Association of Weight Loss Between Early Adulthood and Midlife With All-Cause Mortality Risk in the US

IMPORTANCE

Describing potential mortality risk reduction associated with weight loss between early adulthood and midlife is important for informing primary and secondary prevention efforts for obesity.

OBJECTIVE

To examine the risk of all-cause mortality among adults who lost weight between early adulthood and midlife compared with adults who were persistently obese over the same period.

DESIGN, SETTING, AND PARTICIPANTS

Combined repeated cross-sectional analysis was conducted using data from the National Health and Nutrition Examination Survey III (1988-1994) and continuous waves collected in 2-year cycles between 1999 and 2014. The data analysis was conducted from February 10, 2019, to April 20, 2020. Individuals aged 40 to 74 years at the time of survey (baseline) were included in the analyses (n = 24 205).

EXPOSURES

Weight history was assessed by self-reported weight at age 25 years, at 10 years before baseline (midlife: mean age, 44 years; interquartile range, 37-55), and measured weight at baseline. Body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) at each time was categorized as normal (18.5-24.9), overweight (25.0-29.9), and obese (≥30.0). Weight change patterns were assessed from age 25 years (early adulthood) to 10 years before baseline (midlife).

MAIN OUTCOMES AND MEASURES

Incident all-cause mortality using linked data from the National Death Index.

RESULTS

Of the 24 205 participants, 11 617 were women (49.0%) and 11 567 were non-Hispanic White (76.9%). The mean (SD) BMI was 29.0 (6.1) at baseline. During a mean (SD) follow-up of 10.7 (7.2) years, 5846 deaths occurred. Weight loss from obese to overweight was associated with a 54% (hazard ratio, 0.46; 95% CI, 0.27-0.77) reduction in mortality risk compared with individuals with stable obesity between early adulthood and midlife. An estimated 3.2% (95% CI, 1.6%-4.9%) of early deaths could have been avoided if those who maintained an obese BMI instead lost weight to an overweight BMI by midlife. Overall, an estimated 12.4% (95% CI, 8.1%-16.5%) of early deaths may be attributable to having weight in excess of the normal BMI range at any point between early and mid-adulthood.

CONCLUSIONS AND RELEVANCE

In this study, weight loss from obesity to overweight between early adulthood through midlife appeared to be associated with a mortality risk reduction compared with persistent obesity. These findings support the importance of population-based approaches to preventing weight gain across the life course and a need for greater emphasis on treating obesity early in life.

Alterations in Vascular Function Associated With the Use of Combustible and Electronic Cigarettes

Background Electronic cigarettes (e-cigarettes) have been proposed as a potential harm reduction tool for combustible cigarette smokers. The majority of adult e-cigarette users continue to smoke combustible cigarettes and are considered dual users. The vascular impact of e-cigarettes remains incompletely defined. Methods and Results We examined the association of e-cigarette use with measures of vascular function and tonometry, preclinical measures of cardiovascular injury. As part of the CITU (Cardiovascular Injury due to Tobacco Use) study, we performed noninvasive vascular function testing in individuals without known cardiovascular disease or cardiovascular disease risk factors who were nonsmokers (n=94), users of combustible cigarettes (n=285), users of e-cigarettes (n=36), or dual users (n=52). In unadjusted analyses, measures of arterial stiffness including carotid-femoral pulse wave velocity, augmentation index, carotid-radial pulse wave velocity, and central blood pressures differed across the use groups. In multivariable models adjusted for age, sex, race, and study site, combustible cigarette smokers had higher augmentation index compared with nonusers (129.8±1.5 versus 118.8±2.7, P=0.003). The augmentation index was similar between combustible cigarette smokers compared with sole e-cigarette users (129.8±1.5 versus 126.2±5.9, P=1.0) and dual users (129.8±1.5 versus 134.9±4.0, P=1.0). Endothelial cells from combustible cigarette smokers and sole e-cigarette users produced less nitric oxide in response to A23187 stimulation compared with nonsmokers, suggestive of impaired endothelial nitric oxide synthase signaling. Conclusions Our findings suggest that e-cigarette use is not associated with a more favorable vascular profile. Future longitudinal studies are needed to evaluate the long-term risks of sustained e-cigarette use.

Universal coverage but unmet need: National and regional estimates of attrition across the diabetes care continuum in Thailand

Background

Diabetes is a growing challenge in Thailand. Data to assess health system response to diabetes is scarce. We assessed what factors influence diabetes care cascade retention, under universal health coverage.

Methods

We conducted a cross-sectional analysis of the 2014 Thai National Health Examination Survey. Diabetes was defined as fasting plasma glucose ≥126mg/dL or on treatment. National and regional care cascades were constructed across screening, diagnosis, treatment, and control. Unmet need was defined as the total loss across cascade levels. Logistic regression was used to examine the demographic and healthcare factors associated with cascade attrition.

Findings

We included 15,663 individuals. Among Thai adults aged 20+ with diabetes, 67.0% (95% CI 60.9% to 73.1%) were screened, 34.0% (95% CI 30.6% to 37.2%) were diagnosed, 33.3% (95% CI 29.9% to 36.7%) were treated, and 26.0% (95% CI 22.9% to 29.1%) were controlled. Total unmet need was 74.0% (95% CI 70.9% to 77.1%), with regional variation ranging from 58.4% (95% CI 45.0% to 71.8%) in South to 78.0% (95% CI 73.0% to 83.0%) in Northeast. Multivariable models indicated older age (OR 1.76), males (OR 0.65), and a higher density of medical staff (OR 2.40) and health centers (OR 1.58) were significantly associated with being diagnosed among people with diabetes. Older age (OR 1.80) and higher geographical density of medical staff (OR 1.82) and health centers (OR 1.56) were significantly associated with being controlled.

