Reduced food intake after jejunoileal bypass: a possible association with prolonged gastric emptying and altered gut hormone patterns

The object of this study was to examine whether eating behavior, food preference, gastric emptying, and gut hormone patterns are altered after jejunoileal bypass (JIB) in patients with severe obesity. Eight obese [mean (+/- SD) body mass index (BMI; in kg/m2) 42.9 +/- 4] subjects were studied prospectively before and 9 mo after JIB with eight age- and sex-matched normal-weight control subjects. Total energy intake, data from the universal eating monitor (VIKTOR), eating motivation measured by visual analog scales, a food-preference checklist, a forced-choice list, solid-phase gastric emptying, and postprandial concentrations of cholecystokinin, motilin, and neurotensin were studied. BMI was reduced by 29% after JIB. Compared with normal subjects, the JIB patients showed a reduced desire to eat, decreased hunger, and reduced prospective consumption before a test meal. After surgery, obese subjects selected fewer food items and showed a reduced preference for high-carbohydrate and high-fat items before a test meal. There was a trend from an accelerated toward a decelerated eating pattern in obese subjects after JIB. After JIB, gastric emptying of obese subjects was slowed and similar to that in control subjects. Obese subjects had lower postprandial cholecystokinin concentrations that were lower than those of control subjects both before and after JIB. Postprandial concentrations of neurotensin were higher after JIB. We conclude that after JIB, the desire to eat and preference for high-carbohydrate and high-fat items is reduced, resulting in decreased energy intake. That gastric emptying is prolonged and gut hormone patterns are altered with low postprandial plasma cholecystokinin and high neurotensin plasma concentrations may at least partly account for these observations.

Is walking for exercise too exhausting for obese women?

OBJECTIVES

As exhaustion and pain during walking seem to be common problems among obese women, we decided to analyse the relative oxygen cost (% VO2max) in obese women during level walking.

SUBJECTS

Fifty-seven obese female outpatients, 44.1 +/- 10.7 y, BMI 37.1 +/- 3.4 kg.m-2.

METHODS

Walking tests at a self-selected, comfortable speed were performed indoors. Speed was measured with a speedometer, oxygen consumption (VO2) with the argon-dilution method and oxygen cost was estimated. Heart rate was measured; perceived exertion and pain were assessed with Borg's Category Ratio scale, CR10. Maximum oxygen uptake (VO2max/kg) was predicted from a submaximum bicycle ergometry test.

RESULTS

The women walked more slowly, 70.9 +/- 5.6 m.min-1 (P < 0.0001), and had higher VO2, 1.2 +/- 0.2 l.min-1 (P < 0.001), than normals. A majority experienced exertion and some experienced pain. Their VO2max/kg, 21.2 +/- 5.0 ml.kg-1.min-1, was less than for normals (P < 0.0001). The mean % VO2max during walking was 56%, which was higher than in normal subjects 36% (P < 0.0001). Significant correlations between % VO2max and VO2max/kg (P < 0.0001), heart rate during walking (P = 0.0009) and age (P = 0.0081), respectively, were found.

CONCLUSION

Very low VO2max/kg in obese women, rather than severe obesity per se, seems the most important factor to cause high % VO2max during walking. This might explain why many obese women perceive the exertion to be excessive and cannot follow the advice of their clinicians to exercise through long and brisk walks.

Changes in patients' eating behavior: in the uremic state, on continuous ambulatory peritoneal dialysis treatment, and after transplantation

Nineteen predialysis patients (group A) were studied before and after 3 to 6 months on continuous ambulatory peritoneal dialysis (CAPD) treatment. Six patients (group B) were studied during CAPD treatment and 3 to 6 months after transplantation. Nine uremic patients (group C) were studied before and 3 to 6 months after transplantation. The patients were invited to a single test meal by means of the universal eating monitor VIKTOR. An excess portion of hash was served on a plate placed on a hidden scale that was connected to a computer registering the eating process on line. The patients filled out visual analogue scales concerning appetite and food preferences before and after the test meal. The feeling of fullness before meals was greater in patients on CAPD than in patients in the predialytic state. Transplanted patients felt less full before meals compared with their ratings during the dialysis period. The median total intake of food was lower during dialysis than after transplantation. The palatability of the food was rated lower during dialysis compared with the ratings in the uremic state. Poor appetite and low intake during dialysis is still a problem, but improves after transplantation.

