Weight Loss and Durability of Gastric Banding in Adolescents with Severe Obesity; 8-year Follow-up of a Randomized Controlled Trial

Abstract

Objective

Metabolic and bariatric surgery is an established treatment for severe obesity. Laparoscopic adjustable gastric banding (LAGB) was once considered a promising option for adolescents. However, long-term data in this population are lacking. We aimed to evaluate the long-term effectiveness of LAGB in adolescents extending beyond 3 years postoperatively.

Methods

Adolescents with severe obesity were randomly assigned to the intervention group (LAGB and multidisciplinary lifestyle intervention [MLI]) or the control group (MLI), with annual follow-ups for 3 years. We conducted a follow-up analysis of this cohort after 8.6 years (range: 5.0–12.5).

Results

A total of 59 patients were randomized (29 LAGB + MLI and 30 MLI only). Early differences in weight loss were observed during the first 2 years, but no significant difference persisted after 8.7 years (mean difference body mass index: 1.8 kg/m², 95% CI: −3.2, 6.8). The band removal rate was high (52%).

Conclusion

After nearly 9 years, LAGB resulted in minimal weight loss and had a high removal rate in adolescents with severe obesity. Our study was limited by loss to follow-up, self-reported weights, and crossover. Nonetheless, these findings confirm the lack of efficacy that has led to the global decline in LAGB procedures and underscore the shift toward more effective surgical procedures.

Keywords

obesity - pediatric obesity - metabolic and bariatric surgery - randomized controlled trial

Introduction

Adolescent obesity is a major public health concern that has risen sharply over recent decades.[1] Severe obesity, defined as a body mass index (BMI) ≥ 35 kg/m², is associated with a substantially elevated risk of serious comorbidities, including cardiovascular disease, type 2 diabetes, sleep apnea, and psychological impairment.[2] Longitudinal studies on childhood obesity consistently demonstrate that excess weight in youth frequently persists into adulthood and is linked to both premature mortality and significant long-term morbidity.[3] [4] The considerable medical burden associated with severe obesity underscores the urgency of implementing effective interventions early in life.

Several treatment options for weight loss are available for adolescents with severe obesity. Intensive multidisciplinary lifestyle intervention (MLI) is the standard care in adolescents with obesity. However, previous studies showed that the efficacy of these programs is limited for a subgroup of adolescents with severe obesity.[5] Therefore, additional treatment in this subgroup is warranted. Metabolic and bariatric surgery (MBS) is increasingly considered in adolescents with severe obesity. The updated guidelines by the American Society for Metabolic and Bariatric Surgery and the International Federation for the Surgery of Obesity and Metabolic Disorders state that MBS is safe and effective in the population younger than 18 years old and should be considered in appropriately selected children.[6] Despite these renewed guidelines, long-term follow-up studies in adolescents remain scant.

Prospective Teen-LABS, FABS 5+ studies, and the randomized AMOS study showed impressive results regarding weight loss and comorbidity resolution up to 8 years of follow-up after Roux-en-Y gastric bypass (RYGB).[7] [8] [9] Despite these compelling results, longer follow-up is still essential because of substantial concerns regarding the safety of RYGB in adolescents. Particularly, due to the malabsorptive and irreversible nature of the procedure.[10] [11] Laparoscopic adjustable gastric banding (LAGB) is a restrictive bariatric procedure that offers reversibility in cases of intolerance or insufficient weight loss. Although early experience generated considerable enthusiasm for this minimally invasive approach, its use has declined over time because of concerns regarding long-term effectiveness in adults, including complications, inadequate weight loss, and the need for band removal.[12] [13] [14] Adolescent studies investigating the long-term effects of LAGB are limited. To date, only one study has assessed the long-term efficacy of LAGB in adolescents, including a small subgroup of 14 participants. In this trial, LAGB was selected as a surgical procedure because it can be reversed relatively easily in the case of side effects. Although other bariatric procedures, such as RYGB and sleeve gastrectomy, are now widely performed, long-term safety data in adolescents remain limited. This study aims to address the existing gap in knowledge regarding long-term outcomes following LAGB. A comprehensive understanding of these outcomes is valuable not only from a historical standpoint but also for contextualizing how past experiences with LAGB inform current treatment strategies, including RYGB and emerging pharmacotherapies.

