Increases in morbid obesity in the USA: 2000-2005

Exercise and epilepsy: a survey of Midwest epilepsy patients

Obesity and lack of physical activity are an increasing problem. In addition to common barriers to physical activity, people with epilepsy also face fear of exercise-induced seizures, medication side effects, and, often, confusing advice regarding the safety of exercise. To explore barriers faced by people with epilepsy, we mailed a survey to 412 adult patients with epilepsy from an epilepsy center in Kansas. Survey items assessed patients' exercise habits, attitudes regarding exercise, and barriers to exercise. Forty-seven percent completed the survey. Most respondents reported that they did exercise, though most did so 3 or fewer days per week and at light intensity. Respondents who reported seizures as a barrier to exercise did not exercise with less frequency or intensity than those who did not report seizures as a barrier, but these respondents reported greater fear of seizures. Patient-specific education about the benefits of exercise needs to be initiated by physicians.

The obese patient in the ED

As in any setting, safety and sensitivity are the keys to optimal care.

For better or worse: relationship status and body mass index

Recent increases in the incidence of obesity and declines in marriage have prompted policymakers to implement policies to mitigate these trends. This paper examines the link between these two outcomes. There are four hypotheses (selection, protection, social obligation and marriage market) that might explain the relationship between marital status transitions and changes in Body Mass Index (BMI). The selection hypothesis suggests that those with a lower BMI are more likely to be selected into marriage. The protection hypothesis states that married adults will have better physical health as a result of the increased social support and reduced incidence of risky behavior among married individuals. The social obligation hypothesis states that those in relationships may eat more regular meals and/or richer and denser foods due to social obligations which may arise because of marriage. Finally, the marriage market hypothesis indicates that when adults are no longer in the marriage market they may not maintain a healthy BMI because doing so is costly and they are in a stable union-or on the other hand, adults may enhance their prospects in the marriage market by losing weight. Taking advantage of longitudinal data and complete marriage histories in the National Longitudinal Survey of Youth 1979, we estimate individual fixed effects models to examine associations between the change in log BMI and the incidence of overweight and obesity, and changes in relationship status controlling for the effects of aging and other respondent characteristics. We find no support for the marriage protection hypothesis. Rather we find evidence supporting the social obligation and marriage market hypotheses-BMI increases for both men and women during marriage and in the course of a cohabiting relationship. Separate analyses by race and ethnicity reveal substantial differences in the response of BMI to relationship status across these groups.

Obesity and the built environment: changes in environmental cues cause energy imbalances

The past 30 years have seen dramatic changes in the food and physical activity environments, both of which contribute to the changes in human behavior that could explain obesity. This paper reviews documented changes in the food environment, changes in the physical activity environment and the mechanisms through which people respond to these environments, often without conscious awareness or control. The most important environmental changes have been increases in food accessibility, food salience and decreases in the cost of food. The increases in food marketing and advertising create food cues that artificially stimulate people to feel hungry. The existence of a metabolic pathway that allows excess energy to be stored as fat suggests that people were designed to overeat. Many internal mechanisms favor neurophysiologic responses to food cues that result in overconsumption. External cues, such as food abundance, food variety and food novelty, cause people to override internal signals of satiety. Other factors, such as conditioning and priming, tie food to other desirable outcomes, and thus increase the frequency that hunger is stimulated by environmental cues. People's natural response to the environmental cues are colored by framing, and judgments are flawed and biased depending on how information is presented. People lack insight into how the food environment affects them, and subsequently are unable to change the factors that are responsible for excessive energy consumption. Understanding the causal pathway for overconsumption will be necessary to interrupt the mechanisms that lead to obesity.

The association of diabetes with job absenteeism costs among obese and morbidly obese workers

OBJECTIVE

To determine the extent to which absenteeism costs associated with obesity and morbid obesity are traceable to diabetes, and whether obesity and morbid obesity remain predictors of absenteeism costs after controlling for diabetes.

METHODS

Data from the Medical Expenditure Panel Survey for 2000-2004 are examined. Outcomes are probability of missing work in the previous year and number of workdays missed. Predictors include diabetes, obesity and morbid obesity, age, education, occupation category, and race. Models are estimated by gender.