Conclusions

Substantial attrition in the diabetes care continuum was observed at diabetes screening and diagnosis, related to both individual and health system factors. Even with universal health insurance, Thailand still needs effective behavioral and structural interventions, especially in primary health care settings, to address unmet need in diabetes care for its population.

Assessment of obesity prevalence and validity of obesity diagnoses coded in claims data for selected surgical populations: A retrospective, observational study

In many types of surgery, obesity may influence patient selection, prognosis, and/or management. Quantifying the accuracy of the coding of obesity and other prognostic factors is important for the design and interpretation of studies of surgical outcomes based on administrative healthcare data. This study assessed the validity of obesity diagnoses recorded in insurance claims data in selected surgical populations.This was a retrospective, observational study. Deidentified electronic health record (EHR) and linked administrative claims data were obtained for US patients age ≥20 years who underwent a qualifying surgical procedure (bariatric surgery, total knee arthroplasty [TKA], cardiac ablation, or hernia repair) in 2014Q1-2017Q1 (first = index). Patients' body mass index (BMI) as coded in the claims data (error-prone measure) during the index procedure or 180d pre-index was compared with their measured BMI as recorded in the EHR (criterion standard) to estimate the sensitivity and positive predictive value (PPV) of obesity diagnosis codes.Among patients who underwent bariatric surgery (N = 1422), TKA (N = 8670), cardiac ablation (N = 167), or hernia repair (N = 5450), obesity was present in 98%, 63%, 52%, and 54%, respectively, based on measured BMI. PPVs of obesity diagnosis codes were high: 99.3%, 96.0%, 92.8%, and 94.1% in bariatric surgery, TKA, cardiac ablation, and hernia repair, respectively. The sensitivity of obesity diagnoses was: 99.8%, 46.2%, 41.3%, and 42.3% in bariatric surgery, TKA, cardiac ablation, and hernia repair, respectively. Among false-positive patients diagnosed as obese but with measured BMI <30, the proportion with a BMI ≥28 was 40.0%, 67.6%, 60.7%, and 65.8% for bariatric surgery, TKA, cardiac ablation, and hernia repair, respectively.Our data indicate that obesity is highly prevalent in many surgical populations, obesity diagnosis codes have high PPVs, but also obesity is generally undercoded in claims data. Quantifying the validity of diagnosis codes for obesity and other important prognostic factors is important for the design and interpretation of studies of surgical outcomes based on administrative data. Further research is needed to determine the extent to which undercoding of BMI and obesity can be addressed through the use of proxies that may be better documented in claims data.

Weight History and All-Cause and Cause-Specific Mortality in Three Prospective Cohort Studies

BACKGROUND

The relationship between body mass index (BMI) and mortality is controversial.

OBJECTIVE

To investigate the relationship between maximum BMI over 16 years and subsequent mortality.

DESIGN

3 prospective cohort studies.

SETTING

Nurses' Health Study I and II and Health Professionals Follow-Up Study.

PARTICIPANTS

225 072 men and women with 32 571 deaths observed over a mean of 12.3 years of follow-up.

MEASUREMENTS

Maximum BMI over 16 years of weight history and all-cause and cause-specific mortality.

RESULTS

Maximum BMIs in the overweight (25.0 to 29.9 kg/m2) (multivariate hazard ratio [HR], 1.06 [95% CI, 1.03 to 1.08]), obese I (30.0 to 34.9 kg/m2) (HR, 1.24 [CI, 1.20 to 1.29]), and obese II (≥35.0 kg/m2) (HR, 1.73 [CI, 1.66 to 1.80]) categories were associated with increases in risk for all-cause death. The pattern of excess risk with a maximum BMI above normal weight was maintained across strata defined by smoking status, sex, and age, but the excess was greatest among those younger than 70 years and never-smokers. In contrast, a significant inverse association between overweight and mortality (HR, 0.96 [CI, 0.94 to 0.99]) was observed when BMI was defined using a single baseline measurement. Maximum overweight was also associated with increased cause-specific mortality, including death from cardiovascular disease and coronary heart disease.

LIMITATION

Residual confounding and misclassification.

CONCLUSION

The paradoxical association between overweight and mortality is reversed in analyses incorporating weight history. Maximum BMI may be a useful metric to minimize reverse causation bias associated with a single baseline BMI assessment.

PRIMARY FUNDING SOURCE

National Institutes of Health.

[Sturge-Weber syndrome: differential diagnosis of neurocysticercosis]

INTRODUCTION

The Sturge-Weber syndrome is characterized by facial cutaneous angioma associated with leptomeningeal and cerebral angioma, typically ipsilateral to the facial lesion, which is accompanied by convulsions, mental retardation, contralateral hemiparesia, hemiatrophy, homonymous hemianopsia and glaucoma. Most of the patients with radiographic evidence of intracranial angioma develop convulsive crises, but only half have severe mental retardation. The image of calcification on cranial tomography often leads to confusion in diagnosis, especially with neurocysticercosis, particularly in places where this is endemic and the patients present with minimal skin lesions or these are at atypical sites.

CLINICAL CASE

We present the case of a 13 year-old boy hospitalized with status epilepticus who, since the age of 1 year and 3 months, had had convulsive seizures which were of generalized tonic-clonic type and partially complex with secondary generalization, treated with carbamazepine at a dose of 400 mg per day. Neurocysticercosis was diagnosed on a tomogram showing calcification of the left parieto-occipital gyrus. Following physical examination and complementary tests the diagnosis of Sturge-Weber syndrome was made.

CONCLUSION

We emphasize the importance of the diagnosis of Sturge-Weber syndrome, its clinical picture and treatment.