Indices of relative weight and obesity

Obesity: prevalence and considerations in oral and maxillofacial surgery

PURPOSE

This article examines the prevalence of obesity in an urban hospital-based office population and describes the associated health risks and systemic complications.

PATIENTS AND METHODS

A total of 225 randomly selected patient charts were reviewed. The patients' height and weight were recorded, and a body mass index (BMI) was calculated. Patients were considered to have a normal weight with a BMI between 20 and 24.9 kg/m2, to be overweight with a BMI between 25 and 29.9 kg/m2, and to be obese with a BMI of 30 kg/m2 or greater. Comparisons between sex, age, and race were examined.

RESULTS

Eighty-five males and 140 females were included in the study. The ages ranged from 9 to 86 years, with a mean age of 37.4+/-16.4 years. The BMIs ranged from 13.9 to 57.7 kg/m2, with a mean BMI of 26.5+/-6.8 kg/m2. Over half (51%) of the population studied was overweight, and 23% were obese. Forty-three percent of males were considered overweight, and 18.8% of males were obese. Women tended to be more overweight: 55.7% of women were overweight and 25.7% were obese. The African-American females had mean BMIs that were considered overweight in all age-groups and obese in most age-groups, which included the less than 29-year-old and over 50-year-old groups. Caucasian females had normal mean BMIs at all ages except for the 30- to 39-year-old and 40- to 49-year-old groups.

CONCLUSION

The increasing prevalence of overweight and obese populations has several considerations in oral and maxillofacial surgery. The associated health risks and increased morbidity and mortality pose a serious threat to the patient being treated in an outpatient setting.

Body mass index and alternative indices of obesity in relation to height, triceps skinfold and subsequent mortality: the Busselton health study

OBJECTIVES

The ideal index for leanness and obesity in epidemiological studies should correlate strongly with body weight and with a direct measure of fat while minimizing the influence of height. The preferred index is expected to show meaningful associations with subsequent mortality. Our aims were to compare weight/height, weight/height(2) (body mass index or BMI), and weight/height(3) as candidates for this index.

DESIGN

We analysed cross-sectional data from surveys of 6948 adults (3334 men (mean age 43 y, mean BMI 24.8 kg/m2), and 3614 women (mean age 42 y, mean BMI 24.3 kg/m2)) in Busselton, Australia whose weight, height, triceps skinfold, and cardiovascular risk factors were measured from 1966 through to 1978. In these same subjects we studied the mortality risks of indices of obesity using Cox regression analysis for survival time from first survey to death, or to follow up at the end of December 1995, after adjustment for age. Subjects dying within 5 y of the baseline survey were excluded from the analysis to avoid the bias of concurrent illness. We also studied subgroups including never smokers, subjects with no heart disease, and subjects <60 years of age at first survey.

RESULTS

In men, weight/height2 met the criteria for a satisfactory index in that there was a very strong correlation with triceps skinfold, and a negligible correlation with height. For women, weight/height was as good a measure as weight/height2, with both having strong correlations with triceps skinfold, and minimal correlations with height. Weight/height2 as a predictor of mortality in men of all ages showed the typical U-shaped associations that were similar and consistent and of variable statistical significance. The significances of the hazard ratio curves were the strongest for cardiovascular disease deaths (all men P=0.001; men without heart disease at baseline P<0.001; never smoking men P=0.007). In never smoking men there was a near linear positive relationship with all-cause mortality (P=0.018). In women weight/height2 showed no consistent associations with mortality. There was a shallow U-shaped relationship with all-cause mortality (P=0.087), also seen in never smoking women (P=0.075). In assessing 'ideal' weight for height in this population, a weight/height2 of 25 kg/m2 (range 22.5-27.5 kg/m2) is appropriate. Weight/height and mortality showed very similar patterns in men to weight/height2 with quite similar levels of statistical significance. In women much more pronounced U-shaped curves were apparent in all groups and subgroups, with a significant all-cause mortality trend for all women (P=0.029) and never smoking women (P=0.034). In assessing 'ideal' weight for height a weight/height of 42.5 kg/m (range 35-50 kg/m) appears appropriate for men and women.

CONCLUSIONS

Weight/height2 is an appropriate index of leanness and obesity in males at all ages, whereas weight/height is at least as good an index for females. In mortality studies weight/height2 and weight/height predict mortality similarly in males, but weight/height is a better discriminant of mortality in females. International Journal of Obesity (2000)24, 108-115

Is radical trachelectomy a safe alternative to radical hysterectomy for patients with stage IA-B carcinoma of the cervix?

BACKGROUND

The prognosis associated with lymph node negative, early stage carcinoma of the cervix is excellent, with 5-year survival rates greater than 90%. Radical trachelectomy in combination with pelvic lymph node dissection (RVT + LPL) has emerged as an alternative to radical hysterectomy (RH) for these patients who desire preservation of fertility. However, there are limited data to support its efficacy and safety.

METHODS

All patient information was collected prospectively and was subsequently extracted from the cervical cancer surgery database of the Division of Gynecologic Oncology at the University of Toronto. Patients treated by RVT + LPL for fertility preservation were compared with two groups of patients treated by RH. One control group was matched for age, tumor size, histology, depth of invasion, presence of capillary lymphatic space involvement, lymph node metastases, and use of adjuvant radiation. The other control group consisted of patients with tumor sizes </=2 cm, negative pelvic lymph nodes who had not received adjuvant radiation therapy.

RESULTS

Thirty of 32 patients treated by RVT + LPL between March 1994 and November 1998 were matched. The only statistically significant difference in prognostic factors between the patients who underwent RVT + LPL and unmatched controls (556 patients) was the median depth of invasion in the adenocarcinomas (2. 0 mm vs. 4.0 mm, respectively; P < 0.02). The 2-year actuarial recurrence free survival was 95%, 100%, and 97% for the patients who underwent RVT + LPL, matched controls, and unmatched controls, respectively. The actuarial conception rate at 12 months was 37%.

CONCLUSIONS

Acknowledging the small numbers and short follow-up, RVT + LPL appears to be similar in efficacy to RH. If longer follow-up with more patients confirms the above, this procedure will represent an acceptable alternative to RH for patients with early Stage I carcinoma of the cervix who desire preservation of fertility.

Impact of body mass index and albumin on morbidity and mortality after cardiac surgery

OBJECTIVE

Extremely thin and overly obese patients may not tolerate cardiac surgery as well as other patients. A retrospective study was conducted to determine whether the extremes of body mass index (weight/height(2) [kg/m(2)]) and/or cachexia increased the morbidity and mortality associated with cardiac operations.

METHODS

Body mass index was used to objectively measure "thinness" (body mass index < 20) and "heaviness" (body mass index > 30); preoperative serum albumin was used to quantify nutritional status and underlying disease. Data were gathered between 1993 and 1997 from 5168 consecutive patients undergoing coronary artery bypass or valve operations, or both.

