Alcohol use risk in adolescents 2 years after bariatric surgery

doi:10.1016/j.soard.2016.05.019

Surgery for Obesity and Related Diseases

Volume 13, Issue 1, January 2017, Pages 85-94

https://doi.org/10.1016/j.soard.2016.05.019 Get rights and content

Abstract

Background

Problematic alcohol use and increased sensitivity postoperatively in adult weight loss surgery patients heightens concerns. No data have characterized these behaviors in adolescents—a gap, given adolescent alcohol use and heavy drinking are public health concerns.

Objective

To examine alcohol use behavior in adolescents who underwent weight loss surgery across the first two post-operative years in comparison to nonsurgical adolescents.

Setting

Five academic medical centers.

Methods

Utilizing a prospective controlled design, adolescents undergoing weight loss surgery (n = 242) and nonsurgical adolescents with severe obesity (n = 83) completed the Alcohol Use Disorders Test. Analyses included 216 surgical (M_age = 17.1 ± 1.5, MBMI = 52.9 ± 9.3, 91.8% female, 67.6% white) and 79 nonsurgical participants (M_age = 16.2 ± 1.4, M_BMI = 46.9 ± 6.1, 82.3% female, 53.2% white), with baseline data and at 12 or 24 months postoperatively.

Results

The majority reported never consuming alcohol within the year before surgery (surgical, 92%; nonsurgical, 91%) or by 24 months (surgical, 71%; nonsurgical, 74%), when alcohol use disorder approached 9%. Among alcohol users at 24 months (n = 52 surgical, 17 nonsurgical), 35% surgical and 29% nonsurgical consumed 3+drinks on a typical drinking day; 42% surgical and 35% nonsurgical consumed 6+drinks on at least 1 occasion. For the surgical group, alcohol use changed as a function of older age (odds ratio [OR] = 2.47, P = .01) and lower body mass index (OR = .94, P<.001). Greater percent change in weight (0–24 mo) was associated with increased odds of alcohol use at 24 months (OR = 1.01, 95% confidence interval: 1.002–1.02).

Conclusion

Alcohol use was lower than national base rates. Alcohol use disorder rates and harmful consumption raise concerns given extant adult literature. Alcohol education focused on harm reduction (i.e., lower consumption, managing situations conducive to alcohol-related harm) and monitoring by healthcare providers as patients mature is indicated.

Section snippets

Overview of study design

Teen-LABS is a multicenter prospective longitudinal observational study evaluating safety, efficacy, health, and quality of life outcomes of consecutive adolescent patients with severe obesity (BMI ≥ 40 kg/m²) undergoing a bariatric surgical procedure (March 2007 – February 2012) at 5 academic medical centers in the United States. Teen-LABS’s purpose, inclusion criterion, and methodology were previously reported [26]. TeenView is an ancillary study to Teen-LABS, conducted in parallel and

Sample characteristics

Surgery participants were older than nonsurgical comparators, likely due to lower age eligibility criteria for the TeenView study (Table 1). Surgery participants were also more likely than comparators to be white. All participants were severely obese at baseline, although the nonsurgical group had a lower BMI. Attrition analyses determined that membership in the longitudinal analysis sample (i.e., baseline and either 12 or 24 mo data) versus the nonlongitudinal sample was unrelated to group,

Discussion

Underage alcohol use and heavy drinking are significant public health concerns in the United States. At first glance, results from Teen-LABS suggest normative or even attenuated alcohol use rates for the adolescent/young adult WLS patient across the first 2 postoperative years. Descriptively, past-year alcohol use rates (i.e., frequency of participants who endorse drinking) appear similar for surgical and nonsurgical groups yet were lower than national base rates across time points for both

Conclusion

There is no definition of what would be an acceptable level of alcohol consumption for a WLS patient of any age. That said, it is important to recognize the social norms and conventions surrounding alcohol consumption (when, how often, level, availability) differ for adolescent and adult patients, including the fact that alcohol consumption is illegal for those under 21 years of age in the United States. Of immediate importance to adolescent WLS care is the routine screening of alcohol use

