Swedish obese subjects (SOS): an obesity intervention study with a nutritional perspective

Vitamin A and D Absorption in Adults with Metabolic Syndrome versus Healthy Controls: A Pilot Study Utilizing Targeted and Untargeted LC-MS Lipidomics

SCOPE

Persons with metabolic syndrome (MetS) absorb less vitamin E than healthy controls. It is hypothesized that absorption of fat-soluble vitamins (FSV) A and D2 would also decrease with MetS status and that trends would be reflected in lipidomic responses between groups.

METHODS AND RESULTS

Following soymilk consumption (501 IU vitamin A, 119 IU vitamin D2 ), the triglyceride-rich lipoprotein fractions (TRL) from MetS and healthy subjects (n = 10 age- and gender-matched subjects/group) are assessed using LC-MS/MS. Absorption is calculated using area under the time-concentration curves (AUC) from samples collected at 0, 3, and 6 h post-ingestion. MetS subjects have ≈6.4-fold higher median vitamin A AUC (retinyl palmitate) versus healthy controls (P = 0.07). Vitamin D2 AUC is unaffected by MetS status (P = 0.48). Untargeted LC-MS lipidomics reveals six phospholipids and one cholesterol ester with concentrations correlating (r = 0.53-0.68; P < 0.001) with vitamin A concentration.

CONCLUSIONS

The vitamin A-phospholipid association suggests increased hydrolysis by PLB, PLRP2, and/or PLA2 IB may be involved in the trend in higher vitamin A bioavailability in MetS subjects. Previously observed differences in circulating levels of these vitamins are likely not due to absorption. Alternate strategies should be investigated to improve FSV status in MetS.

Increase in Protein Intake After 3 Months of RYGB Is an Independent Predictor for the Remission of Obesity in the First Year of Surgery

INTRODUCTION

Although bariatric surgery promotes dietary changes, many questions regarding their effect on weight loss remain unanswered.

OBJECTIVE

The aim of this study was to evaluate changes in dietary intake and predictive factors of obesity remission in the first 12 months after RYGB.

METHODS

Fifty-one patients (mean 39.34 ± 9.38 years, 68.7% women) who underwent RYGB were included in this study. Dietary intake was evaluated through a 24-h dietary recall and subsequently classified by NOVA, macronutrients and calories. The predictive factors for obesity remission within 12 months after RYGB were evaluated by Cox regression.

RESULTS

At baseline, 62.7% of the patients presented severe obesity; mean excess weight loss was greater than 80% after 1 year of surgery and about 70% of the patients were no longer diagnosed with obesity. An increase in percentage of calories from protein was observed at 3 and 12 months after surgery. The caloric contribution of ultra-processed foods was low at 3 months after surgery while that of unprocessed or minimally processed foods was high at 3 and 12 months after surgery. From the Cox regression analysis, preoperative BMI (HR, 0.78; 95% CI, 0.69-0.88) and age (HR, 0.94; 95% CI, 0.89-0.99) showed an inverse association with obesity remission. Also, Δ protein (at 3 months-baseline) showed a positive association with obesity remission (HR, 1.06; 95% CI, 1.01-1.12).

CONCLUSION

Lower preoperative BMI, lower age, and higher protein intake at 3 months after surgery may favor remission of obesity in up to 12 months compared with baseline.

Cost-effectiveness of an educational healthcare circuit for bariatric surgery in France

OBJECTIVES

An educational healthcare circuit (EHC) is proposed with the objective of preventing weight recovery of patients after bariatric surgery through education and lifestyle change. The objective of this study was to measure the viability of the EHC (shared medical appointments [SMAs] combined with bariatric surgery) through cost-effectiveness analysis. The EHC presented in this study is innovative because it offers a multidisciplinary approach based on medical, psychological and dietetic expertise to combat obesity. The strategy is to give the patient a diagnosis and then a personalised follow-up.

STUDY DESIGN

A mathematical model based on a decision tree (1 year) and a Markov model (10 years) to measure the efficiency and cost of an EHC in comparison with the customary care offered in France were built.

METHODS

The effects of the EHC were observed for the prevalence of type 2 diabetes and the risk of cardiovascular disease. The chosen financial perspective is from the point of view of the French social security system.

RESULTS

The EHC records an incremental cost-effective ratio (ICER) of € 48,315.43 per quality-adjusted life year (QALY) over a 1-year horizon and € 28,283.77 per QALY over 10 years (with discount rate of 8%: € 25,362.85 per QALY).

CONCLUSION

The results suggest that an EHC is more expensive yet more effective than usual care. That is, in the short term, the costs are high, but at 10 years, the treatment is cost-effective, representing a feasible alternative for those patients who qualify for bariatric surgery in France.

Copy number of pancreatic polypeptide receptor gene NPY4R correlates with body mass index and waist circumference

Multiple genetic studies have linked copy number variation (CNV) in different genes to body mass index (BMI) and obesity. A CNV on chromosome 10q11.22 has been associated with body weight. This CNV region spans NPY4R, the gene encoding the pancreatic polypeptide receptor Y4, which has been described as a satiety-stimulating receptor. We have investigated CNV of the NPY4R gene and analysed its relationship to BMI, waist circumference and self-reported dietary intake from 558 individuals (216 men and 342 women) representing a wide BMI range. The copy number for NPY4R ranged from 2 to 8 copies (average 4.6±0.8). Rather than the expected negative correlation, we observed a positive correlation between NPY4R copy number and BMI as well as waist circumference in women (Pearson’s r = 0.267, p = 2.65×10⁻⁷ and r = 0.256, p = 8×10⁻⁷, respectively). Each additional copy of NPY4R correlated with 2.6 kg/m² increase in BMI and 5.67 cm increase in waist circumference (p = 2.8×10⁻⁵ and p = 6.2×10⁻⁵, respectively) for women. For men, there was no statistically significant correlation between CNV and BMI. Our results suggest that NPY4R genetic variation influences body weight in women, but the exact role of this receptor appears to be more complex than previously proposed.

Macronutrient and alcohol intake is associated with intermuscular adipose tissue in a randomly selected group of younger and older men and women

BACKGROUND

Alcohol and macronutrient intake have been found to be related to general and central body fat distribution. Intermuscular adipose tissue (IMAT) is a small ectopic fat depot located within the muscle bundles. IMAT is important for muscle function, mobility and energy homeostasis and also associated with cardiovascular- and diabetes-related risk factors.

AIM

To test the hypothesis that macronutrient and alcohol intake is associated with IMAT.

METHODS

50 men and 50 women, randomly selected from the general population formed height- and weight-representative age groups of 50 younger (27-31 years) and 50 older (57-61 years) subjects. A dietary questionnaire was used to estimate habitual intake of foods and beverages. Body composition including IMAT was measured with computed tomography.

RESULTS

Energy percent (E%) carbohydrates were negatively associated with IMAT in men (β: -0.6234, P < 0.05) and in younger subjects (β: -0.792, P < 0.05). E% alcohol was positively associated with IMAT in women (β: 2.3663, P < 0.01) and in older subjects (β: 1.232, P < 0.01). In younger individuals, E% protein was positively associated with IMAT (β: 1.840, P < 0.05). Centralized and general body fat distributions were positively associated with IMAT. S- (serum) cholesterol was positively associated with IMAT in men (β: 0.05177, P < 0.01) and younger individuals (β: 0.06701, P < 0.01).

CONCLUSIONS

These cross-sectional analyses showed associations between measures of body fat distribution and IMAT as well as associations between macronutrient- and alcohol intake and IMAT. Since IMAT is situated within the energy demanding striated muscles, our data could suggest that changes in dietary energy intake and macronutrient distribution may induce changes in IMAT in both normal weight and obese subjects.

