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Holmes R, Duan H, Bagley O, Wu D, Loika Y, Kulminski A, Yashin A, Arbeev K, Ukraintseva S. How are APOE4, changes in body weight, and longevity related? Insights from a causal mediation analysis. FRONTIERS IN AGING 2024; 5:1359202. [PMID: 38496317 PMCID: PMC10941013 DOI: 10.3389/fragi.2024.1359202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/07/2024] [Indexed: 03/19/2024]
Abstract
The ε4 allele of the APOE gene (APOE4) is known for its negative association with human longevity; however, the mechanism is unclear. APOE4 is also linked to changes in body weight, and the latter changes were associated with survival in some studies. Here, we explore the role of aging changes in weight in the connection between APOE4 and longevity using the causal mediation analysis (CMA) approach to uncover the mechanisms of genetic associations. Using the Health and Retirement Study (HRS) data, we tested a hypothesis of whether the association of APOE4 with reduced survival to age 85+ is mediated by key characteristics of age trajectories of weight, such as the age at reaching peak values and the slope of the decline in weight afterward. Mediation effects were evaluated by the total effect (TE), natural indirect effect, and percentage mediated. The controlled direct effect and natural direct effect are also reported. The CMA results suggest that APOE4 carriers have 19%-22% (TE p = 0.020-0.039) lower chances of surviving to age 85 and beyond, in part, because they reach peak values of weight at younger ages, and their weight declines faster afterward compared to non-carriers. This finding is in line with the idea that the detrimental effect of APOE4 on longevity is, in part, related to the accelerated physical aging of ε4 carriers.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Svetlana Ukraintseva
- Biodemography of Aging Research Unit, Social Science Research Institute, Duke University, Durham, NC, United States
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Berman MI, Park J, Kragenbrink ME, Hegel MT. Accept Yourself! A Pilot Randomized Controlled Trial of a Self-Acceptance-Based Treatment for Large-Bodied Women With Depression. Behav Ther 2022; 53:913-926. [PMID: 35987548 DOI: 10.1016/j.beth.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 03/04/2022] [Accepted: 03/16/2022] [Indexed: 11/15/2022]
Abstract
A pilot parallel randomized controlled trial compared a self-acceptance, non-weight-loss intervention, Accept Yourself! (AY), to a weight loss program, Weight Watchers (WW), in order to provide preliminary safety, feasibility, and efficacy data in preparation for a definitive RCT of AY as an intervention to enhance the mental and physical health of larger-bodied women with Major Depressive Disorder (MDD). Adult women with MDD and a Body Mass Index ≥30 were eligible. Nineteen women were randomized by random number table into AY (n = 9) or WW (n = 10). Intake, pretreatment, posttreatment, 3-, 6-, 9-, and 12-month follow-up assessments occurred at a rural academic medical center. Primary outcomes included depression severity and cardiovascular fitness. Chi-square and t-tests assessed attrition and participant preferences for treatment; other analyses used intention-to-treat, linear mixed-effects models for repeated measures, including all participants' available data. Both groups improved in self-reported, F(5, 43.81) = 7.45, p < .001, partial η2 = .38, and blinded-clinician-rated depression, F(6, 62.03) = 10.41, p < .001, partial η2 = .5. AY was superior to WW in self-reported depression, F(5, 43.81) = 2.72, p = .03, partial η2 = .11. Neither group improved in fitness. Eating disorder symptoms and weight gain worsened in WW. AY appeared safe, feasible, and offered initial evidence of efficacy for depression; it should be investigated in a definitive RCT, with modifications to increase potency. WW may not be suitable as a comparator intervention for AY because of risk to participants.
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Affiliation(s)
| | - John Park
- Geisel School of Medicine at Dartmouth
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Yannakoulia M, Mamalaki E, Poulimenas D. Intentional weight loss and mortality in middle-aged and older adults: A narrative review. Maturitas 2022; 165:100-103. [DOI: 10.1016/j.maturitas.2022.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Revised: 07/22/2022] [Accepted: 07/27/2022] [Indexed: 11/15/2022]
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Huang S, Shi K, Ren Y, Wang J, Yan WF, Qian WL, Yang ZG, Li Y. Association of magnitude of weight loss and weight variability with mortality and major cardiovascular events among individuals with type 2 diabetes mellitus: a systematic review and meta-analysis. Cardiovasc Diabetol 2022; 21:78. [PMID: 35578337 PMCID: PMC9112517 DOI: 10.1186/s12933-022-01503-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 04/16/2022] [Indexed: 02/08/2023] Open
Abstract
Background Weight management is strongly promoted for overweight or obese patients with type 2 diabetes (T2DM) by current guidelines. However, the prognostic impact of weight loss achieved without behavioural intervention on the mortality and cardiovascular (CV) outcomes in diabetic patients is still contested. Methods We searched the PubMed, Embase, and Cochrane Library databases for studies that investigated the association of weight loss or weight variability with mortality and CV outcomes. Results of studies that measured weight loss by percentage weight loss from baseline and stratified it as > 10% and 5–10% or studies that computed weight variability were pooled using random effects model. Study quality was evaluated using the Newcastle–Ottawa Scale. Results Thirty eligible studies were included in the systematic review and 13 of these were included in the meta-analysis. Large weight loss (> 10%) was associated with increased risk of all-cause mortality (pooled hazard ratio (HR) 2.27, 95% CI 1.51–3.42), composite of major CV events (pooled HR 1.71, 95% CI 1.38–2.12) and CV mortality (pooled HR 1.50, 95% CI 1.27–1.76) among T2DM patients. Moderate weight loss showed no significant association with all-cause mortality (pooled HR 1.17, 95% CI 0.97–1.41) or CV outcomes (pooled HR 1.12, 95% CI 0.94–1.33). Weight variability was associated with high hazard of all-cause mortality (pooled HR 1.54, 95% CI 1.52–1.56). Conclusions Large weight loss and large fluctuations in weight are potential markers of increased risk of mortality and CV events in T2DM patients. Maintaining a stable weight may have positive impact in these patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01503-x.
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Affiliation(s)
- Shan Huang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Ke Shi
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yan Ren
- Department of Endocrinology and Metabolism, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Jin Wang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Wei-Feng Yan
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Wen-Lei Qian
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Zhi-Gang Yang
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China
| | - Yuan Li
- Department of Radiology, West China Hospital, Sichuan University, 37# Guo Xue Xiang, Chengdu, 610041, Sichuan, China. .,Department of Radiology, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, No.37 Guoxue Xiang, Chengdu, 610041, China.
