Health Effects of Overweight and Obesity in 195 Countries over 25 Years

Cardiovascular Diseases in India Compared With the United States

This review describes trends in the burden of cardiovascular diseases (CVDs) and risk factors in India compared with the United States; provides potential explanations for these differences; and describes strategies to improve cardiovascular health behaviors, systems, and policies in India. The prevalence of CVD in India has risen over the past 2 decades due to population growth, aging, and a stable age-adjusted CVD mortality rate. Over the same time period, the United States has experienced an overall decline in age-adjusted CVD mortality, although the trend has begun to plateau. These improvements in CVD mortality in the United States are largely due to favorable population-level risk factor trends, specifically with regard to tobacco use, cholesterol, and blood pressure, although improvements in secondary prevention and acute care have also contributed. To realize similar gains in reducing premature death and disability from CVD, India needs to implement population-level policies while strengthening and integrating its local, regional, and national health systems. Achieving universal health coverage that includes financial risk protection should remain a goal to help all Indians realize their right to health.

Associations between Single Nucleotide Polymorphisms and Total Energy, Carbohydrate, and Fat Intakes: A Systematic Review

A better understanding of the genetic underpinning of total energy, carbohydrate, and fat intake is a prerequisite to develop personalized dietary recommendations. For this purpose, we systematically reviewed associations between single nucleotide polymorphisms (SNPs) and total energy, carbohydrate, and fat intakes. Four databases were searched for studies that assessed an association between SNPs and total energy, carbohydrate, and fat intakes. Screening of articles and data extraction was performed independently by 2 reviewers. Articles in English or German language, published between 1994 and September 2017, on human studies in adults and without specific populations were considered for the review. In total, 39 articles, including 86 independent loci, met the inclusion criteria. The fat mass and obesity-associated (FTO) gene as well as the melanocortin 4 receptor (MC4R) locus were most frequently studied. Limited significant evidence of an association between the FTO SNP rs9939609 and lower total energy intake and between the MC4R SNP rs17782313 and higher total energy intake was reported. Most of the other identified loci showed inconsistent results. In conclusion, there is no consistent evidence that the investigated SNPs are associated with and predictive for total energy, carbohydrate, and fat intakes.

Carbohydrates and cognitive function

PURPOSE OF REVIEW

Recent evidence documents the negative impact of obesity, diabetes mellitus, and other metabolic dysregulation on neurocognitive function. This review highlights a key dietary factor in these relationships: refined carbohydrates.

RECENT FINDINGS

Chronic consumption of refined carbohydrates has been linked to relative neurocognitive deficits across the lifespan. Hippocampal function is especially impacted, but prefrontal and mesolimbic reward pathways may also be altered. Early life exposure to refined carbohydrates, (i.e., prenatal, juvenile, and adolescence periods) may be particularly toxic to cognitive functioning. The impact of acute carbohydrate administration is mixed, with some findings showing benefits while others are neutral or negative. Potential mechanisms of the carbohydrate-cognition relationship include dysregulation in metabolic, inflammatory, and vascular factors, whereas moderators include age, genetic factors, physiological (e.g., glucoregulatory) function and the timing and type of carbohydrate exposure. Critically, the negative neurocognitive impacts of diets high in refined carbohydrates have been shown to be independent of total body weight.

SUMMARY

Neurocognitive deficits induced by a diet high in refined carbohydrates may manifest before overt obesity or metabolic disease onset, suggesting that researchers and providers may need to target subclinical metabolic, inflammatory, and vascular dysregulation factors in efforts to preserve cognitive function across the lifespan.

Hypogonadism and male obesity: Focus on unresolved questions

Obesity, increasing in prevalence globally, is the clinical condition most strongly associated with lowered testosterone concentrations in men and presents as one of the strongest predictors of receiving testosterone treatment. While low circulating total testosterone concentrations in modest obesity primarily reflect reduced concentrations of sex hormone binding globulin, more marked obesity can lead to genuine hypothalamic-pituitary-testicular axis (HPT) suppression. HPT axis suppression is likely mediated via pro-inflammatory cytokine and dysregulated leptin signalling and aggravated by associated comorbidities. Whether oestradiol-mediated negative hypothalamic-pituitary feedback plays a pathogenic role requires further study. Although the obesity-hypogonadism relationship is bidirectional, the effects of obesity on testosterone concentrations are more substantial than the effects of testosterone on adiposity. In markedly obese men submitted to bariatric surgery, substantial weight loss is very effective in reactivating the HPT axis. In contrast, lifestyle measures are less effective in reducing weight and generally only associated with modest increases in circulating testosterone. In randomized controlled clinical trials (RCTs), testosterone treatment does not reduce body weight, but modestly reduces fat mass and increases muscle mass. Short-term studies have shown that testosterone treatment in carefully selected obese men may have modest benefits on symptoms of androgen deficiency and body composition even additive to diet alone. However, longer term, larger RCTs designed for patient-important outcomes and potential risks are required. Until such trials are available, testosterone treatment cannot be routinely recommended for men with obesity-associated nonclassical hypogonadism. Lifestyle measures or where indicated bariatric surgery to achieve weight loss, and optimization of comorbidities remain first line.

Update of the best practice dietetic management of overweight and obese children and adolescents: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

To update an existing systematic review series of randomized controlled trials (RCT) that include a dietary intervention for the management of overweight or obesity in children or adolescents.Specifically, the review questions are: In randomized controlled trials of interventions which include a dietary intervention for the management of overweight or obesity in children or adolescents.

Single Fluid-Filled Intragastric Balloon Safe and Effective for Inducing Weight Loss in a Real-World Population

BACKGROUND & AIMS

The Orbera intragastric balloon (OIB) is a single fluid-filled intragastric balloon approved for the induction of weight loss and treatment of obesity. However, little is known about the effectiveness and safety of the OIB outside clinical trials, and since approval, the Food and Drug Administration has issued warnings to health care providers about risk of balloon hyperinflation requiring early removal, pancreatitis, and death. We analyzed data on patients who have received the OIB since its approval to determine its safety, effectiveness, and tolerance in real-world clinical settings.

