Sympathetic nervous activation in obesity and the metabolic syndrome--causes, consequences and therapeutic implications

The world wide prevalence of obesity and the metabolic syndrome is escalating. Contrary to earlier experimental evidence, human obesity is characterised by sympathetic nervous activation, with the outflows to both the kidney and skeletal muscle being activated. While the mechanisms responsible for initiating the sympathetic activation remain to be unequivocally elucidated, hyperinsulinemia, obstructive sleep apnoea, increased circulating adipokines, stress and beta adrenergic receptor polymorphisms are implicated. The pattern of sympathetic activation may be the pathophysiological mechanism underpinning much obesity-related illnesses with the consequences including, amongst others, the development of hypertension, insulin resistance, diastolic dysfunction and renal impairment. While diet and exercise are the first line therapy for the treatment of obesity and the metabolic syndrome, pharmacological interventions targeting the sympathetic nervous system, either directly or indirectly are also likely to be of benefit. Importantly, the benefit may not necessarily be weight related but may be associated with a reduction in end organ damage.

Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial

CONTEXT

Adolescent obesity is a common and serious health problem affecting more than 5 million young people in the United States alone. Bariatric surgery is being evaluated as a possible treatment option. Laparoscopic adjustable gastric banding (gastric banding) has the potential to provide a safe and effective treatment.

OBJECTIVE

To compare the outcomes of gastric banding with an optimal lifestyle program on adolescent obesity.

DESIGN, SETTING, AND PATIENTS

A prospective, randomized controlled trial of 50 adolescents between 14 and 18 years with a body mass index (BMI) higher than 35, recruited from the Melbourne, Australia, community, assigned either to a supervised lifestyle intervention or to undergo gastric banding, and followed up for 2 years. The study was performed between May 2005 and September 2008.

MAIN OUTCOME MEASURES

Weight loss. Secondary outcomes included change in metabolic syndrome, insulin resistance, quality of life, and adverse outcomes.

RESULTS

Twenty-four of 25 patients in the gastric banding group and 18 of 25 in lifestyle group completed the study. Twenty-one (84%) in the gastric banding and 3 (12%) in the lifestyle groups lost more than 50% of excess weight, corrected for age. Overall, the mean changes in the gastric banding group were a weight loss of 34.6 kg (95% CI, 30.2-39.0), representing an excess weight loss of 78.8% (95% CI, 66.6%-91.0%), 12.7 BMI units (95% CI, 11.3-14.2), and a BMI z score change from 2.39 (95% CI, 2.05-2.73) to 1.32 (95% CI, 0.98-1.66). The mean losses in the lifestyle group were 3.0 kg (95% CI, 2.1-8.1), representing excess weight loss of 13.2% (95% CI, 2.6%-21.0%), 1.3 BMI units (95% CI, 0.4-2.9), and a BMI z score change from 2.41 (95% CI, 2.21-2.66) to 2.26 (95% CI, 1.91-2.43). At entry, 9 participants (36%) in the gastric banding group and 10 (40%) in the lifestyle group had the metabolic syndrome. At 24 months, none of the gastric banding group had the metabolic syndrome (P = .008; McNemar chi(2)) compared with 4 of the 18 completers (22%) in the lifestyle group (P = .13). The gastric banding group experienced improved quality of life with no perioperative adverse events. However, 8 operations (33%) were required in 7 patients for revisional procedures either for proximal pouch dilatation or tubing injury during follow-up.

CONCLUSIONS

Among obese adolescent participants, use of gastric banding compared with lifestyle intervention resulted in a greater percentage achieving a loss of 50% of excess weight, corrected for age. There were associated benefits to health and quality of life.

TRIAL REGISTRATION

ANZCTR Identifier: 12605000160639.

Perceived discrimination and stigmatisation against severely obese women: age and weight loss make a difference

AIMS

Patients' perceptions about weight-related stigma and discrimination were assessed in 2 groups of patients, obese and laparoscopic adjustable gastric banding (LAGB).