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Strelitz J, Lawlor ER, Wu Y, Estlin A, Nandakumar G, Ahern AL, Griffin SJ. Association between weight change and incidence of cardiovascular disease events and mortality among adults with type 2 diabetes: a systematic review of observational studies and behavioural intervention trials. Diabetologia 2022; 65:424-439. [PMID: 34859263 PMCID: PMC8803822 DOI: 10.1007/s00125-021-05605-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 08/25/2021] [Indexed: 12/18/2022]
Abstract
AIMS/HYPOTHESIS Weight loss is often recommended in the treatment of type 2 diabetes. While evidence has shown that large weight loss may lead to diabetes remission and improvement in cardiovascular risk factors, long-term impacts are unclear. We performed a systematic review of studies of weight loss and other weight changes and incidence of CVD among people with type 2 diabetes. METHODS Observational studies of behavioural (non-surgical and non-pharmaceutical) weight changes and CVD events among adults with type 2 diabetes, and trials of behavioural interventions targeting weight loss, were identified through searches of MEDLINE, EMBASE, Web of Science, CINAHL, and The Cochrane Library (CENTRAL) until 9 July 2019. Included studies reported change in weight and CVD and/or mortality outcomes among adults with type 2 diabetes. We performed a narrative synthesis of observational studies and meta-analysis of trial data. RESULTS Of 13,227 identified articles, 17 (14 observational studies, three trials) met inclusion criteria. Weight gain (vs no change) was associated with higher hazard of CVD events (HRs [95% CIs] ranged from 1.13 [1.00, 1.29] to 1.63 [1.11, 2.39]) and all-cause mortality (HRs [95% CIs] ranged from 1.26 [1.12, 1.41] to 1.57 [1.33, 1.85]). Unintentional weight loss (vs no change) was associated with higher risks of all-cause mortality, but associations with intentional weight loss were unclear. Behavioural interventions targeting weight loss showed no effect on CVD events (pooled HR [95% CI] 0.95 [0.71, 1.27]; I2 = 50.1%). Risk of bias was moderate in most studies and was high in three studies, due to potential uncontrolled confounding and method of weight assessment. CONCLUSIONS/INTERPRETATION Weight gain is associated with increased risks of CVD and mortality, although there is a lack of data supporting behavioural weight-loss interventions for CVD prevention among adults with type 2 diabetes. Long-term follow-up of behavioural intervention studies is needed to understand effects on CVD and mortality and to inform policy concerning weight management advice and support for people with diabetes. PROSPERO registration CRD42019127304.
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Affiliation(s)
- Jean Strelitz
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK.
| | - Emma R Lawlor
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Yue Wu
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Annabel Estlin
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Giri Nandakumar
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Amy L Ahern
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Simon J Griffin
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Primary Care Unit, Department of Public Health and Primary Care, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Hu J, Hu Y, Hertzmark E, Yuan C, Liu G, Stampfer MJ, Rimm EB, Hu FB, Wang M, Sun Q. Weight Change, Lifestyle, and Mortality in Patients With Type 2 Diabetes. J Clin Endocrinol Metab 2022; 107:627-637. [PMID: 34741524 PMCID: PMC9006974 DOI: 10.1210/clinem/dgab800] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT The association between weight change and mortality among participants with incident type 2 diabetes (T2D) was unclear. OBJECTIVE To examine above association and evaluate the impact of lifestyle on it. METHODS This prospective analysis included 11 262 incident T2D patients from Nurses' Health Study and Health Professionals Follow-up Study. We assessed weight change bracketing T2D diagnosis in relation to mortality. We also examined potential effect modification by a healthy lifestyle consisting of high-quality diet, regular physical activity, nonsmoking status, and moderate alcohol consumption. RESULTS On average, T2D patients lost 2.3 kg during a 2-year time window spanning the T2D diagnosis, and body weight increased afterwards following a trajectory similar to that of nondiabetics. Compared with patients with a stable weight, T2D patients who lost ≥10% body weight had a 21% (95% CI, 9%-35%) increased all-cause mortality. Lifestyle significantly modified these associations: the hazard ratios (95% CIs) of all-cause mortality comparing ≥10% weight loss with stable weight were 1.63 (1.26-2.09) among participants with a deteriorated lifestyle, 1.27 (1.11-1.46) for a stable lifestyle, and 1.02 (0.81-1.27) for an improved lifestyle (Pinteraction < 0.001). Major weight loss was associated with increased cause-specific mortality and similar effect modifications by lifestyle were also observed. CONCLUSION Significant weight loss upon T2D incidence was associated with increased mortality, although improved lifestyle quality abolished these associations. These results highlight the role of adopting a healthy lifestyle for newly diagnosed T2D patients, especially among those who might lose weight unintentionally, and improving long-term survival.
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Affiliation(s)
| | | | - Ellen Hertzmark
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Chen Yuan
- Department of Medical Oncology, Dana-Farber Cancer Institute and Harvard Medical School, Boston, MA, USA
| | - Gang Liu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meir J Stampfer
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Eric B Rimm
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Frank B Hu
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Molin Wang
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Qi Sun
- Correspondence: Qi Sun, MD, ScD, Department of Nutrition, Harvard T.H. Chan School of Public Health, 665 Huntington Ave., Boston, MA 02115, USA.
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Landgrebe LE, Andersen V, Bang C, Moitinho-Silva L, Schwarz H, Juhl CB, Bladbjerg EM. High-fat meals do not affect thrombin formation and fibrin clot lysis in individuals with obesity during intentional weight loss. Nutr Res 2021; 97:1-10. [PMID: 34922120 DOI: 10.1016/j.nutres.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 11/11/2021] [Accepted: 11/11/2021] [Indexed: 11/29/2022]
Abstract
Repeated weight loss cycles are associated with increased cardiovascular morbidity. Meal-induced thrombin formation, measured as prothrombin fragment 1+2 (F1+2), is observed in individuals with overweight after weight loss, and postprandial effects can be one of the mechanisms underlying harmful effects during intentional weight loss. We hypothesize that consumption of high-fat meals during intentional weight loss triggers a prothrombotic state by increasing postprandial F1+2 or decreasing fibrin clot lysis in individuals with obesity, and that the response associates with the gut bacteria composition. A cross-over meal study was conducted in patients admitted to bariatric surgery during dietary weight loss (N = 20) and surgical weight loss (N = 16) (weight loss groups). High-fat (67 E%) and low-fat (16 E%) meals were served at 08:15 and 10:00 on 2 study days. Blood samples collected at 08:00 (fasting), 12:00, and 14:00 were analyzed for triglycerides, activated factor VII (FVIIa), F1+2, D-dimer, fibrinogen, tissue factor , and fibrin clot lysis. The proportion of Gram-negative bacteria and bacterial diversity were analyzed in fecal samples obtained less than 24 hours before the meal test. Triglyceride and FVIIa increased after high-fat meals in both weight loss groups, whereas D-dimer (dietary group) and F1+2 decreased and tissue factor and fibrin clot lysis did not change. There was a negative association between the proportion of Gram-negative bacteria and changes in FVIIa in the surgery group. Postprandial FVII activation after high-fat meals is not accompanied by increased F1+2, irrespective of the weight loss intervention, but might be associated with the proportion of Gram-negative gut bacteria.
