Approach to weight management in patients with advanced chronic kidney disease in a real-life clinical setting

Objective

Excess adiposity represents a risk factor for chronic kidney disease (CKD) and progression to end-stage kidney disease. Anti-Obesity Medications (AOMs) are vastly underutilized in patients with advanced CKD because of concerns related to safety and efficacy. This study was conducted to evaluate the real-world approach to weight management and the efficacy and safety of AOMs in people with advanced CKD.

Methods

This is a retrospective analysis of individuals with Body Mass Index (BMI) ≥ 27 kg/m2 and eGFR ≤ 30 mL/min/1.73 m2 referred to an academic medical weight-management program between 01/2015 and 09/2022. Evaluation of weight-management approaches, body weight change, treatment-related side effects, and reasons for treatment discontinuation were reported.

Results

Eighty-nine patients met inclusion criteria, 16 were treated with intensive lifestyle modifications (ILM) alone and 73 with AOMs (all treated with glucagon-like peptide-1 receptor agonist [GLP1-RA] +/- other AOMs) along with ILM. Patients treated with AOMs had a longer duration of on-treatment follow-up (median 924 days) compared to (93 days) the ILM group. Over 75% of patients treated with AOMs lost ≥5% body weight versus 25% of those treated with ILM. Only 15% of patients treated with AOMs discontinued therapy due to treatment-related side effects.

Conclusion

In patients with obesity and advanced CKD, GLP-1RA-based anti-obesity treatment was well-tolerated, effective, and led to durable weight reduction.

Factors Associated with the Decision to Complete Bariatric Metabolic Surgery among a Racially and Ethnically Diverse Sample of Adults: A Classification and Regression Tree Analysis

BACKGROUND

Less than 50% of eligible candidates who are referred complete Bariatric Metabolic Surgery (BMS). The factors influencing the decision to complete BMS, particularly how these factors vary across different racial and ethnic groups, remain largely unexplored.

METHODS

This prospective cohort study included adult patients referred to a bariatric surgeon or obesity medicine program between July 2019-September 2022. Sociodemographic characteristics, body mass index (BMI), anxiety, depression, body appreciation, and patient-physician relationship information were collected via survey and electronic health records. The association between BMS completion and potential decision-driving factors was examined using Classification and Regression Tree (CART) analysis.

RESULTS

A total of 406 BMS -eligible patients participated in the study (mean [SD] age: 47.5 [11.6] years; 87.2% women; 18.0% Hispanic, 39% non-Hispanic Black [NHB], and 39% non-Hispanic White [NHW]; mean [SD] BMI: 45.9 [10.1] kg/m2). A total of 147 participants (36.2%) completed BMS. Overall, the most influential factor driving the decision to complete BMS was younger age (< 68.4 years), higher patient satisfaction, and BMI (≥ 38.0 kg/m2). Hispanic participants prioritized age (< 55.4 years), female sex, and body appreciation. For NHB participants, the highest ranked factors were age < 56.3 years, BMI ≥ 35.8 kg/m2, and higher patient satisfaction. For NHW patients, the most influential factors were age (39.1 to 68.6 years) and higher body appreciation.

CONCLUSION

These findings highlight racial and ethnic group differences in the factors motivating individuals to complete BMS. By acknowledging these differences, healthcare providers can support patients from different backgrounds more effectively in their decision-making process regarding BMS.

Association between asthma, obesity, and metabolic syndrome in adolescents and young adults

BACKGROUND

The association of asthma and metabolic syndrome (MetS) among adolescents and young adults (AYAs) remains unclear, as well as the role of obesity in this relationship.

METHODS

AYAs aged 12-25 years who participated in the 2011-2020 National Health and Nutrition Examination Survey were included in this cross-sectional analysis. The moderating effect of obesity (age- and sex-adjusted body mass index ≥ 95th%ile for adolescents or ≥ 30 kg/m2 for adults) on asthma and MetS were evaluated in four groups: 1) both asthma and obesity; 2) asthma and no obesity; 3) obesity and no asthma; and 4) healthy controls with no obesity/asthma.

RESULTS

A total of 7,709 AYAs (53.9% aged 12-18 years, 51.1% males, and 54.4% non-Hispanic White) were included in this analysis. 3.6% (95% CI 2.8-4.3%) had obesity and asthma, 7.6% (95% CI 6.8-8.4%) had asthma and no obesity, 21.4% (95% CI 19.6-23.2%) had obesity and no asthma, and 67.4% (95% CI 65.4-69.4%) had neither obesity nor asthma. The estimated prevalence of MetS was greater among those with both obesity and asthma versus those with only asthma (4.5% [95% CI 1.7-7.3%] vs. 0.2% [95% CI 0-0.5%], p < 0.001). Compared to healthy controls, those with both obesity and asthma had ∼10 times higher odds of having MetS (aOR 10.5, 95% CI 3.9-28.1).

CONCLUSIONS

Our results show the association between MetS and asthma is stronger in AYAs with BMI-defined obesity. Efforts to prevent and treat obesity may reduce MetS occurrence in AYAs with asthma.

Impact of employment status and work setting on body weight and health behaviors among people with obesity

BACKGROUND

The impact of employment and the work-from-home (WFH) setting on body weight among people with obesity is unknown.

OBJECTIVE

This study examined the relationship between employment status, WFH setting, and change in body weight among adults with obesity during the COVID-19 pandemic.

METHODS

Patients from an obesity medicine clinic completed an online survey in 2022 to assess health, work, and lifestyle behaviors. Multiple regression models examined the association between WFH status and change in body weight.