Validity of a web-based dietary questionnaire designed especially to measure the intake of phyto-oestrogens

A diet questionnaire (DQ) designed to assess habitual diet and phyto-oestrogen intake was developed. This study aimed to examine the validity of the DQ in men, with and without having prostate cancer. The DQ was validated against alkylresorcinol metabolites measured in urine as objective biomarkers of whole grain wheat and rye (WG) intake, and a 4-d estimated food record (FR) was used for relative comparison. Participants (n 61) completed both methods and provided spot urine samples. We found a statistically significant correlation between the DQ and FR for reported whole grain intake and isoflavonoids, as well as for intake of macronutrients, except protein. The correlation coefficient between the two methods was on average r 0·30, lowest for lignans (r -0·11) and highest for alcohol (r 0·65). Reported energy intake was lower in the DQ compared with FR (8523 v. 9249 kJ (2037 v. 2211 kcal), respectively; P = 0·014). Bland-Altman plots showed an acceptable agreement; most cases were within the limits (95 % CI) of agreement on reported energy intake, as well as intake of macronutrients, except protein (which was underestimated in the DQ compared with the FR). The correlation of alkylresorcinol with WG intake was statistically significant in the DQ (r 0·31, P = 0·015), but not in the FR (r 0·18, P = 0·12) and the weighted κ was 0·29 and 0·11, respectively. In conclusion, the results showed that the DQ have a reasonable validity for measuring WG intake and most nutrients, and, after some adjustments regarding protein intake assessment have been made, the DQ will be a promising tool.

What do individuals with morbid obesity report as a usual dietary intake? A narrative review of available evidence

BACKGROUND

In several developed countries, as obesity prevalence doubles it has quadrupled for morbid obesity (BMI ≥ 40 kgm^-2). As more individuals with morbid obesity present for weight loss treatment there is a greater need to understand their dietary habits. No reviews were found in the literature, therefore this systematic review aims to identify and describe the existing evidence on the usual dietary intake of individuals with morbid obesity including those from a general population and those seeking treatment such as weight loss surgery.

METHODS

A literature search of ten databases from 1980 to June 2014 was conducted to identify original research of adults with morbid obesity (aged 18-60 years) that reported a usual dietary intake.

RESULTS

Ten studies met all inclusion criteria and reported energy intake, most reported macronutrient composition, two assessed micronutrient intake, and one reported food-based outcomes. Other dietary outcomes were related to surgical intervention. The most plausible energy intake data suggest high intakes, >4000 Kcal/day for those weight stable at the highest levels of morbid obesity (up to BMI 97 kgm^-2). Fat intakes are also high, around 40% of energy intake and up to 57% for some individuals. Suboptimal intakes of iron and calcium are reported.

CONCLUSION

This review draws attention to a limited evidence base, offers preliminary insight suggesting individuals with morbid obesity are prone to consuming poor quality diets similar to those reported for obese populations, and highlights challenges for future research.

Nutritional and Protein Deficiencies in the Short Term following Both Gastric Bypass and Gastric Banding

BACKGROUND

The number of morbidly obese patients undergoing bariatric surgery (BS) has increased dramatically in recent years. Therefore, monitoring food intake and its consequences in terms of nutritional status is necessary to prevent nutritional deficiencies. The aim of this study was to analyze the effect of food restriction on nutritional parameters in the short-term (≤3 months) period after BS in morbid obesity.

METHOD

In a prospective study, we followed 22 obese women who underwent Roux-en-Y gastric bypass (GBP) or adjustable gastric banding (AGB) at baseline (T0) and 1 (T1) and 3 (T3) months after surgery. We evaluated food intake, nutrient adequacy and serum concentrations of vitamins and minerals known to be at risk for deficiency following BS.

RESULTS

Before surgery, we observed suboptimal food intakes, leading to a risk of micronutrient deficiencies. Serum analysis confirmed nutritional deficiencies for iron and thiamine for 27 and 23% of the patients, respectively. The drastic energy and food reduction seen in the short term led to very low probabilities of adequacy for nutrients equivalent across both surgeries. Serum analysis demonstrated a continuous decrease in prealbumin during the follow-up, indicating mild protein depletion in 21 and 57% of GBP patients and 50 and 63% of AGB patients, respectively, at T1 and T3. Regarding vitamins and minerals, systematic supplementation after GBP prevented most nutritional deficiencies. By contrast, AGB patients, for whom there is no systematic supplementation, developed such deficiencies.

CONCLUSIONS

Our results suggest that cautious monitoring of protein intake after BS is mandatory. Furthermore, AGB patients might also benefit from systematic multivitamin and mineral supplementation at least in the short term.

Vitamin concentrations 5 years after gastric bypass

BACKGROUND/OBJECTIVES

Few studies have investigated the effects of bariatric surgery on vitamin status in the long term. We examined changes in vitamin status up to 5 years after Roux-en-Y gastric bypass surgery.

SUBJECTS/METHODS

Using a retrospectively maintained database of patients undergoing weight loss surgery, we identified all patients operated with Roux-en-Y gastric bypass at our tertiary care hospital during July 2004-May 2008. Data on vitamin concentrations and patient-reported intake of dietary supplements were collected up to July 2012. Linear mixed models were used to estimate changes in vitamin concentrations during follow-up, adjusting for age and sex. All patients were recommended daily oral multivitamin, calcium/vitamin D and iron supplements and 3-monthly intramuscular B-12 after surgery.

RESULTS

Out of the 443 patients operated with gastric bypass, we included 441 (99.5%) patients with one or more measurements of vitamin concentrations (75.1% women; mean age 41.5 years, mean body mass index 46.1 kg/m(2) at baseline). At 5 years after surgery, the patients' estimated mean vitamin concentrations were either significantly higher (vitamin B-6, folic acid, vitamin B-12, vitamin C and vitamin A) or not significantly different (thiamine, 25-hydroxyvitamin D and lipid-adjusted vitamin E) compared with before surgery. Use of multivitamin, calcium/vitamin D and vitamin B-12 supplements was reported by 1-9% of patients before surgery, 79-84% of patients at 1 year and 52-83% of patients 5 years after surgery.

CONCLUSIONS

In patients who underwent gastric bypass surgery, estimated vitamin concentrations were either significantly increased or unchanged up to 5 years after surgery.

Does vitamin C deficiency promote fatty liver disease development?

Obesity and the subsequent reprogramming of the white adipose tissue are linked to human disease-complexes including metabolic syndrome and concurrent non-alcoholic fatty liver disease (NAFLD) and non-alcoholic steatohepatitis (NASH). The dietary imposed dyslipidemia promotes redox imbalance by the generation of excess levels of reactive oxygen species and induces adipocyte dysfunction and reprogramming, leading to a low grade systemic inflammation and ectopic lipid deposition, e.g., in the liver, hereby promoting a vicious circle in which dietary factors initiate a metabolic change that further exacerbates the negative consequences of an adverse life-style. Large epidemiological studies and findings from controlled in vivo animal studies have provided evidence supporting an association between poor vitamin C (VitC) status and propagation of life-style associated diseases. In addition, overweight per se has been shown to result in reduced plasma VitC, and the distribution of body fat in obesity has been shown to have an inverse relationship with VitC plasma levels. Recently, a number of epidemiological studies have indicated a VitC intake below the recommended daily allowance (RDA) in NAFLD-patients, suggesting an association between dietary habits, disease and VitC deficiency. In the general population, VitC deficiency (defined as a plasma concentration below 23 μM) affects around 10% of adults, however, this prevalence is increased by an adverse life-style, deficiency potentially playing a broader role in disease progression in specific subgroups. This review discusses the currently available data from human surveys and experimental models in search of a putative role of VitC deficiency in the development of NAFLD and NASH.