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Affiliation(s)
- Line E Landgrebe
- Unit for Thrombosis Research, Department of Clinical Diagnostics, Section of Clinical Biochemistry, University Hospital of Southern Denmark, 6700 Esbjerg, Denmark; Department of Regional Health Research, University of Southern Denmark; Odense Patient data Explorative Network (OPEN), Odense University Hospital, Odense, Denmark.
| | - Vibeke Andersen
- Department of Regional Health Research, University of Southern Denmark; Research Unit for Molecular Diagnostic and Clinical Research, University Hospital of Southern Denmark, 6200 Aabenraa, Denmark; Institute of Molecular Medicine, University of Southern Denmark
| | - Corinna Bang
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, 24118 Kiel, Germany
| | - Lucas Moitinho-Silva
- Institute of Clinical Molecular Biology, Christian-Albrechts-University of Kiel, 24118 Kiel, Germany; Department of Dermatology, Venereology and Allergy, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Herbert Schwarz
- Siemens Healthcare Diagnostics Products GmbH, 35041 Marburg, Germany
| | - Claus B Juhl
- Department of Regional Health Research, University of Southern Denmark; Department of Medicine, Section of Endocrinology, University Hospital of Southern Denmark, 6700 Esbjerg, Denmark; Steno Diabetes Center Odense, Denmark
| | - Else-Marie Bladbjerg
- Unit for Thrombosis Research, Department of Clinical Diagnostics, Section of Clinical Biochemistry, University Hospital of Southern Denmark, 6700 Esbjerg, Denmark; Department of Regional Health Research, University of Southern Denmark
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Ferreira JP, Rossignol P, Bakris G, Mehta C, White WB, Zannad F. Body weight changes in patients with type 2 diabetes and a recent acute coronary syndrome: an analysis from the EXAMINE trial. Cardiovasc Diabetol 2021; 20:187. [PMID: 34521390 PMCID: PMC8442423 DOI: 10.1186/s12933-021-01382-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2021] [Accepted: 09/07/2021] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Patients with type 2 diabetes (T2D) may experience frequent body weight changes over time. The prognostic impact of these weight changes (gains or losses) requires further study. AIMS To study the associations between changes in body weight (intentional or unintentional) with subsequent outcomes. METHODS The EXAMINE trial included 5380 patients with T2D and a recent acute coronary syndrome, who were randomized to alogliptin or placebo. Time-updated Cox models and mixed effects models were used to test the associations between changes in body weight and subsequent outcomes over a median follow-up of 1.6 (1.0-2.1) years. RESULTS During the post-randomization follow-up period, 1044 patients (19.4%) experienced a weight loss ≥ 5% of baseline weight, 2677 (49.8%) had a stable weight, and 1659 (30.8%) had a ≥ 5 % weight gain. Patients with weight loss were more frequently women and had more co-morbid conditions. In contrast, patients who gained ≥ 5% weight were more frequently men with less co-morbid conditions. A weight loss ≥ 5% was independently associated with a higher risk of subsequent adverse outcomes, including all-cause mortality: adjusted HR (95% CI) = 1.79 (1.33-2.42), P < 0.001. Similar associations were found for cardiovascular mortality, the composite of cardiovascular mortality or heart failure hospitalization, and the primary outcome. A weight gain ≥ 5% was independently associated with an increase in the risk of subsequent cardiovascular mortality or heart failure hospitalization only: adjusted HR (95% CI) = 1.34 (1.02-1.76), P = 0.033. CONCLUSIONS In patients with T2D who had a recent ACS/MI, a ≥ 5% loss of body weight was associated with a higher risk of subsequent cardiovascular events and mortality.
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Affiliation(s)
- João Pedro Ferreira
- Centre DInvestigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy hopitaux de Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500, Vandoeuvre lès Nancy, France. .,Cardiovascular Research and Development Center, Faculty of Medicine, University of Porto, Porto, Portugal.
| | - Patrick Rossignol
- Centre DInvestigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy hopitaux de Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500, Vandoeuvre lès Nancy, France
| | - George Bakris
- Department of Medicine, American Heart Association Comprehensive Hypertension Center, University of Chicago, Chicago, IL, USA
| | | | - William B White
- Calhoun Cardiology Center, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Faiez Zannad
- Centre DInvestigation Clinique-Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy hopitaux de Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Institut Lorrain du Coeur et des Vaisseaux Louis Mathieu, 4 Rue du Morvan, 54500, Vandoeuvre lès Nancy, France
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Mensinger JL, Cox SA, Henretty JR. Treatment Outcomes and Trajectories of Change in Patients Attributing Their Eating Disorder Onset to Anti-obesity Messaging. Psychosom Med 2021; 83:777-786. [PMID: 34267090 PMCID: PMC8428859 DOI: 10.1097/psy.0000000000000962] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 02/05/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Given the increased prevalence of eating disorders (EDs) among individuals higher on the weight spectrum, we aimed to 1) report the prevalence of ED patients in higher levels of care (residential, partial hospitalization, and intensive outpatient) attributing the onset of their ED to anti-obesity messaging, 2) report the most commonly recollected sources of those messages, and 3) determine if those attributing the onset of their ED to anti-obesity messaging a) enter, b) exit, and c) respond to treatment differently from peers who did not. METHODS This retrospective cohort study used data from 2901 patients receiving ED treatment in higher levels of care at a US-based center between 2015 and 2018. Multilevel models examined differences in ED symptoms and trajectories of change over time. NVivo was used to analyze the patients' comments about sources of messages. RESULTS Eighteen percent attributed their ED onset to anti-obesity messaging, 45% did not, and 37% were unsure. Of those providing comments, the most common sources included the following: educational curriculum/school context (45.9%), media/Internet (24.7%), health care (10.4%), family (9%), and peer bullying (3.7%). At admission, patients attributing their ED onset to anti-obesity messaging had more severe ED symptoms than those who did not (γ = 0.463, standard error [SE] = 0.086, p < .001) and those who were unsure (γ = 0.288, SE = 0.089, p < .001); no differences were evident at discharge (p > .483). During phase 2 of treatment, patients attributing their ED onset to anti-obesity messaging improved faster than those who did not (γ = 0.003, SE = 0.001, p = .008) and those who were unsure (γ = 0.003, SE = 0.001, p = .014). CONCLUSIONS Anti-obesity messaging may put vulnerable individuals at risk for EDs. We recommend increasing weight bias training for school personnel and health care professionals. To reduce health disparities, we also suggest the promotion of weight-neutral health-enhancing self-care practices in media and public health campaigns, legislative policies, and health care overall.
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Doehner W, Gerstein HC, Ried J, Jung H, Asbrand C, Hess S, Anker SD. Obesity and weight loss are inversely related to mortality and cardiovascular outcome in prediabetes and type 2 diabetes: data from the ORIGIN trial. Eur Heart J 2021; 41:2668-2677. [PMID: 32402060 PMCID: PMC7377581 DOI: 10.1093/eurheartj/ehaa293] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 08/22/2019] [Accepted: 04/09/2020] [Indexed: 12/15/2022] Open
Abstract
AIMS The association of body weight and weight change with mortality and cardiovascular (CV) outcome in patients with diabetes mellitus (DM) is not clearly established. We assessed the relationship between weight, weight change, and outcomes in patients with established CV risk factors and type 2 DM or pre-diabetes. METHODS AND RESULTS A total of 12 521 participants from the ORIGIN trial were grouped in BMI categories of low body weight [body mass index (BMI) < 22 kg/m2] normal (22-24.9), overweight (25-29.9), obesity Grades 1-3 (30-34.9, 35-39.9, ≥40 kg/m2, respectively). Outcome variables included total and CV mortality and composite outcomes of CV death, non-fatal stroke, or myocardial infarction plus revascularization or heart failure hospitalization. Follow-up was 6.2 years (interquartile range 5.8-6.7 years). After multivariable adjustment, lowest risks were seen in patients with overweight and mild obesity for total mortality [overweight: hazard ratio (HR) 0.80 (95% confidence interval (CI) 0.69-0.91); obesity Grade 1: HR 0.82 (0.71-0.95), both P < 0.01)] and CV mortality [overweight: HR 0.79 (0.66-0.94); obesity Grade 1: 0.79 (0.65-0.95), all compared to patients with normal BMI, P < 0.05]. Obesity of any severity was not associated with higher mortality. Low body weight was related to higher mortality [HR 1.28 (1.02-1.61); CV mortality: HR 1.34 (1.01-1.79), P < 0.05]. A continued 2-year weight loss was associated with higher risk of mortality [HR 1.32 (1.18-1.46), P < 0.0001] and CV mortality [HR 1.18 (1.02-1.35), compared to patients without weight loss, P < 0.05]. In turn, weight gain was not related to any adverse outcome. CONCLUSION Obesity in patients with DM or pre-diabetes and CV risk profile was not associated with higher mortality or adverse CV outcome. The lowest mortality risk was seen in patients with overweight and moderate obesity (BMI 25-35 kg/m2). Weight loss was an independent risk factor for higher mortality compared to no weight loss.