Lipolytic catecholamine resistance linked to alpha 2-adrenoceptor sensitivity--a metabolic predictor of weight loss in obese subjects

OBJECTIVE

The weight loss achieved during treatment with very-low-calorie diets (VLCD) varies between individuals. The aim of this study was to investigate whether interindividual variations in catecholamine-induced lipolysis are of importance for the rate of weight loss during VLCD.

DESIGN

Prospective study.

SUBJECTS

Twenty-eight obese, but otherwise healthy and drug-free women aged 20-57 y with BMI 33.3-47.5 kg/m2 were investigated before entering a four week weight reduction program with a calorie-restricted diet.

MEASUREMENTS

A subcutaneous adipose tissue biopsy was obtained from the abdominal area. Isolated fat cells were prepared and incubated in vitro with agents acting on lipolysis at defined steps in the lipolytic cascade. Glycerol release was measured and used as a lipolytic index. Following the biopsy, the subjects underwent a four week VLCD treatment.

RESULTS

The decrease in body weight in the whole group ranged between 4.8 and 13.5 kg. Dietary compliance was ascertained by daily measurements of urine-ketones and regular interviews and was satisfactory in all subjects throughout the study. Based on percent body weight reduction, the material was divided into two equally sized groups, classified as rapid or slow weight losers. The rapid weight losers were 10-fold more sensitive to the lipolytic effect of noradrenaline (P = 0.04) and 10-fold less sensitive (P = 0.002) to the antilipolytic effect induced by the alpha 2-adrenoceptor agonist clonidine than the slow weight losers. In the whole material, weight loss was significantly correlated (adjusted r2 = 0.25) with alpha 2-adrenoceptor sensitivity.

CONCLUSION

Rapid weight loss during VLCD is associated with increased adipocyte lipolytic sensitivity to catecholamines due to decreased alpha 2-adrenoceptor sensitivity, which in turn may promote lipid mobilization. It appears that variations in alpha 2-adrenoceptor sensitivity in adipocytes may be predictive of weight loss during VLCD.

Weight development, drop-out pattern and changes in obesity-related risk factors after two years treatment of obese men

OBJECTIVE

To describe a combined behavioural treatment program for obese men, the 'Gustaf' study, and to evaluate treatment success by the means of weight loss, drop-out analysis and changes in metabolic risk factors.

SUBJECTS

Eighty-six men, aged 43 +/- 9 y (mean +/- s.d.) and BMI 37.7 +/- 4.4 kg/m2, from the waiting list of the outpatient clinic and men directly approaching the Obesity Unit.

DESIGN

Combined, behavioural modification treatment, by the means of group sessions, for one hour every week over a two year period.

MAIN OUTCOME MEASURES

Weight loss and changes in risk factors after completion of one and two years study and description of treatment success in the form of changes in metabolic risk factors.

RESULTS

The one year drop-out rate was 22% and the cumulative rate after two years was 34%. Mean weight decreased significantly from start (121 kg) to one year (114 kg, P < 0.001) and to two years (115 kg, P < 0.001) in completers. Several metabolic risk factors (waist and hip circumferences, systolic blood pressure, serum cholesterol and plasma insulin) remained significantly decreased after two years of treatment. The complete metabolic syndrome was diagnosed in five men at onset, but in no one after two years. There was no difference in change of metabolic risk factors after one year between the men who lost 8-12% of initial body weight and those who lost more.

CONCLUSION

Sixty-six% (57/86) of the obese men who started in the 'Gustaf' program were still in the program after two years. In spite of the relatively modest weight loss, the men maintained a large proportion of this weight loss and also maintained their improved metabolic risk factor pattern.