METHODS

Seven focus group sessions were held including a total of 32 women, 8 obese (body mass index 35+) and 24 who had lost 50% of excess weight following bariatric surgery. During the sessions, participants were asked to consider their experiences in situations including general, family, friends, work place, medical, and educational settings.

RESULTS

Whilst perceptions of discrimination and stigmatisation were common and affected many life situations, they were less prevalent than previous reports. It appeared that it was not the frequency or number of events which affected an individual but the intensity of the experience. Younger women reported greater discrimination than older women and felt the social consequences of obesity to a greater extent. Older women were more concerned about the consequences of being overweight on their health.

CONCLUSIONS

Women who had lost weight considered that aspects of their own behaviours when obese contributed to their experiences of discrimination and stigmatisation. Perceptions of discrimination and stigmatisation appear to be influenced by age and current weight status.

Childhood obesity, BMI calculators, and medical software--time for an upgrade?

National Health and Medical Research Council (NHMRC) guidelines for the management of childhood obesity recommend active screening of children aged 2-18 years, and intervention for those with a body mass index (BMI) (kg/m2) above the 85th percentile for age and gender. However, guidelines and BMI for age percentile charts are not well utilised in the general practice setting. In addition, there is a tendency for clinicians and parents to visually underestimate body mass in children.

Medical versus surgical interventions for the metabolic complications of obesity in children

The global epidemic of obesity has not spared children. Although prevention of obesity is commendable, we cannot hide from the pressing need to identify, assess, and actively manage children seriously afflicted by obesity and its associated conditions. Sustained weight loss (or, for children, lowering of body mass index standard deviation score) delivers major health benefit, but in children has been difficult to achieve. In adults, the success of the diabetes prevention programs using practical lifestyle interventions is indisputable. Medical therapy, although currently limited in it scope, provides some promise for older children. There is now accumulating evidence, generally of poor quality that surgical interventions (laparoscopic adjustable gastric banding and Roux-en-Y gastric bypass) provide excellent sustained weight loss and improvement in comorbidity and quality of life in selected older children. Their benefits in adults are well demonstrated. Surgery comes with risk, both immediate and in the future, as does severe obesity. Carefully weighing risk and benefit is challenging for the individual and for health service providers. Careful health outcomes research with registries and well-conducted trials will provide better direction in the future. In the meantime, we should move forward ethically and cautiously in providing more intensive obesity management in children.

Cost-effectiveness of surgically induced weight loss for the management of type 2 diabetes: modeled lifetime analysis

OBJECTIVE

To estimate the cost-effectiveness of surgically induced weight loss relative to conventional therapy for the management of recently diagnosed type 2 diabetes in class I/II obese patients.

RESEARCH DESIGN AND METHODS

This study builds on a within-trial cost-efficacy analysis. The analysis compares the lifetime costs and quality-adjusted life-years (QALYs) between the two intervention groups. Intervention costs were extrapolated based on observed resource utilization during the trial. The proportion of patients in each intervention group with remission of diabetes at 2 years was the same as that observed in the trial. Health care costs for patients with type 2 diabetes and outcome variables required to derive estimates of QALYs were sourced from published literature. A health care system perspective was adopted. Costs and outcomes were discounted annually at 3%. Costs are presented in 2006 Australian dollars (AUD) (currency exchange: 1 AUD = 0.74 USD).

RESULTS

The mean number of years in diabetes remission over a lifetime was 11.4 for surgical therapy patients and 2.1 for conventional therapy patients. Over the remainder of their lifetime, surgical and conventional therapy patients lived 15.7 and 14.5 discounted QALYs, respectively. The mean discounted lifetime costs were 98,900 AUD per surgical therapy patient and 101,400 AUD per conventional therapy patient. Relative to conventional therapy, surgically induced weight loss was associated with a mean health care saving of 2,400 AUD and 1.2 additional QALYs per patient.