RESULTS

No significant correlations were observed between body mass index and preoperative albumin levels. Low body mass index (<20) and low albumin level (<2.5 g/dL) were each independently associated with increased mortality after cardiopulmonary bypass (P </=.0005). Operative mortality was highest among those with both low body mass index and low albumin level. Multivariable logistic regression, adjusting for potentially confounding variables, demonstrated that an albumin level of less than 2.5 g/dL was independently associated with increased risk of reoperation for bleeding, postoperative renal failure, and prolonged ventilatory support, intensive care unit stay, and total length of stay. A body mass index of more than 30 was associated with increased sternal wound infection and saphenous vein harvest site infection.

CONCLUSIONS

Hypoalbuminemia and low body mass index each independently predict increased morbidity and mortality after cardiac operations. Preoperative risk stratification with the use of body mass index and serum albumin may help to identify subgroups of patients at high risk for adverse outcomes after cardiac operations.

Body-mass index and mortality in a prospective cohort of U.S. adults

BACKGROUND

Body-mass index (the weight in kilograms divided by the square of the height in meters) is known to be associated with overall mortality. We investigated the effects of age, race, sex, smoking status, and history of disease on the relation between body-mass index and mortality.

METHODS

In a prospective study of more than 1 million adults in the United States (457,785 men and 588,369 women), 201,622 deaths occurred during 14 years of follow-up. We examined the relation between body-mass index and the risk of death from all causes in four subgroups categorized according to smoking status and history of disease. In healthy people who had never smoked, we further examined whether the relation varied according to race, cause of death, or age. The relative risk was used to assess the relation between mortality and body-mass index.

RESULTS

The association between body-mass index and the risk of death was substantially modified by smoking status and the presence of disease. In healthy people who had never smoked, the nadir of the curve for body-mass index and mortality was found at a body-mass index of 23.5 to 24.9 in men and 22.0 to 23.4 in women. Among subjects with the highest body-mass indexes, white men and women had a relative risk of death of 2.58 and 2.00, respectively, as compared with those with a body-mass index of 23.5 to 24.9. Black men and women with the highest body-mass indexes had much lower risks of death (1.35 and 1.21), which did not differ significantly from 1.00. A high body-mass index was most predictive of death from cardiovascular disease, especially in men (relative risk, 2.90; 95 percent confidence interval, 2.37 to 3.56). Heavier men and women in all age groups had an increased risk of death.

CONCLUSIONS

The risk of death from all causes, cardiovascular disease, cancer, or other diseases increases throughout the range of moderate and severe overweight for both men and women in all age groups. The risk associated with a high body-mass index is greater for whites than for blacks.

Running closure of clean and contaminated abdominal wounds using a synthetic monofilament absorbable looped suture

The effectiveness of using an absorbable suture material for continuous closure of abdominal wounds, especially contaminated wounds, has not yet been determined. Thus, the present study was conducted to investigate the wound complications that developed following continuous closure of clean and contaminated abdominal wounds using polydioxanone (PDS), compared with those that developed following interrupted closure using braided silk. Running closure using PDS was performed in 152 patients (PDS group), while 280 patients who underwent interrupted closure using braided silk served as controls (SILK group). The occurrence rates of wound dehiscence, early wound infection, and incisional hernia did not differ significantly between the two groups; however, the incidence of late suture sinus formation in the PDS group (1.3%) was significantly lower than that in the SILK group (7.1%). Moreover, late suture sinus formation following PDS suturing healed within 1 week after percutaneous drainage alone without removal of suture strings, whereas late suture sinus following braided silk suturing took an average of 16 days to heal and required removal of the infected suture strings in all 20 patients. These findings indicate the potential usefulness of PDS as a suture material to achieve running closure of clean or contaminated abdominal wounds.

Are preoperative obesity and cachexia risk factors for post heart transplant morbidity and mortality: a multi-institutional study of preoperative weight-height indices. Cardiac Transplant Research Database (CTRD) Group

BACKGROUND

The relationship between pre-transplant body weight and post-transplant outcome has only recently been identified using a single, indirect measure of weight (percent ideal body weight [PIBW]). The literature is equivocal regarding which index is the better indicator of body weight. The purpose of this study was to determine (1) if pre-heart transplant body weight, measured by body mass index (BMI) and PIBW, is associated with post-heart transplant morbidity and mortality and (2) if patient gender, age, and etiology of heart disease affect this association.

METHODS

The sample included 4,515 patients who received a heart transplant from January 1, 1990-December 31, 1995 at 38 institutions participating in the Cardiac Transplant Research Database (CTRD). Patients were divided into groups according to their BMI and PIBW. Data were described using frequencies, measures of central tendency, Pearson correlation coefficients, stratified actuarial analyses and log rank tests for comparisons, and a multivariable risk factor analysis in the hazard domain.

RESULTS

For all patients (n = 4,515), being <80% or >140% of IBW before heart transplant was a risk factor for increased mortality after heart transplant. The association between pre-heart transplant PIBW and post-heart transplant survival was affected by gender, age, and etiology of heart disease. In males, a higher PIBW was a significant risk factor for death early after transplant (p = .0003). Although not significant, there was a trend for a higher PIBW being a risk factor for death in females throughout the post transplant period (p = .07). No differences in cause of death were found for PIBW and BMI. In male and female recipients <55 years, being overweight pre-heart transplant was a risk factor for infection. In patients with pre-transplant ischemic heart disease, the greatest risk for infection was found in patients who were >140% of IBW. Pre-heart transplant BMI and PIBW were not associated with acute rejection or cardiac allograft arteriopathy after transplant.

CONCLUSIONS

In conclusion, being cachectic or obese preoperatively is associated with decreased survival in all patients after heart transplantation. Being obese preoperatively is associated with increased infection after heart transplant in males and females <55 years and in patients with ischemic heart disease. Of the 2 indices of body weight used in this study, percent ideal body weight appears to be the better predictor of future morbidity and mortality following heart transplantation.

Correlates of body mass index in hazardous materials firefighters

We analyzed results from the medical examinations of 340 hazardous materials (HAZMAT) firefighters and observed the relationships between selected parameters and body mass index (BMI). Heights and weights were available for 98% of the subjects (333 of 340). The mean BMI was 28.9 +/- 4.1 kg/m2. Eighty-seven percent (290 of 333) of subjects were overweight (BMI > or = 25) and 34% (113 of 333) were obese (BMI > or = 30). Two percent (7 of 333) were morbidly obese (BMI > or = 39). For comparison purposes, we divided subjects into low (BMI < 27), medium (BMI 27 to < 30), and high (BMI > or = 30) BMI groups. The results demonstrated adverse associations between increasing BMI and resting blood pressures, forced vital capacity, alanine aminotransferase, aspartate aminotransferase, serum cholesterol, and overall morbidity scores. The high prevalence of overweight and obesity and the associated adverse health effects support the development and implementation of fitness-promotion programs for firefighters.