RESULTS

The analytical sample included 380 patients (81.9% female, mean age 52.5 years, mean body mass index 43.25, 50.0% non-Hispanic White, 25.7% non-Hispanic Black, 18.7% Hispanic, 5.7% other ethnicity). During the pandemic, 28.7% were employed in a WFH setting (73.4% of this subgroup were in a WFH setting only), 36.1% were employed but not in a WFH setting, 11.8% were unemployed, and 23.4% were retired. Mean body weight change for participants who partially WFH during the pandemic was +5.4 (±7.2) % compared to those completely WFH -0.3 (±9.8) % (P = 0.006). After adjusting for key demographics, participants who were partially WFH gained 7.8% more weight compared to those completely WFH (β= 7.28, SE = 1.91, p <  0.001). The most significant predictors for weight gain after adjusting for WFH frequency (partially vs. completely) included overeating (aOR 11.07, 95% CI 3.33-36.77), more consumption of fast food (aOR 7.59, 95% 2.41-23.91), and depression (aOR 6.07, 95% CI 1.97-18.68).

CONCLUSION

These results show that during the COVID-19 pandemic, the WFH hybrid (combination of office and WFH) setting is associated with greater weight gain compared to those who completely WFH in people with obesity. Risk factors include overeating, higher fast food consumption, and depression.

Transoral gastric outlet reduction for post-prandial hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Post-prandial hypoglycemia is an uncommon but disabling late complication of Roux-en-Y gastric bypass (RYGB). Most patients can be treated with dietary interventions and medications; however, some patients develop refractory hypoglycemia that may lead to multiple daily episodes and seizures. While RYGB reversal surgery is an effective treatment, complication rates are high, and patients inevitably experience weight regain. Transoral gastric outlet reduction (TORe) is a minimally invasive treatment that is effective for early and late dumping syndrome. However, prior studies have not distinguished the effectiveness of TORe specifically for patients with post-prandial hypoglycemia. This study aims to describe a single institution's experience of TORe for treating post-prandial hypoglycemia.

METHODS

This is a case series of patients with prior RYGB complicated by post-prandial hypoglycemia who underwent TORe from February 2020 to September 2021. Pre-procedural characteristics and post-procedural outcomes were obtained. Outcomes assessed included post-prandial hypoglycemia episodes, dumping syndrome symptoms, and weight change.

RESULTS

A total of 11 patients underwent TORe from 2020 to 2021 for post-prandial hypoglycemia. Three (27%) patients had a history of seizures due to hypoglycemia. All had been advised on dietary changes, and ten patients (91%) were on medications for dumping. All patients reported a reduction in post-prandial hypoglycemic events as well as the majority of dumping syndrome symptoms during an average follow-up time of 409 ± 125 days. Ten patients (91%) had experienced weight regain from their post-RYGB nadir weight. For these patients, the average total body weight loss 12 months post-TORe was 12.4 ± 12%. There were no complications requiring hospitalization. One patient experienced post-TORe nausea and vomiting requiring dilation of the gastrojejunal anastomosis with resolution in symptoms.

CONCLUSION

TORe is a safe and effective treatment for post-prandial hypoglycemia and weight regain after RYGB in patients with symptoms refractory to medications and dietary changes.

Telehealth utilization among multi-ethnic patients with obesity during the COVID-19 pandemic

INTRODUCTION

The science of telemedicine has shown great advances over the past decade. However, the field needs to better understand if a change in care delivery from in-person to telehealth as a result of the COVID-19 pandemic will yield durable patient engagement and health outcomes for patients with obesity. The objective of this study was to examine the association of mode of healthcare utilization (telehealth versus in-person) and sociodemographic factors among patients with obesity during the COVID-19 pandemic.

METHODS

A retrospective medical chart review identified patients with obesity from a university outpatient obesity medicine clinic and a community bariatric surgery practice. Patients completed an online survey (1 June 2020-24 September 2020) to assess changes in healthcare utilization modality during subsequent changes in infection rates in the geographic area. Logistic regression analysis examined the association of mode of healthcare utilization and key sociodemographic characteristics.

RESULTS

A total of 583 patients (87% female, mean age 51.2 years (standard deviation 13.0), mean body mass index 40.2 (standard deviation 6.7), 49.2% non-Hispanic white, 28.7% non-Hispanic black, 16.4% Hispanic, 7% other ethnicity, 33.1% completed bariatric surgery) were included. Adjusted logistic regression models showed older age was inversely associated with telehealth use (adjusted odds ratio = 0.58, 95% confidence interval 0.34-0.98) and non-Hispanic black were more likely to use telehealth compared to non-Hispanic white (adjusted odds ratio = 1.72, 95% confidence interval 1.05-2.81).

CONCLUSIONS

The COVID-19 pandemic is impacting access to healthcare among patients with obesity. Telehealth is an emerging modality that can maintain healthcare access during the pandemic, but utilization varies by age and ethnicity in this high-risk population.

Endoscopic Sleeve Gastroplasty: A Practice Pattern Survey

PURPOSE

Obesity is a complex, chronic disease that is strongly associated with complications which cost the US healthcare system billions of dollars per year. Endoscopic sleeve gastroplasty (ESG) has emerged as a safe and effective procedure for treatment of obesity, but without practice guidelines there are likely to be variations practice. We sought to describe current practice patterns amongst endoscopists who perform ESG to help define areas of focus for future research and guideline development.

METHODS

We conducted an anonymous cross-sectional survey to examine practice patterns related to ESG. The survey was organized in 5 sections: Endoscopic Practice, Training, and Resources; Pre-ESG Evaluation and Payment Model; Perioperative/Operative Period; Post-operative Period; and Endobariatric Practice Other Than ESG.

RESULTS

A variety of exclusion criteria were reported by physicians performing ESG. Most respondents (n = 21/32, 65.6%) would not perform ESG for BMI under 27, and 40.6% (n = 13/32) would not perform ESG on patients with BMI over 50. The majority of respondents (74.2%, n = 23/31) reported ESG was not covered in their region, and most reported patients covered residual costs (67.7%, n = 21/31).