CONCLUSIONS

Surgically induced weight loss is a dominant intervention (it both saves health care costs and generates health benefits) for managing recently diagnosed type 2 diabetes in class I/II obese patients in Australia.

Cost-efficacy of surgically induced weight loss for the management of type 2 diabetes: a randomized controlled trial

OBJECTIVE

To determine the within-trial cost-efficacy of surgical therapy relative to conventional therapy for achieving remission of recently diagnosed type 2 diabetes in class I and II obese patients.

RESEARCH DESIGN AND METHODS

Efficacy results were derived from a 2-year randomized controlled trial. A health sector perspective was adopted, and within-trial intervention costs included gastric banding surgery, mitigation of complications, outpatient medical consultations, medical investigations, pathology, weight loss therapies, and medication. Resource use was measured based on data drawn from a trial database and patient medical records and valued based on private hospital costs and government schedules in 2006 Australian dollars (AUD). An incremental cost-effectiveness analysis was undertaken.

RESULTS

Mean 2-year intervention costs per patient were 13,400 AUD for surgical therapy and 3,400 AUD for conventional therapy, with laparoscopic adjustable gastric band (LAGB) surgery accounting for 85% of the difference. Outpatient medical consultation costs were three times higher for surgical patients, whereas medication costs were 1.5 times higher for conventional patients. The cost differences were primarily in the first 6 months of the trial. Relative to conventional therapy, the incremental cost-effectiveness ratio for surgical therapy was 16,600 AUD per case of diabetes remitted (currency exchange: 1 AUD = 0.74 USD).

CONCLUSIONS

Surgical therapy appears to be a cost-effective option for managing type 2 diabetes in class I and II obese patients.

Motivation, readiness to change, and weight loss following adjustable gastric band surgery

High levels of readiness to change (RTC) are considered critical to the long-term success of weight management programs including bariatric surgery. However, there are no data to support this assertion. We hypothesize that RTC level will not influence weight outcomes following surgery. In 227 consecutive patients undergoing adjustable gastric banding surgery, we recorded reasons for seeking surgery, and RTC measured with the University of Rhode Island Change Assessment. Scores were blinded until study completion. The primary outcome measure was percentage of excess BMI loss at 2 years (%EBMIL-2); others included compliance and surgical complications. Of 227 subjects, 204 (90%) had weight measurement at 2 years. There was no significant correlation between RTC score and %EBMIL-2 (r = 0.047, P = 0.5). Using the median split for RTC score the lowest 102 subjects mean %EBMIL-2 was 52.9 +/- 26.9% and the highest 52.2 +/- 28.3%, P = 0.869. There was no weight loss difference between highest and lowest quartiles, or a nonlinear relationship between weight loss and RTC score. There was no significant relationship between RCT score and compliance, or likelihood of complications. Those motivated by appearance were more likely to be younger women who lost more weight at 2 years. Poor attendance at follow-up visits was associated with less weight loss, especially in men. Measures of RTC did not predict weight loss, compliance, or surgical complications. Caution is advised when using assessments of RTC to predict outcomes of bariatric surgery.

Referral for a bariatric surgical consultation: it is time to set a standard of care

Indications for bariatric surgery have been clear for some time and many would say that they are conservative. Unfortunately few eligible candidates seek or are referred for bariatric surgery, with less than 1% currently treated annually. In recent years, the evidence base supporting surgical therapy has strengthened with demonstrable improvements in both safety and efficacy. We now have evidence of remarkable improvements in health, quality of life, and increased life expectancy. There is continued frustration with the poor efficacy of non-surgical therapies and no indication that this is about to change. A caring physician should, as best care, refer the seriously ill morbidly obese patient for a surgical opinion. It is no different from their obligation to adequately manage type-2 diabetes, depression or unstable angina. Currently, even discussion of a surgical referral is optional. It is time we articulated and defined a group of patients where referral for a surgical opinion is no longer merely an option but a physician's responsibility as best care for the patient. It is time to provide leadership towards the delivery of better care for these patients.