Marital status, marital satisfaction, and body image dissatisfaction

OBJECTIVE

This study examined whether married individuals have comparable body image disturbance to nonmarried individuals and whether the quality of a marital relationship is significantly related to body image disturbance in a sample of dieters.

METHOD

Measures of marital status, marital satisfaction, and body dissatisfaction were administered to a sample of 16,377 subjects who had tried to lose weight at least once within the previous 3 years.

RESULTS

Marital status was not associated with increased body dissatisfaction. Marital satisfaction was significantly related to body dissatisfaction when controlling for age, body mass index, self-esteem, and gender.

DISCUSSION

Body dissatisfaction occurs at comparable levels among married and single individuals and the study of marital functioning among eating-disordered individuals represents a large gap in the literature.

Curve smoothing and transformations in the development of growth curves

Growth charts such as those published by the National Center for Health Statistics (NCHS) consist of a set of smoothed percentile curves showing the distribution of different aspects of body size for infants, children, and adolescents. The original NCHS growth charts are currently being revised to incorporate additional national data, to include growth curves for body mass index (BMI, in kg/m2), to reduce or eliminate dis-continuities, and to use new and improved methods of smoothing. Methods of curve smoothing in the development of growth curves are briefly discussed in the context of this revision by using examples based on the provisional data set for revision of the growth curves. Among the factors that may affect the construction of the revised growth curves are sample sizes, sampling weights, and secular trends. The use of BMI or other weight-height indexes in growth curves presents some new issues because these transformations of weight and height data do not increase monotonically with age. Some of the advantages and disadvantages of several different approaches to creating smoothed percentiles and standardized scores are discussed briefly. These effects need to be considered in the broader context of constructing growth curves. No single method of developing smoothed curves is clearly the best for all purposes, and estimates of overweight and underweight may be sensitive to the method chosen. Alternative approaches to constructing smoothed curves by using weight-height functions other than BMI might warrant further exploration.

Relation of BMI to a dual-energy X-ray absorptiometry measure of fatness

Dual-energy X-ray absorptiometry (DXA) is a valid technique for measuring the fat, bone and lean (muscle, organs and water) masses of the body. We evaluated relationships of BMI (kg/m2) with independent measurements of fat and lean masses using DXA in 226 adult volunteers. The evaluation was an application of a general approach to compositional data which has not previously been used for describing body composition. Using traditional regression analyses, when lean mass was held constant, BMI varied with fat mass (men r 0.75, P < 0.05; women r 0.85, P < 0.05); when fat mass was held constant, BMI varied with lean mass (men r 0.63, P < 0.05; women r 0.47, P < 0.05). In contrast, a regression model for compositional data revealed that BMI was: (a) strongly associated with log fat mass in both sexes (b1 4.86, P < 0.001 for all women and b1 5.96, P < 0.001 for all men); (b) not associated with bone mass, except in older men; (c) related to lean mass in women but not in men (b3 -4.04, P < 0.001 for all women and b1 -2.59, P < 0.15 for all men). Women with higher BMI tended to have more fat mass and more lean mass than women with lower BMI. Men with higher BMI had more fat mass but similar lean mass to men with lower BMI. Investigators need to be alert to the inaccuracy of BMI to assign a fatness risk factor to individuals, especially among women.

Fatness and body mass index from birth to young adulthood in a rural Guatemalan population

Body mass index (BMI; wt in kg/ht2 in m) has been proposed as a simple and valid measure for monitoring fatness. Using data from a 25-y longitudinal study of rural Guatemalans, we found that, as children, this population was stunted (mean height-for-age z = -2.6) and had low triceps skinfold thicknesses ( approximately 10% of reference medians), yet had mean BMIs above US reference medians. As young adults, mean BMIs were at the 50th and 20th percentiles for women and men, respectively. BMIs between ages 1 and 5 y were moderately correlated (r = 0.2-0.3) with those in young adulthood. BMI was correlated with subscapular (r = 0.5-0.8) and triceps (r = 0.2-0.7) skinfold thicknesses at all ages and with predicted percentage body fat in adolescence (r = 0.65) and adulthood (r = 0.8). Fatness was highly centralized, with ratios of subscapular to triceps skinfold thicknesses at the 50th-90th percentiles of reference medians at all ages. BMI was a poor indicator of central fat; the correlation between BMI and waist-to-hip ratio in 14-17-y-old males was -0.21). In stunted populations in developing countries, BMI alone should be interpreted with caution. In stunted children, BMIs may be high despite small extremity skinfold thicknesses; BMI alone may overestimate the prevalence of fatness in these children. In adults, measures in addition to BMI may be required to identify centralized adiposity in these populations.

A cohort study of hepatitis C virus (HCV) infection in an HCV epidemic area of Japan: age and sex-related seroprevalence of anti-HCV antibody, frequency of viremia, biochemical abnormality and histological changes

We studied the age- and sex-specific prevalence of hepatitis C virus (HCV) infection and aminotransferase abnormalities as well as histological changes in the liver associated with HCV infection. Of the eligible 3,707 inhabitants aged 6 years and older in an HCV infection epidemic area 2,382 (64.3%) were examined. The anti-HCV positivity rate was 20.7% on average and increased according to age. Age was the most potential risk indicator for anti-HCV positivity by multiple stepwise regression analysis. The HCV RNA positivity rate in females with anti-HCV was significantly lower than that in males. However, as the age of females increased, the HCV RNA positivity rate became higher. The proportion of subjects with aminotransferase abnormalities among HCV RNA-positive subjects was significantly lower in females than males. Aminotransferase abnormalities significantly increased with age in females. In subjects with abnormal aminotransferase levels, nearly half of the HCV RNA-positive females were aged 50 or older and also nearly half of the male subjects showed CAH2B or liver cirrhosis, while most of the HCV RNA-positive females younger than 50 exhibited histological findings consistent with CPH. In conclusion, age was the principal risk indicator for HCV infection in this area. Females, especially those younger than 50, both biochemically and histologically showed less severity of HCV infection than males. Gender and age might have effects on the outcome of HCV related liver disease.

Physiological deadspace during normocapnic ventilation under anaesthesia

Respiratory physiological deadspace (VDphys) during normocapnic ventilation under anaesthesia was studied in 253 patients scheduled for elective non-thoracic surgery. Subjects were ventilated with SERVO 900B ventilator using CO2 analyser 930 (Siemens-Elema Sweden) to adjust minute volume sufficient to maintain end-tidal carbon dioxide fraction (FECO2) around 5.5kPa with normocapnic confirmation using arterial blood gas analysis. VDphys was calculated using Enghoff's modification of Bohr's equation. VDphys and deadspace to tidal volume ratios (VD/VT) in male patients were 142.6 +/- 28.4 ml and 0.37 +/- 0.068 respectively and were significantly higher than that in females (119.4 +/- 35.6 ml and 0.36 +/- 0.067). Males had significantly higher VDphys/mass (2.5 +/- 0.68 ml.kg) compared with females (2.2 +/- 0.54 ml/kg, P < 0.001) but significantly lower body mass index (BMI) (20.67 +/- 3.2 in males and 22.47 +/- 4.1 in females, P < 0.001). VDphys showed positive correlation with weight, height and body surface area (BSA) but VDphys/kg showed negative correlation with BMI. Multiple regression analysis produced a best fit equation for VDphys = 9.7 + 64.3 x BSA + 13.51S where S = 1 for females and 2 for males.