CONCLUSIONS

We found significant variability with respect to practice setting, exclusion criteria, pre-procedural evaluation, and medication use. Without guidelines for the selection of patients or standards for pre- and post-ESG care, substantial barriers to coverage will remain, and ESG will remain limited to those who can meet out-of-pocket costs. Larger studies are needed to confirm our findings, and future research should be focused on establishing patient selection criteria and standards in practices to provide guidance for endobariatric programs.

Depression and Anxiety as Predictors of Metabolic and Bariatric Surgery Completion Among Ethnically Diverse Patients

BACKGROUND

Mental health conditions including depression and anxiety are often prevalent among metabolic and bariatric surgery (MBS) patients, but it is not known if these conditions predict the decision to complete the procedure and if this varies by race and ethnicity. This study aimed to determine if depression and anxiety are associated with MBS completion among a race/ethnically diverse sample of patients.

METHODS

This prospective cohort study included participants who were referred to an obesity program or two MBS practices between August 2019 and October 2022. Participants completed the Mini International Neuropsychiatric Interview (MINI) instrument to determine history of anxiety and/or depression, as well as MBS completion status (Y/N). Multivariable logistic regression models determined the odds of MBS completion by depression and anxiety status adjusting for age, sex, body mass index, and race/ethnicity.

RESULTS

The sample consisted of 413 study participants (87 % women, 40% non-Hispanic White, 39% non-Hispanic Black, and 18% Hispanic). Participants with a history of anxiety were less likely to complete MBS (aOR = 0.52, 95% CI = 0.30-0.90, p = 0.020). Women had increased odds of a history of anxiety (aOR = 5.65, 95% CI = 1.64-19.49, p = 0.006) and of concurrent anxiety and depression (aOR = 3.07, 95% CI = 1.39-6.79, p = 0.005) compared to men.

CONCLUSIONS

Results showed that participants with anxiety were 48% less likely to complete MBS compared to those without anxiety. Additionally, women were more likely to report a history of anxiety with and without depression versus men. These findings can inform pre-MBS programs about risk factors for non-completion.

American Association of Clinical Endocrinology Consensus Statement: Addressing Stigma and Bias in the Diagnosis and Management of Patients with Obesity/Adiposity-Based Chronic Disease and Assessing Bias and Stigmatization as Determinants of Disease Severity

OBJECTIVE

To focus on the intersection of perception, diagnosis, stigma, and weight bias in the management of obesity and obtain consensus on actionable steps to improve care provided for persons with obesity.

METHODS

The American Association of Clinical Endocrinology (AACE) convened a consensus conference of interdisciplinary health care professionals to discuss the interplay between the diagnosis of obesity using adiposity-based chronic disease (ABCD) nomenclature and staging, weight stigma, and internalized weight bias (IWB) with development of actionable guidance to aid clinicians in mitigating IWB and stigma in that context.

RESULTS

The following affirmed and emergent concepts were proposed: (1) obesity is ABCD, and these terms can be used in differing ways to communicate; (2) classification categories of obesity should have improved nomenclature across the spectrum of body mass index (BMI) using ethnic-specific BMI ranges and waist circumference (WC); (3) staging the clinical severity of obesity based on the presence and severity of ABCD complications may reduce weight-centric contribution to weight stigma and IWB; (4) weight stigma and internalized bias are both drivers and complications of ABCD and can impair quality of life, predispose to psychological disorders, and compromise the effectiveness of therapeutic interventions; (5) the presence and of stigmatization and IWB should be assessed in all patients and be incorporated into the staging of ABCD severity; and (6) optimal care will necessitate increased awareness and the development of educational and interventional tools for health care professionals that address IWB and stigma.

CONCLUSIONS

The consensus panel has proposed an approach for integrating bias and stigmatization, psychological health, and social determinants of health in a staging system for ABCD severity as an aid to patient management. To effectively address stigma and IWB within a chronic care model for patients with obesity, there is a need for health care systems that are prepared to provide evidence-based, person-centered treatments; patients who understand that obesity is a chronic disease and are empowered to seek care and participate in behavioral therapy; and societies that promote policies and infrastructure for bias-free compassionate care, access to evidence-based interventions, and disease prevention.

Effectiveness of semaglutide versus liraglutide for treating post-metabolic and bariatric surgery weight recurrence

OBJECTIVE

The aim of this study was to compare the effectiveness of semaglutide versus liraglutide for treating post-metabolic and bariatric surgery (MBS) weight recurrence.

METHODS

A retrospective analysis of 207 adults with post-MBS weight recurrence treated with semaglutide 1.0 mg weekly (n = 115) or liraglutide 3.0 mg daily (n = 92) at an academic center from January 1, 2015, through April 1, 2021, was conducted. The primary end point was percentage body weight change at 12 months of treatment with regimens containing semaglutide or liraglutide.

RESULTS

The mean sample age was 55.2 years; mean BMI was 40.4 kg/m2 ; 89.9% were female; and 50% completed sleeve gastrectomy, 29% completed Roux-en-Y gastric bypass, and 21% completed adjustable gastric banding. Least-squares mean weight change at 12 months was -12.92% versus -8.77% in the semaglutide and liraglutide groups, respectively (p < 0.001). The adjusted odds ratios were 2.34 (95% CI: 1.28-4.29) for ≥10% weight loss and 2.55 (95% CI: 1.22-5.36) for ≥15% weight loss over 12 months in the semaglutide group versus liraglutide group, respectively. Weight-loss efficacy of semaglutide (vs. liraglutide) did not differ by subgroups explored, including age, sex, and MBS procedure.

CONCLUSIONS

These results show that treatment regimens including semaglutide 1.0 mg weekly lead to superior weight loss compared with liraglutide 3.0 mg daily for treating post-MBS weight recurrence, regardless of procedure type or the magnitude of weight recurrence.