Defining success in obesity management

Obesity is an exploding epidemic in the Western world, with severe consequences for the individual as well as being a burden to society. An increased awareness about the threat of obesity to health and life is therefore essential. Weight normalization is not necessary to achieve significant health benefits. Sustained moderate weight reduction has important effects on morbidity, probably affects mortality, and certainly affects psychosocial aspects of life. New realistic standards to define success should be developed.

VLCD versus LCD in long-term treatment of obesity

OBJECTIVE

To compare the long-term effects of three different programs including initial 6 weeks (V)LCD diets 420 kcal/d, 530 kcal/d, 880 kcal/d) on sustained weight loss, attrition and obesity associated conventional cardiovascular risk factors.

DESIGN

Prospective, randomized clinical 52 weeks trial. Two weeks of a booster (V)LCD period after week 26.

SETTING

University outpatient obesity clinic.

SUBJECTS

Ninety-three middle-aged obese patients (30 men), initial mean BMI 38.7 kg/m2, age 20-65 y, from the waiting list.

MAIN OUTCOME MEASURES

Weight loss pattern, attrition, reported side effects, blood pressure, blood glucose and serum lipid levels. Repeated frequent measurements up to week 26, intermittently up to final measurements at week 52.

RESULTS

One year attrition (30-45%), sustained weight loss (8-15% of initial body weight) and changes in obesity associated risk parameters were similar in all three group. Fewer adverse events were reported in the LCD group.

CONCLUSION

The results compare favorably with most previous reports of similar design. VLCD (420 kcal or 530 kcal/ d and LCD 880 kcal/d) were equally effective in long term treatment of obesity. The tendency to less side effects with LCD suggests that such preparations deserve further attention.

Gastroesophageal reflux in obese patients is not reduced by weight reduction

BACKGROUND

The present study tested the hypothesis that weight reduction improves the subjective and objective manifestations of gastroesophageal reflux.

METHODS

Twenty obese patients with gastroesophageal reflux as shown by 24-h pH measurement and with symptoms requiring daily medication were studied. The patients were randomized into a group (A) treated with very low-caloric diet (VLCD) and a control group (B). Objective measurements were repeated after 6 months. Group B was then treated with VLCD and reexamined.

RESULTS

Patients in group A lost 10.8 +/- 1.4 kg whereas group B gained 0.6 +/- 0.7 kg (P < 0.001). There was no reduction in reflux according to pH measurement. Furthermore, there were no significant changes in reflux symptoms. After VLCD treatment, group B lost 9.7 +/- 1.6 kg, but reflux indicators remained unchanged. All patients except one in group B remained dependent on daily anti-reflux medication.

CONCLUSION

Weight reduction does not improve the subjective or objective manifestations of reflux.

Meal patterns in obese and normal weight men: the 'Gustaf' study

OBJECTIVE

To compare the reported meal patterns between obese and normal weight men.

DESIGN

A dietary survey, by means of 12 repeated telephone-administered 24-hour dietary recalls, was conducted in obese and normal weight men. The study period was three months with all seven days of the week included. The contribution of intake types to the reported daily energy intake (EI) was studied as well as the circadian distribution of EI and the reported number of intakes.

SUBJECTS

86 obese men (BMI 37.7 +/- 4.4 kg/m2, mean +/- SD) from the waiting list of the outpatient clinic completed the study altogether with 61 normal weight men (BMI 23.0 +/- 1.9 kg/m2), randomly selected from the Stockholm County Census Bureau. All men were 20-60 years old.

RESULTS

Results were analyzed for Group A = all men who completed the study and for Group B = the men who exceeded the CUT-OFF 1 limit for energy intake (reasonably true report as defined by Goldberg). The obvious under-reporters amounted to 73% of the obese and to 28% of the normal weight men. The meal patterns were similar for the obese and the normal weight men. The greatest contributors to EI in both groups were cooked meals, sandwich meals, snacks and breakfast-like meals. The circadian eating pattern was mainly the same in both obese and normal weight men. The reported number of intakes was 5.3 (median) per day in all obese men vs 5.6 in all the controls (P = 0.02), and in Group B 5.3 s 5.9 (P = 0.16) intakes. No specific "obese eating style' could be detected in this study.