Neck soft tissue and fat distribution: comparison between normal men and women by magnetic resonance imaging

BACKGROUND

Obesity and increased neck circumference are risk factors for the obstructive sleep apnoea/hypopnoea syndrome (SAHS). SAHS is more common in men than in women, despite the fact that women have higher rates of obesity and greater overall body fat. One factor in this apparently paradoxical sex distribution may be the differing patterns of fat deposition adjacent to the upper airway in men and women. A study was therefore undertaken to compare neck fat deposition in normal men and women.

METHODS

Using T1 weighted magnetic resonance imaging, the fat and tissue volumes in the necks of 10 non-obese men and 10 women matched for age (men mean (SE) 36 (3) years, women 37 (3) years, p = 0.7), body mass index (both 25 (0. 6) kg/m2, p>0.9), and Epworth Sleepiness Score (both 5 (1), p = 0.9) were assessed; all denied symptoms of SAHS.

RESULTS

Total neck soft tissue volume was greater in men (1295 (62) vs 928 (45) cm3, p<0. 001), but the volume of fat did not differ between the sexes (291 (29) vs 273 (18) cm3, p = 0.6). The only regions impinging on the pharynx which showed a larger absolute volume of fat in men (3.2 (0. 7) vs 1.1 (0.3) cm3, p = 0.01) and also a greater proportion of neck fat in men (1.3 (0.3)% vs 0.4 (0.1)%, p = 0.03) were the anterior segments inside the mandible at the palatal level.

CONCLUSIONS

There are differences in neck fat deposition between the sexes which, together with the greater overall soft tissue loading on the airway in men, may be factors in the sex distribution of SAHS.

Relation of circumferences and skinfold thicknesses to lipid and insulin concentrations in children and adolescents: the Bogalusa Heart Study

BACKGROUND

Although body fat patterning has been related to adverse health outcomes in adults, its importance in children and adolescents is less certain.

OBJECTIVE

We examined the relation of circumference (waist and hip) and skinfold-thickness (subscapular and triceps) measurements to lipid and insulin concentrations among 2996 children and adolescents aged 5-17 y.

DESIGN

This was a community-based, cross-sectional study conducted in 1992-1994.

RESULTS

A central or abdominal distribution of body fat was related to adverse concentrations of triacylglycerol, LDL cholesterol, HDL cholesterol, and insulin; these associations were independent of race, sex, age, weight, and height. These associations were observed whether fat patterning was characterized by using 1) waist circumference alone (after adjustment for weight and height), 2) waist-to-hip ratio, or 3) principal components analysis. Compared with a child at the 10th percentile of waist circumference, a child at the 90th percentile was estimated to have, on average, higher concentrations of LDL cholesterol (0.17 mmol/L), triacylglycerol (0.11 mmol/L), and insulin (6 pmol/L) and lower concentrations of HDL cholesterol (-0.07 mmol/L). These differences, which were independent of weight and height, were significant at the 0.001 level and were consistent across race-sex groups.

CONCLUSIONS

These findings emphasize the importance of obtaining information on body fat distribution, waist circumference in particular, in children. Waist circumference, which is relatively easy to measure, may help to identify children likely to have adverse concentrations of lipids and insulin.

Blood pressure in relation to obesity, insulin and the hypothalamic-pituitary-adrenal axis in Swedish men

OBJECTIVE

Some studies have shown a clustering of obesity, insulin and hypertension. The present study was performed to further characterize these associations.

SUBJECTS AND METHODS

In a population of 51-year-old men (n=284), measurements of systolic and diastolic blood pressure were analyzed in relation to general obesity (body mass index) and central obesity (waist: hip circumference ratio and abdominal sagittal diameter), and to the fasting insulin and insulin: glucose ratio as an approximation of insulin sensitivity. The regulation of diurnal cortisol secretion was examined in repeated salivary samples.

RESULTS

Linear regression analysis showed that all three parameters of obesity were significantly and strongly related to both systolic and diastolic blood pressure, more powerfully than insulin, glucose and insulin sensitivity (insulin: glucose ratio). Stepwise multiple regression showed that only central obesity, measured as the abdominal sagittal diameter, remained significantly (P< 0.001), and independently of insulin and insulin sensitivity, associated with both systolic and diastolic blood pressure (beta=7.5 and 4.2, respectively). A diurnal cortisol curve with normal rhythm was associated with lower than average blood pressures (P< 0.001) but not with insulin levels or the heart rate. In contrast, a flattened diurnal cortisol curve, indicating perturbations in the activity of the hypothalamic-pituitary-adrenal axis, was directly related to blood pressures, heart rate and insulin (P<0.001), and has previously been found to be strongly associated with abdominal obesity.

CONCLUSIONS

These findings suggest that general and central obesity is independently related to blood pressure, and that insulin may account for only part of this association. The activity of the hypothalamic-pituitary-adrenal axis is apparently important for blood pressure regulation, suggesting that mechanisms of the central nervous system have an impact.

Obesity and risk of adverse outcomes associated with coronary artery bypass surgery. Northern New England Cardiovascular Disease Study Group

BACKGROUND

Obesity is frequently cited as a risk factor for adverse outcomes of major surgery. The results of prior studies of the relationship between obesity and risk of adverse outcomes of coronary artery bypass grafting (CABG) have been contradictory because of insufficient power to assess relatively infrequent outcomes or data to adjust for confounding factors.

METHODS AND RESULTS

Data on patient age, sex, height, weight, medical history, current clinical status, and treatment factors were assessed prospectively among 11101 consecutive patients undergoing CABG. Body mass index (BMI) was used as the measure of obesity and was categorized as nonobese (1st to 74th percentiles), obese (75th to 94th percentiles), or severely obese (95th to 100th percentiles). Adverse outcomes occurring in-hospital, including mortality, intraoperative/postoperative cerebrovascular accident (CVA), postoperative bleeding, and sternal wound infection, were defined prospectively. Associations between obesity and postoperative outcomes were assessed by use of logistic regression to adjust for potentially confounding variables. Although obesity was not associated with increased mortality (adjusted odds ratio [OR], 1.16; P=.261) or postoperative CVA (adjusted OR, 1.06; P=.765), risks of sternal wound infection were substantially increased in the obese (adjusted OR, 2.10; confidence interval [CI], 1.45 to 3.06; P<.001) and severely obese (adjusted OR, 2.74; CI, 1.49 to 5.02; P=.001). On the other hand, rates of postoperative bleeding were significantly lower in the obese (adjusted OR, 0.66; CI, 0.49 to 0.90; P=.009) and severely obese (adjusted OR, 0.40; CI, 0.20 to 0.81; P=.011).