Funding

This research was supported by grants from the National Institutes of Health (Teen-LABS Consortium U01 DK072493, UM1 DK072493 l; PI: Thomas Inge, M.D., Ph.D.; the Teen-LABS Data Coordinating Center UM1 DK095710; PI: Ralph Buncher, Sc.D.; and TeenView R01 DK080020; PI: Meg Zeller).The study is also supported by grants UL1 TR000077-04 (Cincinnati Children’s Hospital Medical Center), UL1 RR025755 (Nationwide Children’s Hospital), M01-RR00188 (Texas Children’s Hospital/Baylor College of Medicine),

Financial disclosure

Thomas H. Inge has received bariatric research grant funding from Ethicon Endosurgery and has served as consultant for Sanofi Corporation and Imedecs, all unrelated to this project. Anita P. Courcoulas has received research grants from Allergan, Pfizer, Covidien, EndoGastric Solutions, and Nutrisystem and has served on the Scientific Advisory Board of Ethicon J & J Healthcare System. David B. Sarwer has served as consultant for BARONova, Medtronic, and Neothetics. Marc P. Michalsky has received

Conflict of interest

The authors have no commercial associations that might be a conflict of interest in relation to this article.

Acknowledgments

We gratefully acknowledge the dedication and expertise of the additional Teen-LABS Consortium and/or TeenView Study Group co-investigators, the research coordinators at each site, and the administrative, data management, and data quality/integrity staff at the Teen-LABS Data Coordinating Center. Cincinnati Children’s Hospital Medical Center: Michael Helmrath, M.D., Ph.D., Jennie Noll, Ph.D., April Carr, B.S., Lindsey Shaw, M.S., Cynthia Spikes, C.R.C., Shelley Kirk, Ph.D., R.D., Faye Doland,

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Cited by (23)