Obesity among Latinx people in the United States: A review

Obesity is a serious, chronic disease that is associated with a range of adiposity-based comorbidities, including cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease. In the United States, obesity is a public health crisis, affecting more than 40% of the population. Obesity disproportionately affects Latinx people, who have a higher prevalence of obesity and related comorbidities (such as cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease) compared with the general population. Many factors, including genetic predisposition, environmental factors, traditional calorie-dense Latinx diets, family dynamics, and differences in socioeconomic status, contribute to the increased prevalence and complexity of treating obesity in the Latinx population. Additionally, significant heterogeneity within the Latinx population and disparities in health care access and utilization between Latinx people and the general population add to the challenge of obesity management. Culturally tailored interventions have been successful for managing obesity and related comorbidities in Latinx people. Antiobesity medications and bariatric surgery are also important options for obesity treatment in Latinx people. As highlighted in this review, when managing obesity in the Latinx population, it is critical to consider the impact of genetic, dietary, cultural, and socioeconomic factors, in order to implement an individualized treatment strategy.

Discontinuation and reduction of asthma medications after metabolic and bariatric surgery: A systematic review and meta-analysis

Obesity is a risk factor for asthma. Metabolic and bariatric surgery (MBS) is a safe and effective treatment option for obesity. Weight reduction via MBS, in turn, may improve asthma outcomes and decrease the need for asthma medications. The aim of the systematic review and meta-analysis is to explore the available evidence focused on the impact of MBS on the improvement of asthma outcomes via the discontinuation and reduction of asthma medications. After a comprehensive search in the PubMed, Embase, and Cochrane Central Register of Controlled Trials (CENTRAL) databases, 15 studies, including pre-post MBS data on asthma medication use among adults, were eligible for the systematic review. Thirteen studies reported the proportion of patient who discontinued asthma medication post-MBS and was meta-analyzed using random effects. Results showed 54% patients completely discontinued asthma medications (95% confidence interval 42%-67%, I²  = 86.2%, p < 0.001). The average number of asthma medications was also decreased by approximately 22%-46%. MBS provides strong therapeutic benefits for patients with asthma, as evidenced by the complete discontinuation of asthma medications in over 50% of MBS completers. The inference was limited by the small number, variations in follow-up time and rates, and heterogeneity of studies. Studies that include more ethnically diverse participant samples are needed to improve generalizability.

Association Between Patient Satisfaction With Their Patient-Physician Relationship and Completion of Bariatric Surgery by Race and Ethnicity Among US Adults

IMPORTANCE

Metabolic and bariatric surgery (MBS) is an effective and safe treatment for obesity and its comorbidities, but less than 50% of those who are eligible and referred for MBS complete the procedure. The patient-physician relationship could be a decisive factor in the decision to complete MBS; however, this relationship has not been explored, particularly among racially and ethnically diverse populations.

OBJECTIVE

To examine the association between patient-reported satisfaction with their patient-physician relationship and MBS completion by self-reported racial and ethnic group.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study included 408 patients who were referred to a bariatric surgeon or obesity medicine program between July 24, 2019, and May 19, 2022.

EXPOSURE

Patient satisfaction with their physician was measured by 7 dimensions (general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with physician, and accessibility and convenience) using the Patient Satisfaction Questionnaire Short Form.

MAIN OUTCOMES AND MEASURES

Completion status for MBS (yes or no).

RESULTS

A total of 408 patients (mean [SD] age, 47.3 [11.6] years; among 366 with data available, 317 [86.6%] women and 49 [13.4%] men) were included in the study. Of 363 patients with data available on race and ethnicity, 66 were Hispanic/Latinx (18.2%), 136 (37.5%) were non-Hispanic Black, 146 (40.2%) were non-Hispanic White, and 15 (4.1%) were other race or ethnicity. A total of 124 patients (30.4%) completed MBS. Overall, the mean (SD) patient satisfaction score was significantly greater in MBS completers vs noncompleters (3.86 [0.56] vs 3.61 [0.64]; P < .001). Multivariable logistic regression analysis showed technical quality was the most significant factor for MBS completion (adjusted odds ratio [aOR], 1.99 [95% CI, 1.24-3.19]), followed by communication (aOR, 1.78 [95% CI, 1.16-2.72]) and accessibility and convenience (aOR, 1.61 [95% CI, 1.03-2.53]). The interaction between racial and ethnic groups and patient satisfaction was not significant (eg, mean [SD] score for Hispanic/Latinx completers, 3.95 [0.55] vs 3.77 [0.60] for non-Hispanic White completers; P = .46 for interaction).

CONCLUSIONS AND RELEVANCE

These findings suggest that there is an association between patient satisfaction with the patient-physician relationship and the decision to complete MBS regardless of race and ethnicity. These findings have important implications for strategies to improve the proportion of qualified patients who complete MBS to achieve improved health outcomes.

Changes in body weight, health behaviors, and mental health in adults with obesity during the COVID-19 pandemic

OBJECTIVE

The aim of this study was to examine the relationships between body weight changes, health behaviors, and mental health in adults with obesity during the second year of the COVID-19 pandemic.

METHODS

Between March 1, 2021, and November 30, 2021, adults from three obesity practices completed an online survey. The primary outcomes were ≥ 5% of body weight change since March 2020 and associated health behaviors and mental health factors.

RESULTS

The sample (n = 404) was 82.6% female (mean age 52.5 years, mean BMI 43.3 kg/m² ). Mean weight change was + 4.3%. Weight gain ≥ 5% was reported by 30% of the sample, whereas 19% reported ≥ 5% body weight loss. The degree of both weight gain and weight loss correlated positively with baseline BMI. Eighty percent of the sample reported difficulties with body weight regulation. Those who gained ≥ 5% versus those who lost ≥ 5% body weight were more likely to report higher levels of stress, anxiety, and depression; less sleep and exercise; less healthy eating and home-cooked meals; and more takeout foods, comfort foods, fast foods, overeating, and binge eating.

CONCLUSIONS

Weight gain in adults with obesity during the COVID-19 pandemic is associated with higher baseline BMI, deteriorations in mental health, maladaptive eating behaviors, and less physical activity and sleep. Further research is needed to identify effective interventions for healthier minds, behaviors, and body weight as the pandemic continues.