METHODS

We performed a postregulatory approval study of the safety and efficacy of the OIB, and factors associated with intolerance and response. We collected data from the Mayo Clinic's database of patient demographics, outcomes of OIB placement (weight loss, weight-related comorbidities), technical aspects of insertion and removal, and adverse events associated with the device and/or procedure, from 8 centers (3 academic, 5 private, 4 surgeons, and 4 gastroenterologists). Our final analysis comprised 321 patients (mean age, 48.1 ± 11.9 y; 80% female; baseline body mass index, 37.6 ± 6.9). Exploratory multivariable linear and logistic regression analyses were performed to identify predictors of success and early balloon removal. Primary effectiveness outcomes were percentage of total body weight lost at 3, 6, and 9 months. Primary and secondary safety outcomes were rates of early balloon removal, periprocedural complications, dehydration episodes requiring intravenous infusion, balloon migration, balloon deflation or hyperinflation, pancreatitis, or other complications.

RESULTS

Four patients had contraindications for placement at the time of endoscopy. The balloon was safely removed in all instances with an early removal rate (before 6 months) in 16.7% of patients, at a median of 8 weeks after placement (range, 1-6 mo). Use of selective serotonin or serotonin-norepinephrine re-uptake inhibitors at the time of balloon placement was associated with increased odds of removal before 6 months (odds ratio, 3.92; 95% CI, 1.24-12.41). Total body weight lost at 3 months was 8.5% ± 4.9% (n = 204), at 6 months was 11.8% ± 7.5% (n = 199), and at 9 months was 13.3% ± 10% (n = 47). At 6 months, total body weight losses of 5%, 10%, and 15% were achieved by 88%, 62%, and 31% of patients, respectively. Number of follow-up visits and weight loss at 3 months were associated with increased weight loss at 6 months (β = 0.5 and 1.2, respectively) (P < .05). Mean levels of cholesterol, triglycerides, low-density lipoprotein, and hemoglobin A1c, as well as systolic and diastolic blood pressure, were significantly improved at 6 months after OIB placement (P < .05).

CONCLUSIONS

In an analysis of a database of patients who received endoscopic placement of the OIB, we found it to be safe, effective at inducing weight loss, and to reduce obesity-related comorbidities in a real-world clinical population. Rates of early removal (before 8 weeks) did not differ significantly between clinical trials and the real-world population, but were affected by use of medications.

Impact of the driving pressure on mortality in obese and non-obese ARDS patients: a retrospective study of 362 cases

PURPOSE

The relation between driving pressure (plateau pressure-positive end-expiratory pressure) and mortality has never been studied in obese ARDS patients. The main objective of this study was to evaluate the relationship between 90-day mortality and driving pressure in an ARDS population ventilated in the intensive care unit (ICU) according to obesity status.

METHODS

We conducted a retrospective single-center study of prospectively collected data of all ARDS patients admitted consecutively to a mixed medical-surgical adult ICU from January 2009 to May 2017. Plateau pressure, compliance of the respiratory system (Crs) and driving pressure of the respiratory system within 24 h of ARDS diagnosis were compared between survivors and non-survivors at day 90 and between obese (body mass index ≥ 30 kg/m2) and non-obese patients. Cox proportional hazard modeling was used for mortality at day 90.

RESULTS

Three hundred sixty-two ARDS patients were included, 262 (72%) non-obese and 100 (28%) obese patients. Mortality rate at day 90 was respectively 47% (95% CI, 40-53) in the non-obese and 46% (95% CI, 36-56) in the obese patients. Driving pressure at day 1 in the non-obese patients was significantly lower in survivors at day 90 (11.9 ± 4.2 cmH2O) than in non-survivors (15.2 ± 5.2 cmH2O, p < 0.001). Contrarily, in obese patients, driving pressure at day 1 was not significantly different between survivors (13.7 ± 4.5 cmH2O) and non-survivors (13.2 ± 5.1 cmH2O, p = 0.41) at day 90. After three multivariate Cox analyses, plateau pressure [HR = 1.04 (95% CI 1.01-1.07) for each point of increase], Crs [HR = 0.97 (95% CI 0.96-0.99) for each point of increase] and driving pressure [HR = 1.07 (95% CI 1.04-1.10) for each point of increase], respectively, were independently associated with 90-day mortality in non-obese patients, but not in obese patients.

CONCLUSIONS

Contrary to non-obese ARDS patients, driving pressure was not associated with mortality in obese ARDS patients.

Body-mass index, blood pressure, and cause-specific mortality in India: a prospective cohort study of 500 810 adults

BACKGROUND

The association between cause-specific mortality and body-mass index (BMI) has been studied mainly in high-income countries. We investigated the relations between BMI, systolic blood pressure, and mortality in India.

METHODS

Men and women aged 35 years or older were recruited into a prospective study from the general population in Chennai, India between Jan 1, 1998, and Dec 31, 2001. Participants were interviewed (data collected included age, sex, education, socioeconomic status, medical history, tobacco smoking, and alcohol intake) and measured (height, weight, and blood pressure). Deaths were identified by linkage to Chennai city mortality records and through active surveillance by household visits from trained graduate non-medical fieldworkers. After the baseline survey, households were visited once in 2002-05, then biennially until 2015. During these repeat visits, structured narratives of any deaths that took place before March 31, 2015, were recorded for physician coding. During 2013-14, a random sample of participants was also resurveyed as per baseline to assess long-term variability in systolic blood pressure and BMI. Cox regression (standardised for tobacco, alcohol, and social factors) was used to relate mortality rate ratios (RRs) at ages 35-69 years to systolic blood pressure, BMI, or BMI adjusted for usual systolic blood pressure.

FINDINGS

500 810 participants were recruited. After exclusion of those with chronic disease or incomplete data, 414 746 participants aged 35-69 years (mean 46 [SD 9]; 45% women) remained. At recruitment, mean systolic blood pressure was 127 mm Hg (SD 15), and mean BMI was 23·2 kg/m2 (SD 3·8). Correlations of resurvey and baseline measurements were 0·50 for systolic blood pressure and 0·88 for BMI. Low BMI was strongly associated with poverty, tobacco, and alcohol. Of the 29 519 deaths at ages 35-69 years, the cause was vascular for 14 935 deaths (12 504 cardiac, 1881 stroke, and 550 other). Vascular mortality was strongly associated with systolic blood pressure: RRs per 20 mm Hg increase in usual systolic blood pressure were 2·45 (95% CI 2·16-2·78) for stroke mortality, 1·74 (1·64-1·84) for cardiac mortality, and 1·84 (1·75-1·94) for all vascular mortality. Although BMI strongly affected systolic blood pressure (an increase of about 1 mm Hg per kg/m2) and diabetes prevalence, BMI was little related to cardiac or stroke mortality, with only small excesses even for grade 1 obesity (ie, BMIs of 30·0-35·0 kg/m2). After additional adjustment for usual systolic blood pressure, BMI was inversely related to cardiac and stroke mortality throughout the range 15·0-30·0 kg/m2: when underweight participants (ie, BMI 15·0-18·5 kg/m2) were compared with overweight participants (ie, BMI 25·0-30·0 kg/m2), the blood-pressure-adjusted RR was 1·28 (95% CI 1·20-1·38) for cardiac mortality and 1·46 (1·22-1·73) for stroke mortality.

