New medical technologies have been viewed as the primary cause of rising health are expenditures by health policy researchers in the United States. Since the mid 1990s, with the prevalence of obesity among Americans, the utilization of bariatric surgery, a medical innovation, has increased rapidly among U.S. hospitals. Generally, current literature only states that the volume of bariatric procedures is increasing dramatically.Very limited studies have been conducted to investigate the growth of bariatric procedures.The objective of this study is (1) to provide a detailed description about the adoption and utilization of bariatric procedure in hospitals in 11 states, and (2) to identify the factors significantly enhancing hospitals to adopt or expand the service of surgical treatment for obesity.A panel design from 1995 to 2000 was employed in this study. Several databases are merged together for the final analysis. The descriptive analyses show that the increase in bariatric procedures is coming from two contributors: the entry of hospitals into the market of bariatric surgery, and the continuous expansion of capacity of offering the surgery by antecedent adopters. The panel analyses provided mixed support to the factors influencing hospitals' decision on adoption or expansion of bariatric surgery. The fixed-effects logit model suggests that hospital size, competition and cumulative adoption rate in a local market are strong predictors of hospitals' adoption of the surgery. The fixed effects model shows that ownership status, payment mix improvement, and cumulative adoption rate in a local market are strongly impact the expansion rate of bariatric procedures in hospitals.These findings suggest determinants enhancing hospitals to adopt or expand the bariatric service program. As the provision of bariatric procedures continues to increase among U.S. hospitals, health plans and policy makers will face greater challenges to balance the demand of patients with morbid obesity and the rapid increasing healthcare expenditures related to the surgery.

Bariatric surgery is an effective procedure type for morbidly obese patients when all else fails. Because obesity is a chronic disease, prolonged assessment and understanding of the credibility of procedure types and their effects on bariatric surgery outcomes are essential, yet current evidence shows decreasing utilization of one of the dominant procedure types. To better compare outcomes of procedure type, this research was designed to control for volume, hospital size, age, gender, season, month, year, and ethnicity. The goal of the study was to compare the outcomes of laparoscopic adjustable gastric banding (LAGB) and laparoscopic sleeve gastrectomy (LSG) bariatric surgery using the epidemiologic triad model. This study was a retrospective cross-sectional review of Nationwide Inpatient Sample (NIS) from 2009 to 2014. Univariate and multivariate logistic regression were conducted to analyze the data. This study was based on a secondary analysis previously collected from NIS data. A convenience sample of 73,086 patients who underwent bariatric surgery using ICD-9 diagnosis and procedure codes was used. Multiple logistic regression analysis indicated that LAGB (odds ratio [OR] =.043) and LSG (OR =.030) were positively associated with in-hospital mortality. Similarly, LAGB (OR =.041) and LSG (OR =.425) were positively correlated to length of stay (LOS). Finally, LAGB (OR = .461) and LSG (OR = .480) was positively related to reoperation. LAGB, when compared to LSG for LOS, had a substantial advantage over biliopancreatic diversion. The LOS findings may contribute to patients' value proposition, including cost reduction for third party insurance payers and for the community.