Methods

Study Design and Participants

The Bariatric Surgery in Children (BASIC) trial is a randomized controlled trial that included adolescents with an age- and sex adjusted BMI > 40 or >35 kg/m² with the presence of obesity associated comorbidity. All included participants underwent MLI for at least 1 year without the proposed weight loss. Other inclusion criteria were the following: age 14, 15, or 16 years old, adequate level of decisional capacity, sufficient level of Dutch language, and awareness of the randomization process, which was assessed by a pediatric psychologist. The participants were randomized into the intervention group (LAGB with MLI) or the control group (MLI) and were annually followed for 3 years. Further details about the inclusion and exclusion criteria, as well as the study process, have been published before, along with the 1-year weight loss and glycemic results.[15] [16] Study inclusions took place from December 2011 to April 2019, and written informed consent was obtained from all patients and their guardians. After the initial 3 years of follow-up, many patients were no longer in routine follow-up, due to aging and transfers to other hospitals closer to home. To locate the patients for gathering the data for the current study, we used the last known contact details of the participants, for which they previously provided consent during the trial. When the contact details were no longer in use, the general practitioner (GP) was approached to ask for the current telephone number of the patients. Through telephonic consults, participants from the BASIC trial were contacted and asked to complete a predefined questionnaire together with the researcher. Ethical approval for this follow-up questionnaire was obtained from the medical ethics committee of Maastricht University.

Procedures and Measurements

During the BASIC trial, the patients in the intervention group received LAGB (pars flaccida technique) performed by two surgeons: one leading bariatric surgeon and a second surgeon in training. Patients in both the intervention and the control group participated in MLI and were given strict dietary instructions as outlined in the previously published protocol.[16]

Follow-up assessments were at 6, 12, 24, and 36 months. At each visit, height, weight, blood pressure, and blood samples were taken. The long-term follow-up data were collected by clinical researchers through structured telephonic consults wherein a predefined questionnaire was filled out together with the patient. The gathered data was collected using Castor.[17] The data collected included height (cm) and weight (kg). If a patient was uncertain of these measurements, they were asked to perform these measurements at home or at the GP's office if a scale was unavailable at home. For patients who were randomized into the intervention group during the BASIC trial, the data of interest included: re-operation, date of re-intervention, reasons for reoperation, and the type of MBS during a possible second intervention. Regarding the control group, we also gathered data about a possible operation and the type and date of this bariatric intervention. In case the patient knew the year of re-operation but not the exact date, we used a set date of 06/06/year of (re)operation.

Outcomes Measurements

The primary outcome measurement was weight loss over time. Weight loss was defined as absolute change in BMI (kg/m²), relative change in BMI (kg/m²), absolute change in weight (kg), relative change in weight (kg), and %total weight loss (%TWL). %TWL was calculated by dividing initial weight (kg) minus current weight (kg) by initial weight (kg). The secondary outcomes were band retention, reasons for band removal, revisional surgery after the band was removed, and the type of surgery after band removal.

Statistical Analyses

Descriptive statistics are presented as mean ± standard deviation (SD) or median (range) in nonnormally distributed data, where normality was checked using histograms, qq-plots, and pp-plots. Categorical data are presented as numbers and percentages. To analyze the treatment effect on weight loss, marginal models for repeated measures were used. Time (0, 12, 24, 36 months), group, and the interaction time^*group were included in the fixed part of the model, where an unstructured covariance structure was used to account for the correlation between the repeated measures per participant. The long-term follow-up data (one outcome measurement per patient) were analyzed with an intention-to-treat (ITT) linear regression analysis, with study arm, baseline BMI, and follow-up time as independent variables. To evaluate the band survival rates and time to event (removal of LAGB), we conducted a Kaplan–Meier analysis. The mean and median band survival times were calculated. Patients who were lost to follow-up, had premature ending of follow-up, or were at the end of follow-up were censored and included in the analyses. The long-term efficacy of LAGB on weight loss and durability of the band, the rate of revisional surgery, time interval from LAGB placement to removal, reasons for removal, and potential additional surgery were descriptively reported. All analyses were executed using IBM SPSS for Windows version 28.0 (Armonk, New York, United States). Two-sided p-values ≤ 0.05 were considered statistically significant.

Results

The baseline characteristics of the study population are presented in [Table 1]. The mean age of the 59 patients at baseline was 15.8 ± SD 1.00 years, the majority were female (80%), and the mean BMI was 44.1 ± 5.6 kg/m². The long-term data were gathered in 70% of the patients who were originally included in the BASIC trial at a median follow-up time of 8.6 years (5.0–12.5). Reasons for failure to contact all patients were incorrect telephone numbers, change of GP, and/or patient relocation.