INTERPRETATION

In this South Asian population, BMI was little associated with vascular mortality, even though increased BMI is associated with increased systolic blood pressure, which in turn is associated with increased vascular mortality. Hence, some close correlates of below-average BMI must have important adverse effects, which could be of relevance in all populations.

FUNDING

UK Medical Research Council, British Heart Foundation, Cancer Research UK.

A Mediation Analysis on the Relationship of Physical Fitness Components, Obesity, and Academic Performance in Children

OBJECTIVES

To examine the relationship between a battery of obesity indicators and physical fitness components with academic performance in children and to explore the combined and mediation role of the physical fitness components in the relationship between obesity and academic performance in children.

STUDY DESIGN

A cross-sectional study including data from 250 Spanish schoolchildren (Balearic Islands) between 10 and 12 years of age (mean age, 10.98 ± 0.76 years) was conducted. Obesity measures (body mass index, body fat, waist circumference, hip circumference, and waist-to-height ratio), physical fitness components (cardiorespiratory fitness, muscular fitness, and speed-agility), and academic performance (Spanish language, Catalan language, English language, natural sciences, social sciences, arts, physical education, religion, and grade point average [GPA]) were collected.

RESULTS

All obesity measures were negatively related to at least 3 of the 10 academic indicators, including GPA (β range, -0.135 to -0.229; all P < .05). Cardiorespiratory fitness and speed-agility were positively related to all academic indicators (β range, 0.182 to 0.350; all P < .046) and muscular fitness with 3 academic indicators (β range, 0.143 to 0.253; all P < .039). Children considered as fit had better academic performance than their unfit peers (score +0.75; P = .001). The association between body mass index and GPA was mediated by cardiorespiratory fitness and speed-agility.

CONCLUSIONS

This investigation contributes to the current knowledge by adding evidence about the crucial role of physical fitness in terms of academic performance rather than obesity status, suggesting that physical fitness may ameliorate the negative influence of obesity on academic performance.

Non-exercise activity thermogenesis (NEAT): a component of total daily energy expenditure

[Purpose]

The purpose of this review is to promote awareness of non-exercise activity thermogenesis (NEAT) as a new strategy to increase energy expenditure, and to manage obesity.

[Methods]

The content of this review is based on a literature search of PubMed and the Google Scholar search engine, using the search terms obesity, energy expenditure, non-exercise activity thermogenesis (NEAT), and sitting disease.

[Results]

Daily energy expenditure is of great interest because most obese individuals have no exercise activity-related thermogenesis (EAT); thus their physical activity-related energy expenditure (PEE) is comprised almost entirely of NEAT. Consequently, NEAT represents the main variable component of daily total energy expenditure (TEE); this varies considerably, both within among individuals. These somewhat unplanned and unstructured low level physical activities are associated with energy expenditure in excess of the resting metabolic rate (RMR). They may therefore have the potential to stimulate greater energy expenditure over time with a higher rate of adherence.

[Conclusion]

In conclusion, NEAT is a highly variable component of daily TEE and a low level of NEAT is associated with obesity. NEAT enhances lifestyle, and variations in individual and environmental factors can significantly affect daily energy expenditure. Therefore, well designed longitudinal studies that focus on personal behavioral approaches and re-engineered environments to increase NEAT should be conducted in the future.

Predictive regulation and human design

Organisms evolving toward greater complexity were selected across aeons to use energy and resources efficiently. Efficiency depended on prediction at every stage: first a clock to predict the planet's statistical regularities; then a brain to predict bodily needs and compute commands that dynamically adjust the flows of energy and nutrients. Predictive regulation (allostasis) frugally matches resources to needs and thus forms a core principle of our design. Humans, reaching a pinnacle of cognitive complexity, eventually produced a device (the steam engine) that converted thermal energy to work and were suddenly awash in resources. Today boundless consumption in many nations challenges all our regulatory mechanisms, causing obesity, diabetes, drug addiction and their sequelae. So far we have sought technical solutions, such as drugs, to treat complex circuits for metabolism, appetites and mood. Here I argue for a different approach which starts by asking: why does our regulatory system, which evolution tuned for small satisfactions, now constantly demand 'more'?

Overview of Epidemiology and Contribution of Obesity and Body Fat Distribution to Cardiovascular Disease: An Update

Obesity is recognized as a heterogeneous condition in which individuals with similar body mass index may have distinct metabolic and cardiovascular risk profiles. Susceptibility to obesity-related cardiometabolic complications is not solely mediated by overall body fat mass, but is largely dependent upon individual differences in regional body fat distribution and ability of subcutaneous adipose tissue to expand. The present review will discuss to what extent the individual variation in body fat distribution is one of the clinical key variables explaining the metabolic heterogeneity of obesity and its related cardiovascular risk. We will present the evidence for the complex nature of the relationship between obesity and cardiovascular disease, outline our current understanding of the mechanisms involved, and identify future direction of research pertinent to this interaction.

Antiobesity Effects of Ginsenoside Rg1 on 3T3-L1 Preadipocytes and High Fat Diet-Induced Obese Mice Mediated by AMPK

Ginsenosides Rg1 is one of the major pharmacologically active saponins in ginseng, which as an antioxidant reduces oxidative damage in the liver and can also be used to prevent cardiovascular diseases and diabetes. However, there is no research targeting the effect of lipid metabolism in high-fat diet (HFD)-induced mice. In this study, we evaluated the anti-obesity effects of Rg1 in 3T3-L1 adipocyte cells and HFD-induced obese C57BL/6J mice. Administration of Rg1 to HFD-induced obese mice significantly decreased body weight, total cholesterol, and total triglyceride levels. In addition to effects in 3T3-L1 cells, Rg1 reduced the accumulation of lipid droplets in a dose-dependent manner. Furthermore, Rg1 exhibits an anti-adipogenic effect via regulation of the expression of the transcriptional factors and lipid metabolism-related genes in vivo and in vitro. We observed that Rg1 administration significantly increased the phosphorylation level of AMP-activated protein kinase (AMPK) in both epididymal white adipose tissue and 3T3-L1 cells. These results indicated that Rg1 works both in an anti-adipogenic and anti-obesity manner through inducing AMPK activation, inhibiting lipogenesis, and decreasing intracellular lipid content, adipocyte size, and adipose weight.