Restricting night-time eating reduces daily energy intake in healthy young men: a short-term cross-over study

Few experimental data are available to support the notion that reducing night-time eating changes total daily energy intake (EI) or body weight in healthy adults. The present study primarily examined the short-term effect of night eating restriction (NER) on daily EI in healthy young men. It secondarily examined body weight and moods associated with NER. Using a cross-over design, twenty-nine men (20·9 (sd 2·5) years; 24·4 (sd 2·5) kg/m²) initiated a 2-week NER intervention (elimination of EI from 19.00 to 06.00 hours) and a 2-week control condition, counterbalanced and separated by a 1-week washout period. EI and macronutrient intake were assessed using computerised, multiple-pass 24 h food recalls, body weight via a digital scale and mood using the Profile of Mood States survey. Of the twenty-nine participants, twenty-seven (93 %) completed all aspects of the study. During the NER condition, the participants consumed less total energy per d than during the control condition (10 125 v. 11 146 kJ/d; F= 6·41; P= 0·018). During the NER condition, no energy was reported consumed between 19.00 and 06.00 hours; however, during the control condition, the energy intake of participants was 2920 (sd 1347) kJ/d between 19.00 and 06.00 hours. There was a significant difference in weight change between the NER (-0·4 (sd 1·1) kg) and control (+0·6 (sd 0·9) kg) conditions (F= 22·68; P< 0·001). Differences in total mood score or mood subscales between the NER and control conditions were not apparent (P>0·05). These findings provide support for NER decreasing short-term EI in healthy young men.

Long-term dietary intake and nutritional deficiencies following sleeve gastrectomy or Roux-En-Y gastric bypass in a mediterranean population

BACKGROUND

Data on long-term dietary changes and nutritional deficiencies after sleeve gastrectomy (SG) in grade 3 obese patients are scarce.

OBJECTIVE

To prospectively compare dietary changes and nutritional deficiencies in grade 3 obese patients 5 years after SG and Roux-en-y gastric bypass (GBP).

PARTICIPANTS/SETTING

Three hundred and fifty-five patients who had SG (n=61) or GBP (n=294) (May 2001-December 2006) at a Spanish university hospital.

DESIGN

Longitudinal, prospective, observational study. PRIMARY OUTCOMES/STATISTICAL ANALYSES: Changes in energy, macronutrient, and micronutrient intake, and weight loss were analyzed using mixed models for repeated measurements.

RESULTS

At the 5-year follow-up visit, the percentage of excess weight loss (P=0.420) and daily energy intake (P=0.826), as well as the proportion of energy from carbohydrates (P=0.303), protein (P=0.600), and fat (P=0.541) did not differ between surgical groups. Energy intake (P=0.004), baseline weight (P<0.001), and time period (P<0.001), but not the proportion of different macronutrients or the type of surgery, independently predicted the percentage excess weight loss over time. After SG or GBP, the mean daily dietary intake of calcium, magnesium, phosphorus, and iron was less than the current recommendations. Despite universal supplementation, the prevalence of nutritional deficiencies was comparable after SG or GBP, with 25-hydroxyvitamin D being the most commonly observed deficiency (SG, 93.3% to 100%; GBP, 90.9% to 85.7%, P=not significant). In an adjusted multivariate regression model, energy intake and lipid intake independently predicted plasma 25(OH)-vitamin D levels.

CONCLUSIONS

Data show that SG and GBP are associated with similar long-term weight loss with no differences in terms of dietary intake. Furthermore, data demonstrate that both types of surgeries carry comparable nutritional consequences.

Effort-Related Calf Pain in the Obese and Long-Term Changes after Surgical Obesity Treatment**

OBJECTIVE

To compare the prevalence of effort-related calf pain in an obese and a general population and to analyze the incidence of and recovery from such pain after surgical and conventional obesity treatment.

RESEARCH METHODS AND PROCEDURES

A random sample of 1135 subjects from a general population was compared with 6328 obese subjects in the Swedish Obese Subjects study. Obese subjects were followed longitudinally, and information about calf pain was obtained from surgically and conventionally treated patients for up to 6 years.

RESULTS

In both sexes, self-reported calf pain was more common in the obese than in the general population [odds ratios (ORs) 5.0 and 4.0 in men and women, respectively, p<0.001]. Obese patients undergoing surgery had a lower 6-year incidence of calf pain compared with the conventionally treated control group (ORs 0.39 and 0.61, p<0.05). Among subjects reporting symptoms at baseline, the 6-year recovery rate was higher in the surgical group compared with the control group (ORs 15.3 and 5.9, p<0.001).

DISCUSSION

Obese subjects have markedly more problems with effort-related calf pain than the general population. Surgical obesity treatment reduces the long-term risk of developing claudication symptoms and increases the likelihood of recovering from such symptoms.

Fiber, protein, and lupin-enriched foods: role for improving cardiovascular health

Cardiovascular diseases (CVD) are the leading cause of death globally (World Health Organisation, 2011). Many of the risk factors for CVD are modifiable, including overweight and obesity. Numerous strategies have been proposed to fight CVD, with a special focus being placed on dietary interventions for weight management. The literature suggests that two nutrients, fiber and protein, may play significant roles in weight control and hence cardiovascular health. Increasing both protein and fiber in the diet can be difficult because popular low-carbohydrate and high-protein diets tend to have considerably low-fiber intakes (Slavin, 2005). One approach to obtain both is to develop functional foods using unique ingredients. Lupin flour is a novel food ingredient derived from the endosperm of lupin. It contains 40-45% protein, 25-30% fiber, and negligible sugar and starch (Petterson and Crosbie, 1990). Research conducted to date reveals that lupin-enriched foods, which are naturally high in protein and fiber, may have a significant effect on CVD risk factors. This review explores whether there is a role for fiber-, protein-, and lupin-enriched foods in improving cardiovascular health.

Alcohol and macronutrient intake patterns are related to general and central adiposity

BACKGROUND/OBJECTIVES

Alcohol and dietary fat have high energy densities and may therefore be related to body weight and fat deposition. We studied associations between alcohol and macronutrient intake patterns and general and central adiposity.

SUBJECTS/METHODS

A population-based cross-sectional study of 524 men and 611 women. The participants answered a dietary questionnaire describing habitual food consumption including intake of alcoholic beverages. Macronutrient intake was analysed in relation to anthropometric measures and dual energy X-ray absorptiometry determined body fat.

RESULTS

In women, total alcohol intake was negatively associated with body fat percentage (β:-0.67, P<0.01). In men, total alcohol intake was positively associated with sagittal abdominal diameter (SAD) (β: 0.28, P=0.01). In addition, positive associations were found between intake of alcohol from spirits and body fat percentage (β: 1.17, P<0.05), SAD (β: 0.52, P<0.05) and waist circumference (β: 2.29, P=0.01). In men, protein intake was positively associated with body mass index (BMI) (β: 0.03, P=0.001), body fat percentage (β: 0.04, P<0.05), SAD (β: 0.02, P=0.01) and waist circumference (β: 0.09, P<0.01). Also in men only, negative associations between fat intake and BMI (β: -0.03, P<0.01), SAD (β: -0.02, P<0.05) and waist circumference (β: -0.05, P<0.05) were found.

CONCLUSIONS

Alcohol intake was inversely associated to relative body fat in women whereas spirits consumption was positively related to central and general obesity in men. Macronutrient intakes, particularly protein and fat, were differently associated with obesity indicators in men versus women. This may reflect a differential effect by gender, or differential obesity related reporting errors in men and women.

New look at nutritional care for obese patient candidates for bariatric surgery

BACKGROUND

The combination of preoperative deficiencies and the restrictions and malabsorption possibly induced by bariatric surgery could lead patients to experience important nutritional deficits during the late postoperative period. Our objective was to characterize the eating, anthropometric, and biochemical profiles of obese candidates for bariatric surgery at a bariatric surgery center of a university hospital.