Table 1 Baseline characteristics of the study population and follow-up

	Total	Intervention	Control
n	59	29	30
Age (y) at inclusion, mean ± SD	15.76 ± 1.00	15.63 ± 0.98	15.88 ± 1.01
Sex (No. % female)	47 (80%)	24 (80%)	23 (79%)
Baseline BMI (kg/m2), mean ± SD	44.11 ± 5.56	44.29 ± 5.59	43.92 ± 5.61
Long-term follow-up rate (%)	41 (70%)	21 (72%)	20 (67%)
Long-term follow-up years median (range)	8.56 (4.97–12.46)	8.16 (4.97–12.12)	8.70 (5.33–12.46)

Abbreviations: BMI, Body mass index.

Note: Data presented as indicated, mean ± standard deviation or median (range) for not normally distributed data.

Missing Data

[Fig. 1A] shows the missing data and loss to follow-up during the study, and [Fig. 1B] provides an overview of the long-term follow-up. Loss to follow-up was due to withdrawal from the trial directly after randomization, lack of motivation for follow-up visits, and no-shows at appointments.

Fig. 1 (A) Flowchart of the study participants. (B) Flowchart of the participants with long-term follow-up.

Weight Loss

All patients had severe obesity at baseline (mean BMI: 44.1 ± 5.6 kg/m²). Weight loss results are reported in [Table 2]. Weight loss was significantly greater in the intervention group than in the control group in the first 12 months (corrected mean difference BMI: −5.6 kg/m², 95% CI: −7.6, −3.6) After 24 months this significant difference between the groups for weight loss sustained (mean difference BMI: −3.6 kg/m², 95% CI: −7.0, −0.2). The last in-hospital anthropometric assessment during the BASIC trial was at 36 months and showed no statistically significant difference in weight loss between the groups (mean difference BMI: −1.8 kg/m², 95% CI: −5.9, 2.3). Long-term follow-up data were gathered at a median follow-up time of 8.2 years (5.0–12.1) in the intervention group and 8.7 years (5.3–12.5) in the control group. A total of 21 (72%) patients from the intervention group and 20 (67%) patients from the control group were successfully contacted. Two patients in the intervention group did not have access to a scale, resulting in missing weight data in these two patients ([Fig. 1B]). [Table 3] presents the ITT analysis for the long-term follow-up and shows no statistically significant differences in weight loss between the groups.

Table 2 Marginal model for repeated measures; observed mean ± SD as well as intervention effects (corrected difference in estimated means) through time are presented for BMI (kg/m²), weight, and TWL (%)

	Baseline		1-y FU		Treatment effect (95% CI)	2-y FU		Treatment effect (95% CI)	3-y FU		Treatment effect (95% CI)
	Intervention	Control	Intervention	Control		Intervention	Control		Intervention	Control
n (patients)	29	30	29	23	–	24	20	–	15	15	–
Mean BMI (kg/m2)	44.2 ± 5.59	43.92 ± 5.61	39.01 ± 1.26	45.23 ± 1.39	−5.60 (95% CI: −7.58, −3.63)[a] [b]	38.72 ± 1.18	42.73 ± 1.30	−3.60 (95% CI: −7.01, −0.20)[a] [b]	40.04 ± 1.80	41.30 ± 1.87	−1.82 (95% CI: −5.88, 2.25)[a]
Absolute change in BMI (kg/m2)	–	–	−5.24 ± 3.50	0.37 ± 3.66	−5.72 (95% CI:[b] −7.71, −3.72)	−5.49 ± 4.11	−1.20 ± 7.10	−3.97 (95% CI: −7.41, −0.54)[b]	−4.94 ± 4.48	−2.33 ± 6.45	−1.72 (95% CI: −5.77, 2.32)
Relative change in BMI (%)	–	–	−12.23 ± 8.36	0.89 ± 8.05	−13.40 (95% CI:[b] −18.01, −8.80)	−12.65 ± 9.62	−1.54 ± 14.24	−10.34 (95% CI: −17.49, −3.19)[b]	−11.35 ± 10.14	−5.59 ± 15.31	−3.74 (95% CI: −13.21, 5.74)
Mean weight (kg)	128.96 ± 18.51	128.57 ± 21.31	114.67 ± 20.31	134.00 ± 26.48	−16.90 (95% CI: −22.83, −10.81)[b]	119.93 ± 21.59	120.06 ± 22.88	−0.91 (95% CI: −17. 65, 15.84)	117.36 ± 22.79	122.62 ± 33.54	−0.45 (−13.51, 12.61)
Absolute change in weight (kg)	–	–	−14.29 ± 10.16	2.48 ± 11.18	−17.03 (−22.98, −11.09)[b]	−10.30 ± 32.50	−11.42 ± 27.22	0.54 (95% CI: −17.66, 18.73)	−13.40 ± 15.11	−10.42 ± 20.68	−0.21 (95% CI: −13.35, 12.93)
TWL (%)	–	–	11.23 ± 7.76	−1.74 ± 8.05	13.17 (8.75, 17.60)[b]	5.30 ± 25.56	6.64 ± 22.25	−0.83 (95% CI: −15.39, 13.74)	10.18 ± 10.43	7.54 ± 15.31	0.71 (95% CI: −8.83, 10.25)