Adolescence and the next generation

Adolescent growth and social development shape the early development of offspring from preconception through to the post-partum period through distinct processes in males and females. At a time of great change in the forces shaping adolescence, including the timing of parenthood, investments in today's adolescents, the largest cohort in human history, will yield great dividends for future generations.

The yo-yo effect of Ramadan fasting on overweight/obese individuals in Indonesian: A prospective study

BACKGROUND: Ramadan fasting has been associated with a significant body weight, fat mass and waist-hip circumference reduction. However, this is mostly followed by weight regain in 2 weeks after the fasting is stopped. Currently there is no explanation on how this rebound phenomena occurred. OBJECTIVE: The aim of this study was to examine the role of lifestyle and hormonal background on weight regain after Ramadan fasting in overweight individuals. METHODS: This was an observational study with prospective cohort design. Subjects were overweight/obese men and women adults with age between 21 and 56 years old. Body weight, percent fat, fat free mass and hip-waist circumference were measured before (week 0), 28 days after Ramadan fasting (week 4) and 2 weeks after the end of Ramadan (week 6). In addition, data on lifestyle factors such as dietary intake and physical activity were collected in those time points. Leptin was measured before and at the end of Ramadan fasting period. RESULTS: Body weight was significantly reduced at the end of Ramadan (week 4, p < 0,0001) and increased after Ramadan (week 6, p < 0,0001). Leptin was significantly reduced after Ramadan (p = 0,018) and we found that leptin level at the end of Ramadan was associated with percent body weight reduction (p = 0,011). CONCLUSION: We conducted a study to understand Ramadan fasting yo-yo effect in overweight and obese individuals and this study showed that dietary factor prior to the fasting has a significant impact on overweight/obese individual.

Health of Philippine Emigrants Study (HoPES): study design and rationale

BACKGROUND

Immigrants to the United States are usually healthier than their U.S.-born counterparts, yet the health of immigrants declines with duration of stay in the U.S. This pattern is often seen for numerous health problems such as obesity, and is usually attributed to acculturation (the adoption of "American" behaviors and norms). However, an alternative explanation is secular trends, given that rates of obesity have been rising globally. Few studies of immigrants are designed to distinguish the effects of acculturation versus secular trends, in part because most studies of immigrants are cross-sectional, lack baseline data prior to migration, and do not have a comparison group of non-migrants in the country of origin. This paper describes the Health of Philippine Emigrants Study (HoPES), a study designed to address many of these limitations.

METHODS

HoPES is a dual-cohort, longitudinal, transnational study. The first cohort consisted of Filipinos migrating to the United States (n = 832). The second cohort consisted of non-migrant Filipinos who planned to remain in the Philippines (n = 805). Baseline data were collected from both cohorts in 2017 in the Philippines, with follow-up data collection planned over 3 years in either the U.S. for the migrant cohort or the Philippines for the non-migrant cohort. At baseline, interviewers administered semi-structured questionnaires that assessed demographic characteristics, diet, physical activity, stress, and immigration experiences. Interviewers also measured weight, height, waist and hip circumferences, blood pressure, and collected dried blood spot samples.

DISCUSSION

Migrants enrolled in the study appear to be representative of recent Filipino migrants to the U.S. Additionally, migrant and non-migrant study participants are comparable on several characteristics that we attempted to balance at baseline, including age, gender, and education. HoPES is a unique study that approximates a natural experiment from which to study the effects of immigration on obesity and other health problems. A number of innovative methodological strategies were pursued to expand the boundaries of current immigrant health research. Key to accomplishing this research was investment in building collaborative relationships with stakeholders across the U.S. and the Philippines with shared interest in the health of migrants.

Exposure to Vinyl Chloride and Its Influence on Western Diet-Induced Cardiac Remodeling

Obesity, usually caused by high fat diets (HFD), is a major public health issue worldwide, causing obesity associated cardiomyopathy. Moreover, the environmental toxicant vinyl chloride (VC) can exacerbate HFD-induced fatty liver disease. However, whether VC serves to enhance obesity-associated cardiomyopathy remains unclear. This study aims to investigate the interaction of western diet (WD) containing relatively low fat (42%) with VC on cardiac remodeling and its underling mechanisms. Adult male C57BL/6J mice were exposed to WD coinhalation of low-dose VC (<1 ppm/d) for 12 weeks. Results showed that WD feeding for 12 weeks caused slight cardiac systolic dysfunction without significant hypertrophy or fibrosis, even with VC. Nevertheless, WD upregulated NF-κB function and expression of IL-1β and PAI-1, while VC showed no significant impact on these effects. In contrast, WD together with VC significantly increased the expression of CHOP and TGF-β1, key markers for endoplasmic reticulum stress and profibrotic cytokine, respectively. In summary, exposure to low-dose of environmental toxicant VC while a WD is consumed for a relatively short time does not have significant impact on cardiac remodeling except for a mild systolic dysfunction of the heart.

Cardiovascular risk in chronic kidney disease: what is new in the pathogenesis and treatment?

The prevalence of chronic kidney disease (CKD) has increased markedly over past decades due to the aging of the worldwide population. Despite the progress in the prevention and treatment, the cardiovascular (CV) morbidity and mortality remain high among patients with CKD. Although CKD is a progressive and irreversible condition, it is possible to slow decreasing kidney function, as well as the development and progression of associated with kidney disease comorbidities. Diabetes mellitus has become major cause of CKD worldwide. It is estimated that the prevalence of diabetes will increase from 425 million worldwide in 2017 to 629 million by 2045, substantially the percentage of diabetic nephropathy among CKD patients is set to rise markedly. The results of multicenter trials concerning novel antidiabetic drugs suggest that efficacy in reducing CV risk is independent of the improvement in glycemic control. This review discusses underlying causes of high CV risk and strategies reducing individual burden among CKD patients.

Healthcare utilisation and expenditure of overweight and non-overweight children

BACKGROUND

Quantification of the burden of overweight on the healthcare system is becoming increasingly urgent for health policy, but accurate estimates are hard to obtain.

METHODS

In order to assess healthcare utilisation and expenditure of overweight and non-overweight children, we linked, on an individual basis, data on body mass index from a birth cohort study with administrative health insurance claims data. In children aged 14-15 years, we compared utilisation and expenditure on general practice care, dental care, hospital/specialist care, prescribed medication, allied healthcare and mental healthcare of overweight children (overweight at age 11 and 14, n=80) and non-overweight children (no overweight at age 11 and 14, n=1253).