RESULTS

Probability of missing work in the past year, number of days missed, and absenteeism costs rise significantly with diabetes among the obese and morbidly obese, with costs higher for the morbidly obese, after controlling for diabetes.

CONCLUSIONS

Diabetes is strongly predictive of absenteeism among obese and morbidly obese workers. Employer efforts to reduce absenteeism should include consideration of anti-obesity interventions and diabetes prevention.

Sporting activity, prevalence of overweight, and risk factors: cross-sectional study of more than 12 500 participants aged 16 to 25 years

BACKGROUND

Recent studies show that habits detrimental to health are becoming established ever earlier in life. Because most of these investigations focus on adolescents up to the age of 18 years, it is largely unknown whether and to what extent negative behavioral modifications are intensified in young adults.

METHODS

Within the cross-sectional study "Fit fürs Leben" (Fit for Life) 12 835 volunteers aged 16 to 25 years were anthropometrically investigated and interviewed about their lifestyle and habits (sporting activity, nutrition and health-related behavior).

RESULTS

Data on anthropometric (BMI, waist circumference, body fat) and health-relevant (lack of exercise, smoking) characteristics as well as the frequency of cardiovascular risk factors show a clear increase in unhealthy attributes, particularly among those aged 20 to 25 years. Fifty percent of 25-year-old men are overweight, 60% smoke, and around one third do not participate in sport. Although only one quarter of women aged 16 to 25 years are overweight, women engage in sport much less frequently. Only one quarter of all study participants display none of the investigated cardiovascular risk factors.

DISCUSSION

The health-detrimental tendencies increase considerably after the age of 20. Efficient cross-institutional prevention campaigns are urgently necessary to promote and continually support a health-conscious life-style.

Self-reported stigmatization among candidates for bariatric surgery

The popularity of bariatric surgery has increased the focus on the psychological aspects of extreme obesity. Although a growing literature has documented the psychosocial burden associated with extreme obesity, surprisingly little attention has been paid to the experience of weight-related stigmatization among extremely obese individuals. The present study investigated self-reported experiences of weight-related stigmatization, weight-related quality of life, and depressive symptoms among 117 extremely obese individuals (BMI = 48.2 +/- 7.5 kg/m2) who presented for bariatric surgery at the Hospital of the University of Pennsylvania. In general, these individuals reported infrequent weight-related stigma, which was unrelated to BMI. Some specific forms of stigmatization, however, appear to be related to body size. The occurrence of stigmatization was associated with poorer weight-related quality of life and greater symptoms of depression.

Adiposity measures and oxidative stress among police officers

Our objective was to investigate associations between adiposity measures (BMI, waist circumference, waist-to-hip ratio, waist-to-height ratio, and abdominal height) and biomarkers of oxidative stress (glutathione (GSH), GSH peroxidase (GSH-Px), vitamin C, thiobarbituric acid reactive substances (TBARS), and trolox equivalent antioxidant capacity (TEAC)) among police officers. This cross-sectional study included randomly selected police officers (43 policewomen; 67 policemen) from Buffalo, New York. Adiposity measures were performed using standardized methods. Biomarkers were measured on fasting blood specimens. An oxidative stress score (OSS) was created as a composite of the biomarkers. ANOVAs were used to compare mean levels of biomarkers across tertiles of the adiposity measures. Officers were 26- to 61-years old. GSH was inversely associated with waist circumference (trend P = 0.030) and waist-to-hip ratio (trend P = 0.026). GSH-Px was inversely associated with BMI (trend P = 0.004) and with waist-to-height ratio (trend P = 0.017). No associations were observed for TEAC, TBARS, or OSS with any adiposity measure. Significant interactions were observed by physical activity status for GSH with waist circumference and waist-to-hip ratio and for vitamin C with waist circumference, waist-to-hip and waist-to-height ratios. The above associations were inversely related only among officers who reported engaging in physical activity. Inverse associations were observed for BMI and waist circumference with GSH, but only among women; the interaction with gender was significant. Larger indices of adiposity were associated with increased levels of oxidative stress and decreased levels of antioxidant defense.