METHODS

A retrospective study with the analysis of medical records of candidates for bariatric surgery from 2007 to 2008 was performed. A total of 80 adult patients, aged 45 ± 11 years, were included in the present study.

RESULTS

The mean patient weight was 145 ± 24 kg, and the mean body mass index was 54 ± 8 kg/m(2). Of the 80 patients, 78% had ≥1 co-morbidities related to obesity. The reported daily energy intake before surgery was 1981 ± 882 kcal, with 48% ± 11% consisting of carbohydrate, 29% ± 8% of lipids, and 23% ± 8% of protein. The mean number of daily meals was 4 ± 1. Patients with a greater body mass index ingested a smaller amount of calories per kilogram of current weight. The occurrence of hyperglycemia, hyperuricemia, and dyslipidemia and of nutritional deficiencies, among them magnesium (19%), vitamin A (15%), vitamin C (16%), iron (9%), β-carotene (3%), and vitamin B12 (3%), was high.

CONCLUSION

The high occurrence of micronutrient deficiency detected by biochemical analysis in morbidly obese candidates for bariatric surgery, representing a disabsorptive process, might involve a poorer prognosis during the late postoperative period. A preoperative evaluation of the nutritional parameters and the food intake pattern is recommended for these patients, together with the necessary interventions.

Nutritional pyramid for post-gastric bypass patients

BACKGROUND

Life-long nutrition education and diet evaluation are key to the long-term success of surgical treatment of obesity. Diet guidelines provided for bariatric surgery patients generally focus on a progression through dietary stages, from the immediate post-surgical period to 6 months after surgery. However, long-term dietary guidelines for those surgically treated for obesity are not readily available. Therefore, there is a need for dietary recommendations for meal planning and nutritional supplementation for bariatric surgery patients beyond the short-term, post-operative period. The purpose of this paper is to construct an educational tool to provide long-term nutritional and behavioral advice for the post-bariatric patient.

METHODS

The manuscript summarizes the current knowledge on dietary strategies and behaviors associated with beneficial nutritional outcomes in the long term of post-bariatric surgery patients.

RESULTS

Dietary and nutritional recommendations are presented in the form of a "bariatric food pyramid" designed to be easily disseminated to patients.

CONCLUSIONS

The development of educational tools that are easy to understand and follow is essential for effective patient management during the surgery follow-up period. The pyramid can be used as a tool to help both therapists and patients to understand nutrition recommendations and thus promote a healthy long-term post-op dietary pattern based on high-quality protein, balanced with nutrient-dense complex carbohydrates and healthy sources of essential fatty acids.

Chronic dieting among extremely obese bariatric surgery candidates

BACKGROUND

Extremely obese bariatric surgery candidates report numerous episodes of both successful and unsuccessful dieting attempts, but little is known about the clinical significance of frequent dieting attempts in this patient group.

METHODS

The current study examined psychological and weight-related correlates of self-reported dieting frequency in 219 bariatric surgery candidates (29 men and 190 women). Prior to surgery, patients completed a battery of established self-report assessments. Patients were dichotomized into chronic dieters (n=109) and intermittent dieters (n=110) based on a median split of self-reported percent time spent dieting during adulthood. The two dieting groups were compared on demographics, eating and weight history, eating disorder psychopathology, and global functioning.

RESULTS

Chronic dieters had significantly lower pre-operative body mass indexes (BMIs), lower highest-ever BMIs, more episodes of weight cycling, and earlier ages of onset for overweight and dieting than intermittent dieters. After controlling for differences in BMI, chronic dieters were found to have statistically but not clinically significant elevations in eating concerns, dietary restraint, and body dissatisfaction than infrequent dieters. The two groups, however, did not differ significantly on depressive symptoms, self-esteem, or health-related quality of life; nor did they differ in binge-eating status.

CONCLUSIONS

Chronic dieting is commonly reported among extremely obese bariatric candidates and is not associated with poorer psychological functioning or binge eating and may be beneficial in attenuating even greater weight gain. Our findings provide preliminary data to suggest that requiring additional presurgical weight loss attempts may not be warranted for the vast majority of extremely obese bariatric candidates.

A Review of the Role of Soluble Fiber in Health with Specific Reference to Wheat Dextrin

Dietary fiber is widely recognized to have a beneficial role in overall health, but only at adequate levels (25 − 38 g/day for healthy adults). Wheat dextrin in particular is a soluble fiber that can easily be added to the diet and is widely used in the food industry. There is some debate about whether increased intake of soluble fibers leads to health benefits. This paper reviews the evidence regarding the physiological effects and potential health benefits of the addition of soluble dietary fibers, with specific reference to wheat dextrin, based on a search of PubMed. The evidence suggests that soluble fibers help to regulate the digestive system, may increase micronutrient absorption, stabilize blood glucose and lower serum lipids, may prevent several gastrointestinal disorders, and have an accepted role in the prevention of cardiovascular disease. It is concluded that supplementation with soluble fibers (e.g. wheat dextrin) may be useful in individuals at risk of a lower than recommended dietary fiber intake.

Hunger control and regular physical activity facilitate weight loss after laparoscopic adjustable gastric banding

BACKGROUND

Bariatric surgery facilitates substantial and durable weight loss; however, outcomes vary. In addition to physiological and technical factors, weight loss efficacy is dependent on modification of behavior to maintain a long-term change in energy balance. This study aimed to assess the extent and nature of change in energy intake and physical activity and identify factors associated with percentage weight loss (%WL) 12 months after laparoscopic adjustable gastric banding (LAGB).

METHODS

129 bariatric surgery candidates (26 men/103 women, mean age 45.2 +/- 11.5, mean body mass index [BMI] 44.3 +/- 6.8, range 31.9 to 66.7) completed the study. Data were collected at baseline and 12 months. Validated questionnaires included the Cancer Council Victoria Food Frequency Questionnaire, Three Factor Eating Questionnaire, Short Form-36, Baecke Physical Activity Questionnaire, and Beck Depression Inventory. Symptoms of "non-hungry eating," "emotional eating," and "grazing" were assessed.

RESULTS

Mean %WL was 20.8 +/- 8.5%, and excess weight loss was 50.0 +/- 20.7 (p < 0.001). Mean total energy intake reduced from 9,991 +/- 3,986 kj to 4,077 +/- 1,493 kj (p < 0.001). Average leisure time and sport-related physical activity scores increased (both p < 0.001). Regression analysis identified baseline BMI (beta = 0.241; p = 0.002), subjective hunger (beta = -0.275; p = 0.001), physical function (beta = 0.309; p < 0.001), and leisure time physical activity (beta = 0.213; p = 0.010) as independent predictors of %WL, total R (2) 0.34%. "Non-hungry eating" and symptoms of depression were also related to poorer %WL.

CONCLUSION

LAGB affects marked behavior change and facilitates substantial weight loss in the first 12 months. However, variations in adopted behaviors can affect energy balance and weight loss success. Achievement and maintenance of favorable behaviors should be an important consideration during on-going postsurgical review and counseling. Management should include adequate band adjustment to control physical hunger, optimization of physical function and activity, and reinforcement of strategies to reduce energy intake.

Vitamin status in morbidly obese patients: a cross-sectional study

BACKGROUND

Morbid obesity is associated with low circulating concentrations of 25-hydroxyvitamin D. Few data on the concentrations of other vitamins in morbidly obese patients are available.

OBJECTIVE

The objective was to compare serum and blood vitamin concentrations in morbidly obese patients with those in healthy subjects.