RESULTS

For overweight children, mean 1-year healthcare expenditure was €837 per child and for non-overweight children €616. This difference was mainly due to significant differences in utilisation of hospital care (49% vs 37%) and mental healthcare (14% vs 7%) and to a lesser extent to higher expenditure per user.

CONCLUSION

Our results indicate the potential value of linking survey data to claims data in order to obtain insight into the healthcare costs of childhood overweight. Further studies should elucidate whether the observed differences are causally related to overweight.

Sleep-disordered breathing, circulating exosomes, and insulin sensitivity in adipocytes

BACKGROUND

Sleep-disordered-breathing (SDB), which is characterized by chronic intermittent hypoxia (IH) and sleep fragmentation (SF), is a prevalent condition that promotes metabolic dysfunction, particularly among patients suffering from obstructive hypoventilation syndrome (OHS). Exosomes are generated ubiquitously, are readily present in the circulation, and their cargo may exert substantial functional cellular alterations in both physiological and pathological conditions. However, the effects of plasma exosomes on adipocyte metabolism in patients with OHS or in mice subjected to IH or SF mimicking SDB are unclear.

METHODS

Exosomes from fasting morning plasma samples from obese adults with polysomnographically-confirmed OSA before and after 3 months of adherent CPAP therapy were assayed. In addition, C57BL/6 mice were randomly assigned to (1) sleep control (SC), (2) sleep fragmentation (SF), and (3) intermittent hypoxia (HI) for 6 weeks, and plasma exosomes were isolated. Equivalent exosome amounts were added to differentiated adipocytes in culture, after which insulin sensitivity was assessed using 0 nM and 5 nM insulin-induced pAKT/AKT expression changes by western blotting.

RESULTS

When plasma exosomes were co-cultured and internalized by human naive adipocytes, significant reductions emerged in Akt phosphorylation responses to insulin when compared to exosomes obtained after 24 months of adherent CPAP treatment (n = 24; p < 0.001), while no such changes occur in untreated patients (n = 8). In addition, OHS exosomes induced significant increases in adipocyte lipolysis that were attenuated after CPAP, but did not alter pre-adipocyte differentiation. Similarly, exosomes from SF- and IH-exposed mice induced attenuated p-AKT/total AKT responses to exogenous insulin and increased glycerol content in naive murine adipocytes, without altering pre-adipocyte differentiation.

CONCLUSIONS

Using in vitro adipocyte-based functional reporter assays, alterations in plasma exosomal cargo occur in SDB, and appear to contribute to adipocyte metabolic dysfunction. Further exploration of exosomal miRNA signatures in either human subjects or animal models and their putative organ and cell targets appears warranted.

Phoenixin-A Pleiotropic Gut-Brain Peptide

Phoenixin is a recently discovered brain peptide initially thought to be restricted to reproductive functions. The subsequent identification of phoenixin’s expression in peripheral tissues was accompanied by the description of several other actions of this hormone, such as effects on behavior, sensory perception, memory retention, the cardiovascular system as well as food intake, pointing towards a pleiotropic role of this peptide. The present review will discuss the present knowledge on phoenixin and the signaling involved as well as highlight gaps in knowledge to stimulate further research.

Daily Intake of Protein from Cod Residual Material Lowers Serum Concentrations of Nonesterified Fatty Acids in Overweight Healthy Adults: A Randomized Double-Blind Pilot Study

Improved process technologies have allowed fishing vessels to utilize residuals from cod fillet production (head, backbone, skin, cuttings, and entrails) and convert this to high-quality protein powders for human consumption. In this double-blind pilot study, 42 healthy overweight or obese adults were randomized to three experimental groups consuming tablets corresponding to 6 g/day of proteins from cod residuals as presscake meal (Cod-PC), presscake and stickwater meal (Cod-PCW), or placebo tablets (control) for eight weeks. The primary outcome of this study was changes in metabolites related to glucose regulation in overweight or obese healthy adults after intake of proteins from cod residuals. Cod-PC supplementation decreased postprandial serum nonesterified fatty acids (NEFA) concentration and increased gene expressions of diglyceride acyltransferase 1 and 2 in subcutaneous adipose tissue compared with controls. Fasting insulin increased while fasting NEFA and 120-min postprandial glucose decreased within the Cod-PC group, but these changes did not differ from the other groups. In conclusion, supplementation with Cod-PC beneficially affected postprandial serum NEFA concentration compared with the other groups in overweight or obese adults. Supplementation with Cod-PCW, which contains a higher fraction of water-soluble protein compared to Cod-PC, did not affect serum markers of glucose regulation.

Obesity and intensive staffing needs of nursing home residents

The objective of this study is to examine how increasing body mass index (BMI) among nursing home residents affects the amount of staffing assistance needed for activities of daily living (ADL). We analyzed 1,627,141 US nursing home residents reported in the 2013 Minimum Data Set in seven BMI categories, from underweight (BMI < 18.5 kg/m²) to obesity Class IIIB (≥50 kg/m²). Logistic regression models estimated the odds of nursing home-reported need for extensive (≥2 staff member) assistance needed for ADLs. The adjusted odds increased from 1.07 (95% Confidence Interval (95%CI) 1.06-1.08) for Class I, 1.16 (95%CI 1.14-1.17) for Class II, 1.33 (95%CI 1.31-1.35) for Class IIIA, and 1.90 (95%CI 1.86-1.95) for Class IIIB obesity residents compared to residents of normal weight. As a nursing home resident's BMI increases, especially for BMI ≥40 kg/m², the need for extensive staffing assistance with ADLs also increases substantially.

Early breast cancer: why does obesity affect prognosis?

High BMI is associated with an increased risk of breast cancer in post-menopausal women but poorer outcomes in all age groups. The underlying mechanism is likely to be multi-factorial. Patients with a high BMI may present later due to body habitus. Some studies have also indicated an increased incidence of biologically adverse features, including a higher frequency of oestrogen receptor (ER negative) tumours, in obese patients. Obese patients have a higher frequency of surgical complications, potentially delaying systemic therapies, and reports suggest that chemotherapy and endocrine therapy are less effective in patients with BMI ≥30 kg/m2.High BMI is generally interpreted as excess adiposity and a World Cancer Research Fund report judged that the associations between BMI and incidence of breast cancer were due to body fatness. However, BMI cannot distinguish lean mass from fat mass, or characterise body fat distribution. Most chemotherapy drugs are dosed according to calculated body surface area (BSA). Patients with a similar BSA or BMI may have wide variations in their distribution of adipose tissue and skeletal muscle (body composition); however, few studies have looked at the effect of this on chemotherapy tolerance or effectiveness. Finally, adjuvant treatments for breast cancer can themselves result in body composition changes.Research is required to fully understand the biological mechanisms by which obesity influences cancer behaviour and the impact of obesity on treatment effectiveness and tolerance so that specific management strategies can be developed to improve the prognosis of this patient group.