Marijuana, e-cigarette, and tobacco product use in young adults who underwent pediatric bariatric surgery
2023, Surgery for Obesity and Related Diseases
Citation Excerpt :
The upstream prioritization of effective strategies to prevent uptake and escalation of marijuana and tobacco product use among all youth with obesity in primary, tertiary, and MBS care are needed. For pediatric MBS, these data further underscore the need for planful, age-salient, and holistic postoperative care guidelines addressing not only tobacco product/devices and marijuana use, but all health risk behaviors across this AYA transition (e.g., alcohol use, sexual risk, suicide behaviors [48–51]), particularly as clinic follow-up may wane and when preventive health care is suboptimal among YA, in general [52,53]. Noteworthy findings, consistent with our earlier work (i.e., year 4 [16]), illustrated the influence and potency of circulating in social environments that likely reinforce and/or encourage use and may facilitate greater access (e.g., friend use, residing with smoker, in school/working), factors known to increase use in the general YA population [30–33].
The postoperative course after pediatric metabolic and bariatric surgery (MBS) cuts across a developmental phase when substance-use behaviors emerge as significant public health concerns.
We examined use of marijuana, conventional cigarettes, and alternate tobacco products/devices (e.g., e-cigarettes, hookah, smokeless, dissolvable) in young adults (YA) to 6 years postsurgery.
Five academic medical centers.
In a prospective observational cohort series, 139 surgical (M_age = 16.9, M_{body mass index [BMI]} = 51.5, 80% female, 66% white) and 83 nonsurgical comparisons (M_age = 16.1, M_BMI = 44.9, 82% female, 54% white) completed assessments at presurgery/baseline and postsurgery years 2, 4, and 6 (year 6 [2014–2018]: surgical n = 123 [89%], M_age = 23.0, M_BMI = 39.8; nonsurgical n = 63 [76%], M_age = 22.4, M_BMI = 53.6). Lifetime and current (past 30 days) use were reported.
Consistent with national YA trends (2014–2018), the most commonly used were (1) conventional cigarettes (30% surgical, 41% nonsurgical, nonsignificant [ns]); (2) marijuana (25% surgical, 27% nonsurgical, ns); and (3) e-cigarettes (12% surgical, 10% nonsurgical). A sizable minority (26% surgical, 18% nonsurgical) used one or more alternate tobacco product/device. Many YA reported persistent and/or heavy use (e.g., >50% marijuana at year 6 and year 2 or 4; ≈50% ≥.5 pack/d of cigarettes), suggesting more established (versus intermittent) health risk behaviors. For the surgical group at year 6, current tobacco product/device use was associated with lower BMI (P < .001) and greater percent weight loss (P = .002).
Pediatric MBS demonstrates promise in lowering risks for adult chronic disease, which may be diminished by age-typical health risk behaviors. Developmentally salient and holistic pediatric postoperative care guidelines are needed.
Metabolic and bariatric surgery versus intensive non-surgical treatment for adolescents with severe obesity (AMOS2): a multicentre, randomised, controlled trial in Sweden
2023, The Lancet Child and Adolescent Health
Severe obesity in adolescents has a profound impact on current and future health. Metabolic and bariatric surgery (MBS) is increasingly used in adolescents internationally. However, to our knowledge, there are no randomised trials examining the currently most used surgical techniques. Our aim was to evaluate changes in BMI and secondary health and safety outcomes after MBS.
The Adolescent Morbid Obesity Surgery 2 (AMOS2) study is a randomised, open-label, multicentre trial done at three university hospitals in Sweden (located in Stockholm, Gothenburg, and Malmö). Adolescents aged 13–16 years with a BMI of at least 35 kg/m², who had attended treatment for obesity for at least 1 year, passed assessments from a paediatric psychologist and a paediatrician, and had a Tanner pubertal stage of at least 3, were randomly assigned (1:1) to MBS or intensive non-surgical treatment. Exclusion criteria included monogenic or syndromic obesity, major psychiatric illness, and regular self-induced vomiting. Computerised randomisation was stratified for sex and recruitment site. Allocation was concealed for both staff and participants until the end of the inclusion day, and then all participants were unmasked to treatment intervention. One group underwent MBS (primarily gastric bypass), while the other group received intensive non-surgical treatment starting with 8 weeks of low-calorie diet. The primary outcome was 2-year change in BMI, analysed as intention-to-treat. The trial is registered at ClinicalTrials.gov, NCT02378259.