CONCLUSIONS

With the exception of sternal wound infection, the perception among clinicians that obesity predisposes to various postoperative complications with CABG is not supported by these data. Further work is needed to understand the apparent protective effect of obesity on risks of postoperative bleeding.

Seven-year incidence of hypertension in a cohort of middle-aged African Americans and whites

Many studies have suggested that African Americans have a higher prevalence of hypertension than whites. The authors conducted a prospective study of hypertension incidence from 1987-1988 to 1994-1995 in 140 African American and 237 white adults aged 30 to 54 years at baseline. The study participants were screened for participation in the Trials of Hypertension Prevention, phase 1, an 18-month lifestyle modification intervention trial aimed at lowering blood pressure, at the Baltimore Clinical Center. Baseline age, blood pressure, body mass index, and heart rate were similar in the two groups. Compared with whites, however, African Americans had a lower percentage of men, college graduates, and households with an income > or = $40,000 per year. African Americans also had lower mean urinary sodium to creatinine ratio and potassium to creatinine ratio, but a similar sodium to potassium ratio. The incidence of hypertension (blood pressure > or = 160/95 mm Hg and/or taking antihypertensive medication) over 7 years of follow-up was nearly identical: 25.7% in African Americans and 25.3% in whites. Baseline age, gender, blood pressure, and heart rate were all associated with the incidence of hypertension. Even after adjustment for these covariables, the risk of hypertension was not higher in African Americans compared with whites. These results indicate that middle-aged African Americans and whites have a similar risk of developing hypertension given the same age, initial blood pressure, and body mass index at baseline.

Underlying dimensions and psychometric properties of the Eating Behaviors and Body Image Test for preadolescent girls

Developed a rating scale to measure body image satisfaction and eating behaviors and disturbances in preadolescent girls and evaluated the psychometric properties of the instrument. The Eating Behaviors and Body Image Test (EBBIT) for preadolescent girls was administered to 291 fourth-, fifth-, and sixth-grade girls to identify the measure's factor structure. Body Image Silhouettes (BIS; Childress, Brewerton, Hodges, & Jarrell, 1993) were also administered, and height and weight measurements were obtained. Although four factors were predicted (maladaptive thoughts about body size, restrictive eating, bingeing, and compensatory behavior for overeating), corresponding to adult criteria for the diagnoses of anorexia and bulimia, factor analysis of the EBBIT suggested only two factors: Body Image Dissatisfaction/Restrictive Eating and Binge Eating Behaviors. Only two compensatory behaviors (exercising to burn off food eaten and skipping meals after overeating) loaded on the scale, and they loaded on the Body Image Dissatisfaction/Restrictive Eating factor. Internal consistency and test-retest reliabilities were adequate to good, and initial validity of the scale was established by using scores on the Body Image Silhouettes, body mass index ratios, age, and race as predictors of EBBIT scores.

An evaluation of a structural model for studies of the initiation of dieting among adolescent girls

A model proposed to elucidate the sociopsychological processes involved in the initiation of dieting behavior among female adolescents was evaluated in the present study. The model incorporates social influence (as modeling, conformity, and compliance), autonomous functioning (as conformity disposition, individuation, self-reliance, and locus of control), skill-related functioning (as interpersonal negotiation skills and social self-efficacy), and parental style (in care and overprotection). It was investigated using path analytic procedures. One hundred forty-eight female high school students, aged between 13 and 16 years, completed a battery of questionnaires and were also interviewed individually. The results emphasized that adolescent dieting needs to be understood as a complex multicausal phenomenon. Adolescents' perceptions of direct pressure from their parents to diet was found to be a significant predictor of dieting, and perceived parental encouragement of autonomy, and self-confidence were associated with less dieting behavior. Moreover, whereas body mass index (BMI) and body dissatisfaction significantly predicted dieting, the three sociopsychological variables remained significant predictors of dieting when taking BMI into account, and perceived parent influence to diet remained a significant predictor when taking body dissatisfaction into account. The effect of autonomous functioning on dieting was mediated by body dissatisfaction. The findings suggest a reformulated model for use in large-scale longitudinal investigations.

Effective treatment of chronic plantar fasciitis with dorsiflexion night splints: a crossover prospective randomized outcome study

Chronic plantar fasciitis frustrates patients and treating physicians. Our hypothesis was that use of a dorsiflexion night splint for 1 month would effectively treat patients with recalcitrant plantar fasciitis. A 6-month randomized crossover study included 37 patients with chronic plantar fasciitis. Patients were treated with dorsiflexion night splints for 1 month. Group A wore splints for the 1st month and group B for the 2nd month. No splints were used in either group for the final 4 months of the study. No other medications, stretching, or strengthening exercises were prescribed. Eighty-eight percent of patients who completed the study improved. Eighty percent of the involved feet improved subjectively. Results of the AOFAS Ankle-Hindfoot Rating System and the Mayo Clinical Scoring System demonstrated significant improvement for both groups during the period of splint wear. Improvements were maintained at study completion. Response to splinting did not correlate with foot type, degree of obesity, or the presence of heel spur on radiographs. We believe dorsiflexion splints provide relief from the symptoms of recalcitrant plantar fasciitis in the majority of patients.

Modeling obesity using abductive networks

This paper investigates the use of abductive-network machine learning for modeling and predicting outcome parameters in terms of input parameters in medical survey data. Here we consider modeling obesity as represented by the waist-to-hip ratio (WHR) risk factor to investigate the influence of various parameters. The same approach would be useful in predicting values of clinical parameters that are difficult or expensive to measure from others that are more readily available. The AIM abductive network machine learning tool was used to model the WHR from 13 other health parameters. Survey data were collected for a randomly selected sample of 1100 persons aged 20 yr and over attending nine primary health care centers at Al-Khobar, Saudi Arabia. Models were synthesized by training on a randomly selected set of 800 cases, using both continuous and categorical representations of the parameters, and evaluated by predicting the WHR value for the remaining 300 cases. Models for WHR as a continuous variable predict the actual values within an error of 7.5% at the 90% confidence limits. Categorical models predict the correct logical value of WHR with an error in only 2 of the 300 evaluation cases. Analytical relationships derived from simple categorical models explain global observations on the total survey population to an accuracy as high as 99%. Simple continuous models represented as analytical functions highlight global relationships and trends. Results confirm the strong correlation between WHR and diastolic blood pressure, cholesterol level, and family history of obesity. Compared to other statistical and neural network approaches, AIM abductive networks provide faster and more automated model synthesis. A review is given of other areas where the proposed modeling approach can be useful in clinical practice.