DESIGN

In 2 public hospital departments (southeast Norway), we prospectively examined 110 consecutive patients (76 women) and 58 healthy controls (30 women) not taking multivitamin supplements. Patients and controls did not differ significantly in age or ethnicity. The mean (+/-SD) body mass index (in kg/m(2)) was 45 +/- 7 in the patients and was 24 +/- 3 in the controls. Patients with vitamin concentrations lower than 2 SD below the sex-specific mean in controls were considered to have inadequate vitamin status.

RESULTS

The morbidly obese women and men had significantly lower concentrations of vitamin B-6, vitamin C, 25-hydroxyvitamin D, and lipid-standardized vitamin E than did the healthy controls (P < 0.01 for each). The status of these vitamins was inadequate in a substantial proportion of the patients (11-38%). The status of vitamins A, B-1, B-2, and B-12 and of folic acid was adequate in most of the patients (95-100%). A moderately elevated C-reactive protein concentration was associated with lower vitamin A, B-6, and C concentrations. In a multiple regression analysis, concentrations of alkaline phosphatase (inverse relation) and vitamin C were the strongest determinants of serum vitamin B-6 concentrations.

CONCLUSIONS

Low concentrations of vitamin B-6, vitamin C, 25-hydroxyvitamin D, and vitamin E adjusted for lipids are prevalent in morbidly obese Norwegian patients seeking weight-loss treatment.

Effect of a post-dinner snack and partial meal replacement program on weight loss

The objectives of this study were to examine whether providing a structured post-dinner snack would enhance weight loss among obese night snackers participating in a novel partial meal replacement (PMR) program and to examine the efficacy of that program. Sixty adults (age 18-65 years; body mass index >or=30 kg/m2), 29 randomized to the 'post-dinner snack' and 32 to the 'no snack' groups, completed the 8-week program. Both groups showed improvements in weight (-4.23 kg, P < 0.0001), body mass index (-1.48 kg/m2, P < 0.0001), body fat (-1.36%, P < 00.0001), waist circumference (-6.40 cm, P < 0.0001), and high-density lipoprotein-cholesterol (-2.72 mmol/l, P < 0.01), and on a night snacking question (-1.31, P < 0.0001). The 'post-dinner snack' group did not show significantly greater weight loss outcomes than the 'no snack' group either before or after taking compliance into consideration. Providing a structured post-dinner snack along with a PMR program did not enhance weight loss treatment outcomes; however, the PMR program produced beneficial weight loss changes for obese night snackers.

Biomedical issues of dietary fiber beta-glucan

Beta-glucan is a polysaccharide in the form of fiber and the main element of fiber in grains such as barley, oats, yeast and mushrooms. Many studies have examined the efficacy of beta-glucan in terms of the lipid lowering effects, blood sugar reduction, weight reduction, immune modulator, and anticarcinogenic effect. However, there is no comprehensive review article on the biomedical issues regarding beta-glucan. The authors searched for systematic reviews and clinical experiments for each relevant topic and reviewed the biomedical effects of beta-glucan, for the purpose of developing research strategies for the future.

The effects of fructo-oligosaccharides in combination with soy protein on bone in osteopenic ovariectomized rats

OBJECTIVE

The intestinal microflora is important in rendering soy isoflavones bioavailable by facilitating their conversion to equol. Hence, substances that can modulate the intestinal microflora could affect the bioavailability of isoflavones. In this study, we examined the effects of fructo-oligosaccharides (FOS), a prebiotic, on enhancing the effects of soy isoflavones on bone in ovariectomized osteopenic female rats.

DESIGN

Sixty-three 9-month-old female Sprague-Dawley rats were either sham-operated (Sham; one group) or ovariectomized (Ovx; four groups) and were fed a control diet for 3 months to induce bone loss. After bone loss was confirmed via dual-energy x-ray absorptiometry, rats were placed on dietary treatment for 4 months. The Sham and one Ovx group received a control diet, and the remaining Ovx groups received either a soy protein-based diet (Soy), a FOS-supplemented diet (FOS), or a soy protein-based and FOS-supplemented diet (Soy+FOS). Before the termination of the study, whole-body bone mineral density (BMD) and bone mineral content (BMC) were assessed under anesthesia. Immediately after euthanasia, bone specimens were collected for the assessments of BMD, BMC, and biomechanical and microarchitectural properties.

RESULTS

Whole-body BMD values were significantly higher in FOS and Soy+FOS groups compared with Ovx controls. The tibial BMC increased by 10%, 6%, and 4% in Soy, FOS, and Soy+FOS groups, respectively, compared to the Ovx control group. FOS and FOS+Soy treatments had the most pronounced effects in enhancing lumbar BMC and BMD. The FOS+Soy combination effectively improved tibial microarchitectural properties by enhancing trabecular number and lowering trabecular separation compared with Ovx controls. The effects of dietary treatments on lumbar microarchitectural properties were minimal and biomechanical properties of the femur were not affected by any of the dietary treatments.

CONCLUSION

Our findings suggest that, although incorporation of either soy or FOS in the diet of Ovx rats can improve BMD of the whole body, tibiae, and lumbar vertebrae, their combination had no any additive effects. However, in terms of microarchitecture, the combination of soy and FOS had a greater effect in reversing the loss of certain microarchitectural parameters such as tibial trabecular number, separation, and thickness.

Health Hunters–an intervention to prevent overweight and obesity in young high-risk women

AIM

The aim of the study was to develop and implement an obesity and weight gain prevention program targeted to a high-risk group.

METHOD

Women, 18-28 years old, with at least one severely obese parent, were randomized to the intervention or control group of the 'Health Hunters' program. During 1 year of follow-up, the intervention group received an individualized behavioral program focusing on food choice, physical activity and other lifestyle factors. Anthropometric measures, DXA-based body composition and fitness levels were measured at baseline and after 1 year. Self-reported changes in obesity-related behaviors were also assessed.

RESULTS

Baseline examinations were conducted in 40 women, of whom 30 completed follow-up examinations 1 year later. Pregnancy was the most common reason for failure to complete the study. Compared to the control group (which gained weight), the intervention group displayed significant improvements in body weight, body mass index, waist circumference, waist-to-hip ratio and self-reported physical activity. Changes in body composition, although not significant, suggested that the intervention tended to be associated with improved body composition. Further analysis of changes in diet and fitness in relation to concurrent weight changes indicated that the strongest 'protective' associations were for energy percent protein, fiber density and fitness.

CONCLUSION

Pilot data from the Health Hunters obesity prevention program indicates that it is effective in high-risk young women with familial predisposition for obesity.

Dietary fiber and body weight

OBJECTIVE

This review provides an update of recent studies of dietary fiber and weight and includes a discussion of potential mechanisms of how dietary fiber can aid weight loss and weight maintenance.

METHODS

Human studies published on dietary fiber and body weight were reviewed and summarized. Dietary fiber content of popular low-carbohydrate diets were calculated and are presented.

RESULTS

Epidemiologic support that dietary fiber intake prevents obesity is strong. Fiber intake is inversely associated with body weight and body fat. In addition, fiber intake is inversely associated with body mass index at all levels of fat intake after adjusting for confounding factors. Results from intervention studies are more mixed, although the addition of dietary fiber generally decreases food intake and, hence, body weight. Many mechanisms have been suggested for how dietary fiber aids in weight management, including promoting satiation, decreasing absorption of macronutrients, and altering secretion of gut hormones.

CONCLUSION

The average fiber intake of adults in the United States is less than half recommended levels and is lower still among those who follow currently popular low-carbohydrate diets, such as Atkins and South Beach. Increasing consumption of dietary fiber with fruits, vegetables, whole grains, and legumes across the life cycle is a critical step in stemming the epidemic of obesity found in developed countries. The addition of functional fiber to weight-loss diets should also be considered as a tool to improve success.