Abbreviations: BMI, body mass index; FU, follow-up; kg, kilogram; TWL, total weight loss.

Note: Treatment effect is the mean difference between the study groups with 95% confidence interval.

^a Corrected for baseline BMI.

^b Statistically significant, p-value ≤ 0.05.

Table 3 Intention to treat regression analyses for long-term follow-up

	Intervention	Control	Mean difference[a] (95% CI)	p-Value
n (patients)	19	20	–	–
Median follow-up time (y)	8.16 (4.97–12.12)	8.70 (5.33–12.46)	–	–
Mean BMI (kg/m2)	36.05 ± 8.51	34.96 ± 8.67	1.78 (−3.23, 6.78)	0.48
Relative change in BMI (%)	−18.73 ± 15.64	−22.86 ± 15.79	4.18 (−6.35, 14.70)	0.43
Mean weight (kg)	101.89 ± 22.01	98.95 ± 22.50	4.84 (−8.54, 18.22)	0.47
TWL (%)	18.18 ± 16.32	22.88 ± 15.27	−4.75 (−15.32, 5.82)	0.37

Abbreviations: BMI, Body mass index; TWL, total weight loss.

Note: Data presented as mean ± SD or median (range), treatment effect is presented as mean difference (95% confidence interval).

^a Corrected for baseline BMI and follow-up time.

The ten patients with the band in place achieved 12% TWL at a median follow-up length of 7.0 years (5.3–11.6). The 11 patients who had their band removed and converted to RYGB (82%) or SG (18%) achieved 25% TWL at a median follow-up time of 9.4 years (5.0–12.1).

Reoperation Rate Intervention Group

After randomization, a total of 29 patients received LAGB with MLI. [Table 4] provides an overview of the reoperation rate over time in the intervention group. The long-term data were collected in 21 (72%) of the original intervention group at a median follow-up length of 8.2 years (5.0–12.1). In a total of 11/21 (52%) patients, the LAGB was removed with a median time to removal of 3.0 years (1.7–7.4). Causes of LAGB removal included: weight loss failure (36%), abdominal pain (27%), vomiting/nausea (18%), dysphagia (9%), and reflux (9%). All 11 patients underwent alternative MBS, specifically RYGB (82%) or sleeve gastrectomy (18%).

Table 4 Band removal in the intervention group

Variable	Total (n = 21)
Missing data (%)	8/29 (28%)
Follow-up time (y)	8.16 (4.97–12.12)
LAGB removal (no.; %)	11/21 (52%)
Time interval from LAGB to removal (y), median (range)	2.96 (1.68–7.40)
Causes of band removal: no. (%)
Abdominal pain	3 (27%)
Weight loss failure	4 (36%)
Vomiting/nausea	2 (18%)
Dysphagia	1 (9%)
Reflux	1 (9%)
Type of reintervention: no. (%)
Into the gastric bypass	9 (82%)
Into sleeve gastrectomy	2 (18%)

Abbreviation: LAGB, laparoscopic adjustable gastric banding.

Note: Time to LAGB removal and follow-up time are not normally distributed and presented as median (range).

Time to Reoperation

Kaplan–Meier survival analysis ([Fig. 2]) indicated a median estimate time to band removal of 7.4 (95% CI: 5.8, 9.0) years and a mean estimate of 7.3 (95% CI: 5.5, 9.1) years. Kaplan–Meier estimated band survival rates were 100% at 1 year, 66% at 4 years, and 40% at 8 years.