La sleeve gastrectomie (SG) est une opération qui consiste à réduire le volume de l’estomac. L’hypothèse que d’autres mécanismes indépendants de la perte de poids sont impliqués dans l’amélioration des complications métaboliques de l’obésité après SG a été émise. L’effet de la SG chez des souris soumis à un régime High Fat Diet a été étudié chez trois groupes d’animaux : SG, sham pair fed (SPF) et sham. Le test de tolérance au glucose montrait une amélioration de l’insulinorésistance des animaux SG à J23. Au niveau hépatique les animaux SG montraient une diminution significative de la stéatose. Il existe donc des mécanismes améliorant les complications hépatiques et métaboliques de l’obésité qui sont en partie indépendants de la réduction de l’apport calorique. Dans le second volet nous avons étudié l’évolution à long terme des lésions hépatiques liées à la NASH chez des patients obèses morbides avec une NASH lors de la chirurgie bariatrique. Dix patients d’une cohorte prospective ont été inclus. La deuxième biopsie a été réalisée à une médiane de 57 mois après le RYGB. La perte de poids moyenne était de –13,3 points de l’IMC lors du suivi. La rémission du syndrome métabolique et du diabète a été observée chez 71,6 % et 100 % des patients respectivement. Le NAS score a été amélioré chez tous les patients. Le taux sérique moyen du fragment clivé de la cytokératine 18 (M30), marqueur de l’apoptose hépatocytaire, était significativement abaissé. Le RYGB a permis une amélioration à long terme des lésions hépatocytaires liées à la NASH chez les patients obèses morbides. L’amélioration post-opératoire de la souffrance hépatocytaire corrèle avec la baisse du taux sérique du M30. / The mechanisms responsible for weight loss and improvement of metabolic disturbances have not been completely elucidated. We investigated the effect of sleeve gastrectomy (SG) on body weight, adipose tissue depots, glucose tolerance, and liver steatosis independent of reduced caloric intake in high-fat-diet-induced obese mice. Mice fed a high fat diet were divided into 3 groups: SG, sham-operated ad libitum fed and sham-operated pair fed. SG mice showed improved glucose tolerance and lower levels of liver steatosis. This was associated with a decrease in the ratios of the weight of pancreas, epididymal and inguinal adipose tissues to body weight. Reduced white adipose tissue inflammation, modification of adipose tissue development, and ectopic fat are potential mechanisms that may account for the reduced caloric intake independent effects of SG. We also investigated long-term impact of RYGB surgery on liver complications in morbidly obese patients with NASH. Ten morbidly obese patients with biopsy-proven NASH were followed after RYGB and underwent a second liver biopsy. The median interval between the RYGB and second liver biopsy was 57 months. Clinical and biological data were obtained at baseline and ≥40 months after RYGB. RYGB was associated with significant weight loss, improved hepatic steatosis, resolution of hepatic inflammation and hepatocyte ballooning. Hepatocyte apoptosis, as evaluated by serum K18 fragment improved within the first year and at 57 months. Hepatic fibrosis resolved in 90% of cases. RYGB in morbidly obese patients with NASH is associated with a long-term beneficial impact on hepatic steatosis, inflammation, injury and, possibly, fibrosis.

<p>Introduktion: Övervikt och fetma är ett globalt växande folkhälsoproblem vilket leder till enorma ekonomiska samhällskostnader. Fetmakirurgi, bland annat Reglerbart gastriskt band (Adjustable Gastric Banding, AGB), har visat långsiktiga effekter på viktminskning, medan icke-kirurgisk fetmabehandling har visat mindre tydliga effekter. Detta har lett till att fetmakirurgin ökat dramatiskt. Trots detta har vissa kirurgipatienter svårigheter i att upprätthålla viktminskning över tid. Fetmakirurgi kan även leda till senkomplikationer och biverkningar. Flertalet experter argumenterar för att långtidsbehandling är väsentlig för vidmakthållande av beteendeförändring. Dagvårdsbehandling anses vara värd att överväga för patienter med fetma. Den har använts brett inom diabetesvård men ej lika mycket inom fetmabehandling. Syfte: Att strukturera och undersöka population och datamaterial från en redan genomförd men opublicerad, tre år lång interventionsstudie, med tre uppföljningar, om viktminskning och ätbeteende hos patienter med fetma, efter behandling med: Adjustable Gastric Banding, Dagvård alternativt en kombination av de båda behandlingarna. Metod: Datamaterial i 30 pärmar, från patienter (baseline: n= 212) i en redan genomförd men opublicerad interventionsstudie, lästes igenom och strukturerades in i ett index i Microsoft Words. Därefter skapades en databas i Microsoft Excel. I databasen räknades de patienter samman som visat angivna mått på viktminskning (BMI) och ätbeteende (TFEQ) vid något, några eller samtliga av de totalt tre uppföljningstillfällena i studien. Resultat: Efter strukturering och undersökning av datamaterialet framgick att enbart (n=10) av (n=212) fullföljt studien genom uppvisade mått på BMI samt TFEQ vid samtliga av studiens tre uppföljningstillfällen. För att i denna masteruppsats visa resultat från en större studiepopulation presenterades även uppvisade mått (BMI, TFEQ) från patienter som deltagit vid baseline och tredje uppföljningstillfället, men som nödvändigtvis inte deltagit vid uppföljnigstillfälle ett eller två (n=43). BMI och TFEQ presenterades i medelvärde och median för varje behandlingsgrupp. Slutsats: Resultatet visar att majoriteten av de deltagande patienterna inte fullföljde hela programmet. Därför kunde inga effekter av respektive behandling på förändring av vikt och ätbeteende beräknas.</p> / <p>Introduction: Overweight and obesity is a globally growing public health problem leading to enormous economic costs for the society. Obesity surgery, including Adjustable Gastric Banding (AGB), has shown long-term positive effects on weight loss, while non-surgical obesity treatment has shown less evident effects. This has led to a dramatic increase in obesity surgery. Still, some surgery patients have difficulties in maintaining weight loss over time. The majority of experts argue that long-term treatment is essential for maintaining behavioral changes. According to experts, Daycare treatment is worth considering for patients suffering from obesity. It has been used broadly within the diabetes care though not to the same extent in obesity treatment. Aim: To structure and investigate the population and data from an already completed but unpublished three year old intervention study, with three follow ups, of weight loss and eating behavior in patients with obesity after treatment with Adjustable Gastric Banding, Daycare or a combination of the both treatments. Method: Data in 30 binders, from participants (baseline n=212) in an already completed but unpublished intervention study, was read and structured into an index in Microsoft Words. A database in Microsoft Excel was then structured were patients with specified measures for weight loss (BMI) and eating behavior (TFEQ), for one, two or three of the total three follow ups, was counted together. Results: After the structuration and investigation of the material it became evident that due to drop-out or missing data only (n=10) out of (n=212) had fulfilled the study by showing specified measures of BMI and TFEQ at every of the total three follow ups. To, in the present Master thesis, show results from a greater sample, also participants with measures (BMI, TFEQ) from baseline and the third follow up, but not necessary from the first or second follow up (n=43), was included in the presentation. BMI and TFEQ were presented in mean and median for each of the treatment groups. Conclusion: The result shows that a majority of the participants not completed the program. Hence could no effect of the treatments on changes of weight and eating behavior be rated.</p>