Raised CRP levels in obese patients: symptoms of depression have an independent positive association

BACKGROUND

Depression and obesity, the two common ailments of modern society, are associated with increased risk of coronary artery disease and raised C-reactive protein (CRP) levels. Are the effects of depression and obesity related or do they influence CRP levels independently?

OBJECTIVE

In 493 consecutive patients presenting for obesity surgery, we explored the relationship between symptoms of depression and raised CRP levels after controlling for confounding factors.

METHODS AND PROCEDURES

Depression was measured using the Beck Depression Inventory (BDI). Confounding variables were age, gender, BMI, waist and hip measures, smoking and alcohol habits, medications, biochemical measures of the metabolic syndrome, and indirect measures of insulin resistance. General linear regression sought variables independently associated with CRP levels.

RESULTS

These patients had a BMI range from 31 to 91 kg/m2, participants age ranged from 14 to 71 years, and 76% were women. The median CRP concentration was 7.7mg/l (interquartile range: 3.9-14), 40% had an abnormally raised concentration (> 10mg/l). The mean BDI score was 17.0 +/- 9.0, indicating symptoms of moderate depression. We found five independent factors associated with raised CRP levels. In order of strength of association, these were: higher BMI (beta = 0.36, P < 0.001), female gender (beta = -0.19, P < 0.001), estrogen therapy (beta = 0.18, P < 0.001), higher BDI score (beta = 0.11, P = 0.01), and insulin resistance index (beta = 0.11, P = 0.01), and with a combined R2 = 0.24, (P < 0.001).

DISCUSSION

In obese patients, symptoms of depression were associated with raised CRP levels after controlling for confounding variables. Obese women on estrogen therapy are at risk of high CRP levels.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Loss of control is central to psychological disturbance associated with binge eating disorder

OBJECTIVE

Binge eating disorder (BED) is positively associated with obesity and psychological distress, yet the behavioral features of BED that drive these associations are largely unexplored. The primary aim of this study was to investigate which core behavioral features of binge eating are most strongly related to psychological disturbance.

METHODS AND PROCEDURES

A cross-sectional study involved 180 bariatric surgery candidates, 93 members of a non-surgical weight loss support group, and 158 general community respondents (81 men/350 women, mean age 45.8 +/- 13.3, mean BMI 34.8 +/- 10.8, BMI range 17.7-66.7). Validated questionnaires assessed BED and binge eating, symptoms of depression, appearance dissatisfaction (AD), quality of life (QoL) and eating-related behaviors. Features of binge eating were confirmed by interview. BMI was determined by clinical assessment and self-report.

RESULTS

The loss of control (LOC) over eating, that is, being unable to stop eating or control what or how much was consumed was most closely related to psychological markers of distress common in BED. In particular, those who experienced severe emotional disturbance due to feelings of LOC reported higher symptoms of depression (P < 0.001), AD (P = 0.009), and poorer mental health-related QoL (P = 0.027).

DISCUSSION

Persons who report subjective binge episodes or do not meet BED frequency criteria for objective binge episodes may still be at elevated risk of psychological disturbance and benefit from clinical intervention. Feelings of LOC could drive binge eaters to seek bariatric surgery in an attempt to gain control over body weight and psychologically disturbing eating behavior.

Grazing and loss of control related to eating: two high-risk factors following bariatric surgery

BACKGROUND

Gastric restrictive surgery induces a marked change in eating behavior. However, the relationship between preoperative and postoperative eating behavior and weight loss outcome has received limited attention.

OBJECTIVE

This study assessed a range of eating behaviors before and 1 year after laparoscopic adjustable gastric banding (LAGB) and explored the nature and extent of change in eating patterns, their clinical associates, and impact on weight loss.