The trends in total energy, macronutrients and sodium intake among Japanese: findings from the 1995-2016 National Health and Nutrition Survey

Monitoring nutritional status of the population is essential in the development and evaluation of national or local health policies. In this study, we aimed to demonstrate analysis on the trends in dietary intake of energy and macronutrients, as well as Na, in Japanese population using the data of series of cross-sectional national surveys - the National Nutrition Survey (NNS) and the National Health Nutrition Survey (NHNS) - during the period from 1995 to 2016. The NNS and NHNS participants aged 20-79 years were included in the analysis. Dietary intake was estimated using 1-d household-based dietary record. The trend in total energy intake, energy intake from macronutrients (fat and protein), Na intake and energy-adjusted Na intake were analysed using regression models adjusted to 2010 age distribution and anthropometry status. A total of 94 270 men and 107 890 women were included the analysis. Total energy intake showed a decreasing trend in both men and women. Similarly, energy intake from protein decreased, but energy intake (%) from fat increased in both sexes. Energy-adjusted Na intake showed a decreasing trend in both men and women. This study identified the decrease in total energy intake and energy intake from protein, whereas there were inverse trends in energy intake from fat among Japanese adults. Continued monitoring of trends in dietary intake will be needed, and there should be efforts to increase the accuracy of current survey procedures.

Obesity, metabolic abnormalities, and mortality in older men

BACKGROUND

Older adults are prone to obesity and metabolic abnormalities and recommended to pursue a normal weight especially when obesity and metabolic abnormalities are co-existed. However, few studies have reported the possible differences in the effect of obesity on outcomes between older adults with metabolic abnormalities and those without metabolic abnormalities.

METHODS

A total of 3485 older men were included from 2000 to 2014. All-cause mortality and cardiovascular mortality were obtained during a mean follow-up of five years. Metabolic abnormalities were defined as having established hypertension, diabetes, or dyslipidemia and taking the disease-related medications. All participants were stratified by the presence or absence of metabolic abnormalities.

RESULTS

In the non-metabolic abnormalities group, all-cause and cardiovascular deaths were lowest in overweight participants and highest in obese participants. In the metabolic abnormalities group, mortality was also lowest in overweight participants but highest in participants with normal weight. After adjustment for covariates, hazard ratios (95% CI) for all-cause death and cardiovascular death were 0.68 (0.51, 0.92) and 0.59 (0.37, 0.93), respectively, in overweight participants with metabolic abnormalities. Furthermore, obesity was not associated with mortality risk in both groups. These findings were unchanged in stratified analyses.

CONCLUSIONS

Overweight was negatively associated with mortality risk in older men with metabolic abnormalities but not in those without metabolic abnormalities. Obesity did not increase death risk regardless of metabolic abnormalities. These findings suggest that the recommendation of pursuing a normal weight may be wrong in overweight/obese older men, especially for those with metabolic abnormalities.

Glucocorticoid-Induced Metabolic Disturbances Are Exacerbated in Obese Male Mice

The purpose of this study was to determine the effects of glucocorticoid-induced metabolic dysfunction in the presence of diet-induced obesity. C57BL/6J adult male lean and diet-induced obese mice were given dexamethasone, and levels of hepatic steatosis, insulin resistance, and lipolysis were determined. Obese mice given dexamethasone had significant, synergistic effects on fasting glucose, insulin resistance, and markers of lipolysis, as well as hepatic steatosis. This was associated with synergistic transactivation of the lipolytic enzyme adipose triglyceride lipase. The combination of chronically elevated glucocorticoids and obesity leads to exacerbations in metabolic dysfunction. Our findings suggest lipolysis may be a key player in glucocorticoid-induced insulin resistance and fatty liver in individuals with obesity.

Targeting autophagy in obesity: from pathophysiology to management

Obesity poses a severe threat to human health, including the increased prevalence of hypertension, insulin resistance, diabetes mellitus, cancer, inflammation, sleep apnoea and other chronic diseases. Current therapies focus mainly on suppressing caloric intake, but the efficacy of this approach remains poor. A better understanding of the pathophysiology of obesity will be essential for the management of obesity and its complications. Knowledge gained over the past three decades regarding the aetiological mechanisms underpinning obesity has provided a framework that emphasizes energy imbalance and neurohormonal dysregulation, which are tightly regulated by autophagy. Accordingly, there is an emerging interest in the role of autophagy, a conserved homeostatic process for cellular quality control through the disposal and recycling of cellular components, in the maintenance of cellular homeostasis and organ function by selectively ridding cells of potentially toxic proteins, lipids and organelles. Indeed, defects in autophagy homeostasis are implicated in metabolic disorders, including obesity, insulin resistance, diabetes mellitus and atherosclerosis. In this Review, the alterations in autophagy that occur in response to nutrient stress, and how these changes alter the course of obesogenesis and obesity-related complications, are discussed. The potential of pharmacological modulation of autophagy for the management of obesity is also addressed.

Efficacy of gamification-based smartphone application for weight loss in overweight and obese adolescents: study protocol for a phase II randomized controlled trial

BACKGROUND

Overweight and obesity are significant public health concerns that are prevalent in younger age cohorts. Preventive or therapeutic interventions are difficult to implement and maintain over time. On the other hand, the majority of adolescents in the United States have a smartphone, representing a huge potential for innovative digitized interventions, such as weight loss programs delivered via smartphone applications. Although the number of available smartphone applications is increasing, evidence for their effectiveness in weight loss is insufficient. Therefore, the proposed study aims to assess the efficacy of a gamification-based smartphone application for weight loss in overweight and obese adolescents. The trial is designed to be a phase II, single-centre, two-arm, triple-blinded, randomized controlled trial (RCT) with a duration of 6 months.