The main objectives of this dissertation were to examine the effects of bariatric surgery on medication and health services utilization among a cohort of Commercial and Medicare insured members from a large health benefits organization in the U.S.. A total of 1,492 members with morbid obesity underwent gastric bypass (n=785) or gastric banding (n=707) procedure between January 2005 and June 2008. Administrative claims databases were accessed and three data files including a member file, a medical file and a pharmacy file were merged at the member level. Non-parametric Wilcoxon signed rank tests revealed that the average number of all prescription claims were significantly lower during the 12 months post-surgery, compared to the 12 months pre surgery (p<0.0001). Moreover, McNemar’s Chi Square analyses showed that after the surgery, there was a statistically significant (p=<0001) decline in the proportion of members utilizing antihypertensives, antidiabetics and antihyperlipidemics. Our results also showed that the average number of prescription claims for each of these medication groups significantly declined during the 12-month post-surgery period, among members who had at least one prescription for these medications before the surgery (p<0.0001). Logistic regression modeling revealed that members who underwent bypass procedures were more likely to discontinue antihypertensives (OR=2.04; 95% CI= 1.30-3.23) , antihyperlipidemics (OR=3.25; 95% CI 1.96-5.40) and antidiabetics (OR=1.89; 95% CI 1.13–3.08) post-surgery than members who underwent banding procedures. In terms of medical services utilization, our results showed a significant decline in the average number of medical claims for all outpatient services overall from the 12 months pre to the 12 months post-surgery (p<0.0001). In contrast, the average number of medical claims for emergency room and inpatient hospitalizations were significantly increased from the pre to the post-surgery period (p<0.01). Logistic regression modeling revealed that the type of bariatric surgery was a significant positive predictor for inpatient hospitalizations post-surgery (OR =2.33; 95% CI= 1.76-3.08; p<0.0001) but not for emergency room visits (OR=1.23; 95% CI 0.97–1.56). The implications of the findings from a managed care perspective are discussed, along with limitation and future directions.