Energy intake in patients on continuous ambulatory peritoneal dialysis and haemodialysis

OBJECTIVES

To compare patients on continuous ambulatory peritoneal dialysis (CAPD) with those on haemodialysis (HD) regarding food composition and energy intake.

DESIGN

Prospective food recording during 5 consecutive days.

SETTING

Nephrology section at a University hospital.

SUBJECTS

Fifteen patients on CAPD and 15 patients on HD, matched for age, gender, duration of dialysis and body mass index (BMI).

MAIN OUTCOME MEASURES

Percentage macronutrient energy composition, with and without inclusion of transperitoneal glucose uptake. Daily energy intake, both total and from the different macronutrients.

RESULTS

The percentage contribution of the dietary macronutrients to the energy intake was about the same in the two dialysis groups, although the actual energy intake in CAPD patients was lower from all three macronutrients (P = 0.02-0.04). The mean intraperitoneal glucose load in CAPD patients was 159 g day-1, which is approximately equivalent to 2700 kJ. Inclusion of this additional energy (estimated uptake: 70% of the intraperitoneal energy load = 19% of total energy intake) significantly increased the carbohydrate fraction and decreased the protein and fat fractions (P < 0.0001). Furthermore, this inclusion resulted in almost identical values for total energy intake in the two groups (approximately 144 kJ kg-1 day-1) and, in CAPD patients, a significantly higher actual energy contribution from carbohydrates (P = 0.04).

CONCLUSIONS

Transperitoneal energy intake more than compensates for the lower oral dietary energy intake seen in CAPD patients. Nevertheless, the level of total energy intake places both patient groups in the risk zone for developing malnutrition.

Regulation of lipolysis in fat cells of obese women during long-term hypocaloric diet

OBJECTIVE

To investigate the influence of four weeks treatment with a strictly defined very low calorie diet (VLCD) on the regulation of adipocyte matabolism in vitro in subcutaneous fat cells of obese subjects.

DESIGN

Prospective study.

SUBJECTS

Nine obese, but otherwise healthy and drug-free women aged 26-48 years with BMI 36.4-51.9 kg/m2 were investigated before and during the fourth week on a calorie restricted diet.

MEASUREMENTS

A subcutaneous adipose tissue biopsy was obtained from the abdominal area. Isolated fat cells were prepared and incubated in vitro with different agents acting on lipolysis at defined steps in the lipolytic cascade. Glycerol (lipolytic index), hormone-sensitive lipase activity and incorporation of glucose into lipids were measured.

RESULTS

VLCD caused a two-fold rise in basal lipolysis (p < 0.005). In spite of this, the maximal lipolytic response of noradrenaline, isoprenaline (non-selective beta-adrenoceptor agonist), dobutamine (beta 1-adrenoceptor agonist), terbutaline (beta 2-adrenoceptor agonist), CGP 12177 (beta 3-adrenoceptor agonist), forskolin (stimulating adenylyl cyclase), dibuturyl cyclic AMP and 8-bromo cyclic AMP (cyclic AMP analogues resistant or sensitive to phosphodiesterase, respectively) were maintained. No differences were found in the hormone-sensitive lipase activity before or during VLCD. The specific alpha 2-adrenoceptor agonist UK 14304 was equally effective in inducing antilipolysis both before and during calorie restriction. However, during VLCD, the sensitivity and maximal antilipolytic effect of insulin were significantly reduced (p < 0.05) and the ability of insulin to stimulate lipogenesis was almost completely blunted.

CONCLUSIONS

Four weeks of VLCD induced elevated basal lipolysis, a resistance to the ability of insulin to induce antilipolysis and lipogenesis in subcutaneous fat cells, but preserved lipolytic catecholamine action. These are factors that together promote fat mobilization and thereby weight reduction during long-term calorie restriction.