What is clinically relevant weight loss for your patients and how can it be achieved? A narrative review

Obesity is a chronic disease with increasing prevalence. It affects quality of life and renders those affected at increased risk of mortality. For people living with obesity, weight loss is one of the most important strategies to improve health outcomes and prevent or reverse obesity-related complications. In line with newly released clinical practice guidelines, weight loss targets for people living with obesity should be defined individually based on their clinical profile, and progress measured in the context of improvements in health outcomes, rather than weight loss alone. We outline current treatment options for clinically meaningful weight loss and briefly discuss pharmacological agents and devices under development. Numerous studies have shown that weight loss of ≥5% results in significant improvements in cardiometabolic risk factors associated with obesity; this degree of weight loss is also required for the approval of novel anti-obesity medications by the US Food and Drug Administration. However, some obesity-related comorbidities and complications, such as non-alcoholic steatohepatitis, obstructive sleep apnea, gastroesophageal reflux disease and remission of type 2 diabetes, require a greater magnitude of weight loss to achieve clinically meaningful improvements. In this review, we assessed the available literature describing the effect of categorical weight losses of ≥5%, ≥10%, and ≥15% on obesity-related comorbidities and complications, and challenge the concept of clinically meaningful weight loss to go beyond percentage change in total body weight. We discuss weight-loss interventions including lifestyle interventions and therapeutic options including devices, and pharmacological and surgical approaches as assessed from the available literature.

Diabetes Status Modifies the Association Between Different Measures of Obesity and Heart Failure Risk Among Older Adults: A Pooled Analysis of Community-Based NHLBI Cohorts

BACKGROUND

Obesity and diabetes are associated with a higher risk of heart failure (HF). The interrelationships between different measures of adiposity-overall obesity, central obesity, fat mass (FM)-and diabetes status for HF risk are not well-established.

METHODS

Participant-level data from the ARIC study (Atherosclerosis Risk in Communities; visit 5) and the CHS (Cardiovascular Health Study; visit 1) cohorts were obtained from the National Heart, Lung, and Blood Institute Biologic Specimen and Data Repository Information Coordinating Center, harmonized, and pooled for the present analysis, excluding individuals with prevalent HF. FM was estimated in all participants using established anthropometric prediction equations additionally validated using the bioelectrical impedance-based FM in the ARIC subgroup. Incident HF events on follow-up were captured across both cohorts using similar adjudication methods. Multivariable-adjusted Fine-Gray models were created to evaluate the associations of body mass index (BMI), waist circumference (WC), and FM with risk of HF in the overall cohort as well as among those with versus without diabetes at baseline. The population attributable risk of overall obesity (BMI≥30 kg/m²), abdominal obesity (WC>88 and 102 cm in women and men, respectively), and high FM (above sex-specific median) for incident HF was evaluated among participants with and without diabetes.

RESULTS

The study included 10 387 participants (52.9% ARIC; 25.1% diabetes; median age, 74 years). The correlation between predicted and bioelectrical impedance-based FM was high (R²=0.90; n=5038). During a 5-year follow-up, 447 participants developed HF (4.3%). Higher levels of each adiposity measure were significantly associated with higher HF risk (hazard ratio [95% CI] per 1 SD higher BMI=1.15 [1.05, 1.27], WC=1.22 [1.10, 1.36]; FM=1.13 [1.02, 1.25]). A significant interaction was noted between diabetes status and measures of BMI (P interaction=0.04) and WC (P interaction=0.004) for the risk of HF. In stratified analysis, higher measures of each adiposity parameter were significantly associated with higher HF risk in individuals with diabetes (hazard ratio [95% CI] per 1 SD higher BMI=1.29 [1.14-1.47]; WC=1.48 [1.29-1.70]; FM=1.25 [1.09-1.43]) but not those without diabetes, including participants with prediabetes and euglycemia. The population attributable risk percentage of overall obesity, abdominal obesity, and high FM for incident HF was higher among participants with diabetes (12.8%, 29.9%, and 13.7%, respectively) versus those without diabetes (≤1% for each).

CONCLUSIONS

Higher BMI, WC, and FM are strongly associated with greater risk of HF among older adults, particularly among those with prevalent diabetes.

Substance Use, Mental Health, and Weight-Related Behaviors During the COVID-19 Pandemic Among Metabolic and Bariatric Surgery Patients

Purpose

The impact of the COVID-19 pandemic on behavioral issues among those who have completed bariatric surgery (BS) is not well described in ethnically diverse populations. The aim of this study was to compare the impact of COVID-19 lockdown orders and after lockdown orders were lifted on substance use, mental health, and weight-related behaviors among a sample of post-BS adults.

Materials and Methods

A retrospective medical chart review identified BS patients from one university-based obesity medicine clinic and two BS practices. An online non-anonymous survey was implemented in two phases: during lockdown (April 1–May 31, 2020) and after lockdown orders were lifted (June 1, 2020–September 30, 2020) to obtain information about the COVID-19 pandemic’s impact on BS patients.

Results

A total of 189 (during lockdown=39, post-lockdown=150) participants (90.4% female, mean age 52.4 years, SD 11.1, 49.8% non-Hispanic White, 30.6% non-Hispanic Black, 16.1% Hispanic) participated. Lockdown participants were more likely to have sleep problems (74.3% vs. 56.1%, P=.039) and feel anxious (82.0% vs. 63.0%, P=.024) versus post-lockdown participants. A majority (83.4%) reported depression in both lockdown/post-lockdown. Post-lockdown participants were more than 20 times more likely to report substance use compared those in lockdown (aOR 20.56, 95% CI 2.66–158.4).

Conclusions and Relevance

The COVID-19 pandemic is having a substantial negative impact on substance use, mental health, and weight-related health behaviors in diverse BS patients. These findings have important implications for post-BS patient care teams and may suggest the integration of screening tools to identify those at high risk for behavioral health issues.