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Affiliation(s)
- Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, 13353 Berlin, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (Virchow Hospital), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
| | - Hertzel C Gerstein
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, L8S 4K1 Hamilton, ON, Canada
| | - Janina Ried
- Sanofi-Aventis Deutschland GmbH, Research & Development, 65926 Frankfurt, Germany
| | - Hyejung Jung
- Population Health Research Institute, McMaster University, Hamilton Health Sciences, L8S 4K1 Hamilton, ON, Canada
| | - Christian Asbrand
- Sanofi-Aventis Deutschland GmbH, Research & Development, 65926 Frankfurt, Germany
| | - Sibylle Hess
- Sanofi-Aventis Deutschland GmbH, Research & Development, 65926 Frankfurt, Germany
| | - Stefan D Anker
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin Berlin, 13353 Berlin, Germany.,Division of Cardiology and Metabolism, Department of Cardiology (Virchow Hospital), German Centre for Cardiovascular Research (DZHK), Partner Site Berlin and Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, 13353 Berlin, Germany
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11
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Polemiti E, Baudry J, Kuxhaus O, Jäger S, Bergmann MM, Weikert C, Schulze MB. BMI and BMI change following incident type 2 diabetes and risk of microvascular and macrovascular complications: the EPIC-Potsdam study. Diabetologia 2021; 64:814-825. [PMID: 33452586 PMCID: PMC7940263 DOI: 10.1007/s00125-020-05362-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 11/02/2020] [Indexed: 12/17/2022]
Abstract
AIMS/HYPOTHESIS Studies suggest decreased mortality risk among people who are overweight or obese compared with individuals with normal weight in type 2 diabetes (obesity paradox). However, the relationship between body weight or weight change and microvascular vs macrovascular complications of type 2 diabetes remains unresolved. We investigated the association between BMI and BMI change with long-term risk of microvascular and macrovascular complications in type 2 diabetes in a prospective cohort study. METHODS We studied participants with incident type 2 diabetes from the European Prospective Investigation into Cancer and Nutrition (EPIC)-Potsdam cohort, who were free of cancer, cardiovascular disease and microvascular disease at diagnosis (n = 1083). Pre-diagnosis BMI and relative annual change between pre- and post-diagnosis BMI were evaluated in multivariable-adjusted Cox models. RESULTS There were 85 macrovascular (myocardial infarction and stroke) and 347 microvascular events (kidney disease, neuropathy and retinopathy) over a median follow-up of 10.8 years. Median pre-diagnosis BMI was 29.9 kg/m2 (IQR 27.4-33.2), and the median relative annual BMI change was -0.4% (IQR -2.1 to 0.9). Higher pre-diagnosis BMI was positively associated with total microvascular complications (multivariable-adjusted HR per 5 kg/m2 [95% CI]: 1.21 [1.07, 1.36], kidney disease 1.39 [1.21, 1.60] and neuropathy 1.12 [0.96, 1.31]) but not with macrovascular complications (HR 1.05 [95% CI 0.81, 1.36]). Analyses according to BMI categories corroborated these findings. Effect modification was not evident by sex, smoking status or age groups. In analyses according to BMI change categories, BMI loss of more than 1% indicated a decreased risk of total microvascular complications (HR 0.62 [95% CI 0.47, 0.80]), kidney disease (HR 0.57 [95% CI 0.40, 0.81]) and neuropathy (HR 0.73 [95% CI 0.52, 1.03]), compared with participants with a stable BMI; no clear association was observed for macrovascular complications (HR 1.04 [95% CI 0.62, 1.74]). The associations between BMI gain compared with stable BMI and diabetes-related vascular complications were less apparent. Associations were consistent across strata of sex, age, pre-diagnosis BMI or medication but appeared to be stronger among never-smokers compared with current or former smokers. CONCLUSIONS/INTERPRETATION Among people with incident type 2 diabetes, pre-diagnosis BMI was positively associated with microvascular complications, while a reduced risk was observed with weight loss when compared with stable weight. The relationships with macrovascular disease were less clear.
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Affiliation(s)
- Elli Polemiti
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Julia Baudry
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Olga Kuxhaus
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Susanne Jäger
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
- German Center for Diabetes Research (DZD), Neuherberg, Germany
| | - Manuela M Bergmann
- Human Study Center, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany
| | - Cornelia Weikert
- German Federal Institute for Risk Assessment, Department of Food Safety, Berlin, Germany
| | - Matthias B Schulze
- Department of Molecular Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke (DIfE), Nuthetal, Germany.
- German Center for Diabetes Research (DZD), Neuherberg, Germany.
- Institute of Nutritional Science, University of Potsdam, Potsdam, Germany.
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12
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Kang J, Lee JY, Lee MY, Sung KC. Risk of Incident Hypertension According to Physical Activity and Temporal Changes in Weight. Am J Hypertens 2021; 34:212-219. [PMID: 33452526 DOI: 10.1093/ajh/hpaa133] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/22/2020] [Accepted: 01/14/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Physical activity (PA) and maintenance of a normal weight contribute to the prevention of hypertension but not always concurrently. Our aim was to investigate whether maintaining PA, regardless of weight change, is associated with a reduced risk of developing hypertension. METHODS We conducted a cohort study of 195,045 Koreans (mean age, 37.7 years; standard deviation, 7.1 years) who participated in an occupational health screening program from January 2011 to December 2016. PA levels were measured using the validated Korean version of the International Physical Activity Questionnaire Short Form, and participants were classified into 3 categories as inactive, active, and health-enhancing physically active (HEPA). Weight was tracked, and participants were divided into 2 categories: those whose weight change >0 and those whose weight change ≤0. RESULTS During 616,326.5 person-years, 12,206 participants developed hypertension (19.8 per 1,000 person-years). A higher PA level and greater reduction in body mass index were associated with lower risk for incident hypertension. Hazard ratio (HR) for incident hypertension was lower (0.83; 95% confidence interval, 0.79-0.88) in subjects with active/HEPA at baseline and decreased weight than in those in the inactive and increased weight groups after adjustment for confounding factors. Even in the increased weight group, HR for incident hypertension was 0.85 (0.81-0.90) in subjects whose PA was consistently maintained at active or HEPA levels during follow-up. CONCLUSIONS In this large cohort of young and middle-aged Koreans, maintaining active or HEPA PA levels was associated with reduced risk of developing hypertension regardless of weight change.