Fig. 2 Kaplan–Meier curve band survival over time (intervention group).

Additional Surgery Control Group

A total of 30 patients were randomized into the control group and received MLI. [Table 5] presents the rate of additional surgery in the control group. The long-term data were collected for 24 (67%) patients in the original control group at a median follow-up length of 8.7 years (5.3–12.5). A total of 20 (83%) of these patients received additional MBS at a median time interval from the start of the trial to MBS of 2.0 years (0.6–7.6). Types of MBS included: RYGB (25%), sleeve gastrectomy (20%), and LAGB (55%). These patients achieved a mean TWL 25.8%, while the four patients who did not receive MBS had a TWL of 11.2%.

Table 5 Additional surgery after MLI in the control group

Variable	Total (n = 24)
Missing data (%)	6/30 (20%)
Follow-up time (y), median (range)	8.70 (5.33–12.46)
Additional bariatric surgery after MLI (no.; %)	20/24 (83%)
Time interval from start MLI in trial to BS (y), median (range)	2.02 (0.55–7.59)
Type of bariatric surgery: no. (%)
Into the gastric bypass	5 (25%)
Into sleeve gastrectomy	4 (20%)
Into LAGB	11 (55%)

Abbreviations: BS, bariatric surgery; LAGB, laparoscopic adjustable gastric banding; MLI, multidisciplinary lifestyle intervention.

Note: Time to LAGB removal and follow-up time are not normally distributed and presented as median (range).

Complications

As published before,[15] the first year, complications were: three patients experienced peptic complaints and were treated with proton pump inhibitors (Clavien Dindo Grade 1 surgical complication).[18] In one patient, the access port of the band became dislocated and was repositioned under local anesthesia. (Clavien Dindo Grade 3-a surgical complication). One patient developed symptomatic cholecystolithiasis, for which a laparoscopic cholecystectomy was performed (Clavien Dindo Grade 3-b surgical complication). In the following 2 years, two patients had band slippage (Clavien Dindo Grade 1 surgical complication), and one patient experienced symptomatic cholecystolithiasis and received cholecystectomy (Clavien Dindo Grade 3b surgical complication). At long-term follow-up, 52% of the participants from the intervention group had their band removed due to weight loss failure or band intolerance (abdominal pain, vomiting, dysphagia, and reflux).

Discussion

This is the first RCT evaluating weight loss and durability of LAGB in adolescents beyond 3 years postoperative. After a median follow-up of 8.6 years (range: 5.0–12.5), adolescents treated with LAGB and MLI did not experience greater weight loss (18.2% TWL) compared with those who received MLI alone (22.9% TWL). These findings should be interpreted cautiously, given the sample size, high attrition, and crossovers between the study groups. The high rate of alternative bariatric procedures in the ITT further confounded the long-term comparison. We confirm the high band-removal rate, as it was removed in 52% of the patients who were successfully contacted at a median follow-up time of 8.6 years (72% follow-up rate) with a median time to removal of 3.0 years (1.7–7.4).

While LAGB procedures have been largely abandoned in current practice, our earlier follow-up at 1 and 2 years postoperative demonstrated encouraging short-term efficacy and safety, consistent with previous reports in adolescents. The studies by O'brien, Nadler, and Zitsman[19] [20] [21] all reported successful weight loss after LAGB in adolescents up to 36 months. The RCT by O'brien et al,[19] included 50 participants (25 of whom received LAGB), who observed more weight loss (12.7 BMI units, 95% CI: 11.3–14.2) after 24 months compared with our trial. This large difference may be attributed to the higher revision rate (32%) in the study by O'brien et al, which consisted of band replacement or replacement of the access port, potentially improving functionality of the band. A prospective study in adolescents by Zitsman et al[20] showed weight loss results that are more comparable to those of the current study, namely 12.4, 21.8, and 24.2 kg after 12, 24, and 36 months, respectively. However, these short-term studies may underestimate late complications, reoperation, and attrition. In our extended follow-up, early weight loss differences between the study groups decrease by year 3, likely due to crossover of participants from the control group to the intervention group. Roughly half of the participants from the control group turned 18 years old and were offered the opportunity to crossover to the intervention group and received surgical treatment, which may have undermined the observed treatment effect. This reflects the clinical reality of adolescent obesity management, in which transition into adulthood is often accompanied by greater autonomy, readiness for surgery, and expanded treatment eligibility.