Validity of reported energy expenditure and reported intake of energy, protein, sodium and potassium in rheumatoid arthritis patients in a dietary intervention study

OBJECTIVES

The aim of the study was to validate a diet history interview (DHI) method and a 3-day activity registration (AR) with biological markers.

SUBJECTS AND STUDY DESIGN

The reported dietary intake of 33 rheumatoid arthritis patients (17 patients on a Mediterranean-type diet and 16 patients on a control diet) participating in a dietary intervention study was assessed using the DHI method. The total energy expenditure (TEE), estimated by a 3-day AR, was used to validate the energy intake (EI). For nine subjects the activity registration was also validated by means of the doubly labelled water (DLW) method. The excretion of nitrogen, sodium and potassium in 24-h urine samples was used to validate the intake of protein, sodium and potassium.

RESULTS

There was no significant difference between the EI and the TEE estimated by the activity registration or between the intake of protein, sodium and potassium and their respective biological markers. However, in general, the AR underestimated the TEE compared to the DLW method. No significant differences were found between the subjects in the Mediterranean diet group and the control diet group regarding the relationship between the reported intakes and the biological markers.

CONCLUSION

The DHI could capture the dietary intake fairly well, and the dietary assessment was not biased by the dietary intervention. The AR showed a bias towards underestimation when compared to the DLW method. This illustrates the importance of valid biological markers.

Sensory-specific satiety in obese and normal-weight women

BACKGROUND

Sensory-specific satiety has been found to play an important role in food choice and meal termination, and it might be a factor contributing to obesity.

OBJECTIVE

We hypothesized that obese and normal-weight people have different sensitivities to sensory-specific satiety for high-fat foods.

DESIGN

Sensory-specific satiety was measured in 21 obese [x body mass index (BMI; in kg/m(2)): 33.1] and 23 normal-weight (BMI: 22.8) women who were matched for restrained eating behavior, physical activity, age, and smoking behavior. Food intake, appetite ratings, and liking scores before and after an ad libitum lunch were measured. Products differed in fat content and taste (ie, low-fat sweet, low-fat savory, high-fat sweet, and high-fat savory), and the subjects tested all 4 products. In the first study, sandwiches were tested; in the second study, snacks were tested.

RESULTS

Sensory-specific satiety for all products was observed in both subject groups. No significant differences were observed between the obese and normal-weight subjects in either sensory-specific satiety or food intake for any of the products or product categories tested. Taste (sweet or savory) had a significantly (P < 0.05) stronger effect on sensory-specific satiety than did fat content. Appetite ratings strongly decreased after lunch, and appetite for a meal or snack after lunch was significantly higher in obese than in normal-weight subjects, whereas scores before lunch did not differ significantly.

CONCLUSIONS

Obese and normal-weight people do not differ in their sensitivity to sensory-specific satiety, and factors other than fat content have the greatest effect on sensory-specific satiety.

Severe obesity and personality: a comparative controlled study of personality traits

OBJECTIVE

The primary purpose was to assess personality trait differences between the severely obese seeking treatment and a mainly non-obese reference group. We also investigated gender differences and differences between obese patients and obese not seeking treatment.

METHOD

Personality traits were assessed using 7 of 15 scales from the Karolinska Scales of Personality (KSP): Somatic Anxiety, Muscular Tension, Psychastenia, Psychic Anxiety, Monotony Avoidance, Impulsiveness, and Irritability. Patients from the Swedish Obese Subjects (SOS) intervention study (n=3270, ages 37-57, 71% women) and the SOS reference study (n=1135, 54% women) completed the survey. Data presented in this study were gathered prior to treatment. Significance tests and effects sizes were calculated.

RESULTS

Although statistically significant differences were found between obese patients and reference subjects on nearly all personality traits, effect sizes were at most moderate. Of the three scales with moderate effects sizes, differences on Somatic Anxiety and Psychastenia could be traced to items tapping condition-specific symptoms, e.g., problems with sweating and breathing as indicators of Somatic Anxiety. Moderate differences on the Impulsiveness scale (men alone) could not be explained by item composition. Further, the obese patients differed from obese in the reference group, and both obese and reference women reported significantly higher levels on Somatic Anxiety, Muscular Tension and Psychic Anxiety compared to men (effect size: small).

CONCLUSIONS

Our results provided no evidence of a general obese personality profile, instead considerable heterogeneity in personality traits was observed across our obese samples (treatment seekers vs non-seekers, men vs women) and generally only small differences were noted compared to a reference study population. Further research is needed to investigate if the somewhat elevated levels of Impulsiveness, particularly among male obese patients, is affected by weight loss. When assessing personality traits in diseased groups consideration should be given to possible confounding from, e.g., somatic symptoms.

Musculoskeletal pain in the obese: a comparison with a general population and long-term changes after conventional and surgical obesity treatment

Obesity is associated with musculoskeletal pain and osteoarthritis. This study compares the prevalence of work-restricting musculoskeletal pain in an obese and a general population and investigates changes in the incidence of and recovery from musculoskeletal pain after bariatric surgery or conventional obesity treatment. A random sample of 1135 subjects from a general population was compared with 6328 obese subjects in the Swedish obese subjects (SOS) study. For the obese subjects, information about musculoskeletal pain was also collected 2 and 6 years after obesity surgery or the start of non-surgical treatment. In both sexes, self-reported work-restricting pain in the neck and back area and in the hip, knee and ankle joints was more common in the obese subjects than in the general population (odds ratios (ORs) ranging from 1.7 to 9.9, P<0.001). Operated obese women had a lower incidence of work-restricting pain in the knee and ankle joints compared with the conventionally treated control group over 2 and 6 years (ORs 0.51-0.71). Among subjects reporting symptoms at baseline, the recovery rate for pain in the knee and ankle joints in men and pain in the neck and back and in the hip, knee and ankle joints in women improved in the surgical group compared with the control group after 2 years (ORs 1.4-4.8). Obese subjects have more problems with work-restricting musculoskeletal pain than the general population. Surgical obesity treatment reduces the long-term risk of developing work-restricting musculoskeletal pain and increases the likelihood of recovering from such pain.

Antioxidant intake, plasma antioxidants and oxidative stress in a randomized, controlled, parallel, Mediterranean dietary intervention study on patients with rheumatoid arthritis

BACKGROUND

Previously we have reported that patients with rheumatoid arthritis (RA) obtained a significant reduction in disease activity by adopting a Mediterranean-type diet. The present study was carried out to investigate the antioxidant intake, the plasma levels of antioxidants and a marker of oxidative stress (malondialdehyde) during the study presented earlier.

METHODS

RA patients randomized to either a Mediterranean type diet (MD group; n = 26) or a control diet (CD group; n = 25) were compared during a three month dietary intervention study. Their antioxidant intake was assessed by means of diet history interviews and their intake of antioxidant-rich foods by a self-administered questionnaire. The plasma levels of retinol, antioxidants (alpha- and gamma-tocopherol, beta-carotene, lycopene, vitamin C and uric acid) and urinary malondialdehyde (MDA), a marker for oxidative stress, were determined using high performance liquid chromatography. The Student's t-test for independent samples and paired samples were used to test differences between and within groups. For variables with skewed distributions Mann-Whitney U-test and Wilcoxon signed ranks test were performed. To evaluate associations between dietary intake of antioxidants, as well as between disease activity, MDA and antioxidants we used Pearson's product moment correlation or Spearman's rank correlation.

RESULTS

The MD group had significantly higher intake frequencies of antioxidant-rich foods, and also higher intakes of vitamin C (p = 0.014), vitamin E (p = 0.007) and selenium (p = 0.004), and a lower intake of retinol (p = 0.049), compared to the CD group. However, the difference between the groups regarding vitamin C intake was not significant when under- and over-reporters were excluded (p = 0.066). There were no changes in urine MDA or in the plasma levels of antioxidants (after p-lipid adjustments of the tocopherol results), from baseline to the end of the study. The levels of retinol, vitamin C and uric acid were negatively correlated to disease activity variables. No correlation was found between antioxidant intake and the plasma levels of antioxidants.