500 people were assessed for eligibility between Aug 27, 2014, and June 7, 2017. 450 participants were excluded (397 did not meet inclusion criteria, 39 declined to participate, and 14 were excluded for various other reasons). Of the 50 remaining participants, 25 (19 females and six males) were randomly assigned to receive MBS and 25 (18 females and seven males) were assigned to intensive non-surgical treatment. Three participants (6%; one in the MBS group and two in the intensive non-surgical treatment group) did not participate in the 2-year follow-up, and in total 47 (94%) participants were assessed for the primary endpoint. Mean age of participants was 15·8 years (SD 0·9) and mean BMI at baseline was 42·6 kg/m² (SD 5·2). After 2 years, BMI change was –12·6 kg/m² (–35·9 kg; n=24) among adolescents undergoing MBS (Roux-en-Y gastric bypass [n=23], sleeve gastrectomy [n=2]) and –0·2 kg/m² (0·4 kg; [n=23]) among participants in the intensive non-surgical treatment group (mean difference –12·4 kg/m² [95% CI –15·5 to –9·3]; p<0·0001). Five (20%) patients in the intensive non-surgical group crossed over to MBS during the second year. Adverse events (n=4) after MBS were mild but included one cholecystectomy. Regarding safety outcomes, surgical patients had a reduction in bone mineral density, while controls were unchanged after 2 years (z-score change mean difference –0·9 [95% CI –1·2 to –0·6]). There were no significant differences between the groups in vitamin and mineral levels, gastrointestinal symptoms (except less reflux in the surgical group), or in mental health at the 2-year follow-up.
MBS is an effective and well tolerated treatment for adolescents with severe obesity resulting in substantial weight loss and improvements in several aspects of metabolic health and physical quality of life over 2 years, and should be considered in adolescents with severe obesity.
Sweden's Innovation Agency, Swedish Research Council Health.
Suicidal thoughts and behaviors in adolescents who underwent bariatric surgery
2020, Surgery for Obesity and Related Diseases
Citation Excerpt :
While the most common substance used in the surgical post-STB group was marijuana (9/10), use of barbiturates, tranquilizers, and/or narcotics was also reported. In a previous report at year 2 with these participants [40], warnings of safety concerns regarding adolescents’ postsurgical hazardous alcohol were relayed particularly given pharmacokinetic evidence of elevated risk of intoxication and impairment after surgery [65]. Moreover, when these year 4 data are considered against adult evidence indicating elevated risks postsurgery for drug- and alcohol-related deaths and self-harm via drug poisoning [15,16,61,66], concern is warranted.
Extant literature warns of elevated suicide risks in adults postbariatric surgery, making understanding risks for adolescent patients imperative.
To examine prevalence and predictors/correlates of suicidal thoughts and behaviors (STBs) in adolescents with severe obesity who did/did not undergo bariatric surgery from presurgery/baseline to 4 years postsurgery.
Five academic medical centers.
Using a prospective observational design, surgical adolescents (n = 153; 79% female, 65% white, mean [M]_age = 17 yr, M_{body mass index[BMI]} = 52 kg/m²) and nonsurgical comparators (n = 70; 80% female, 54% white, M_age = 16 yr, M_BMI = 47 kg/m²) completed psychometrically sound assessments at presurgery/baseline and postsurgery years 2 and 4 (year 4: n = 117 surgical [M_BMI = 38 kg/m²], n = 56 nonsurgical [M_BMI = 48 kg/m²]).
For the surgical group, rates of STBs were low (year 2 [1.3%–4.6%]; year 4 [2.6%–7.9%], similar to national base rates. Groups did not differ on a year 4 postsurgical STBs (post-STBs) composite (post-STBs: ideation/plan/attempt; n = 18 surgical [16%], n = 10 nonsurgical [18%]; odds ratio = .95, P = .90). For the surgical group, predictors/correlates identified within the broader suicide literature (e.g., psychopathology [P < .01], victimization [P < .05], dysregulation [P < .001], drug use [P < .05], and knowing an attemptor/completer [P < .001]) were significantly associated with post-STBs. Surgery-specific factors (e.g., percent weight loss, weight satisfaction) were nonsignificant. Of those reporting a lifetime attempt history at year 4, only a minority (4/13 surgical, 3/9 nonsurgical) reported a first attempt during the study period. Of 3 decedents (2 surgical, 1 nonsurgical), none were confirmed suicides.
The present study indicates that undergoing bariatric surgery in adolescence does not heighten (or lower) risk of STB engagement across the initial 4 years after surgery. Suicide risks present before surgery persisted, and also newly emerged in a subgroup with poorer psychosocial health.
Preoperative considerations for the pediatric patient undergoing metabolic and bariatric surgery
2020, Seminars in Pediatric Surgery
Citation Excerpt :
As with any procedure, a psychologist should also assess and counsel the patient for alcohol and nicotine use or abuse. Adolescents have lower rates of alcohol and drug use compared to adults; however, they tend to engage in higher-risk drinking (e.g. binge drinking).60,61 The Brief Screener for Tobacco, Alcohol, and other Drugs can be used to screen patients prior to surgery.62
To ensure successful outcomes in pediatric patients with severe obesity who undergo metabolic and bariatric surgery (MBS), a number of pre-operative patient management options should be considered. This manuscript will review the indications and contraindications of MBS and special considerations for youth who might benefit from MBS. The treatment team conducts a thorough pre-operative evaluation, assessing risks and benefits of surgical intervention, and prepares patients and families to be successful with MBS by providing education about the surgical intervention and lifestyle changes that will be necessary. This article reviews the pre-operative considerations for adolescents with severe obesity who are being considered for MBS, based upon recent clinical practice guidelines.