METHODS AND PROCEDURES

A 12-month observational study assessed presurgical and postsurgical binge eating disorder (BED), uncontrolled eating, night eating syndrome (NES), grazing, nutrient intake and eating-related behaviors, and markers of psychological distress. A total of 129 subjects (26 male and 103 female, mean age 45.2 +/- 11.5 and BMI 44.3 +/- 6.8) participated in this study.

RESULTS

Presurgical BED, uncontrolled eating, and NES occurred in 14%, 31%, and 17.1% of subjects, which reduced after surgery to 3.1%, 22.5%, and 7.8%, respectively (P = 0.05 for all). Grazing was prevalent before (26.3%) and after surgery (38.0%). Preoperative BED most frequently became grazers (P = 0.029). The average percentage weight loss (%WL) was 20.8 +/- 8.5%; range -0.67 to 50.0% and percentage of excess weight loss (%EWL) 50.0 +/- 20.7%; range -1.44 to 106.9% (P < 0.001). Uncontrolled eating and grazing after surgery showed high overlap and were associated with poorer %WL (P = 0.008 and P < 0.001, respectively) and elevated psychological distress.

DISCUSSION

Consistent with recent studies, uncontrolled eating and grazing were identified as two high-risk eating patterns after surgery. Clearer characterization of favorable and unfavorable postsurgical eating behaviors, reliable methods to assess their presence, and empirically tested postsurgical intervention strategies are required to optimize weight loss outcomes and facilitate psychological well-being in at-risk groups.

Adjustable gastric banding and conventional therapy for type 2 diabetes: a randomized controlled trial

CONTEXT

Observational studies suggest that surgically induced loss of weight may be effective therapy for type 2 diabetes.

OBJECTIVE

To determine if surgically induced weight loss results in better glycemic control and less need for diabetes medications than conventional approaches to weight loss and diabetes control.

DESIGN, SETTING, AND PARTICIPANTS

Unblinded randomized controlled trial conducted from December 2002 through December 2006 at the University Obesity Research Center in Australia, with general community recruitment to established treatment programs. Participants were 60 obese patients (BMI >30 and <40) with recently diagnosed (<2 years) type 2 diabetes.

INTERVENTIONS

Conventional diabetes therapy with a focus on weight loss by lifestyle change vs laparoscopic adjustable gastric banding with conventional diabetes care.

MAIN OUTCOME MEASURES

Remission of type 2 diabetes (fasting glucose level <126 mg/dL [7.0 mmol/L] and glycated hemoglobin [HbA1c] value <6.2% while taking no glycemic therapy). Secondary measures included weight and components of the metabolic syndrome. Analysis was by intention-to-treat.

RESULTS

Of the 60 patients enrolled, 55 (92%) completed the 2-year follow-up. Remission of type 2 diabetes was achieved by 22 (73%) in the surgical group and 4 (13%) in the conventional-therapy group. Relative risk of remission for the surgical group was 5.5 (95% confidence interval, 2.2-14.0). Surgical and conventional-therapy groups lost a mean (SD) of 20.7% (8.6%) and 1.7% (5.2%) of weight, respectively, at 2 years (P < .001). Remission of type 2 diabetes was related to weight loss (R2 = 0.46, P < .001) and lower baseline HbA1c levels (combined R2 = 0.52, P < .001). There were no serious complications in either group.

CONCLUSIONS

Participants randomized to surgical therapy were more likely to achieve remission of type 2 diabetes through greater weight loss. These results need to be confirmed in a larger, more diverse population and have long-term efficacy assessed.

TRIAL REGISTRATION

actr.org Identifier: ACTRN012605000159651.

Bleeding complications in skin cancer surgery are associated with warfarin but not aspirin therapy

BACKGROUND

The aim was to identify risk factors for postoperative bleeding following skin cancer surgery.

METHODS

This was a prospective study of 5950 skin lesions excised in 2394 patients. No patient stopped taking aspirin or warfarin unless the international normalized ratio (INR) exceeded 3.0.

