of adolescents reported binge eating, and 20% reported symptoms of clinical depression. No significant associations were found between neurodevelopmental problems and binge eating or depressive symptoms. Only a third of the adolescents reported no problems in either area.Two thirds of adolescents seeking surgical weight loss presented with substantial mental health problems (reported by themselves or their parents). This illustrates the importance of a multi-professional approach and the need to screen for and treat mental health disorders in adolescents with obesity.
Introduction: Childhood obesity is associated with cardiometabolic and psychosocial comorbidity, weight stigma, and premature adult mortality. Physical activity provides many health benefits for adolescents with obesity. Aim: The purpose of this study was to explore what experiences adolescents who have or have had obesity between 13–18 years of age have from long-term participation in regular physical activity in a lifestyle intervention. Method: Semi-structured interviews were performed with nine adolescents (five girls, four boys) ages 13–18 years who had been participating in physical activity in a regular way in this intervention. They had been participating for one to six years (average 2.8 years). Qualitative content analysis with an inductive approach was used to analyse the data. Result: The adolescent’s experiences of regular physical activity in this intervention was divided into three categories: 1) to experience the joy of movement; 2) to experience influence of the group; 3) to experience personal development. An inclusive and accepting group increased positive feelings of participation and they experienced that they achieved weight loss, improved self-esteem, and generally felt better when they started to be physically active. Conclusion: When adolescents who have or have had obesity are given the proper circumstances for physical activity, they experience it as fun and self-developing. It is important for adolescents to be allowed to be with friends with similar experiences and be among individuals they feel comfortable with and connected to.
Dear Editor, Our thanks go to Mazzetto et al. [1] for their interest in our paper on personalized obesity treatment, recently published in the Journal of Internal Medicine [2]. We welcome their comments on the interesting connection between obesity treatment and chronic cutaneous conditions, especially because these aspects are not commonly noted in clinical practice. At present, treatment with the new glucagon-like peptide-1 (GLP-1) receptor agonists is demonstrated to have beneficial effects on various conditions besides obesity and diabetes type 2, such as reducing the risk of worsened cardiovascular outcomes [3] and delaying the progression of diabetes-related nephropathy [4]. Obesity is characterized by a state of chronic inflammation. Thus, weight loss as such could be hypothesized to lead to inflammation improvement. Nonetheless, consistent evidence from both preclinical studies and clinical trials suggests that GLP-1 receptor agonists exhibit anti-inflammatory effects influencing the immune system, irrespective of glycemic state and even before significant weight loss occurs. These potential immunomodulatory effects of GLP-1 and its agonists introduce new possibilities for treating inflammatory diseases. GLP-1 receptor agonists have been shown to be associated with a decrease of inflamed airways causing asthma attacks [5], to improve the inflammation in metabolic dysfunction-associated steatotic liver disease [6], and as Mazzetto et al. point out [1], a number of studies have also shown improvements in psoriasis, another inflammatory condition. This anti-inflammatory effect on chronic cutaneous conditions, such as psoriasis, has also been found after metabolic and bariatric surgery. GLP-1 levels substantially increase postoperatively, suggesting that the response is GLP-1 mediated. In the Swedish Obese Subjects study comparing persons who had metabolic and bariatric surgery to controls with obesity, none had psoriasis at baseline. However, during 25 years of follow-up, metabolic and bariatric surgery were associated with a lower incidence of psoriasis, HR: 0.65 [0.47–0.89] [7]. Interestingly, a longer duration of obesity was independently associated with a higher risk for psoriasis, thus supporting that chronic inflammation is a risk factor. However, the degree of weight loss seems important, as gastric bypass surgery reduced both the risk of new-onset psoriasis (adjusted HR 0.52 [0.33–0.81]) and progression to severe psoriasis (adjusted HR 0.44 [0.23–0.86]) in