Sexual behaviors, risks, and sexual health outcomes for adolescent females following bariatric surgery
2019, Surgery for Obesity and Related Diseases
Adolescents females with severe obesity are less likely to be sexually active, but those who are sexually active engage in risky sexual behaviors.
To examine patterns and predictors of sexual risk behaviors, contraception practices, and sexual health outcomes in female adolescents with severe obesity who did or did not undergo bariatric surgery across 4 years.
Five academic medical centers.
Using a prospective observational controlled design, female adolescents undergoing bariatric surgery (n = 111; M_age = 16.95 ± 1.44 yr; body mass index: M_BMI = 50.99 ± 8.42; 63.1% white) and nonsurgical comparators (n = 68; M_age = 16.18 ± 1.36 yr; M_BMI = 46.47 ± 5.83; 55.9% white) completed the Sexual Activities and Attitudes Questionnaire at presurgery/baseline and 24- and 48-month follow-up, with 83 surgical females (M_BMI = 39.27 ± 10.08) and 49 nonsurgical females (M_BMI = 48.56 ± 9.84) participating at 48 months.
Most experienced sexual debut during the 4-year study period, with a greater increase in behaviors conferring risk for sexually transmitted infections (STIs) for surgical females (P = .03). Half (50% surgical, 44.2% nonsurgical, P = .48) reported partner condom use at last sexual intercourse. The proportion of participants who had ever contracted an STI was similar (18.7% surgical, 14.3% nonsurgical). Surgical patients were more likely to report a pregnancy (25.3% surgical, 8.2% nonsurgical, P = .02) and live birth (16 births in 15 surgical, 1 nonsurgical), with 50% of offspring in the surgical cohort born to teen mothers (age ≤19 yr).
Bariatric care guidelines and practices for adolescent females must emphasize the risks and consequences of teen or unintended pregnancies, sexual decision-making, dual protection, and STI prevention strategies to optimize health and well-being for the long term.
Five-year changes in dietary intake and body composition in adolescents with severe obesity undergoing laparoscopic Roux-en-Y gastric bypass surgery
2019, Surgery for Obesity and Related Diseases
Information is scarce on long-term changes in energy intake (EI), dietary energy density (DED), and body composition in adolescents undergoing laparoscopic Roux-en-Y gastric bypass (RYGB).
To investigate long-term changes in EI, DED, and body composition in adolescents after LRYGB.
University hospitals, multicenter study, Sweden.
Eighty-five adolescents (67% girls; mean ± standard deviation, age 16.0 ± 1.2 yr, body mass index 45.5 ± 6.1 kg/m²) were assessed preoperatively (baseline) and 1, 2, and 5 years after LRYGB with diet history interviews and dual-energy x-ray absorptiometry. Matched obese adolescent controls receiving nonsurgical treatment were assessed only at 5 years.
Weight decreased 31%, 33%, and 28% at 1, 2, and 5 years after LRYGB (P < .001) while controls gained 13% over 5 years (P < .001). Dietary assessments were completed in 98%, 93%, 87%, and 75% at baseline and 1, 2, and 5 years, respectively, and in 65% of controls. Baseline EI (2558 kcal/d), decreased by 34%, 22%, and 10% after 1, 2, and 5 years (P < .05). DED decreased at 1 year (P = .03). Macronutrient distribution was not different from controls at 5 years, but EI and DED were 31% and 14% lower (P < .015). Fat, fat-free, and muscle mass decreased through 5 years after LRYGB (P < .001). Boys preserved muscle mass more than girls (P < .01). Adequate protein intake was associated with preservation of muscle mass (P = .003).
In adolescents undergoing LRYGB EI remained 10% lower 5 years after surgery. Decreased EI and DED, rather than macronutrient distribution, are important factors in weight loss after surgery. Higher protein intake may facilitate preservation of muscle mass.

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Original articlesAlcohol use risk in adolescents 2 years after bariatric surgery

Abstract

Background

Objective

Setting

Methods

Results

Conclusion

Section snippets

Overview of study design

Sample characteristics

Discussion

Conclusion

Funding

Financial disclosure

Conflict of interest

Acknowledgments

Surg Obes Relat Dis

Surg Obes Relat Dis

J Psychiat Res

Surg Obes Relat Dis

J Am Coll Surg

Surg Obes Relat Dis

Surg Obes Relat Dis

J Am Coll Surg

Addict Behav

Drug Alcohol Depend

J Pediatr Surg

Surg Obes Relat Dis

J Adolesc Health

Prevalence of alcohol use disorders before and after bariatric surgery

JAMA

Alcohol consumption and alcohol problems after bariatric surgery in the Swedish Obese Subjects (SOS) study

Obesity

Effect of Roux-en-Y gastric bypass surgery: converting 2 alcoholic drinks to 4

JAMA Surg

Alcohol metabolism is not affected by sleeve gastrectomy

Surg Endosc

Original articles
Alcohol use risk in adolescents 2 years after bariatric surgery