RESULTS

The rate of postoperative bleeding was 0.7 per cent overall and 2.5 per cent in the 320 patients taking warfarin. The rate of bleeding was 1.0 per cent for skin flap repairs, 0.4 per cent for simple excision and closure, and 5.0 per cent for skin grafts. Diabetic patients and smokers were not at increased risk of bleeding. There were four independent factors for bleeding: age 67 years or older (odds ratio (OR) 4.7 (95 per cent confidence interval 1.8 to 12.2); P = 0.002), warfarin therapy (OR 2.9 (1.4 to 6.3); P = 0.006), surgery on or around the ear (OR 2.6 (1.2 to 5.7); P = 0.012) and closure with a skin flap or graft (OR 2.7 (1.4 to 5.3); P = 0.004). Aspirin therapy was not an independent risk factor for bleeding.

CONCLUSION

Most postoperative bleeds were inconvenient but not life threatening, unlike the potential risk of thromboembolism after stopping warfarin or aspirin. There was no case for discontinuing aspirin before skin surgery, but the INR should be monitored in patients taking warfarin.

Smaller hip circumference is associated with dyslipidemia and the metabolic syndrome in obese women

BACKGROUND

There is great need for simple anthropometric measures that predict risk. The authors explored the relationship between body composition measures and features of the metabolic syndrome (MtS) in women aged between 20 and 50 years with class I obesity.

METHODS

This is a cross-sectional study of 49 obese (BMI 30-35) women recruited into a weight management randomized trial. An analysis was conducted of the baseline weight, anthropometric measures, skin-fold thickness, bioelectrical impedance, whole body dual-energy x-ray absorptiometry (DEXA), and their relationships with the features of the MtS.

RESULTS

All women but one (n=48) had a population risk waist circumference of >88 cm. 16 of the 49 (33%) fulfilled the criteria of the metabolic syndrome. Simple anthropometric measures provided the strongest correlations with the presence of the MtS. Cut-off values were selected using receiver operator characteristics. Waist circumference of >100 cm and hip circumference <115cm was associated with odds ratios of 5.2 (95% CI, 1.4-20) and 12.3 (95% CI, 3.0-51) respectively for the MtS. Regional DEXA analysis showed that lower leg fat mass rather than fat-free mass was associated with the MtS. The dyslipidemia of the MtS was associated with a lower leg fat mass, while higher HbAlc levels and HOMA, an indirect measure of insulin resistance, were seen with increased trunk fat. Percentage fat as measured by skin-fold thickness and bioelectrical impedance were not related to any features. Women with the metabolic syndrome were found to have lower bone mineral content as measured by DEXA.

CONCLUSION

Weight distribution is highly predictive of metabolic risk. Smaller hip and larger waist circumference provided independent effect. BMI adjusted anthropometric measures may be of value.

Daytime sleepiness in the obese: not as simple as obstructive sleep apnea

OBJECTIVE

Excessive daytime sleepiness is a common symptom in obese patients, but what drives this condition is unclear. The objective was to look for clinical, anthropometric, biochemical, and polysomnographic predictors of excessive daytime sleepiness as measured by the Epworth Sleepiness Scale (ESS) in obese patients.

RESEARCH METHODS AND PROCEDURES

The ESS questionnaire was completed by 1,055 consecutive patients presenting for obesity surgery. Those at high risk for obstructive sleep apnea (n = 331) had diagnostic overnight polysomnography preoperatively. All patients had preoperative clinical, hematologic, and biochemical measurements and completed multiple questionnaires.

RESULTS

There was no significant relationship between ESS score and any measure of diagnostic polysomnography factors, including total apnea hypopnea index. Subtle increases in ESS scores were reported in men, older patients, and those with type 2 diabetes. However, general demographic, anthropometric, and biochemical measures of the metabolic syndrome explained only 3% of ESS score variance, and inflammatory markers of C-reactive protein and total white cell count were not predictive. Poor Short Form-36 energy scores (b = -0.18, p < 0.001) and high Beck Depression Inventory scores were predictive of higher ESS scores (b = 0.15, p < 0.001) and, along with increasing age and male gender, explained 10% of variance. Symptoms related to disturbed nocturnal sleep explained 30% of variance.