Obesity and age of first non-ST-segment elevation myocardial infarction

OBJECTIVES

Because excess adiposity is one of the most important determinants of adipokines and inflammatory factors associated with coronary plaque rupture, we hypothesized that obesity was associated with myocardial infarction at earlier ages.

BACKGROUND

The developing obesity pandemic of the past 50 years has gained considerable attention as a major public health threat.

METHODS

The CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines) registry was a voluntary observational data collection and quality improvement initiative that began in November 2001, with retrospective data collection from January 2001 to January 2007. The CRUSADE initiative included high-risk patients with unstable angina and non-ST-segment elevation myocardial infarction (NSTEMI). We retrospectively examined, among 189,065 patients with acute coronary syndrome (between January 2001 and September 2006) in the CRUSADE initiative, the relationship of body mass index (BMI) with patient age of first NSTEMI.

RESULTS

A total of 111,847 patients with NSTEMI were included in the final analysis. There was a strong, inverse linear relationship between BMI and earlier age of first NSTEMI. The mean patient ages (+/- SD) of first NSTEMI were 74.6 +/- 14.3 years and 58.7 +/- 12.5 years for the leanest (BMI <or=18.5 kg/m(2)) and most obese (BMI >40.0 kg/m(2)) cohorts, respectively (p < 0.0001). After adjustment for baseline demographic data, cardiac risk factors, and medications, the age of first NSTEMI occurred 3.5, 6.8, 9.4, and 12.0 years earlier with ascending levels of adiposity (BMI 25.1 to 30.0, 30.1 to 35.0, 35.1 to 40.0, and >40.0 kg/m(2), respectively; referent 18.6 to 25.0 kg/m(2)) (p < 0.0001 for each estimate).

CONCLUSIONS

Excess adiposity is strongly related to first NSTEMI occurring prematurely.

[Operative management and fracture care of the lower leg with the Ilizarov fixator in morbidly obese patients: literature review and results]

Given the rising prevalence of obesity, surgeons and hospitals must become more familiar with the treatment and operative management of obese patients. Several additional pre- and postoperative considerations must be involved such as appropriate assessment of comorbidities and requirements for special equipment. There are still very few data regarding morbidly obese patients with BMIs >50 kg/m(2). After a general literature review of operative management of obese patients, we report on fracture care of the lower limb in such patients with custom-made Ilizarov ring fixators. We found them suited to bear enormous weight-loading but that associated comborbidities can limit successful fracture care.

Deep brain stimulation in the treatment of obesity

Obesity is a growing global health problem frequently intractable to current treatment options. Recent evidence suggests that deep brain stimulation (DBS) may be effective and safe in the management of various, refractory neuropsychiatric disorders, including obesity. The authors review the literature implicating various neural regions in the pathophysiology of obesity, as well as the evidence supporting these regions as targets for DBS, in order to explore the therapeutic promise of DBS in obesity.

The lateral hypothalamus and ventromedial hypothalamus are the appetite and satiety centers in the brain, respectively. Substantial data support targeting these regions with DBS for the purpose of appetite suppression and weight loss. However, reward sensation associated with highly caloric food has been implicated in overconsumption as well as obesity, and may in part explain the failure rates of conservative management and bariatric surgery. Thus, regions of the brain's reward circuitry, such as the nucleus accumbens, are promising alternatives for DBS in obesity control.

The authors conclude that deep brain stimulation should be strongly considered as a promising therapeutic option for patients suffering from refractory obesity.

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient

American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Stemming the global obesity epidemic: what can we learn from data about social and economic trends?