METHOD

The intervention consists of a smartphone application that provides both tracking and gamification elements, while the control arm consists of an identically designed application solely with tracking features of health information. The proposed trial will be conducted in an urban primary care clinic of an academic centre in the United States of America, with expertise in the management of overweight and obese adolescents. Eligible adolescents will be followed for 6 months. Changes in body mass index z score from baseline to 6 months will be the primary outcome. Secondary objectives will explore the effects of the gamification-based application on adherence, as well as anthropometric, metabolic and behavioural changes. A required sample size of 108 participants (54 participants per group) was calculated.

DISCUSSION

The benefits of the proposed study include mid-term effects in weight reduction for overweight and obese adolescents. The current proposal will contribute to fill a gap in the literature on the mid-term effects of gamification-based interventions to control weight in adolescents. This trial is a well-designed RCT that is in line with the Consolidated Standards of Reporting Trials statement.

The genetics of adiposity

Genome-wide discovery efforts have identified more than 500 genetic loci associated with adiposity traits. The vast majority of these loci were found through large-scale meta-analyses for body mass index (BMI) and waist-to-hip ratio (WHR), and in European ancestry populations. However, alternative approaches, focusing on non-European ancestry populations, more refined adiposity measures, and low-frequency (minor allele frequency (MAF)<5%) coding variants, identified additional novel loci that had not been identified before. Loci associated with overall obesity implicate pathways that act in the brain, whereas loci associated with fat distribution point to pathways involved in adipocyte biology. Pinpointing the causal gene within each locus remains challenging, but is a critical step towards translation of genome-wide association study (GWAS) loci into new biology. Ultimately, new genes may provide pharmacological targets for the development of weight loss drugs.

Editorial: de novo inflammatory bowel disease following bariatric surgery-potential implications for research and clinical practice

Linked Content

This article is linked to Ungaro et al and Ungaro and Colombel papers. To view these articles visit https://doi.org/10.1111/apt.14569 and https://doi.org/10.1111/apt.14667.

Media and Its Influence on Obesity

PURPOSE OF REVIEW

To review how the media frames obesity and the effect it has upon on public perceptions.

RECENT FINDINGS

The scientific and public health understanding of obesity increasingly points away from individual behaviors and toward medical and community factors, but diffusion of this knowledge is slow. Growing awareness of the importance of body positivity is driving attention to the harms of weight bias and fat shaming. Health science reporting related to obesity, nutrition, and physical activity tends to perpetuate myths and misunderstandings. Moving forward, greater attention to accurate messages about obesity and evidence-based interventions will be essential for progress to reduce suffering and the impact on public health from this chronic disease.

Prevention of Excessive Gestational Weight Gain and Postpartum Weight Retention

PURPOSE OF REVIEW

The purpose of this review is to summarize the current evidence on the prevention of excessive gestational weight gain (GWG) and reduction of postpartum weight retention (PPWR) by lifestyle intervention and pharmacotherapy.

RECENT FINDINGS

Recent findings demonstrate that tailored nutrition counseling and adapting certain eating patterns, supervised exercise programs aiming at achieving at least moderate level of physical activity, and interactive and monitored behavior change interventions are effective in reducing excessive GWG and PPWR. Among the pharmacologic agents, Metformin has been shown to reduce GWG. Excessive GWG and PPWR are associated with adverse maternal and neonatal outcomes. Recent evidence shows that weight during gestation and the postpartum period can be significantly reduced by more frequent nutrition counseling sessions on balanced diet focusing on healthier food choices and eating patterns, supervised moderate-intensity exercise for at least 30 min three times a week, and interactive behavior change interventions with regular feedback and follow-up. The benefits on weight are seen when these interventions are utilized together in a multimodality approach. Metformin is effective in preventing excessive GWG but has no impact on neonatal outcomes.

The interaction among obesity, Type 2 diabetes mellitus, and periodontitis in Vietnamese patients

To examine the relationship between obesity, Type 2 diabetes, and periodontal disease in Vietnamese patients. The sample included 712 patients aged 18 years or older who first visited the Institute of Traditional Medicine, Ho Chi Minh City. All participants completed a questionnaire and underwent anthropometric index measurements for obesity (height, weight, waist, and hip circumferences) and had their body fat percentage measured. A full periodontal examination was performed and a fasting glycemic level was determined. Occurrence and risk of periodontal outcomes were compared across 3 different measurements of obesity (body mass index, waist-hip ratio, and body fat percentage). The prevalence of periodontitis in obese group (37.0%, 36.4%, and 24.6% by body mass index, waist-hip ratio, and body fat percentage, respectively) or Type 2 diabetic group (50.7%) was significantly higher than those without these conditions (p < .05). Subjects with obesity or Type 2 diabetes had significantly greater pocket depth and clinical attachment loss than those who are not obese or diabetic (p < .001). Multivariate logistic regression, adjusted for confounding variables, showed that the likelihood (odds ratio, OR) for periodontitis was highest in the obese and Type 2 diabetic group (OR = 4.24, CI [2.29, 7.86]; OR = 4.06, CI [2.24, 7.36]; and OR = 5.44, CI [2.94, 10.03]), followed by the obese and non-Type 2 diabetic group (OR = 2.28, CI [1.05, 4.95]; OR = 2.02, CI [1.34, 3.56]), and then the nonobese and Type 2 diabetic group (OR = 2.20, CI [1.21, 3.98]; OR = 1.99, CI [0.93, 4.24] and OR = 5.22, CI [2.76, 9.84]) when obesity was defined by body mass index, waist-hip ratio, and body fat percentage, respectively, (p < .05). There was a significant association between obesity, Type 2 diabetes, or those with both systemic conditions and periodontitis in Vietnamese patients.

Rapidly increasing body mass index among children, adolescents and young adults in a transitioning population, South Africa, 2008-15

Background

There is a global epidemic of overweight and obesity; however, this rate of increase is even greater in some low- and middle-income countries (LMIC). South Africa (SA) is undergoing rapid socioeconomic and demographic changes that have triggered a rapid nutrition transition. The paper focuses on the recent rate of change of body mass index (BMI) among children, adolescents and young adults, further stratified by key sociodemographic factors.

Methods

We analysed mean BMI of 28 247 individuals (including children) from 7301 households by age and year, from anthropometric data from four national cross-sectional (repeated panel) surveys using non-linear fitted curves and associated 95% confidence intervals.

Results

From 2008 to 2015, there was rapid rise in mean BMI in the 6-25 age band, with the highest risk (3-4+ BMI unit increase) among children aged 8-10 years. The increase was largely among females in urban areas and of middle-high socioeconomic standing. Prominent gains were also observed in certain rural areas, with extensive geographical heterogeneity across the country.