Indices of obesity and behaviour of the pedicled tram flap in breast reconstruction

The association between obesity and the outcome of pedicled transverse rectus abdominis musculocutaneous (TRAM) flaps was studied in 12 patients. Obesity was assessed preoperatively by body mass index (BMI) and waist:hip circumference ratio (WHCR). The thickness of the abdominal fat and muscles was measured preoperatively with ultrasonography on the abdomen and during the nine postoperative months on the flap. Marginal or fat necrosis was more common among patients with lower body type fat distribution (WHCR less than 0.80) than in patients with medium or upper body type fat distribution. BMI and abdominal muscle and fat thicknesses were not associated with marginal or fat necrosis of the flaps. We conclude that lower body (female type) fat distribution may be associated with marginal cutaneous or fat necrosis in pedicled TRAM flaps.

Posteroanterior stiffness in the lumbosacral spine. The correlation between adjacent vertebral levels

STUDY DESIGN

A descriptive design of posteroanterior stiffness in the lumbosacral spine.

OBJECTIVES

To measure posteroanterior stiffness between L1 and S1 to establish the pattern of stiffness in individuals with no history of low back pain.

SUMMARY OF BACKGROUND DATA

In clinical examination for low back pain, manual assessment of abnormal stiffness is used to determine the site of the pain-producing lesion. However, there is little objective evidence of the variation in stiffness between levels in normal spines or of the factors that determine posteroanterior stiffness.

METHOD

Posteroanterior stiffness was measured with a specially developed measuring device at each of the six vertebral levels between L1 and S1. Force-displacement relations were computed for each vertebral level. The gradient of the linear part of the force-displacement relation was used as a coefficient of stiffness, and the amount of displacement between 5 N and 30 N of applied force (D5-30) was used as a measure of the length of the toe region.

RESULTS

Overall there was a significant linear trend of increasing stiffness from L1 to S1. Ninety percent of the difference scores for adjacent level comparisons were less than 3.6 N/mm. There was considerable variation in the patterns of stiffness found in different individuals. The stiffness coefficient and D5-30 correlated significantly with skinfold thickness measurements and body mass index.

CONCLUSION

A linear trend of increasing stiffness was found between L1 and S1, but this pattern was influenced by variables related to body type (adiposity).

Cigarette smoking, weight gain, and coronary mortality: results from the Chicago Western Electric Study

BACKGROUND

Prospective studies of overweight and coronary heart disease (CHD) have presented inconsistent findings. Previous inconsistencies may be explained by the modifying effect of cigarette smoking on the association between weight gain and coronary mortality.

METHODS AND RESULTS

We prospectively studied 1531 men 40 to 59 years of age who were employed at the Hawthorne Works of the Western Electric Company in Chicago, Ill. Information collected at the initial examination in 1958 included recalled weight at age 20, present weight, height, smoking status, and other CHD risk factors. Vital status was known for all men on the 25th anniversary: 257 CHD deaths occurred over 31,644 person-years of experience. Cox regression analysis was used to investigate risk of coronary mortality associated with change in body mass index (deltaBMI) and its modification by smoking status after adjustment for age, major organ system disease, family history of CHD, and BMI at age 20. Adjustment was not performed for blood pressure or serum total cholesterol because these are intervening variables. DeltaBMI was positively associated with risk of coronary mortality in never-smokers but not in current-smokers (P for interaction =.088). For never-smokers with deltaBMI classified as stable, low gain, moderate gain, or high gain, adjusted relative risks of coronary mortality were 1.00, 1.75, 1.75, and 3.07, respectively (P for trend=.010). For current-smokers, the respective adjusted relative risks were 1.00, 0.78, 1.05, and 1.03 (P for trend=.344).

CONCLUSIONS

These results support the hypothesis that cigarette smoking modifies the association between weight gain and coronary mortality. Future investigations of weight gain and coronary mortality should account for the modifying effect of cigarette smoking.

Birthweight for length: ponderal index, body mass index or Benn index?

This study compares how effectively the ponderal index and the body mass index adjust birthweight for length at different gestations, and derives an improved index suitable for all gestations. The study was a cross-sectional survey, in a London teaching hospital, using a total of 999 neonates of 33 weeks gestation or later. Main outcome measures were the ponderal index (birthweight/length3), body mass index (birthweight/length2), and Benn index (birthweight/length(n)), where the length power n varies with gestation and is estimated by log-log regression. Results showed that up to 39 weeks gestation, the ponderal index is uncorrelated with length and so is a good index of birthweight for length. Past 39 weeks gestation, the ponderal index is negatively correlated with length, while the body mass index is uncorrelated, so that the body mass index is better. Neither index is optimal at all gestations. Deriving the Benn index (birthweight/length(n)) for each week of gestation, choosing n to make the index uncorrelated with length, shows that n falls steadily and very significantly (p < 0.0001) with increasing gestation. This in turn means that predicted birthweight for length depends on gestation: for a neonate 48 cm long, predicted birthweight varies from 2485 g at 34 weeks to 3030 g at 43 weeks, a 20% range. However, for a 54 cm long infant, predicted birthweight is the same at all gestations. A Benn index where the value of n changes linearly with gestation is described. We conclude that the ponderal index is not appropriate for measuring intra-uterine malnutrition, as it fails to adjust for length at all gestations. No other index of birthweight/length(n) with constant n is any better, as different gestations require different indices. Birthweight predicted from an infant's length depends on the infant's gestation. If, as Barker proposes, thinness at birth assessed by birthweight for length is used to predict later health status, more account needs to be taken of the complex relationship between birthweight, length and gestation.

Body mass index compared to dual-energy x-ray absorptiometry: evidence for a spectrum bias

The objective of this study was to evaluate the accuracy of body mass index (BMI) in the diagnosis of obesity. The relationship of this weight-for-height index to body composition was determined using dual-energy x-ray absorptiometry (DEXA) in 226 Caucasian subjects. BMI-obesity was defined as a BMI greater than 27.8 kg/m2 in males and greater than 27.3 kg/m2 in females. BMI-obesity was weakly sensitive (males: 12.5%, females 13.6%) compared with diagnosis by DEXA, defined as percent body fat mass (%BF) greater than 20% in males and greater than 25% in females. Conversely, the specificity of BMI-obesity was high (males and females: 100%). When analyzing subgroups of subjects according to weight, sensitivity was higher among heavier subjects than among lighter ones. In both sexes and in all subgroups, the specificity was 100%. The clinical implication of this spectrum bias is that, in men or women weighing less than 80 kg, measures of obesity other than BMI, such as bioelectrical impedance, should be preferred.

Therapeutic effects of restricted diet and exercise in obese patients with fatty liver

BACKGROUND/AIMS

The incidence of obese patients with fatty liver has recently increased in Japan as well as in the United States and Europe. Fatty liver may occasionally progress to liver cirrhosis. In this study, we have compared the effects of restricted diet and exercise versus no treatment in obese patients with fatty liver.