The Gustaf study: repeated, telephone-administered 24-hour dietary recalls of obese and normal-weight men--energy and macronutrient intake and distribution over the days of the week

OBJECTIVE

A dietary survey of obese and control men was conducted through 24-hour dietary recalls administered by telephone at 12 times selected randomly over a period of 3 months. Energy and macronutrient intake and distribution were studied for all days of the week.

SUBJECTS

Eighty-six obese men, 20 to 60 years old, body mass index (BMI) = 37.7 +/- 4.4 (mean +/- standard deviation) from the waiting list of the outpatient clinic and 6I normal-weight (BMI = 23.0 +/- 1.9), age-matched men selected randomly from the Stockholm County Census Bureau.

MAIN OUTCOME MEASURES

Energy and macronutrient intake, intakes by energy tertiles, and distribution over the days of the week.

STATISTICAL ANALYSES

Nonparametric tests were used because of skewed distribution of most food data.

RESULTS

A median daily energy intake of 2,700 kcal was found in both groups. The obese men reported a higher protein (P < .001) and a lower alcohol (P < .001) intake than the control subjects. Both groups reported a maximum intake of energy and macronutrients on Saturdays. When separated into tertiles according to reported energy intake, the obese men in tertile 3 reported a higher intake from fat (% energy, P < .001) and a lower intake from protein (P < .01) compared with men in tertile 1. Normal-weight men intertile 3 reported a higher intake fat (% energy, P < .01) compared with men intertile 1.

CONCLUSIONS

When reported energy intake was compared with calculated total daily energy expenditure, there was a greater discrepancy in the obese group than in the control group. The normal-weight men may have had a special interest in food and health, and this group may not reflect the population at large.

Factors related to body weight changes during and after pregnancy: the Stockholm Pregnancy and Weight Development Study

The Stockholm Pregnancy and Weight Development Study is a prospective study of body weight changes in women, whose maternity unit charts were reviewed and who were then invited for a 1-year follow-up, including weigh-in sessions and questionnaires on dietary habits, physical activity and socio-demographic factors. Total weight gain during pregnancy was related to weight gain already during the first trimester. Women reporting previous weight cycling had slightly higher weight gain during pregnancy. Successful return towards pre-pregnancy weight was found more often in women with regular breakfast and lunch habits. Lactation had only a small effect on weight loss after delivery, independent of eating habits. Lack of physical activity was more common in women who had low lactation scores. Twenty-eight percent reported an increased interest in sweets during pregnancy; these women increased 1 to 2 kg more than others in weight during pregnancy. Postpartum weight retention was more affected by lifestyle changes during and after pregnancy than by factors before pregnancy.

Obesity and self-perceived health in Sweden

Data on self-perceived health in relation to relative body weight from the nationally representative adult Swedish population (12988 men and 13414 women) obtained from Statistics Sweden were analysed. The results are adjusted for age, socio-economic groups, self-reported chronic disease and marital status. Obesity was associated with 40% higher prevalence of severe pains from several joints in men and women and higher consumption of analgetics (OR = 1.6, 95% CI 1.2-2.2, in men, OR = 1.9, 95% CI 1.6-2.3, in women). Overweight and more often obese subjects reported physical impairment and in particular reduced mobility (OR = 1.9, 95% CI 1.5-2.5 in obese men and OR = 2.4, 95% CI 2.0-2.9 in obese women). Intake of vitamins was 20-40% significantly lower in overweight and obese than in normal weight subjects; the intake of iron pills was 60% lower in obese women. Dental status was worse in overweight and obese subjects. Dentures were found more often in overweight (OR = 1.5, 95% CI 1.3-1.7) and obese women (OR 2.2, 95% CI 1.9-2.7) in comparison to those with normal weight. Underweight was associated with adverse self-perceived health with regard to all these indicators. Our findings suggest that already moderate overweight in particular in women results in reduced mobility and physical impairment.