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Affiliation(s)
- Jeonggyu Kang
- Center for Cohort Studies, Total Healthcare Center, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jong-Young Lee
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Mi Yeon Lee
- Division of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Ki-Chul Sung
- Division of Cardiology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
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13
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Strelitz J, Sharp SJ, Khunti K, Vos RC, Rutten GEHM, Webb DR, Witte DR, Sandbæk A, Wareham NJ, Griffin SJ. Association of weight loss and weight loss maintenance following diabetes diagnosis by screening and incidence of cardiovascular disease and all-cause mortality: An observational analysis of the ADDITION-Europe trial. Diabetes Obes Metab 2021; 23:730-741. [PMID: 33269535 PMCID: PMC7614211 DOI: 10.1111/dom.14278] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 11/13/2020] [Accepted: 11/28/2020] [Indexed: 02/02/2023]
Abstract
AIMS Short-term weight loss may lead to remission of type 2 diabetes but the effect of maintained weight loss on cardiovascular disease (CVD) is unknown. We quantified the associations between changes in weight 5 years following a diagnosis of diabetes, and incident CVD events and mortality up to 10 years after diagnosis. MATERIALS AND METHODS Observational analysis of the ADDITION-Europe trial of 2730 adults with screen-detected type 2 diabetes from the UK, Denmark and the Netherlands. We defined weight change based on the maintenance at 5 years of weight loss achieved during the year after diabetes diagnosis, and as 5-year overall change in weight. Incident CVD events (n = 229) and all-cause mortality (n = 225) from 5 to 10 years follow-up were ascertained from medical records. RESULTS Gaining >2% weight during the year after diabetes diagnosis was associated with higher hazard of all-cause mortality versus maintaining weight [hazard ratio (95% confidence interval): 3.18 (1.30-7.82)]. Losing ≥5% weight 1 year after diagnosis was also associated with mortality, whether or not weight loss was maintained at 5 years: 2.47 (0.99-6.21) and 2.72 (1.17-6.30), respectively. Losing ≥10% weight over 5 years was associated with mortality among those with body mass index <30 kg/m2 [4.62 (1.87-11.42)]. Associations with CVD incidence were inconclusive. CONCLUSIONS Both weight loss and weight gain after screen-detected diabetes diagnosis were associated with higher mortality, but not CVD events, particularly among participants without obesity. The clinical implications of weight loss following a diagnosis of diabetes probably depend on its magnitude and timing, and may differ by body mass index status. Personalization of weight loss advice and support may be warranted.
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Affiliation(s)
- Jean Strelitz
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Stephen J Sharp
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Rimke C Vos
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center-Campus The Hague, the Netherlands
| | - Guy EHM Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht University, Utrecht, the Netherlands
| | - David R Webb
- Diabetes Research Centre, University of Leicester, Leicester General Hospital, Leicester, UK
| | - Daniel R Witte
- Department of Public Health, Section of Epidemiology, Aarhus University, Aarhus, Denmark
- Danish Diabetes Academy, Odense, Denmark
| | - Annelli Sandbæk
- Section for General Practice, Department of Public Health, Aarhus University, Aarhus, Denmark
- Steno Diabetes Center, Aarhus University Hospital, Aarhus, Denmark
| | - Nicholas J Wareham
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Simon J Griffin
- MRC Epidemiology Unit, Institute of Metabolic Science, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- The Primary Care Unit, Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge UK
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14
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How Much Weight Loss is Required for Cardiovascular Benefits? Insights From a Metabolic Surgery Matched-cohort Study. Ann Surg 2020; 272:639-645. [PMID: 32932320 DOI: 10.1097/sla.0000000000004369] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The aim of this study was to determine the minimum amount of weight loss required to see a reduction in major adverse cardiovascular events (MACE). BACKGROUND Although obesity is an established risk factor for morbidity and mortality, the minimum amount of weight loss to have a meaningful impact on cardiovascular health and survival is unknown. METHODS Patients with obesity (body mass index ≥30 kg/m) and type 2 diabetes who underwent metabolic surgery in an academic center (1998-2017) were propensity-matched 1:5 to nonsurgical patients who received usual care. The adjusted linear and nonlinear effects of weight loss (achieved in the first 18 months after the index date) were studied to identify cut-offs for the minimum weight loss to achieve decreased risk of all-cause mortality and MACE (composite of all-cause mortality, coronary artery events, cerebrovascular events, heart failure, nephropathy, and atrial fibrillation). RESULTS A total of 7201 patients (1223 surgical and 5978 nonsurgical) with a median follow-up time of 4.9 years (interquartile range, 3.5-7) were included. The positive effect of metabolic surgery was still present after adjusting for weight loss amounts, suggesting that there are weight loss-independent factors contributing to a reduction in risk of MACE and all-cause mortality in the surgical cohort. After considering the weighted estimates from a diverse set of models, the risk of MACE decreases after approximately 10% of weight is lost in the surgical group and approximately 20% in the nonsurgical group. For all-cause mortality, the threshold for benefit appeared to be approximately 5% weight loss after metabolic surgery and 20% in the nonsurgical group. CONCLUSIONS This large matched-cohort study identified the minimum weight loss thresholds for reduction in risk of MACE and all-cause mortality in patients with obesity and diabetes. Furthermore, in our analysis, the effect of surgery was still present after accounting for weight loss, which may suggest the presence of weight-independent beneficial effects of metabolic surgery on MACE and survival.