METHODS

Twenty-five obese patients with fatty liver were divided into treated and control groups. Fifteen obese patients followed a program of restricted diet (ideal weight x 25 Cal x kg(-1)) and exercise (walking or jogging) for a trial period of 3 months. No changes in diet or lifestyle were made by the other 10 patients during the same trial period. Blood biochemical tests and liver histology were compared in all patients before and after the trial.

RESULTS

In the treated group, weight, blood biochemical data such as aminotransferase, albumin, cholinesterase, total cholesterol and fasting blood glucose values, and steatosis were significantly decreased after the trial. In the control group, there were no significant differences in the clinical and histological findings before and after the trial.

CONCLUSIONS

These results indicate that restricted diet and exercise therapy, such as walking and jogging, are useful means of improving blood biochemical data and histological findings in liver tissues related to fatty liver.

Self-directed hostility and family functioning in normal-weight bulimics and overweight binge eaters

The aim of this study was to examine whether overweight binge eaters demonstrate similar perceptions of family interactions and views of the self as do normal-weight bulimics. We compared 37 obese binge eaters and 37 normal-weight bulimics to 38 normal-weight non-bulimic controls, and 10 overweight nonbulimic controls on the Bulimia Test (BULIT). Profile of Mood States (POMS), Structural Analysis of Social Behavior (SASB) Short Form, which includes measure of hostility of family interactions and self-directed hostility; the Family Interaction Survey (FIS), and a measure of history of physical and sexual abuse and familial psychopathology. Both normal-weight bulimics and overweight binge eaters differed from nonbulimic controls across all measures of symptomatology, family functioning, history of abuse, familial psychopathology, and self-directed hostility. Normal-weight bulimics demonstrated significantly higher BULIT scores and self-directed hostility than did overweight binge eaters. Post hoc analysis showed that among binge eaters and bulimics, self-directed hostility accounted for a significant percentage of the variance of BULIT scores when controlling for the effects of age, BMI, family hostility, and mood. The possible role of self-directed hostility in the maintenance of bulimic symptomatology is discussed.

Why do adolescent girls watch their weight? An interview study examining sociocultural pressures to be thin

Body concerns, dieting, and weight watching were examined in 30 year 10 adolescent girls. Semistructured interviews consisting of open-ended and rated questions assessed descriptions of and reasons for weight loss attempts, with an emphasis on noting sociocultural influences. Audiotaped and transcribed interviews were assessed for themes, coded and rated. Findings suggested a strong role of sociocultural influences leading to both unhealthy and healthy body attitudes and eating behaviors. Media and fashion were reported to exert the strongest pressures to be thin for subjects. While a few subjects reported direct pressures to diet from friends and parents, indirect social influences were more common. These influences included social comparison, joint dieting and avoidance of social disapproval.

Left atrial abnormality in acute myocardial infarction

This study assessed left atrial abnormality by electrocardiogram as a predictor of left ventricular dysfunction during acute myocardial infarction. Hemodynamic, angiocardiographic, echocardiographic, and serial creatine kinase-MB studies revealed the electrocardiogram to be a significant predictor of location of acute myocardial infarction, prevalence of occlusive disease in coronary vessels, myocardial contractility, low ejection fraction, increased left ventricular end-diastolic pressure, and serial creatine kinase-MB.

Secular increases in relative weight and adiposity among children over two decades: the Bogalusa Heart Study

OBJECTIVE

To examine trends in relative weight and obesity among 5- to 24-year-olds between 1973 and 1994.

DESIGN

A panel design consisting of seven cross-sectional surveys of schoolchildren and three surveys of post-high-school subjects. Anthropometric measurements included height, weight, and subscapular and triceps skinfolds.

STUDY POPULATION

All schoolchildren residing in Ward 4 of Washington Parish, Louisiana, a biracial community, were considered eligible; participation rates were >80%. Young adults were eligible if they had participated previously as schoolchildren. A total of 26,371 examinations were performed on 11,564 persons.

RESULTS

During the study period, substantial increases in mean levels of weight (0.2 kg/y) and skinfold thickness (0.15 mm/y) were observed; these changes were independent of height, age, and other covariates. The prevalence of overweight, defined by the 85th percentile of weight-for-height in 1973 to 1974, increased approximately twofold by 1994. Although secular increases were seen both among boys and girls and among blacks and whites, the largest increases were seen among 19- to 24-year-olds. Furthermore, the yearly increases in relative weight and obesity during the latter part of the study period (1983 through 1994) were approximately 50% greater than those between 1973 and 1982.

CONCLUSIONS

The increasing prevalence of obesity in early life indicates a need for primary prevention. Additional study is needed to determine whether these trends are continuing to accelerate and to examine possible explanations, such as diet and physical activity, for these changes.

Association of body mass index with blood pressure in elderly Japanese American men. The Honolulu Heart Program

Few data are available on the association between body mass index (BMI) and blood pressure in elderly individuals, particularly among minority groups. We studied the cross-sectional association of BMI with systolic and diastolic pressures in 1378 Japanese American men 60 to 82 years of age who were participants in the population-based Third Lipoprotein Examination of the Honolulu Heart Program conducted between 1980 and 1982. When the subjects were divided into 5-year age groups, mean BMI decreased linearly with increasing age. Mean systolic pressure rose from 134.8 mm Hg in the first quintile of BMI to 138 in the second and 141.8 in the third quintiles, with levels of 139.2 and 142 in the fourth and fifth quintiles, respectively (test for trend, P = .083). Mean diastolic pressure rose from 78.1 mm Hg in the lowest quintile of BMI to 83.9 in the highest (test for trend, P = .008). We performed multiple regression analysis, controlling for factors known to influence blood pressure values, including age, physical activity index, alcohol intake, current smoking status, and diabetes mellitus. The association between BMI and both systolic and diastolic pressures remained highly statistically significant in these analyses. These results show that obesity and high blood pressure continue to be highly correlated even in old age and suggest that it may be possible to modify rates of hypertension by changes in body weight.

Delayed puberty in girls with cystic fibrosis despite good clinical status

BACKGROUND

Previous studies have shown that puberty is delayed among patients with cystic fibrosis (CF). Malnutrition has been considered the main etiologic factor. Today with improved medical therapy and nutritional support, most CF patients obtain an almost normal nutritional status.

OBJECTIVES

To investigate whether pubertal development among female CF patients at the Stockholm CF Center was normal and, if not, what other parameters besides nutrition might influence this.

METHODS

Seventeen patients were studied retrospectively regarding age at peak height velocity and menarche. Menarcheal age (MA) was compared with normal population data and related to clinical and nutritional status, genotype, oral glucose tolerance test (OGTT), and essential fatty acid levels.