CONCLUSION

In severely obese subjects, increased daytime sleepiness does not seem to be driven by obstructive sleep apnea, the degree of obesity, or anthropometric, metabolic, or inflammatory markers of the metabolic syndrome. It is, however, associated with poor energy, symptoms of depression, and symptoms of nocturnal sleep disturbance.

Eating behavior as a prognostic factor for weight loss after gastric bypass

BACKGROUND

Binge-eating disorder (BED) may be associated with unsatisfactory weight loss in obese patients submitted to bariatric procedures. This study aims to investigate whether the presence of binge eating before Roux-en-Y gastric bypass (RYGBP) influences weight outcomes.

METHODS

In a prospective design, 216 obese patients (37 males, 178 females, BMI=45.9 +/- 6.0 kg/m2) were assessed for the lifetime prevalence of BED and classified at structured interview into 3 subgroups: no binge eating (NBE=43), sub-threshold binge eating (SBE=129), and binge-eating disorder (BED=44). All patients were encouraged to take part in a multidisciplinary program following surgery, and weight loss at follow-up was used as the outcome variable.

RESULTS

At 1-year follow-up, NBE patients (n=41) showed percent excess BMI loss (%EBL) significantly higher than SBE patients (n=112) (P=0.027), although this effect was not significantly different between NBE and BED patients (n=44). At 2-year follow-up, NBE patients (n=33) showed %EBL higher than SBE (n=64) (P=-0.003) and BED patients (n=34) (P<0.001). Nevertheless, we found no significant weight loss differences between SBE (subclinical) and BED (full criteria) patients at any period of follow-up. Preliminary results at 3-year follow-up suggest that such an effect may be enduring.

CONCLUSION

The presence of a history of binge eating prior to treatment is associated with poorer weight loss in obese patients submitted to RYGBP. Because BED is highly prevalent in obese patients seeking bariatric surgery, its early recognition and treatment may be of important clinical value.

Prospective study of long-term patient perceptions of their skin cancer surgery

BACKGROUND

We identified factors that influence patient perceptions of their skin cancer surgery through a prospective study of patients referred to a single surgeon during 18 months.

METHOD

Patients having surgery resulting in a wound sutured and dressed were surveyed 6 to 9 months later. Monitoring for complaints continued for 3 years.

RESULTS

In all, 74% of patients returned the survey (576 of 778). A total of 250 (43%) rated their scar excellent, 177 (31%) very good, 72 (12.5%) good, 40 fair (6.9%), and 14 (2.4%) poor or very poor. Age, sex, diagnosis, or closure method did not result in a variation in scar perception. In all, 27.3% of scars (21/77) on the trunk were rated neutral or negative compared with 6.9% (33/476) of scars elsewhere (P < .001) and only 5% (15/305) of head and neck scars (P < .001). Complications did not change scar or overall evaluation ratings. In all, 393 patients (68%) rated the overall service excellent, 145 (25%) very good, 22 (4%) good, and 3 (0.5%) fair. No patient rated the service poor or very poor. Patients rating the service lower were most dissatisfied with scar appearance, time waiting before surgery, pain from the local anesthetic, nursing care, follow-up care, cost, and written material. In all, 99% of patients who rated their scar very good or excellent rated the overall service optimally, compared with only 85% of patients who rated their scar as good or worse.

LIMITATIONS

A single experienced surgeon in a southern Australia locale might not reflect the perceptions in other clinicians and locations.

CONCLUSION

Complications and patient complaints do not identify patient dissatisfaction from cutaneous surgery. The patients' perception of their scars markedly influences their overall service perception. Patients experienced more dissatisfaction with repairs on the trunk.