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15
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Lee D, Jacobs DR, Lind L, Lind PM. Lipophilic Environmental Chemical Mixtures Released During Weight‐Loss: The Need to Consider Dynamics. Bioessays 2020; 42:e1900237. [DOI: 10.1002/bies.201900237] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/06/2020] [Indexed: 12/25/2022]
Affiliation(s)
- Duk‐Hee Lee
- Department of Preventive MedicineSchool of MedicineKyungpook National University Daegu 41944 Korea
| | - David R Jacobs
- Division of Epidemiology and Community HealthSchool of Public HealthUniversity of Minnesota Minneapolis Minnesota 55454 USA
| | - Lars Lind
- Department of Medical SciencesCardiovascular EpidemiologyUppsala University Uppsala 75237 Sweden
| | - P. Monica Lind
- Department of Medical SciencesOccupational and Environmental MedicineUppsala University Uppsala 75185 Sweden
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16
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Strelitz J, Ahern AL, Long GH, Hare MJL, Irving G, Boothby CE, Wareham NJ, Griffin SJ. Moderate weight change following diabetes diagnosis and 10 year incidence of cardiovascular disease and mortality. Diabetologia 2019; 62:1391-1402. [PMID: 31062041 PMCID: PMC6647260 DOI: 10.1007/s00125-019-4886-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/26/2019] [Indexed: 12/14/2022]
Abstract
AIMS/HYPOTHESIS Adults with type 2 diabetes are at high risk of developing cardiovascular disease (CVD). Evidence of the impact of weight loss on incidence of CVD events among adults with diabetes is sparse and conflicting. We assessed weight change in the year following diabetes diagnosis and estimated associations with 10 year incidence of CVD events and all-cause mortality. METHODS In a cohort analysis among 725 adults with screen-detected diabetes enrolled in the Anglo-Danish-Dutch Study of Intensive Treatment in People with Screen-Detected Diabetes in Primary Care (ADDITION)-Cambridge trial, we estimated HRs for weight change in the year following diabetes diagnosis and 10 year incidence of CVD (n = 99) and all-cause mortality (n = 95) using Cox proportional hazards regression. We used linear regression to estimate associations between weight loss and CVD risk factors. Models were adjusted for age, sex, baseline BMI, smoking, occupational socioeconomic status, cardio-protective medication use and treatment group. RESULTS Loss of ≥5% body weight in the year following diabetes diagnosis was associated with improvements in HbA1c and blood lipids and a lower hazard of CVD at 10 years compared with maintaining weight (HR 0.52 [95% CI 0.32, 0.86]). The associations between weight gain vs weight maintenance and CVD (HR 0.41 [95% CI 0.15, 1.11]) and mortality (HR 1.63 [95% CI 0.83, 3.19]) were less clear. CONCLUSIONS/INTERPRETATION Among adults with screen-detected diabetes, loss of ≥5% body weight during the year after diagnosis was associated with a lower hazard of CVD events compared with maintaining weight. These results support the hypothesis that moderate weight loss may yield substantial long-term CVD reduction, and may be an achievable target outside of specialist-led behavioural treatment programmes.
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Affiliation(s)
- Jean Strelitz
- MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK.
| | - Amy L Ahern
- MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
| | | | - Matthew J L Hare
- Departments of Endocrinology, Diabetes and Vascular Medicine, Monash Health, Melbourne, VIC, Australia
| | - Greg Irving
- Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Clare E Boothby
- MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
| | - Nicholas J Wareham
- MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
| | - Simon J Griffin
- MRC Epidemiology Unit, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge School of Clinical Medicine, Box 285, Cambridge, CB2 0QQ, UK
- Primary Care Unit, Institute of Public Health, University of Cambridge School of Clinical Medicine, Cambridge, UK
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Kim MK, Han K, Koh ES, Kim ES, Lee MK, Nam GE, Kwon HS. Weight change and mortality and cardiovascular outcomes in patients with new-onset diabetes mellitus: a nationwide cohort study. Cardiovasc Diabetol 2019; 18:36. [PMID: 30890169 PMCID: PMC6423842 DOI: 10.1186/s12933-019-0838-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 03/03/2019] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Because weight control is a cornerstone of diabetes management, it is important to understand the relationship of weight change to risk of cardiovascular disease (CVD) among patients with type 2 diabetes mellitus (DM). We aimed to investigate whether changes in weight early after diagnosis influence the incidence of CVD and all-cause mortality in patients with type 2 DM. METHODS Using nationally representative data from the Korean National Health Insurance System, 173,246 subjects with new-onset DM who underwent health examinations during 2007-2012 were included. Weight was measured at the time of diabetes diagnosis and 2 years later. Weight change over 2 years was divided into five categories of 5% weight change, from weight loss ≥ - 10% to weight gain ≥ 10%. RESULTS There were 3113 deaths (1.8%), 2060 cases of stroke (1.2%), and 1767 myocardial infarctions (MIs) (1.0%) during a median follow-up of 5.5 years. Subjects with weight gain ≥ 10% had a significantly higher risk of stroke (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.23-1.84), compared with the group with stable weight. There was no significant association between weight change after diagnosis of DM and incident MI. All-cause mortality showed a U-shaped curve according to weight change. The group with weight loss ≥ - 10% had the highest HR for all-cause mortality (HR 1.86; 95% CI 1.61-2.14) and the HR for weight gain ≥ 10% was 1.61 (95% CI 1.37-1.89). CONCLUSIONS Weight changes of more than 10% after diabetes diagnosis were associated with higher mortality and over 10% weight gain was associated with increased risk of stroke.
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Affiliation(s)
- Mee Kyoung Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #10 63-ro, Yeongdeungpo-gu, Seoul, 07345, South Korea
| | - Kyungdo Han
- Department of Medical Statistics, College of Medicine, The Catholic University of Korea, Seoul, 06591, South Korea
| | - Eun Sil Koh
- Division of Nephrology, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, 07345, South Korea
| | - Eun Sook Kim
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, 21431, South Korea
| | - Min-Kyung Lee
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Myongji Hospital, Goyang-Si, Gyeonggi-do, 10475, South Korea
| | - Ga Eun Nam
- Department of Family Medicine, Sahmyook Medical Center, Seoul, 02500, South Korea
| | - Hyuk-Sang Kwon
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Yeouido St. Mary's Hospital, College of Medicine, The Catholic University of Korea, #10 63-ro, Yeongdeungpo-gu, Seoul, 07345, South Korea.
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Kemps H, Kränkel N, Dörr M, Moholdt T, Wilhelm M, Paneni F, Serratosa L, Ekker Solberg E, Hansen D, Halle M, Guazzi M. Exercise training for patients with type 2 diabetes and cardiovascular disease: What to pursue and how to do it. A Position Paper of the European Association of Preventive Cardiology (EAPC). Eur J Prev Cardiol 2019; 26:709-727. [PMID: 30642190 DOI: 10.1177/2047487318820420] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Patients with type 2 diabetes mellitus suffer from dysregulation of a plethora of cardiovascular and metabolic functions, including dysglycaemia, dyslipidaemia, arterial hypertension, obesity and a reduced cardiorespiratory fitness. Exercise training has the potential to improve many of these functions, such as insulin sensitivity, lipid profile, vascular reactivity and cardiorespiratory fitness, particularly in type 2 diabetes mellitus patients with cardiovascular comorbidities, such as patients that suffered from an acute myocardial infarction, or after a coronary intervention such as percutaneous coronary intervention or coronary artery bypass grafting. The present position paper aims to provide recommendations for prescription of exercise training in patients with both type 2 diabetes mellitus and cardiovascular disease. The first part discusses the relevance and practical applicability of treatment targets that may be pursued, and failure to respond to these targets. The second part provides recommendations on the contents and methods to prescribe exercise training tailored to these treatment targets as well as to an optimal preparation and dealing with barriers and risks specific to type 2 diabetes mellitus and cardiac comorbidity.