Although the policy debate is only slowly moving away from the focus on individual-level psychological and social factors, the research community has largely recognized that changes in dietary and physical activity patterns are driven by changes in the environment and by the incentives that people face. Many factors have been suggested as causes of the 'obesity epidemic'. Putting a multitude of isolated data points into a coherent picture is a challenging, but necessary, task to assess whether proposed solutions are promising or likely to lead down a blind alley. Conventional wisdom is an unreliable guide and some widely held beliefs are incorrect. Can one distinguish between important and less important behavioural changes and relate them to environmental incentives? People face trade-offs in allocating their scarce resources of time and money to best achieve their goals, including health. Studying what people are doing with their time and money is a good start towards understanding how economic incentives have altered energy intake and energy expenditure in a way that has led to weight gain. A challenging task for policy will be finding the right levers. Both economic and public health/medical perspectives play an important role in the policy process, but often approach policy questions in an incompatible way. Economics and public health perspectives can complement each other, but harnessing any synergy requires an understanding of the other perspective. Arguably the most effective community intervention would be multi-faceted and would include several goals about diet and physical activity. In practice, however, it appears that much more effort is devoted to promoting increased fruit/vegetable consumption, and exhorting individuals to increase physical activity than to environmental intervention that would make it easier for people to reduce energy intake and sedentary entertainment. Politically, it may often be more expedient to promote an increase than a decrease, but it may be far less effective.

Challenges of treating a 466-kilogram man with acute kidney injury

Caring for super obese patients (body mass index > 50 kg/m(2)) presents a number of complex and unique clinical challenges, particularly when acute kidney injury is present. We describe our experience treating the heaviest individual with acute kidney injury requiring renal replacement therapy reported to date. A 24-year-old black man was admitted to our hospital with fever, vomiting, progressive weakness, shortness of breath, and hemoptysis. Admission weight was 1,024 lbs (466 kg), height was 6 ft 4 in (1.9 m), and body mass index was 125 kg/m(2). During hospitalization, the patient experienced oligoanuric acute kidney injury and required initiation of continuous and subsequently intermittent renal replacement therapy. This clinical scenario identifies the many challenges involved in caring for super obese patients with acute kidney injury and may be a harbinger of what awaits the nephrology community in the obesity pandemic era.

Changes in perceived weight discrimination among Americans, 1995-1996 through 2004-2006

OBJECTIVE

Little is known about the prevalence and patterns of weight discrimination in the United States. This study examined the trends in perceived weight/height discrimination among a nationally representative sample of adults aged 35-74 years, comparing experiences of discrimination based on race, age, and gender.

METHODS AND PROCEDURES

Data were from the two waves of the National Survey of Midlife Development in the United States (MIDUS), a survey of community-based English-speaking adults initially in 1995-1996 and a follow-up in 2004- 2006. Reported experiences of weight/height discrimination included a variety of settings in major lifetime events and interpersonal relationships.

RESULTS

The prevalence of weight/height discrimination increased from 7% in 1995-1996 to 12% in 2004-2006, affecting all population groups but the elderly. This growth is unlikely to be explained by changes in obesity rates.

DISCUSSION

Weight/height discrimination is highly prevalent in American society and increasing at disturbing rates. Its prevalence is relatively close to reported rates of race and age discrimination, but virtually no legal or social sanctions against weight discrimination exist.

Negative peer perceptions of obese children in the classroom environment

OBJECTIVE

It is asserted that the more immediate and observable consequences of pediatric obesity are psychosocial in nature. This study examines the peer relations of clinically referred obese youth compared to demographically comparable nonoverweight peers within the classroom environment.

METHODS AND PROCEDURES

Peer-, teacher-, and self-reports of behavioral reputation (Revised Class Play (RCP)), and peer reports of social acceptance, nonsocial attributes (attractiveness, athleticism, academic competence), and health interference (school absence, illness, fatigue) were obtained regarding 90 obese youth (BMI > 95th percentile; 8-16 years, 57% girls, 50% African American) and 76 nonoverweight demographically similar comparison classmates.

RESULTS

Relative to comparison peers, obese children were nominated significantly less often as a best friend and rated lower in peer acceptance, although the two groups did not differ in the number of reciprocated friendships. Obese youth were described by peer, teacher, and self-report as more socially withdrawn and by peers as displaying less leadership and greater aggressive-disruptive behavior. Peers also described obese youth as less physically attractive, less athletic, more sick, tired, and absent from school. Being seen as less attractive and less athletic by peers helped to explain differences in obese and nonoverweight youth's levels of peer acceptance.