Historically, LAGB was favored due to its minimally invasive approach and reversibility, but concerns about durability led to a shift away from its use in current practice. In our cohort, 52% of participants had their band removed after a median of 5.6 years; most converted to RYGB (82%) or sleeve gastrectomy (18%). This removal rate exceeds adult reports, perhaps reflecting our younger age group and progressive loss to follow-up.[12] [22] It is well known that structural follow-up is of critical importance to decrease the number of band-removals. Despite our efforts to keep patients motivated to come to appointments, a significant number of patients were lost to follow-up.

A total of 48% of the participants from the original intervention group still had their band in place after a median time interval of 8.2 years (range: 5.0–12.1) with a mean 12% TWL. Similarly, the recently published TEEN-LABS follow-up study[23] reported limited benefit from LAGB long-term, with an overall increase in BMI after 10 years. Fourteen patients in their cohort received LAGB, of whom two had band removal, two converted to alternative MBS, and one withdrew from the study. Taken together, these data underscore the limited efficacy of LAGB in adolescents.

The evolving landscape of obesity treatment now includes pharmacologic options. The American Academy of Pediatrics recommends weight-loss anti-obesity medication, such as glucagon-like peptide-1 (GLP-1) agonists and sodium-glucose cotransporter-2 inhibitors, to all adolescents with obesity aged ≥ 12 years in addition to MLI.[24] A recent study with once-weekly GLP-1 agonists has demonstrated a mean BMI reduction of 16.1% after 68 weeks, an effect comparable to early weight loss following LAGB. Nonetheless, weight loss maintenance is difficult in adolescents using medication, which may be due to suboptimal adherence to the medical treatment and the weight relapse after discontinuation of the medication. Long-term data on the durability and safety of anti-obesity medication are needed to determine how these therapies compare with minimally invasive surgical options such as LAGB. A recent systematic review found a mean decrease in BMI of 19.1 kg/m² 5 years after RYGB, which is superior to LAGB and medical treatment.[25] Nonetheless, long-term adverse nutritional effects are observed, and the long-term effects on bone mineral density are yet to be determined.

We are the first RCT to provide follow-up data (beyond 3 years) of adolescents who underwent LAGB, but some limitations of the study should be taken into account. Patients were progressively lost to follow-up or had missed appointments, resulting in missing data and a possible lack of statistical power. Potential bias linked to loss to follow-up is that the participants with the poorest responses are lost to follow-up, which may alter the judgment of the treatment effect. Comparison of the group that is lost to follow-up to the group that continued follow-up revealed no significant differences in baseline characteristics. In the first 3 years, participants visited the hospital for standardized anthropometric measurements, but for the long-term data, we were limited to self-reported weight and overall health status of the patients, resulting in potential recall bias. Notwithstanding these limitations, the relatively long follow-up, randomization of the study groups, and the performance of surgery in one center are strengths of this study.

In conclusion, LAGB demonstrates only modest effectiveness and appears beneficial for a limited subset of adolescents with severe obesity. Its long-term durability is suboptimal, as approximately half of patients ultimately require band removal. With the growing availability of anti-obesity pharmacotherapy—yielding weight-loss outcomes comparable to those achieved with LAGB—its role may increasingly be that of a bridging intervention toward bypass procedures. A randomized controlled trial comparing a pharmacotherapy-based bridging strategy with primary RYGB in adolescents would substantially advance our understanding of optimal treatment pathways and the appropriate timing of MBS in this population.

Conflict of Interest

The authors declare that they have no conflict of interest.

Contributors' Statement

F.D.B.: formal analysis, resources, software, validation, visualization, and writing—original draft, review, and editing. A.T.: conceptualization, data curation, funding acquisition, investigation, methodology, supervision, and writing—review and editing. Y.G.M.R.: data curation, funding acquisition, investigation, methodology, supervision, validation, and writing—review and editing. G.F.P. and L.W.E.V.H.: conceptualization, data curation, funding acquisition, investigation, methodology, project administration, supervision, and writing—review and editing. B.W.: conceptualization, formal analysis, investigation, methodology, supervision, and writing—review and editing. N.D.B.: conceptualization, funding acquisition, investigation, methodology, supervision, and writing—review and editing.

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Publication History

Received: 08 July 2025

Accepted: 14 January 2026

Accepted Manuscript online:
19 January 2026

Article published online:
31 January 2026