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Affiliation(s)
- Hareld Kemps
- 1 Department of Cardiology, Máxima Medical Centre, Veldhoven, The Netherlands
| | - Nicolle Kränkel
- 2 Charité - Universitätsmedizin Berlin, Klinik für Kardiologie, Campus Benjamin Steglitz, Germany.,3 DZHK (German Centre for Cardiovascular Research), partner site Berlin, Germany
| | - Marcus Dörr
- 4 University Medicine Greifswald, Department of Internal Medicine B, Germany.,5 DZHK (German Centre for Cardiovascular Research), partner site Greifswald, Germany
| | - Trine Moholdt
- 6 Department of Circulation and Medical Imaging, Norwegian University of Science and Technology Trondheim, Norway.,7 St Olav's Hospital, Trondheim, Norway
| | - Matthias Wilhelm
- 8 Department of Cardiology, Bern University Hospital and University of Bern, Switzerland
| | - Francesco Paneni
- 9 Centre for Molecular Cardiology and Cardiology, Zurich University Hospital, University of Zurich, Switzerland
| | - Luis Serratosa
- 10 Hospital Universitario Quironsalud, Madrid, Spain.,11 Ripoll & De Prado Sport Clinic, FIFA Medical Centre of Excellence, Murcia, Spain
| | | | - Dominique Hansen
- 13 Hasselt University, Faculty of Rehabilitation Sciences, Diepenbeek, Belgium.,14 Heart Centre Hasselt, Jessa Hospital, Belgium
| | - Martin Halle
- 15 Technical University Munich, Department of Prevention, Rehabilitation and Sports Medicine, Germany.,16 DZHK (German Centre for Cardiovascular Research), partner site Munich, Germany
| | - Marco Guazzi
- 17 University Cardiology Department and Heart Failure Unit and Cardiopulmonary Laboratory, Cardiology, I.R.C.C.S., Milan, Italy.,18 Policlinico San Donato University Hospital, Milan, Italy
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GAESSER GLENNA, BLAIR STEVENN. The Health Risks of Obesity Have Been Exaggerated. Med Sci Sports Exerc 2019; 51:218-221. [DOI: 10.1249/mss.0000000000001746] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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20
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Oshakbayev K, Bimbetov B, Manekenova K, Bedelbayeva G, Mustafin K, Dukenbayeva B. Severe nonalcoholic steatohepatitis and type 2 diabetes: liver histology after weight loss therapy in a randomized clinical trial. Curr Med Res Opin 2019; 35:157-165. [PMID: 30431378 DOI: 10.1080/03007995.2018.1547696] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To evaluate the effectiveness of the fast weight loss method on liver steatosis, fibrosis, inflammation, glycemic and lipid features and body composition in patients with severe nonalcoholic steatohepatitis (NASH) and type 2 diabetes (T2D). METHODS A 24 week open prospective randomized controlled clinical trial including 80 adult patients (aged 40-65 years) was performed. The patients after randomization were divided into two groups: the main group followed the fast weight loss method; the control group received conventional drug treatment. The fast weight loss method included calorie restriction, salt intake, walking and sexual self-restraint. The conventional drug therapy included vitamin E, orlistat, pioglitazone hydrochloride, atorvastatin, lisinopril, benzodiazepines and anti-inflammatory agents. Primary endpoints were: ultrasound and histology suggestive of steatohepatitis, hepatic enzymes, weight loss, 2 hour oral glucose tolerance test and glycosylated hemoglobin A1C (HbA1c). Secondary endpoints were: blood pressure and lipids. RESULTS A total of 83% patients completed the study. In the main group weight lost was 7-16 kg (10-20% from baseline) for 8-10 weeks. In this group weight was lost due to reduction of fat mass only. The main vs. control group showed higher decrease in fat mass from baseline (p < .001). Ultrasound imaging and liver histological scoring system evidenced significant improvement in liver steatosis/fibrosis in the main group (p < .001). In the main vs. control group weight lost at 24 weeks led to positive laboratory changes in alanine aminotransferase (ALT), aspartate aminotransferase (AST), 2 hour oral glucose tolerance test (OGTT), HbA1c, Homeostasis Model Assessment insulin resistance indexes (HOMA-IR), blood pressure (BP), cholesterol, triglycerides, bilirubin total and blood hemoglobin (p = .01). The fast weight loss in the patients adequately led to decrease in symptomatic drugs up to complete abolition. CONCLUSIONS The study showed benefits of the fast weight loss method improving in steatosis/fibrosis and biochemical/metabolic outcomes in patients with severe NASH and T2D.
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Affiliation(s)
- Kuat Oshakbayev
- a Metabolic Syndrome Department , Nazarbayev University Medical Center, "ANADETO" medical center , Astana , Kazakhstan
| | - Bakytzhan Bimbetov
- b Gastroenterology and Hepatology Department , Nazarbayev University Medical Center , Astana , Kazakhstan
| | | | - Gulnara Bedelbayeva
- d Faculty of Postgraduate Education , Kazakh National Medical University named Asfendiarov , Almaty , Kazakhstan
| | - Khalit Mustafin
- e Department of Surgery , National Center for Neurosurgery , Astana , Kazakhstan
| | - Bibazhar Dukenbayeva
- f Faculty of Pathology and Forensic Medicine , Medical University Astana, "ANADETO" medical center , Astana , Kazakhstan
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21
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Jenkins DA, Bowden J, Robinson HA, Sattar N, Loos RJF, Rutter MK, Sperrin M. Adiposity-Mortality Relationships in Type 2 Diabetes, Coronary Heart Disease, and Cancer Subgroups in the UK Biobank, and Their Modification by Smoking. Diabetes Care 2018; 41:1878-1886. [PMID: 29970414 DOI: 10.2337/dc17-2508] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 06/05/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The obesity paradox in which overweight/obesity is associated with mortality benefits is believed to be explained by confounding and reverse causality rather than by a genuine clinical benefit of excess body weight. We aimed to gain deeper insights into the paradox through analyzing mortality relationships with several adiposity measures; assessing subgroups with type 2 diabetes, with coronary heart disease (CHD), with cancer, and by smoking status; and adjusting for several confounders. RESEARCH DESIGN AND METHODS We studied the general UK Biobank population (N = 502,631) along with three subgroups of people with type 2 diabetes (n = 23,842), CHD (n = 24,268), and cancer (n = 45,790) at baseline. A range of adiposity exposures were considered, including BMI (continuous and categorical), waist circumference, body fat percentage, and waist-to-hip ratio, and the outcome was all-cause mortality. We used Cox regression models adjusted for age, smoking status, deprivation index, education, and disease history. RESULTS For BMI, the obesity paradox was observed among people with type 2 diabetes (adjusted hazard ratio for obese vs. normal BMI 0.78 [95% CI 0.65, 0.95]) but not among those with CHD (1.00 [0.86, 1.17]). The obesity paradox was pronounced in current smokers, absent in never smokers, and more pronounced in men than in women. For other adiposity measures, there was less evidence for an obesity paradox, yet smoking status consistently modified the adiposity-mortality relationship. CONCLUSIONS The obesity paradox was observed in people with type 2 diabetes and is heavily modified by smoking status. The results of subgroup analyses and statistical adjustments are consistent with reverse causality and confounding.