Introduktion: Övervikt och fetma är ett globalt växande folkhälsoproblem vilket leder till enorma ekonomiska samhällskostnader. Fetmakirurgi, bland annat Reglerbart gastriskt band (Adjustable Gastric Banding, AGB), har visat långsiktiga effekter på viktminskning, medan icke-kirurgisk fetmabehandling har visat mindre tydliga effekter. Detta har lett till att fetmakirurgin ökat dramatiskt. Trots detta har vissa kirurgipatienter svårigheter i att upprätthålla viktminskning över tid. Fetmakirurgi kan även leda till senkomplikationer och biverkningar. Flertalet experter argumenterar för att långtidsbehandling är väsentlig för vidmakthållande av beteendeförändring. Dagvårdsbehandling anses vara värd att överväga för patienter med fetma. Den har använts brett inom diabetesvård men ej lika mycket inom fetmabehandling. Syfte: Att strukturera och undersöka population och datamaterial från en redan genomförd men opublicerad, tre år lång interventionsstudie, med tre uppföljningar, om viktminskning och ätbeteende hos patienter med fetma, efter behandling med: Adjustable Gastric Banding, Dagvård alternativt en kombination av de båda behandlingarna. Metod: Datamaterial i 30 pärmar, från patienter (baseline: n= 212) i en redan genomförd men opublicerad interventionsstudie, lästes igenom och strukturerades in i ett index i Microsoft Words. Därefter skapades en databas i Microsoft Excel. I databasen räknades de patienter samman som visat angivna mått på viktminskning (BMI) och ätbeteende (TFEQ) vid något, några eller samtliga av de totalt tre uppföljningstillfällena i studien. Resultat: Efter strukturering och undersökning av datamaterialet framgick att enbart (n=10) av (n=212) fullföljt studien genom uppvisade mått på BMI samt TFEQ vid samtliga av studiens tre uppföljningstillfällen. För att i denna masteruppsats visa resultat från en större studiepopulation presenterades även uppvisade mått (BMI, TFEQ) från patienter som deltagit vid baseline och tredje uppföljningstillfället, men som nödvändigtvis inte deltagit vid uppföljnigstillfälle ett eller två (n=43). BMI och TFEQ presenterades i medelvärde och median för varje behandlingsgrupp. Slutsats: Resultatet visar att majoriteten av de deltagande patienterna inte fullföljde hela programmet. Därför kunde inga effekter av respektive behandling på förändring av vikt och ätbeteende beräknas. / Introduction: Overweight and obesity is a globally growing public health problem leading to enormous economic costs for the society. Obesity surgery, including Adjustable Gastric Banding (AGB), has shown long-term positive effects on weight loss, while non-surgical obesity treatment has shown less evident effects. This has led to a dramatic increase in obesity surgery. Still, some surgery patients have difficulties in maintaining weight loss over time. The majority of experts argue that long-term treatment is essential for maintaining behavioral changes. According to experts, Daycare treatment is worth considering for patients suffering from obesity. It has been used broadly within the diabetes care though not to the same extent in obesity treatment. Aim: To structure and investigate the population and data from an already completed but unpublished three year old intervention study, with three follow ups, of weight loss and eating behavior in patients with obesity after treatment with Adjustable Gastric Banding, Daycare or a combination of the both treatments. Method: Data in 30 binders, from participants (baseline n=212) in an already completed but unpublished intervention study, was read and structured into an index in Microsoft Words. A database in Microsoft Excel was then structured were patients with specified measures for weight loss (BMI) and eating behavior (TFEQ), for one, two or three of the total three follow ups, was counted together. Results: After the structuration and investigation of the material it became evident that due to drop-out or missing data only (n=10) out of (n=212) had fulfilled the study by showing specified measures of BMI and TFEQ at every of the total three follow ups. To, in the present Master thesis, show results from a greater sample, also participants with measures (BMI, TFEQ) from baseline and the third follow up, but not necessary from the first or second follow up (n=43), was included in the presentation. BMI and TFEQ were presented in mean and median for each of the treatment groups. Conclusion: The result shows that a majority of the participants not completed the program. Hence could no effect of the treatments on changes of weight and eating behavior be rated.