CONCLUSIONS

Despite an increase in reported consumption of antioxidant-rich foods during the Mediterranean diet intervention, the levels of plasma antioxidants and urine MDA did not change. However, the plasma levels of vitamin C, retinol and uric acid were inversely correlated to variables related to RA disease activity.

Laparoscopic adjustable gastric banding for morbid obesity

Morbid obesity, with its accompanying human and monetary costs, is a serious and growing health problem worldwide. Surgical treatments are recognized as being effective, but until recently, the available surgical options entailed invasive techniques that permanently altered the gastrointestinal tract. In June 2001, the US Food and Drug Administration approved an adjustable gastric banding system that can be implanted laparoscopically for the treatment of morbid obesity. This article discusses laparoscopic adjustable gastric banding, including patient selection and evaluation, perioperative care, and the importance of a team approach to patient management and follow-up care.

Psychosocial functioning in the obese before and after weight reduction: construct validity and responsiveness of the Obesity-related Problems scale

OBJECTIVE

The Obesity-related Problems scale (OP) is a self-assessment module developed to measure the impacts of obesity on psychosocial functioning. Our principal aim was to evaluate the construct validity and responsiveness of the OP scale. Our specific aims were to test: (1). the psychometric performance of OP; (2). if OP scores differed by gender and weight category; (3). if OP scores are inversely related to mental well-being; (4). if weight reduction in the obese is accompanied by improvements in psychosocial functioning (OP).

SUBJECTS

Four samples were used: 6863 subjects in the SOS cross-sectional study; 2128 in the SOS intervention study; 1017 nonobese in the SOS reference study; and 3305 obese subjects in the XENDOS study.

MEASUREMENTS

Psychosocial functioning was measured by OP. Overall mood was measured by MACL. Anxiety and depression symptoms were measured by HAD.

RESULTS

Psychometric testing provided strong support for the construct validity of OP. Factor analysis confirmed the homogeneity of the construct and multitrait/multi-item scaling analysis demonstrated strong item-convergent/discriminant validity. Reliability coefficients were high and floor and ceiling effects were small. Psychometric results were cross-validated and replicated in subgroups by gender, age and body mass index (BMI). As expected, large differences in OP were observed between obese and nonobese (P<0.0001). Obese women reported more weight-related psychosocial problems than obese men (P<0.0001). Psychosocial disturbances (OP) among the obese were significantly related to poor mood (MACL; P<0.0001) and anxiety and depression symptoms (HAD; P<0.0001). Change in OP over time was strongly correlated with weight loss (P<0.0001). A distinct dose-response effect between weight reduction and improvements in OP was demonstrated. Scores on psychosocial functioning (OP) and mental well-being (MACL, HAD) in nonobese (BMI<30) surgical patients at 4-y follow-up were equal to scores observed in nonobese reference subjects (NS).

CONCLUSION

OP is a psychometrically valid obesity-specific measure suitable for evaluating HRQL effects of obesity interventions. The negative impact of obesity on psychosocial functioning is considerable and disturbances are connected with poor mental well-being. Weight reduction in the obese is followed by improvements in both psychosocial functioning and mental well-being.

Gallstones, gallbladder disease, and pancreatitis: cross-sectional and 2-year data from the Swedish Obese Subjects (SOS) and SOS reference studies

OBJECTIVES

Obesity and weight loss have been associated with gallstone disease. There is also an association between gallstones and pancreatitis. We investigated cross-sectional relationships between body mass index (BMI), body fat distribution, and prevalence of gallstones, gallbladder disease, and pancreatitis in men and women. Furthermore, 2-yr incidences of these disorders were examined in relation to changes in weight and body fat distribution after surgical and conventional obesity treatment.

METHODS

Self-administered questionnaires were used to assess biliary and pancreatic disease. In the cross-sectional investigation, 6328 obese patients and 1135 randomly selected reference individuals were used. Longitudinally, 1422 operated and 1260 conventionally treated patients were examined.

RESULTS

Obese subjects had significantly higher prevalence of cholelithiasis, cholecystitis, cholecystectomies, and pancreatitis as compared with the reference population. In women, BMI and waist-hip ratio (WHR) were independently related to an increased biliary disease prevalence. In men, only BMI was independently associated with biliary disease. Compared with conventional treatment, obesity surgery significantly increased the incidence of cholelithiasis, cholecystitis, and cholecystectomies in men. There was no incidence difference among women. In both genders, weight loss, but not change in WHR, was related to an increased incidence of biliary disease.

CONCLUSIONS

This study showed an increased prevalence of gallstones, gallbladder disease, and pancreatitis in the obese. Biliary disease was related to BMI and WHR in women, but only to BMI in men. Weight loss, but not change in WHR, increased the risk of biliary disease in both genders.

Interaction of body mass index and attempt to lose weight in a national sample of US adults: association with reported food and nutrient intake, and biomarkers

OBJECTIVE

This study examined the interaction between body mass index (BMI) and attempting to lose weight for reporting of: (1) macro- and micronutrient intake; (2) intake of low-nutrient-density foods; and (3) serum biomarkers of dietary exposure and cardiovascular disease risk.

METHODS

Dietary, anthropometric and biochemical data were from the third National Health and Nutrition Examination Survey (1988-1994), n=13 095. Multiple regression methods were used to examine the independent associations of BMI, trying to lose weight, or the interaction of BMI-trying to lose weight with reported intakes of energy, nutrients, percentage energy from low-nutrient-density foods (sweeteners, baked and dairy desserts, visible fats and salty snacks), and serum concentrations of vitamins, carotenoids and lipids.

RESULTS

BMI was an independent positive predictor (P<0.05) of percentage of energy from fat, saturated fat, but a negative predictor of the ratio of reported energy intake to estimated expenditure for basal needs (EI/BEE), percentage of energy from carbohydrate and alcohol (men only), and serum concentrations of folate, vitamin C, vitamin E and most carotenoids in both men and women. Trying to lose weight was a negative predictor (P<0.05) of EI/BEE, intake of energy, and energy density, but not micronutrient intake. Higher mean serum ascorbate, vitamin E, lutein/zeaxanthin, and other carotenoids (men only) concentrations were associated with trying to lose weight (P<0.05) in both men and women. Few adverse BMI-trying to lose weight interaction effects were noted.

CONCLUSIONS

There was little evidence of increased nutritional risk in those reportedly trying to lose weight irrespective of weight status.

Number of teeth, body mass index, and dental anxiety in middle-aged Swedish women

Risk factors for poor dental health include obesity, low socio-economic status, poor dietary habits, and dental anxiety. The aim of this study was to explore the complex relation between body mass index (BMI) and number of teeth in middle-aged women taking education, dietary intake patterns, dental care utilization, and dental anxiety into account. Three groups of women (37-60 years): reference women (group I, BMI 23.8 +/- 3.1 kg/m2), obese women (group II, BMI 35.0 +/- 2.6 kg/m2), and severely obese women (group III, BMI 41.0 +/- 3.4 kg/m2) were included. Questionnaires were used to assess education, smoking, number of teeth, dental care utilization, dental anxiety, dietary intake, and meal patterns. Age, education, and smoking habits did not differ significantly between groups. However, there were significant global differences in number of teeth (27.2 +/- 3.4, 23.0 +/- 9.2, 24.7 +/- 5.9) and reported daily energy intake (9756 +/- 3363 kJ, 10344 +/- 3850 kJ, 11970 +/- 3786 kJ in groups I, II, and m, respectively). In a multiple regression model, a lower number of teeth was independently associated with higher age, higher BMI, lower education, irregular dental care, high dental anxiety, higher energy intake, and lower iron intake. These variables explained 25% of the variation in number of teeth. In conclusion, BMI is an independent predictor of number of teeth in middle-aged women when socio-economic, dietary, and psychological factors are taken into account.