Graphical abstract

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-021-05488-6.

Immunosuppression and Clostridioides (Clostridium) difficile Infection Risk in Metabolic and Bariatric Surgery Patients

BACKGROUND

Immunosuppressant use increases risk of Clostridioides (Clostridium) difficile infection. To date, no studies have analyzed the relationship between immunosuppressant use and C difficile infections after metabolic and bariatric surgery (MBS).

METHODS

A retrospective analysis of the 2015-2018 MBSAQIP data was conducted. The MBSAQIP data include information from 854 affiliated practices in the US and Canada. Initial sample size was 760,076 MBS patients. After excluding participants due to missing variables (n = 188,106) and the use of surgical procedures other than Roux-en-Y gastric bypass and sleeve gastroplasty (n = 129,712), final analyses were performed on 442,258 participants. Logistic regression models generated the odds of C difficile infection developing post MBS, according to immunosuppressant status (positive or negative).

RESULTS

Unadjusted logistic regression analysis showed that patients using immunosuppressants were 95% more likely to have postoperative C difficile infection (odds ratio 1.945; 95% CI, 1.230 to 3.075; p < 0.001) vs MBS patients not taking immunosuppressants. After adjusting for age, sex, ethnicity, preoperative BMI, diabetes status, and surgical procedure type, the association remained unaffected (adjusted odds ratio 1.956; 95% CI, 1.236 to 3.095; p < 0.01). Patients who completed the laparoscopic Roux-en-Y gastric bypass procedure had more than double the odds of C difficile infection developing compared with those who completed the laparoscopic sleeve gastrectomy procedure (odds ratio 2.183; 95% CI, 1.842 to 2.587; p < 0.0001).

CONCLUSIONS

Our results using a population-based sample of MBS patients showed that those taking immunosuppressants have a significantly higher risk of developing Clostridioides (Clostridium) difficile infection postoperatively. These findings suggest that patients using immunosuppressants should be closely monitored both pre and post procedure.

Pharmacotherapies for Post-Bariatric Weight Regain: Real-World Comparative Outcomes

OBJECTIVE

This study aimed to compare outcomes of treatment strategies for weight regain after bariatric surgery.

METHODS

This is a retrospective analysis of 207 individuals treated for post-bariatric weight regain at an academic center from January 1, 2014, through November 25, 2019. Percentage body weight loss was compared after 3, 6, 9, and 12 months of treatment among an intensive lifestyle modification (ILM) group, a non-glucagon-like-1 receptor agonist (GLP-1-RA)-based weight-loss pharmacotherapy (WLP) group, and a GLP-1-RA-based WLP group (the latter two groups in conjunction with ILM).

RESULTS

The percentage body weight loss was significantly different between groups after 3 months (1.4% vs. 2.2% vs. 4.5% [P < 0.001] for ILM, non-GLP-1-RA-based WLP, and GLP-1-RA-based WLP groups, respectively), 6 months (0.8% vs. 2.9% vs. 6.7% [P < 0.001]), and 9 months (-1.6% vs. 5.6% vs. 6.9% [P = 0.007]). There was a significant difference in the percentage of individuals achieving ≥5% weight loss after 3, 6, and 9 months, with most occurring in the GLP-1-RA-based WLP group. In a multiple regression analysis including bariatric surgery type, treatment group was the only significant predictor of percentage weight change.

CONCLUSIONS

GLP-1-RA-based WLP therapies were found to be more effective for treating post-bariatric weight regain than non-GLP-1-RA-based WLP or ILM, regardless of surgery type.

Substance use, mental health and weight-related behaviours during the COVID-19 pandemic in people with obesity

Studies have shown the negative impact of COVID-19 lockdown orders on mental health and substance use in the general population. The aim of this study was to examine the impact of the COVID-19 pandemic onsubstance use, mental health and weight-related behaviors in a sample of adults with obesity after lockdown orders were lifted (June-September 2020). A retrospective medical chart review identified patients with obesity from one university-based obesity medicine clinic, and two metabolic and bariatric surgery (MBS) practices. Patients who completed an online survey from June 1, 2020 to September 30, 2020 were included. The primary outcome measure was substance use (various drugs, alcohol, tobacco). Substance use and mental health survey questions were based on standardized, validated instruments. A total of 589 patients (83.3% female, mean age 53.6 years [SD 12.8], mean BMI 35.4 [SD 9.1], 54.5% Non-Hispanic white, 22.3% post-MBS) were included. Seventeen patients (2.9%) tested positive for SARS-CoV-2 and 13.5% reported symptoms. Nearly half (48.4%) of the sample reported recreational substance use and 9.8% reported increased use since the start of the pandemic. There was substantial drug use reported (24.3% opioids, 9.5% sedative/tranquilizers, 3.6% marijuana, and 1% stimulants). Patients who reported stockpiling food more (adjusted Odds Ratio [aOR] 1.50, 95% CI 1.03-2.18), healthy eating more challenging (aOR 1.47, 95% CI 1.01-2.16), difficulty falling asleep (aOR 1.64, 95% CI 1.14-2.34), and anxiety (aOR 1.47, 95% CI 1.01-2.14) were more likely to report substance use versus non-users. Results here show that the COVID-19 pandemic is having a deleterious impact on substance use, mental health and weight-related health behaviors in people with obesity regardless of infection status.

Type 2 Diabetes and HbA1c Predict All-Cause Post-Metabolic and Bariatric Surgery Hospital Readmission

OBJECTIVE

The main goal of this analysis was to determine whether type 2 diabetes and hemoglobin A1c (HbA1c) predict all-cause 30-day hospital readmission after metabolic and bariatric surgery (MBS). It was hypothesized that a diagnosis of type 2 diabetes or high HbA1c values would predict all-cause hospital readmission rates post MBS.

METHODS

A retrospective analysis from the 2015-2018 Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) cohort was completed (N = 744,776); 30,972 participants were readmitted during the 30 days post MBS.