DISCUSSION

Clinically referred obese youth are characterized by peer relations that differ from those of nonoverweight youth. The peer environment provides a rich context to understand the social consequences of pediatric obesity as well as factors that could be targeted in intervention to promote more positive health and psychosocial outcomes.

Current perspectives on the obesity hypoventilation syndrome

PURPOSE OF REVIEW

Identifying and treating obesity hypoventilation syndrome is an important therapeutic goal, especially given the high morbidity and mortality associated with untreated disease. Significant weight loss or effective treatment of upper airway obstruction will reverse daytime hypoventilation, suggesting that these two mechanisms play key roles in the development and progression of this disorder. Only a subset of morbidly obese patients will develop awake hypercapnia, however, even in the presence of sleep disordered breathing. This implies that complex interplay between a number of known and unknown mechanisms is needed to produce daytime respiratory failure in this patient population.

RECENT FINDINGS

Work in the mouse model of obesity has been central in advancing our understanding of the role leptin plays in stimulating ventilation. Leptin deficiency or development of leptin resistance in obesity leads to alterations in central respiratory drive and reduced ventilatory responsiveness, permitting development of carbon dioxide retention. Changes in neuromodulators resulting from the effects of hypoxia may further exacerbate the problem by depressing arousal from sleep in the face of abnormal breathing.

SUMMARY

Understanding the various mechanisms contributing to development of obesity hypoventilation is important in order to identify new approaches to effective long-term management of this disorder.

Prevalence of obesity and abdominal obesity in Swedish primary care and occupational health clinics

BACKGROUND

The objective of this study was to describe the prevalence of obesity and abdominal obesity in the Swedish primary and occupational health care setting.

PATIENTS AND METHODS

Weight, height, and waist circumference (WC) were measured in 1,583 consecutive patients, aged between 18-65 years (46.4 +/- 12.7 years), in 39 primary care and occupational health practices in Sweden, in 2006. The National Cholesterol Education Program (NCEP) WC reference values were used to define abdominal obesity (102 and 88 cm for men and women, respectively).

RESULTS

The distribution across obesity categories differed significantly between men and women with close to 70 and 55% of men and women, respectively, having a body mass index (BMI) >or= 25. More men than women were overweight (BMI 25-29.9; 45.1 vs. 31.1%) and obese (BMI 30-34.9; 19.8 vs. 12.9%), but less men than women were morbidly obese (4.0 vs. 8.9%; BMI >or= 35). Increasing prevalence with age was seen until age 60 for both overweight and obesity. More women than men were abdominally obese (42.5 vs. 32.7%; p < 0.001). Only 48 and 64% of the abdominally obese women and men, respectively, had a BMI >or= 30.

CONCLUSION

Compared to national Swedish data, the prevalence of overweight and obesity was higher in primary and occupational health care settings. Both morbid obesity and abdominal obesity were highly prevalent and more common in women, implying that awareness of sex differences may be important or that recommended cut-offs are not comparable across sex. Furthermore, a large fraction of the abdominally obese had a BMI < 30. Both BMI and WC may therefore be important to determine routinely and incorporate into treatment guidelines, in order not to miss patients at risk of obesity-related morbidity.

Shift in the composition of obesity in young adult men in Sweden over a third of a century

OBJECTIVE

To assess whether the composition of the obese category (body mass index (BMI)> or =30) has changed during the last one-third of a century in young adult men.

DESIGN

Retrospective study of 1,580,913 men (18.3+/-0.4 years) representing 82% of the Swedish male population at military conscription age between 1969 and 2005. Measured height and weight were used to define moderate and morbid obesity as BMI 30-34.9 and > or =35, respectively. Data on socio-economic position (SEP), place of residence (urban, semi-urban and rural), age and test center were also collected.