Meal patterns and obesity in Swedish women-a simple instrument describing usual meal types, frequency and temporal distribution

OBJECTIVE

To characterize meal patterns in relation to obesity in Swedish women using a simple instrument describing meal frequency, meal types and temporal distribution.

DESIGN

Cross-sectional parallel group design.

SUBJECTS

Eighty-three obese women from the Swedish Obese Subjects (SOS) study were compared with 94 reference women, randomly recruited from the population.

METHOD

A new, simplified and self-instructing questionnaire was used to assess meal patterns. Usual meal pattern was reported as time and meal type for each intake episode during a typical day.

RESULTS

The obese women consumed 6.1 meals/day compared with 5.2 meals/day among the reference women (P<0.0001). All types of meals except 'drink meals' were significantly more frequently consumed in the obese group. The obese women also displayed a different meal pattern across the day, consuming a larger number of meals later in the day. As a result a larger fraction of each obese woman's total meals were consumed in the afternoon and in the evening/night. There was no difference in the number of obese vs reference women consuming breakfast. Snack meals were positively associated with total energy intake in both groups.

CONCLUSIONS

A new simplified method assessing meal pattern revealed that the number of reported intake occasions across a usual day was higher in obese women compared with controls and the timing was shifted to later in the day. These findings should be considered in the treatment of obesity.

Factors influencing energy intake and body weight loss after gastric bypass

OBJECTIVE

The gastric bypass-induced quantitative and qualitative modifications of energy intake (En In, kcal/day) and their impact on body weight (bw) loss were evaluated. The factors influencing energy intake and body weight loss were also investigated.

DESIGN

Longitudinal study.

SETTING

University Hospital of Geneva.

SUBJECTS

Fifty obese women undergoing a Roux-en-Y gastric bypass.

RESULTS

The reduction of EnIn was significantly related to bw loss expressed either in kg or as percentage correction of excess bw (P<0.01 for both), whereas the post-operative modifications of diet composition did not play a role. Age and initial bw significantly influenced bw loss (P<0.0001 and P<0.001, respectively), as shown by multiple regression analysis. Patients were divided into four sub-groups according to their age (under or over 35 y) and initial bw (under or over 120 kg). ANOVA showed that under 35-y-old subjects reduced their EnIn significantly more than their older counterparts having similar bw (P<0.02 and P<0.05); consequently, bw loss, expressed in kg, was significantly (P<0.0001 and P<0.0005) larger in younger patients. Subjects with an initial bw over 120 kg lost significantly (P<0.001 and P<0.02) more weight as compared to patients with a smaller degree of obesity (under 120 kg) and similar age.

CONCLUSIONS

Gastric bypass-induced body weight loss is mainly due to the reduction of EnIn, whereas the qualitative modifications of the diet do not play a role. Younger subjects have a greater capacity to reduce EnIn and, therefore, lose more weight. Pre-operative high degree of obesity leads to a larger weight reduction, probably because of a greater energy deficit.

Plasma ghrelin levels after diet-induced weight loss or gastric bypass surgery

BACKGROUND

Weight loss causes changes in appetite and energy expenditure that promote weight regain. Ghrelin is a hormone that increases food intake in rodents and humans. If circulating ghrelin participates in the adaptive response to weight loss, its levels should rise with dieting. Because ghrelin is produced primarily by the stomach, weight loss after gastric bypass surgery may be accompanied by impaired ghrelin secretion.

METHODS

We determined the 24-hour plasma ghrelin profiles, body composition, insulin levels, leptin levels, and insulin sensitivity in 13 obese subjects before and after a six-month dietary program for weight loss. The 24-hour ghrelin profiles were also determined in 5 subjects who had lost weight after gastric bypass and 10 normal-weight controls; 5 of the 13 obese subjects who participated in the dietary program were matched to the subjects in the gastric-bypass group and served as obese controls.

RESULTS

Plasma ghrelin levels rose sharply shortly before and fell shortly after every meal. A diet-induced weight loss of 17 percent of initial body weight was associated with a 24 percent increase in the area under the curve for the 24-hour ghrelin profile (P=0.006). In contrast, despite a 36 percent weight loss after gastric bypass, the area under the curve for the ghrelin profile in the gastric-bypass group was 77 percent lower than in normal-weight controls (P<0.001) and 72 percent lower than in matched obese controls (P=0.01). The normal, meal-related fluctuations and diurnal rhythm of the ghrelin level were absent after gastric bypass.

CONCLUSIONS

The increase in the plasma ghrelin level with diet-induced weight loss is consistent with the hypothesis that ghrelin has a role in the long-term regulation of body weight. Gastric bypass is associated with markedly suppressed ghrelin levels, possibly contributing to the weight-reducing effect of the procedure.

Estimating the consequences of anti-psychotic induced weight gain on health and mortality rate

Many anti-psychotic medications produce marked weight gain. In this study, we estimate the expected impact of degrees of antipsychotic-induced weight gain on selected mortality rate and incidence rates of impaired glucose tolerance (IGT) and hypertension (HTN) among US adults. Using raw data from 5209 respondents from the Framingham Heart Study's public use data set and national statistics on population demographics, we estimated the expected effect of weight gain on number of deaths and incident cases of IGT and HTN for a 10-year period commencing in 1999. Results indicated that the estimated deleterious effects of weight gain were greater for people with higher BMIs at baseline, for greater degrees of weight gain, for men than women, and for older than younger persons. Because there is a 'U-shaped' relation between BMI and mortality rate, small to moderate weight gains among people with baseline BMIs less than 23 were predicted to decrease mortality rates, whereas weight gains among people with baseline BMIs above that level were expected to increase mortality rates. However, the relations of IGT and HTN with BMI are monotonically increasing. Thus, the anticipated effect of weight gain on IGT and HTN is deleterious regardless of baseline BMI. Because it is unclear whether the beneficial effects of the atypical agents on, for example, reducing suicide mortality, outweigh the putative increase in mortality due to weight gain, we estimate the beneficial effects due to decreased death from suicide with the potential deleterious effects due to a 10-kg weight gain. We found that 492 suicide deaths per 100,000 schizophrenic patients would be prevented over 10 years with the use of clozapine compared to 416 additional deaths due to antipsychotic induced weight gain. Although this estimate is rather crude and should be seen only as offering a sense of the likely situation, results suggest that the lives saved via clozapine may essentially be offset by the deaths due to weight gain. As we discuss, it is not possible to provide definitive estimates of the effect of antipsychotic-induced weight gain on health and mortality, but our findings suggest that the magnitude of weight gains induced by many antipsychotic agents is likely to have important deleterious effects on mortality and health.

The Nutrition Society Medical Lecture. Obesity: from molecules to man

Obesity is now a major public health problem in both developed and developing countries. In the UK over 16% men and 17.5% women are obese, an increase of more than 100% since 1980. However, interventions to prevent and treat obesity are hampered by an inadequate understanding of the aetiology of this condition. The present paper considers the current state of knowledge regarding the causes of obesity, including some of the genetic, metabolic, behavioural and environmental factors which influence energy balance. The present paper comprises The Nutrition Society Medal Lecture and focuses in particular on the research carried out at the MRC Dunn Nutrition Centre in Cambridge. It argues that despite decades of intensive research there is relatively little evidence of genetic or metabolic defects to explain the majority of cases of human obesity. Instead we must look to behavioural and/or environmental factors which may be underpinning the current epidemic of obesity.