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Affiliation(s)
- David A Jenkins
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K.
| | - Jack Bowden
- MRC Integrative Epidemiology Unit, Population Health Sciences, University of Bristol, Bristol, U.K
| | - Heather A Robinson
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, U.K
| | - Ruth J F Loos
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.,The Mindich Child Health and Development Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Martin K Rutter
- Division of Endocrinology, Diabetes and Gastroenterology, School of Medical Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K.,Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, U.K
| | - Matthew Sperrin
- School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K
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22
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Chen Y, Yang X, Wang J, Li Y, Ying D, Yuan H. Weight loss increases all-cause mortality in overweight or obese patients with diabetes: A meta-analysis. Medicine (Baltimore) 2018; 97:e12075. [PMID: 30170423 PMCID: PMC6392938 DOI: 10.1097/md.0000000000012075] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Overweight and obese patients with diabetes are advised to lose weight to improve their health; however, recent studies have demonstrated that weight loss may be associated with worse long-term survival in patients with diabetes. This meta-analysis aimed to examine the relationships between weight loss and all-cause mortality in overweight or obese individuals with diabetes. METHODS We searched the PubMed and EMBASE databases from inception to February 2017. We included prospective studies that reported sufficient information to extract mortality-specific relative risks (RRs) with corresponding 95% confidence intervals (CIs). RRs with 95% CIs were pooled using a random-effects model. A subgroup analysis was also performed to explore sources of heterogeneity. RESULTS Of the 1652 studies identified, 8 met the inclusion criteria. A total of 18,887 patients were included in this analysis. We found that compared with a stable weight, weight loss was associated with an increased risk of all-cause mortality (RR, 1.15; 95% CI, 1.04 to 1.28) and cardiovascular disease (CVD) mortality (RR, 1.15; 95% CI, 1.02 to 1.29) in overweight or obese adults with diabetes, whereas intentional weight loss was not associated with changes in all-cause mortality (RR, 0.90; 95% CI, 0.67 to 1.22). Weight gain was not associated with changes in all-cause mortality (RR, 1.17; 95% CI, 0.87 to 1.58) or CVD mortality (RR, 0.97; 95% CI, 0.93 to 1.01). Compared with an initial body mass index (BMI) of 25 to 30 kg/m, an initial BMI of >35 kg/m was associated with increased all-cause mortality (RR, 1.23; 95% CI, 1.01 to 1.50), which was further increased with an initial BMI of >40 kg/m (RR, 1.50; 95% CI, 1.16 to 1.94). CONCLUSION Our results indicate that weight loss but not weight gain increased all-cause mortality and CVD mortality in overweight or obese adults with diabetes.
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23
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Rennemark M, Jogréus C, Elmståhl S, Welmer AK, Wimo A, Sanmartin-Berglund J. Relationships Between Frequency of Moderate Physical Activity and Longevity: An 11-Year Follow-up Study. Gerontol Geriatr Med 2018; 4:2333721418786565. [PMID: 30046648 PMCID: PMC6055105 DOI: 10.1177/2333721418786565] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 05/21/2018] [Accepted: 05/23/2018] [Indexed: 11/17/2022] Open
Abstract
Objectives: Moderate physical activity gains survival. There are, however, several variables that may affect this relationship. In this study, the relationship between moderate physical activity and longevity was investigated, taking into account age, gender, smoking habits, cohabitation status, body mass index, leg strength and balance, education level and cognitive function. Method: A sample of 8,456 individuals aged 60 to 96 years, representative of the Swedish population, was included. Participants were followed from 2004 to 2015. Cox regression analyses were used to investigate the predictive value of physical activity on longevity. Results: Participants still alive in the follow-up measure were more physically active on a moderate level. Being active 2 to 3 times a week or more was related to a 28% lower risk of not being alive at the follow-up measure. Discussion: The low frequency of physical activity, necessary for survival benefits should be considered in public health programs.
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Affiliation(s)
- Mikael Rennemark
- Blekinge Institute of Technology, Karlskrona, Sweden.,Linnaeus University, Växjö, Sweden
| | - Claes Jogréus
- Blekinge Institute of Technology, Karlskrona, Sweden
| | | | | | - Anders Wimo
- Karolinska Institutet, Stockholm, Sweden.,Uppsala University, Sweden
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24
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Flegal KM, Ioannidis JPA. The Obesity Paradox: A Misleading Term That Should Be Abandoned. Obesity (Silver Spring) 2018; 26:629-630. [PMID: 29570246 DOI: 10.1002/oby.22140] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/09/2018] [Accepted: 01/13/2018] [Indexed: 01/09/2023]
Abstract
The term "obesity paradox" is a figure of speech, not a scientific term. The term has no precise definition and has been used to describe numerous observations that have little in common other than the finding of an association of obesity with a favorable outcome. The terminology has led to misunderstandings among researchers and the public alike. It's time for authors and editors to abandon the use of this term. Simply labeling counterintuitive findings as the "obesity paradox" adds no value. Unexpected findings should not be viewed negatively; such findings can lead to new knowledge, better treatments, and scientific advances.
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Affiliation(s)
- Katherine M Flegal
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Health Research and Policy and Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, California, USA
- Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California, USA
- Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, California, USA
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25
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26
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Li ZB, Wang ML, Dong SY, Sun BR, Miao XY, Fang FS, Dai ZX, Li CL, Tian H. Effects of body mass index and weight change on mortality in older men with impaired glucose regulation. Exp Gerontol 2017; 89:87-92. [DOI: 10.1016/j.exger.2016.12.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2016] [Revised: 12/28/2016] [Accepted: 12/30/2016] [Indexed: 11/26/2022]
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27
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Mensinger JL, Calogero RM, Stranges S, Tylka TL. A weight-neutral versus weight-loss approach for health promotion in women with high BMI: A randomized-controlled trial. Appetite 2016; 105:364-74. [PMID: 27289009 DOI: 10.1016/j.appet.2016.06.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/04/2016] [Accepted: 06/06/2016] [Indexed: 12/29/2022]
Abstract
Weight loss is the primary recommendation for health improvement in individuals with high body mass index (BMI) despite limited evidence of long-term success. Alternatives to weight-loss approaches (such as Health At Every Size - a weight-neutral approach) have been met with their own concerns and require further empirical testing. This study compared the effectiveness of a weight-neutral versus a weight-loss program for health promotion. Eighty women, aged 30-45 years, with high body mass index (BMI ≥ 30 kg/m(2)) were randomized to 6 months of facilitator-guided weekly group meetings using structured manuals that emphasized either a weight-loss or weight-neutral approach to health. Health measurements occurred at baseline, post-intervention, and 24-months post-randomization. Measurements included blood pressure, lipid panels, blood glucose, BMI, weight, waist circumference, hip circumference, distress, self-esteem, quality of life, dietary risk, fruit and vegetable intake, intuitive eating, and physical activity. Intention-to-treat analyses were performed using linear mixed-effects models to examine group-by-time interaction effects and between and within-group differences. Group-by-time interactions were found for LDL cholesterol, intuitive eating, BMI, weight, and dietary risk. At post-intervention, the weight-neutral program had larger reductions in LDL cholesterol and greater improvements in intuitive eating; the weight-loss program had larger reductions in BMI, weight, and larger (albeit temporary) decreases in dietary risk. Significant positive changes were observed overall between baseline and 24-month follow-up for waist-to-hip ratio, total cholesterol, physical activity, fruit and vegetable intake, self-esteem, and quality of life. These findings highlight that numerous health benefits, even in the absence of weight loss, are achievable and sustainable in the long term using a weight-neutral approach. The trial positions weight-neutral programs as a viable health promotion alternative to weight-loss programs for women of high weight.
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Affiliation(s)
- Janell L Mensinger
- Reading Health System, Sixth Avenue and Spruce Street, West Reading, PA, 19611, USA.
| | | | - Saverio Stranges
- Department of Population Health, Luxembourg Institute of Health, Luxembourg
| | - Tracy L Tylka
- Department of Psychology, The Ohio State University, USA
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