a population-based Danish study, whereas gastric banding—resulting in lower weight loss—demonstrated a slightly increased risk for both conditions with time [8]. In this context, we would also like to remind all readers of the frequent need for excess skin removal after successful obesity treatment with significant weight loss to avoid cutaneous conditions such as skin infections and fungal rashes [9]. In summary, besides the well-known effect on weight and glycemic control, GLP-1 receptor agonists exert effects on a wide range of physiological and pathological processes, including inflammation. It is essential that specialists—beyond those managing obesity and diabetes—consider these medications as adjuncts in the management or as a potential treatment option for their patients. Kind regards from all authors. Expert committee for the Swedish national guidelines for obesity care: all authors. Board members of the Swedish organization for obesity research: Kajsa Järvholm, Lovisa Sjögren, Paulina Nowicka, and Ylva Trolle Lagerros; the Swedish organization for childhood obesity: Kajsa Järvholm; the Swedish pediatric treatment registry: Lovisa Sjögren; the Scandinavian Obesity Surgery Registry: Magnus Sundbom. Local principal investigator in a global phase III study of a GLP-1/glucagon dual agonist for adults: Ylva Trolle Lagerros (part of clinical work). Local principal investigator in a global phase III study of a GLP-1 agonist for children: Lovisa Sjögren (part of clinical work). Lecturing fees from industry: Kajsa Järvholm (part of clinical work).
Introduction: With the rapid development of treatment modalities for obesity management, there is a growing need for guidelines. This was acknowledged by the Swedish National Board of Health and Welfare and in 2020 the process of producing the first national guidelines for obesity care, including both children and adults, was initiated. The main aim was to ensure equal high standard care throughout Sweden by supporting decision makers to allocate resources to the best knowledge-based care. Methods: The standardized procedures of the National Board of Health and Welfare were applied to construct guidelines in a systematic and transparent way, including priority setting of recommendations and quality indicators to evaluate the progress of implementation. The process involved independent expert committees including professionals and patient representatives, and the guidelines were reviewed through an open public consultation. Results: In total, 20 recommendations were issued encompassing a broad scope, from identification and diagnosis to multiple treatment modalities, embedded in a life course perspective from pregnancy to the elderly, as well as highlighting the need for improved knowledge and competence of health care providers. Conclusions: National guidelines for improved standard care and evidence based and efficient use of health care resources for obesity treatment can be developed in a systematic way with professionals and patient representatives.
The aim of this study was to measure 11β-HSD-1 activity in subcutaneous adipose tissue by an ex vivo method in three subgroups; lean, obese, and type 2 diabetes subjects, both in the fasting state and after a mixed meal and to determine the variability and reproducibility of this method. Eighteen subjects were investigated; 6 lean, 6 abdominally obese, and 6 type 2 diabetes subjects (BMI 22±1, 30±3 and 31±3 kg/m2, respectively). Needle biopsies were taken repeatedly and an index of 11β-HSD-1 activity was measured as percent conversion of 3H-cortisone to 3H-cortisol/100 mg tissue. For two separate biopsies taken in the fasting state on the same day, the within subjects CV was 16% and the between CV was 36% for 11β-HSD-1 activity for all subjects. For two biopsies taken in the fasting state at two different days, the total within subjects CV was 38% and the between subjects CV was 46%. Lean subjects had lower 11β-HSD-1 activity (4.8±1.5% conversion of 3H-cortisone to 3H-cortisol/100 mg tissue) than both obese (14.4±1.6% conversion, p<0.01) and type 2 diabetes subjects (11.7±1.9% conversion, p<0.05) in the fasting state. There was no effect of a meal on 11β-HSD-1 activity in any of the three groups. The conclusions from this study are: 1) the variation coefficient for the ex vivo adipose tissue 11β-HSD-1 activity method was ∼25% for repeat measures within subjects; 2) food intake had no major impact on enzyme activity; and 3) 11β-HSD-1 activity in subcutaneous adipose tissue was significantly increased in obese subjects with or without T2DM compared to lean subjects without diabetes.