RESULTS

The mean age at peak height velocity (12.9 +/- 0.8 years) and at menarche (14.9 +/- 1.4 years) was significantly higher in the CF patients compared with normal controls (11.9 +/- 1.0 years and 13.0 +/- 1.0 years, respectively). No correlation was found between menarchal age and nutritional or clinical parameters. The patients with pathological OGTT without overt diabetes were significantly older at menarche (15.8 +/- 1.7 years) compared with the patients with normal OGTT (14.3 +/- 0.9 years). The patients who were homozygous for the most common mutation, deltaF508, were significantly older at menarche (15.2 +/- 1.9 years) than those who were not (14.7 +/- 0.9 years).

CONCLUSIONS

Pubertal delay still existed among the CF patients despite good clinical status. The patients homozygous for deltaF508 and those with pathological OGTT showed the most delayed puberty.

Gastroesophageal reflux following male abdominoplasty

: Complications of female abdominoplasty are well known. Males prone to centripetal obesity may have minimal subcutaneous fat and significant hypogastric skin laxity making them apparent good candidates for abdominoplasty. We describe a case of severe gastroesophageal reflux following male abdominoplasty presumably secondary to increased intraabdominal pressure. This type of regional obesity should be recognized preoperatively as it may place the patient at higher risk. A preoperative diet and exercise program is a consideration.

Emotional distress among males with "syndrome X"

The present study examined traditional risk factors and various indices of emotional distress in males with positive angiograms (N = 122), "syndrome X" males with negative or nominal results on angiogram (N = 53), and age- and socioeconomic status-matched males with no manifest history of otherosclerotic disease (N = 56). Syndrome X patients reported more depression on the Ketterer Stress Symptom Frequency Checklist (KSSFC) than positive angiographic patients. And compared with healthy controls, they were more likely to be perceived by a spouse/friend as depressed and anxious on the KSSFC, scored higher on the Framingham Type A Scale, and reported more unprovoked nocturnal awakening. Syndrome X patients generally appear to be similar to patients with positive angiograms with regard to traditional risk factor history but are more distressed than healthy controls. This becomes most evident when denial is circumvented by discussion with significant others or inquiries are "framed" appropriately.

Measures of adiposity and coronary heart disease mortality in the Chicago Western Electric Company Study

Associations of body mass index (BMI), two measures of percent body fat derived from skinfolds, body weight adjusted for height, triceps and subscapular skinfolds, and their sum, with 22-year coronary heart disease (CHD) mortality were compared in 1707 white men ages 40-55 years at baseline (1958) and free of CHD and cancer in 1961 in the Western Electric Study. Because associations of adiposity measures with CHD mortality differed by length of follow-up, analyses were conducted separately for the first 14 years of follow-up and years 15 through 22. In Cox regression analyses, none of the adiposity measures was significantly related to CHD mortality for the first 14 years of follow-up. For years 15-22, all adiposity measures, except triceps skinfold, were significantly related with adjustment for age, as well as eight other covariates. These results indicate that a positive relation of adiposity to CHD risk may not become apparent until several years after the assessment of adiposity.

The progestogen challenge test in postmenopausal women: clinical and morphologic aspects

The clinical aspects and anatomopathological patterns of 150 postmenopausal women were studied using the progestogen challenge test. An endometrial biopsy was obtained and submitted to the progestogen test. A histopathological analysis of the uterine mucosa from women with a positive progestogen test revealed that the endometrium was active in 44 percent of cases and atrophic or inactive in 56 percent. In contrast, among women with a negative response, the endometrium was atrophic in 94 percent of cases and active in 6 percent. Analysis of clinical aspects did not show significant differences between groups in terms of age; age at menarche and at menopause; fasting blood glucose levels; or body mass. However, postmenopausal time was significantly shorter for women with a positive test, with a correlation between postmenopausal time of one to two years and test positivity. The progestogen challenge test for the detection of atrophic endometrium presented 78.57 percent sensitivity, 77.05 percent specificity, 44 percent positive predictive value, and 94 percent negative predictive value. Thus, when negative, the test is highly valuable, indicating the presence of atrophic endometrium in 94 percent of cases. False-negative results occurred in only 6 percent of the subjects, with no case of hyperplasia detected. However, when the response to the test was positive, the endometrium was atrophic in 56 percent of the cases. We suggest that, in order to avoid invasive procedures, the progestogen challenge test be combined with other methods such as transvaginal ultrasonography.

Quantitative analysis of the submandibular gland using computed tomography

OBJECTIVE

To evaluate the normal variation in size of the submandibular gland from computed tomographic (CT) scans.

MATERIALS AND METHODS

CT was performed parallel to the Frankfurt horizontal (FH) and mandibular (MP) planes in 130 subjects (64 men and 66 women) with healthy submandibular glands, six patients with sialoadenitis and four with masseteric hypertrophy.

RESULTS

The mean (s.d.) maximum cross-sectional area (MCSA) of the submandibular glands for FH was 324 (89) mm2 and for MP 364(101) mm2. There was a high correlation between individuals' right and left glands. There was no significant difference in the mean MCSA between the right and left, which varied by less than 10%. The mean (s.d.) volume of the gland was 8072 (2574) mm3. With a high correlation with mean MCSA in both scanning planes, the mean MCSA may be an indicator of the volume of the gland. MCSA increased significantly with body height, weight and body mass index, but decreased with age. The MCSA of the affected side in patients with sialoadenitis and masseteric hypertrophy was larger than both that of the normal side and the predicted values.

CONCLUSION

MCSA is a useful indicator of gland volume, and differences of greater than 10% between the two sides may be used in the diagnosis of submandibular gland disease.

Obesity and prognosis in endometrial cancer

OBJECTIVE

We tested the null hypothesis that morbid obesity as measured by the Quetelet index has no influence on survival in endometrial cancer.

STUDY DESIGN

A retrospective study of 492 women with endometrial carcinoma was performed. Age, height, weight, Quetelet index, stage, cell type, grade, node status, peritoneal cytologic findings, and depth of myometrial invasion were analyzed for influence on survival.

RESULTS

Mean Quetelet index was 34 (range 16 to 89). Quetelet index was < 30 in 45% of patients, 30 to 40 in 33%, and > 40 in 22%. Five percent of those with a Quetelet index > 40 had positive nodes, but 64% of patients with a Quetelet index > 40 did not have lymph node sampling done. Lack of sampling of lymph nodes in the entire group had no adverse effect on survival. In a proportional hazards regression model for time from diagnosis to death from disease, grade, node status, myometrial invasion, and stage had highly significant effects. When Quetelet index was analyzed as a continuous variable, as Quetelet index increased, time to recurrence was significantly increased (p = 0.0136), and significance was approached for survival (p = 0.0645). Quetelet index was strongly related to grade (p = 0.013), depth of myometrial invasion (p = 0.031), negative cytologic findings (p = 0.004), and stage (p = 0.011) with obese patients having better differentiated, less invasive tumors of lower stage with negative washings.

CONCLUSIONS

Morbid obesity positively affects survival in endometrial carcinoma. This effect is accounted for by the association of obesity with less aggressive disease. Morbid obesity is not associated with increased death from other causes. Lack of sampling of negative lymph nodes does not adversely affect survival.