Progressive fibrosis in nonalcoholic steatohepatitis: association with altered regeneration and a ductular reaction

BACKGROUND & AIMS

Portal fibrosis and linkage is a key feature of progressive disease in nonalcoholic steatohepatitis (NASH), but not simple steatosis. It is underappreciated and poorly understood. Fatty liver has impaired regeneration that induces a secondary replicative pathway using bipotential, periportal, hepatic progenitor cells (HPCs). We propose that activation of this pathway, with increased cell injury in NASH, also induces a periportal ductular reaction (DR) that could produce a profibrogenic stimulus.

METHODS

Biopsy specimens from 107 patients with nonalcoholic fatty liver disease and 11 controls were immunostained with cytokeratin-7 to quantify the DR and HPCs, and with p21 to assess hepatocyte replicative arrest. These results were correlated with clinicopathologic variables.

RESULTS

Patients with nonalcoholic fatty liver disease had expansion of HPCs, with a strong association between HPCs and the DR (r(s) = 0.582, P < .0001). In those with NASH (n = 69) there was an increased DR compared with simple steatosis, which correlated with the stage of fibrosis (r(s) = 0.510, P < .0001). The DR increased with the grade of NASH activity (r(s) = 0.478, P < .0001), grade of portal inflammation (r(s) = 0.445, P < .0001), and extent of hepatocyte replicative arrest (r(s) = 0.446, P < .0001). Replicative arrest was in turn associated with insulin resistance (r(s) = 0.450, P < .0001) and NASH activity (r(s) = 0.452, P < .0001). By multivariate analysis, the extent of DR (odds ratio [OR] = 17.9, P = .016), hepatocyte ballooning (OR = 8.1, P < .0001), and portal inflammation (OR = 3.3, P = .005) were associated independently with fibrosis.

CONCLUSIONS

These findings suggest that an altered replication pathway in active NASH promotes a periportal DR, which in turn may provoke progressive periportal fibrogenesis.

Night eating syndrome and nocturnal snacking: association with obesity, binge eating and psychological distress

OBJECTIVE

Night eating syndrome (NES) is characterized by a time-delayed pattern of eating relative to sleep, where most food is consumed in the evening and night. This study aimed to investigate the clinical significance of NES and nocturnal snacking by exploring the relationship between NES and (1) obesity, (2) binge eating disorder (BED) and (3) psychological distress.

SUBJECTS

One hundred and eighty bariatric surgery candidates, 93 members of a non-surgical weight loss support group and 158 general community respondents (81 males/350 females, mean age: 45.8+/-13.3 years, mean body mass index (BMI): 34.8+/-10.8 and BMI range: 17.7-66.7).

METHODS

NES diagnosis required within the previous 3 months: (1) no appetite for breakfast, (2) consumption of > or =50% of daily energy after 1900 hours and (3) sleep difficulties > or =3 nights/week. Nocturnal snacking (awakening to eat) was recorded. Validated questionnaires assessed BED, symptoms of depression, appearance dissatisfaction (AD) and mental health-related quality of life (MHQoL). NES and binge eating (BE) (> or =1 episode/week) were confirmed by interview.

RESULTS

NES criteria were met by 11.1% of the total cohort. Across all groups, BE (P=0.001), BMI (P=0.003) and male gender (P=0.013) explained 10% of NES variance. Individuals with co-morbid NES and BE reported similarly elevated psychological distress as other binge eaters. NES alone was not associated with psychological distress. Those with NES who consumed nocturnal snacks reported poorer MHQoL (P=0.007) and greater depressive symptoms (P=0.039) and hunger (P=0.013) than others with NES. Low MHQoL (P=0.007) and male gender (P=0.022) explained 27% of the variance in the nocturnal snacking group.

DISCUSSION

In this study, NES was positively associated with BMI, BE and male gender. Elevated psychological distress was only apparent in those who consumed nocturnal snacks. Further characterization and understanding of the clinical significance of NES and nocturnal snacking is required.