RESULTS

From the period 1969-1974 to 2000-2005, the prevalence of moderate obesity almost quintupled (0.8-3.8%; P<0.0001), while morbid obesity increased 10-fold (0.1-1.3%; P<0.0001). The composition of the obese category changed from 12.9 to 25.1% morbidly obese during the same time, corresponding to an annual growth in the odds of 2.8% (CI(95%) 2.5-3.1%) per year within the obese category. Compared to 1969-1974, the odds ratios of obesity and morbid obesity, respectively, were 1.6 (1.6-1.7) and 1.9 (1.7-2.2) in 1980-1984, 2.8 (2.7-2.9) and 4.0 (3.5-4.5) in 1990-1994, and 6.0 (5.7-6.3) and 11.4 (10.1-12.9) in 2000-2005, after adjustment for SEP, urban/rural place of residence, age and test center. Extrapolation of the growth rate during the observation period resulted in an estimated 4% morbidly obese in 2020.

CONCLUSION

Morbid obesity increased faster than moderate obesity during the last 35 years. As the health risks and costs of obesity-related morbidity increase disproportionately in the morbidly obese, it is important to assess morbid obesity in prevalence studies, and distinguish the morbidly from the moderately obese in cost analyses.

Participation in 150 min/wk of moderate or higher intensity physical activity yields greater weight loss after gastric bypass surgery

BACKGROUND

The American College of Sports Medicine's position stand on weight loss and prevention of weight regain in adults has suggested that overweight adults should participate in a minimum of 150 min/wk of moderate intensity physical activity (PA). This study compared the 3-, 6-, and 12-month postoperative weight loss between gastric bypass surgery (GBS) patients who met or exceeded the recommended 150 min/wk of moderate or higher PA and those not meeting the recommendation.

METHODS

The self-administered short version of the International Physical Activity Questionnaire was used to assess moderate or higher intensity PA participation at 3 (n = 178), 6 (n = 128), and 12 months (n = 209) after GBS. The patients' height and body weight were obtained to determine the kilograms of weight lost, percentage of excess weight loss, body mass index change, and total weight loss percentage. The weight loss differences were analyzed using analysis of covariance at each point, with age and preoperative body mass index as covariates.

RESULTS

Patients reporting 150 min/wk of moderate or higher PA had significantly (P <.05) greater weight lost, percentage of excess weight loss, change in body mass index, and total weight loss percentage at 6 and 12 months postoperatively. The percentage of excess weight loss was 56.0% +/- 11.5% versus 50.5% +/- 11.6% and 67.4% +/- 14.3% versus 61.7% +/- 17.0% for the group meeting and not meeting the PA requirement at 6 and 12 months after GBS, respectively. No significant difference existed at 3 months after GBS.

CONCLUSION

Participation in a minimum of 150 min/wk of moderate or higher intensity PA was associated with greater postoperative weight loss at 6 and 12 months postoperatively. Patients should be encouraged to meet or exceed this recommendation until prospective, randomized studies have definitively established a link between PA and greater postoperative weight loss and maintenance.

Reproductive implications of bariatric surgery: pre- and postoperative considerations for extremely obese women of childbearing age

Extreme obesity remains a frustrating and formidable disease, with most sufferers requiring surgical intervention in order to achieve long-term, sustained weight loss. Most bariatric procedures today are performed on women, many of whom are of reproductive age; yet minimal evidence exists to guide clinicians in the care of such women before, during, and after pregnancy. This review outlines the fundamental nutritional and surgical alterations of the most commonly performed bariatric procedures with the aim to elucidate a physiologically sound approach to counseling and management of extremely obese women of childbearing age who are either contemplating or have already undergone bariatric surgery. Preconception, pregnancy, and lactation guidelines are offered based on available evidence. Outstanding questions are highlighted for further investigation.

Lysosomal hydrolases of the epidermis. I. Glycosidases

Seven distinct glycosidases (EC 3.2) have been characterized in guinea-pig epidermis. Their properties indicate them to be of lysosomal origin. The 'profile' of the epidermal glycosidases is significantly different from that reported for whole skin, the activities of beta-galactosidase and beta-acetylglucosaminidase being very high and those of the remaining enzymes relatively low in epidermis.