RESULTS

Mean age of the MBSAQIP sample was 45.1 (11.5) years, and the majority were female (80.7%) and non-Hispanic White (59.4%). The all-cause hospital readmission rate was 4.2% and increased by 10% in those with uncontrolled type 2 diabetes (HbA1c > 7.5% [> 58 mmol/mol]); after adjustment, diabetes was not associated with increased readmission. Uncontrolled type 2 diabetes, type 2 diabetes, and prediabetes resulted in less weight loss 30 days post MBS.

CONCLUSIONS

These results based on a national MBS cohort showed that uncontrolled type 2 diabetes is associated with a greater likelihood of all-cause hospital readmission and reduced weight loss 30 days post MBS. Both type 2 diabetes and prediabetes were also associated with decreased weight loss 30 days post MBS. These findings highlight the need to classify and optimize glycemic control prior to MBS.

Impact of COVID-19 stay-at-home orders on weight-related behaviours among patients with obesity

How the impact of the COVID-19 stay-at-home orders is influencing physical, mental and financial health among vulnerable populations, including those with obesity is unknown. The aim of the current study was to explore the health implications of COVID-19 among a sample of adults with obesity. A retrospective medical chart review identified patients with obesity from an obesity medicine clinic and a bariatric surgery (MBS) practice. Patients completed an online survey from April 15, 2020 to May 31, 2020 to assess COVID-19 status and health behaviours during stay-at-home orders. Logistic regression models examined the impact of these orders on anxiety and depression by ethnic group. A total of 123 patients (87% female, mean age 51.2 years [SD 13.0]), mean BMI 40.2 [SD 6.7], 49.2% non-Hispanic white (NHW), 28.7% non-Hispanic black, 16.4% Hispanic, 7% other ethnicity and 33.1% completed MBS were included. Two patients tested positive for severe acute respiratory syndrome coronavirus 2 and 14.6% reported symptoms. Then, 72.8% reported increased anxiety and 83.6% increased depression since stay-at-home orders were initiated. Also 69.6% reported more difficultly in achieving weight loss goals, less exercise time (47.9%) and intensity (55.8%), increased stockpiling of food (49.6%) and stress eating (61.2%). Hispanics were less likely to report anxiety vs NHWs (adjusted odds ratios 0.16; 95% CI, 0.05-0.49; P = .009). Results here showed the COVID-19 pandemic is having a significant impact on patients with obesity regardless of infection status. These results can inform clinicians and healthcare professionals about effective strategies to minimize COVID-19 negative outcomes for this vulnerable population now and in post-COVID-19 recovery efforts.

Metabolic syndrome remission after Roux-en-Y gastric bypass or sleeve gastrectomy

BACKGROUND

Bariatric surgery is known to decrease weight and the prevalence of comorbidities, but there is little evidence on the differential effect of Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) on the remission of the aggregate outcome, metabolic syndrome, 4 years after surgery. The purpose of this study was to determine the effectiveness of RYGB and SG on metabolic syndrome in veterans.

METHODS

We retrospectively reviewed consecutive patients who underwent SG and RYGB at the Dallas Veterans Affairs Medical Center from 2003 to 2012. We determined the effect of both the operations on the remission of metabolic syndrome, its individual components, and medium-term morbidity and mortality. A sensitivity analysis was performed using propensity matching.

RESULTS

A total of 266 patients were identified (159 RYGB and 107 SG) with 96% follow-up after 4 years. The mean age of the cohort was 51.4 years; the majority of patients were male (59%) and Caucasian (69%). RYGB patients had a greater mean body mass index and were more likely to have hypertension or hypertriglyceridemia. RYGB was associated with a similar metabolic syndrome remission to SG (37.6% vs 26.8%; P=0.09). The percentage of weight loss was 26.5% after RYGB and 10.8% after SG at 4 years post operation (P<0.01). Predictors of metabolic syndrome persistence were male gender, type 2 diabetes, and low high-density lipoprotein. While both the operations were associated with similar mortality (RYGB 4.4%, SG 2.8%; P=0.74), RYGB was associated with a greater rate of morbidity.

CONCLUSION

RYGB and SG seem to be associated with similar remission rates of metabolic syndrome at 4 years. RYGB yields greater weight loss with greater medium-term complications.

Spillover of Fatty acids during dietary fat storage in type 2 diabetes: relationship to body fat depots and effects of weight loss

Spillover of lipoprotein lipase-generated fatty acids from chylomicrons into the plasma free fatty acid (FFA) pool is an important source of FFA and reflects inefficiency in dietary fat storage. We measured spillover in 13 people with type 2 diabetes using infusions of a [(3)H]triolein-labeled lipid emulsion and [U-(13)C]oleate during continuous feeding, before and after weight loss. Body fat was measured with dual energy X-ray absorptiometry and computed tomography. Participants lost ∼14% of body weight. There was an ∼38% decrease in meal-suppressed FFA concentration (P < 0.0001) and an ∼23% decrease in oleate flux (P = 0.007). Fractional spillover did not change (P = NS). At baseline, there was a strong negative correlation between spillover and leg fat (r = -0.79, P = 0.001) and a positive correlation with the trunk-to-leg fat ratio (R = 0.56, P = 0.047). These correlations disappeared after weight loss. Baseline leg fat (R = -0.61, P = 0.027) but not trunk fat (R = -0.27, P = 0.38) negatively predicted decreases in spillover with weight loss. These results indicate that spillover, a measure of inefficiency in dietary fat storage, is inversely associated with lower body fat in type 2 diabetes.