The number of operations for morbid obesity is rising fast. We have examined aspects of postoperative physiology and results after bariatric surgery. The pH in the proximal pouch after Roux-en-Y gastric bypass (RYGBP) was investigated with catheter-based and wire-less technique. Gastric emptying, PYY-levels in the fasting state and after a standardized meal was evaluated after biliopancreatic diversion with duodenal switch (DS). A clinical trial was undertaken, comparing DS to RYGBP in patients with BMI&gt;48. Main outcome variables were safety and long-term weight results as well as abdominal symptoms and laboratory results. Patients with stomal ulcer had significantly lower pH in their proximal gastric pouch as compared to asymptomatic control subjects. Long-time pH measurements with the wire-less BRAVO-system were feasible and demonstrated pH&lt;4 in median 10.5% of the time in asymptomatic post-RYGBP patients. After DS, the T50 of gastric emptying was 28±16 minutes. PYY-levels were higher after DS than in age-matched control subjects. BMI-reduction was greater after DS (24 BMI-units) than after RYGBP (17 BMI-units) in median 3.5 (2.0-5.3) years after surgery (p&lt;0.001). Fasting glucose and HbA1c levels were lower one and three years after DS as compared to RYGBP. On the other hand, DS-patients reported having more diarrhea and malodorous flatus. This thesis has resulted in deepened knowledge. Acid produced in the proximal pouch is an important pathogenetic factor in the development of stomal ulcer after RYGBP. However, symptom-free patients have an acidic environment in the proximal Roux-limb as well. After DS, gastric emptying is fast, but not instantaneous, and PYY-levels are high. DS results in superior weight reduction and better glucose control as compared to RYGBP in patients with BMI&gt;48. We believe that DS has a place in surgical treatment of the super-obese, even though symptoms of diarrhea and malodorous flatus are more common after DS.

This thesis investigates a contextual behavioral approach for obesity surgery patients. In a contextual approach a behavior is interpreted as inseparable from its current and historical context. Candidates for bariatric surgery often have a history of self-stigma, body dissatisfaction and eating for emotional relief. Despite losing a large amount of weight post surgery, psychological problems may still be present for some patients. One possible common underlying process observed in body concerns and eating patterns is experiential avoidance. Experiential avoidance is defined as; any attempt to avoid, change, or control unwanted thoughts and feelings when so doing causes harm. Though a multidisciplinary team is recommended for post-surgical care, there are few studies evaluating the psychological treatment of patients undergoing bariatric surgery. In this thesis a protocol based on Acceptance and Commitment Therapy (ACT), was developed and implemented, partly via the Internet, in a clinical setting. In an acceptance-based approach to obesity, psychological well-being is the main outcome. ACT was significantly more effective than ‘treatment as usual’ in terms of body dissatisfaction and quality of life after surgery. Both groups improved in eating disordered attitudes and behaviors. Predictions based on the underlying treatment model were also investigated. Positive treatment outcomes were found to be associated with increased psychological flexibility.  Despite some methodological limitations, the results are promising and future studies should further evaluate ACT in the context of bariatric surgery. This thesis also acknowledges the need for clinical assessment tools appropriate for the bariatric surgery context. The Acceptance and Action Questionnaire for Weight (AAQ-W) is a measure of experiential avoidance, and was evaluated in the present thesis. The AAQ-W was found to be a reliable and valid measure for people undergoing bariatric surgery. Another measure, Disordered Eating in Bariatric Surgery (DEBS) was developed and evaluated. The DEBS was found to posses satisfactory psychometric properties in terms of reliability and validity.  The AAQ-W and the DEBS may facilitate both systematic clinical evaluation and future research within the area of bariatric surgery.

Övervikt och fetma har ökat kraftig de senaste åren och risken för följdsjukdomar har därmed ökat markant. I samband med övervikt och fetma kan den hälsorelaterade livskvaliteten komma att påverkas. En av de metoder som används för att hjälpa dessa  patienter att minska i vikt är kirurgi i viktminskningssyfte. Syftet med studien var att belysa patienters hälsorelaterade livskvalitet efter kirurgi i viktminskningssyfte. Studien genomfördes som en litteraturstudie där 14 vetenskapliga artiklar granskades och analyserades. Studiens resultat visade att de variabler som kan påverka den hälsorelaterade livskvalitén var fysisk aktivitet, psykiska funktioner och smärta. De patienter som  genomgått någon form av kirurgi i viktminskningssyfte fick generellt sett en högre hälsorelaterad livskvalitet under flera månader postoperativt, ibland upp till flera år. Vissa skillnader fanns mellan patienterna beroende på om de var  män eller kvinnor, gifta eller ogifta. Vidare forskn behöver göras på skillnader mellan kön, samt hur de hälsorelaterade livskvalitén förändras under lång tid.

The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file. Title from PDF of title page (University of Missouri--Columbia, viewed on January 5, 2010). Thesis advisor: Paul J. Fadel. "December 2009" Includes bibliographical references.