Conclusions

We have demonstrated a major deviation from the current understanding of patterns of BMI increase, with a rate of increase substantially greater in the developing world context compared with the global pattern. This population-wide effect will have major consequences for national development as the epidemic of related non-communicable disease unfolds, and will overtax the national health care budget. Our refined understanding highlights that risks are further compounded for certain groups/places, and emphasizes that urgent geographical and population-targeted interventions are necessary. These interventions could include a sugar tax, clearer food labelling, revised school feeding programmes and mandatory bans on unhealthy food marketing to children.The scenario unfolding in South Africa will likely be followed in other LMICs.

Kinetics of human brown adipose tissue activation and deactivation

Brown adipose tissue (BAT) has been identified as a potential target in the treatment and prevention of obesity and metabolic disease. The precise kinetics of BAT activation and the duration of stimulus required to recruit metabolically active BAT, and its subsequent deactivation, are not well-understood. In this clinical trial, 19 healthy adults (BMI: 23.7 ± 0.7 kg/m², Age: 31.2 ± 2.8 year, 12 female) underwent three different cooling procedures to stimulate BAT glucose uptake, and active BAT volume was determined using ¹⁸F-Fluorodeoxyglucose (FDG) PET/CT imaging. We found that 20 min of pre-injection cooling produces activation similar to the standard 60 min (39.9 mL vs. 44.2 mL, p = 0.52), indicating that BAT activity approaches its peak function soon after the initiation of cooling. Furthermore, upon removal of cold exposure, active BAT volume declines (13.6 mL vs. 44.2 mL, p = 0.002), but the deactivation process persists even hours following cessation of cooling. Thus, the kinetics of human BAT thermogenesis are characterized by a rapid increase soon after cold stimulation but a more gradual decline after rewarming. These characteristics reinforce the feasibility of developing mild, short-duration cold exposure to activate BAT and treat obesity and metabolic disease.

The use of a food logging app in the naturalistic setting fails to provide accurate measurements of nutrients and poses usability challenges

OBJECTIVE

MyFitnessPal is the most popular commercial nutrition weight loss app. The aim of this study was to assess how individuals in naturalistic settings performed when recording their dietary intake in MyFitnessPal, and their usability experiences with the app.

METHODS

Adults not regularly using MyFitnessPal (N = 43) logged their dietary intake in the app for 4 consecutive days and completed two researcher-administered 24-h recalls collected based on the Automated Multiple Pass Method. Food items from 24-h recalls were coded into food categories and foods omitted from corresponding MyFitnessPal records were calculated. Comparative validity of energy and macronutrient outputs from MyFitnessPal were compared against 24-h recalls using paired t tests. Inductive thematic analysis was applied to app usability responses.

RESULTS

Individuals omitted a mean of 18% (SD, 15) of food items, particularly energy-dense and nutrient-poor foods from MyFitnessPal records. Relative to 2-day 24-h recalls, 4-day MyFitnessPal records significantly underestimated mean energy intake by 1863 kJ (SD, 2952 kJ, P = 0.0002) and intake of all macronutrients. Although 80% of participants rated MyFitnessPal as easy to use, only 20% said they would continue use, citing challenges in matching foods, estimating portion size, and logging being time-consuming, as affecting motivation for long-term use.

CONCLUSIONS

Large discrepancies in nutrient measurements from MyFitnessPal indicate suboptimal performance with using the app to record intake, particularly given food omissions in records and difficulties encountered with app usability relating to the food database and input of portion sizes. Stand-alone use of MyFitnessPal is therefore cautioned and guidance from dietitians is necessary to support use of nutrition apps in collecting accurate dietary data.

Stroke, cerebrovascular diseases and vascular cognitive impairment in Africa

With increased numbers of older people a higher burden of neurological disorders worldwide is predicted. Stroke and other cerebrovascular diseases do not necessarily present with different phenotypes in Africa but their incidence is rising in tandem with the demographic change in the population. Age remains the strongest irreversible risk factor for stroke and cognitive impairment. Modifiable factors relating to vascular disease risk, diet, lifestyle, physical activity and psychosocial status play a key role in shaping the current spate of stroke related diseases in Africa. Hypertension is the strongest modifiable risk factor for stroke but is also likely associated with co-inheritance of genetic traits among Africans. Somewhat different from high-income countries, strokes attributed to cerebral small vessel disease (SVD) are higher >30% among sub-Saharan Africans. Raised blood pressure may explain most of the incidence of SVD-related strokes but there are likely other contributing factors including dyslipidaemia and diabetes in some sectors of Africa. However, atherosclerotic and cardioembolic diseases combined also appear to be common subtypes as causes of strokes. Significant proportions of cerebrovascular diseases are ascribed to various forms of infectious disease including complications of human immunodeficiency virus. Cerebral SVD leads to several clinical manifestations including gait disturbance, autonomic dysfunction and depression. Pathological processes are characterized by arteriolosclerosis, lacunar infarcts, perivascular spaces, microinfarcts and diffuse white matter changes, which can now all be detected on neuroimaging. Except for isolated cases of cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy or CADASIL, hereditary arteriopathies have so far not been reported in Africa. Prevalence estimates of vascular dementia (2-3%), delayed dementia after stroke (10-20%) and vascular cognitive impairment (30-40%) do not appear to be vastly different from those in other parts of the world. However, given the current demographic transition in both urban and rural settings these figures will likely rise. Wider application of neuroimaging modalities and implementation of stroke care in Africa will enable better estimates of SVD and other subtypes of stroke. Stroke survivors with SVD type pathology are likely to have low mortality and therefore portend increased incidence of dementia.

The vagus neurometabolic interface and clinical disease

The nervous system both monitors and modulates body metabolism to maintain homoeostasis. In disease states such as obesity and diabetes, the neurometabolic interface is dysfunctional and contributes to clinical illness. The vagus nerve, in particular, with both sensory and motor fibres, provides an anatomical substrate for this interface. Its sensory fibres contain receptors for important circulating metabolic mediators, including leptin and cholecystokinin, and provide real-time information about these mediators to the central nervous system. In turn, efferent fibres within the vagus nerve participate in a brain-gut axis to regulate metabolism. In this review, we describe these vagus nerve-mediated metabolic pathways and recent clinical trials of vagus nerve stimulation for the management of obesity. These early studies suggest that neuromodulation approaches that employ electricity to tune neurometabolic circuits may represent a new tool in the clinical armamentarium directed against obesity.