Kinetics of saturated, monounsaturated, and polyunsaturated fatty acids in humans

Plasma free fatty acid (FFA) kinetics in humans are often measured with only one tracer. In study 1, healthy volunteers received infusions of [U-¹³C]linoleate, [U-¹³C]oleate, and [U-¹³C]palmitate during continuous feeding with liquid meals low (n = 12) and high (n = 5) in palmitate and containing three labeled fatty acids to measure FFA appearance and fractional spillover of lipoprotein lipase-generated fatty acids. Study 2 used an intravenous lipid emulsion to increase FFA concentrations during infusion of linoleate and palmitate tracers. In study 1, there were no differences in spillover of the three fatty acids for the low-palmitate meal, but linoleate spillover was greater than oleate or palmitate for the high-palmitate meal. In studies 1 and 2, clearance was significantly greater for linoleate than for the other FFAs. There was a negative correlation between clearance and concentration for each fatty acid in the two studies. In study 1, concentration and spillover correlated positively for oleate and palmitate but negatively for linoleate. In conclusion, linoleate spillover is greater than that of other fatty acids under some circumstances. Linoleate clearance is greater than that of palmitate or oleate, indicating a need for caution when using a single FFA to infer the behavior of all fatty acids.

Hypothyroidism: etiology, diagnosis, and management

Hypothyroidism is the result of inadequate production of thyroid hormone or inadequate action of thyroid hormone in target tissues. Primary hypothyroidism is the principal manifestation of hypothyroidism, but other causes include central deficiency of thyrotropin-releasing hormone or thyroid-stimulating hormone (TSH), or consumptive hypothyroidism from excessive inactivation of thyroid hormone. Subclinical hypothyroidism is present when there is elevated TSH but a normal free thyroxine level. Treatment involves oral administration of exogenous synthetic thyroid hormone. This review presents an update on the etiology and types of hypothyroidism, including subclinical disease; drugs and thyroid function; and diagnosis and treatment of hypothyroidism.

Body composition and quality of life in adults treated with GH therapy: a systematic review and meta-analysis

OBJECTIVE

To summarise the evidence about the efficacy and safety of using GH in adults with GH deficiency focusing on quality of life and body composition.

DATA SOURCES

We searched MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science and Scopus through April 2011. We also reviewed reference lists and contacted experts to identify candidate studies.

STUDY SELECTION

Reviewers, working independently and in duplicate, selected randomised controlled trials (RCTs) that compared GH to placebo.

DATA SYNTHESIS

We pooled the relative risk (RR) and weighted mean difference (WMD) by the random effects model and assessed heterogeneity using the I(2) statistic.

RESULTS

Fifty-four RCTs were included enrolling over 3400 patients. The quality of the included trials was fair. GH use was associated with statistically significant reduction in weight (WMD, 95% confidence interval (95% CI): -2.31 kg, -2.66 and -1.96) and body fat content (WMD, 95% CI: -2.56 kg, -2.97 and -2.16); increase in lean body mass (WMD, 95% CI: 1.38, 1.10 and 1.65), the risk of oedema (RR, 95% CI: 6.07, 4.34 and 8.48) and joint stiffness (RR, 95% CI: 4.17, 1.4 and 12.38); without significant changes in body mass index, bone mineral density or other adverse effects. Quality of life measures improved in 11 of the 16 trials although meta-analysis was not feasible.

RESULTS

GH therapy in adults with confirmed GH deficiency reduces weight and body fat, increases lean body mass and increases oedema and joint stiffness. Most trials demonstrated improvement in quality of life measures.

Clinical review: The effect of vitamin D on falls: a systematic review and meta-analysis

CONTEXT

Vitamin D affects bone and muscle health and likely reduces the risk of falls in the elderly.

OBJECTIVE

The aim of this systematic review is to summarize the existing evidence on vitamin D use and the risk of falls.

DATA SOURCES

We searched electronic databases from inception through August 2010.

STUDY SELECTION

Eligible studies were randomized controlled trials in which the intervention was vitamin D and the incidence of falls was reported.

DATA EXTRACTION

Reviewers working in duplicate and independently extracted study characteristics, quality, and outcomes data.

DATA SYNTHESIS

Odds ratio and associated 95% confidence interval were estimated from each study and pooled using the random effects model.

RESULTS

We found 26 eligible trials of moderate quality that enrolled 45,782 participants, the majority of which were elderly and female. Vitamin D use was associated with statistically significant reduction in the risk of falls (odds ratio for suffering at least one fall, 0.86; 95% confidence interval, 0.77-0.96). This effect was more prominent in patients who were vitamin D deficient at baseline and in studies in which calcium was coadministered with vitamin D. The quality of evidence was low to moderate because of heterogeneity and publication bias.

CONCLUSIONS

Vitamin D combined with calcium reduces the risk of falls. The reduction in studies without calcium coadministration did not reach statistical significance. The majority of the evidence is derived from trials enrolling elderly women.

Vitamin D and cardiovascular outcomes: a systematic review and meta-analysis

CONTEXT

Several studies found association between vitamin D levels and hypertension, coronary artery calcification, and heart disease.

OBJECTIVE

The aim of this study was to summarize the evidence on the effect of vitamin D on cardiovascular outcomes.

DESIGN AND METHODS

We searched electronic databases from inception through August 2010 for randomized trials. Reviewers working in duplicate and independently extracted study characteristics, quality, and the outcomes of interest. Random-effects meta-analysis was used to pool the relative risks (RR) and the weighted mean differences across trials.

RESULTS

We found 51 eligible trials with moderate quality. Vitamin D was associated with nonsignificant effects on the patient-important outcomes of death [RR, 0.96; 95% confidence interval (CI), 0.93, 1.00; P = 0.08], myocardial infarction (RR, 1.02; 95% CI, 0.93, 1.13; P = 0.64), and stroke (RR, 1.05; 95% CI, 0.88, 1.25; P = 0.59). These analyses were associated with minimal heterogeneity. There were no significant changes in the surrogate outcomes of lipid fractions, glucose, or diastolic or systolic blood pressure. The latter analyses were associated with significant heterogeneity, and the pooled estimates were trivial in absolute terms.

CONCLUSIONS

Trial data available to date are unable to demonstrate a statistically significant reduction in mortality and cardiovascular risk associated with vitamin D. The quality of the available evidence is low to moderate at best.