Indices of relative weight and obesity

Nutrition after vertical banded gastroplasty

The authors assessed the nutritional status of 60 morbidly obese patients by determining body composition, using multiple isotope dilution at 13.6 +/- 0.4 months following operation. Body weight was followed for an additional 12.3 +/- 0.8 months. Twenty-four patients lost more than 25% of their preoperative weight and were within 30% of ideal weight (a "good" result). At 1 year they had lost 41.4 +/- 1.8% of preoperative weight and the body mass index (BMI) decreased from 46.7 +/- 1.2 to 27.0 +/- 0.6 kg/m2. Despite rapid weight loss, malnutrition did not develop and their body composition became indistinguishable from that of normally nourished volunteers. Twenty-nine patients had a "satisfactory" result with more than 25% weight loss but were not within 30% of ideal. Their weight decreased by 34.8 +/- 1.0% as their BMI decreased from 55.4 +/- 1.2 to 36.0 +/- 0.8 kg/m2. Seven patients lost less than 25% of their preoperative weight (an "unsatisfactory" result). Malnutrition did not develop in any patient. In the authors' experience, in contrast to other weight reducing operations, vertical banded gastroplasty (VBG) results in rapid weight loss without the concomitant development of malnutrition even in patients who return to normal weight.

Insulin action in non-insulin-dependent diabetes mellitus: the relationship between hepatic and extrahepatic insulin resistance and obesity

To determine the contribution of obesity to the insulin resistance of non-insulin-dependent diabetes mellitus, insulin dose response curves for suppression of glucose production and stimulation of glucose utilization were generated in lean and obese diabetic patients and compared to those observed in weight-matched nondiabetic subjects. Glucose utilization during 0.4, 1.0, and 10.0 mU/kg x min insulin infusions (producing insulin concentrations ranging from approximately 50 to 2,000 microU/mL) was lower (p less than .02 to .001) in lean and obese diabetic patients compared to weight-matched nondiabetic subjects indicating insulin resistance. Glucose utilization was not correlated with obesity in the diabetic subjects. Suppression of glucose production was impaired (P less than .03 and .001) in both the lean and obese diabetic subjects at physiologic but not supraphysiologic insulin concentrations. We conclude that patients with NIDDM have both hepatic and extrahepatic insulin resistance, the severity of which appears to be independent of the degree of obesity.

Medical evaluation and treatment of the obese patient with cardiovascular disease

The incidence of coronary artery disease only weakly correlates with the percent of excess body weight; however, obesity in humans is not a homogeneous condition. Classification of obesity based on anatomic distribution of body fat allows for identification of a group of patients at increased risk for cardiovascular disease. Abdominal (upper body) obesity, measured as the waist/hip ratio, is a strong independent risk factor of cardiovascular disease and should be used to assess a subgroup in need of medical weight loss treatment. A focus on dietary fat intake and the magnitude of overeating "caloric intake" are central to the pathogenesis of cardiovascular disease observed in the obese person. Identification of the process of overeating (magnitude of recent weight gain, episodes of weight cycling) is important in the design of successful medical nutrition treatment programs. A nutrition/medical history that includes age of obesity onset and duration of obesity provides additional criteria for assessment of risk of disease. Childhood-onset obesity and prolonged obesity (greater than 15 years) has been associated with increased cardiovascular disease risk. Recently, grades of obesity based on body mass index have provided a valuable marker for treatment. Each reduction in obesity grade (equal to delta 5 body mass index or delta 11.6 kg) is associated with a decrease in risk of medical illness. The new focus of obesity treatment should be to decrease body weight in 10% to 15% increments (equal to 1 grade) with emphasis on reducing the risk of medical illness and treatment intensity (e.g., number of existing medical visits, hospitalization).(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory evaluation of sleep disturbance and therapeutic effects in sleep apnea syndrome by wrist activity monitoring

A new wrist actometer was used to obtain ambulatory activity-rest recordings in 18 patients with sleep apnea syndrome (SAS) and in 22 control subjects. A movement index (MI) and a fragmentation index (FI) during sleep time were computed, giving an estimate of the stability of sleep. In control subjects, we observed a clear differentiation between night and day activity levels. The distribution of MI and FI was very narrow, with a mean +/- SD of 13.9 +/- 5.4 and 16.1 +/- 5.8%. No correlation of MI and FI with body mass index, even in heavily obese subjects, was found; MI and FI decrease significantly with age. A diagnosis of SAS was made by standard all-night polysomnography. Patients with SAS had a significantly higher MI and FI than did control subjects (p less than 0.001). With respect to polysomnographic diagnosis of SAS, the sensitivity of activity recordings was 89%, whereas the specificity was 95%. Five patients were studied after treatment, and decreases in MI and FI at home were in good agreement with the improvement in their sleep as assessed clinically and by polysomnography. We conclude that this technique is useful for an objective measurement of sleep restlessness and fragmentation, and for a simple evaluation of therapeutic effects under real life conditions in SAS.

Pregnancy hypertension, blood pressure during labor, and blood lead levels

Pregnancy hypertension, blood pressure during labor, and the umbilical cord blood lead concentration were assessed in 3851 women for whom additional demographic, medical, and personal information was available. Lead levels correlated with both systolic (Pearson r = 0.081, p = 0.0001) and diastolic (r = 0.051, p = 0.002) blood pressures during labor. The incidence of pregnancy hypertension increased with lead level. Multivariate models of pregnancy hypertension and systolic blood pressure as a function of maternal age, parity, hematocrit, ponderal index, race, and diabetes were improved by including lead as a predictor variable. At these observed levels of exposure (mean blood lead, 6.9 +/- 3.3 [SD] micrograms/dl), lead appears to have a small but demonstrable association with pregnancy hypertension and blood pressure at the time of delivery, but not with preeclampsia.

Determinants of nutritional status in hospital patients in Italy

The prevalence of protein-calorie malnutrition (PCM) and micronutrient deficiency (MND) at the time of admission and discharge from hospital was evaluated in 91 patients consecutively admitted to the Surgery Clinic of the University Hospital of Rome. Anthropometric parameters and circulating levels of vitamins (A, E, C, B1, and B2) and visceral proteins [retinol-binding protein (RBP, prealbumin (PA), and transferrin] were measured. Twenty-one patients (23%) had moderate to severe PCM, and 70 patients (77%) had normal nutritional status (NNS) at admission. Two patients with PCM died in the hospital. At discharge, the prevalence of PCM was unchanged in the remaining 19 patients. Single or multiple MND was observed initially in 71% of patients with PCM and in 36% with apparently normal nutritional status. Despite vitamin supplementation, MND was present at the time of discharge in 73% of patients with PCM and 44% with NNS. Nutritional status at the time of admission was assessed in hospitals in six different Italian cities. The criterion for admission to the study was the diagnosis of chronic (greater than 1 yr duration) illness (excluding cancer and multiple organ disorders). Two hundred eighty-four patients (145 males, 139 females), ages 25-88 yr, were selected. The findings indicated a high prevalence of MND (64%). Also, in disorders that usually do not have significant alterations of digestion or absorption, such as uncomplicated cardiorespiratory disease, the prevalence of MND was high (9-38%). The prevalence of MND was not related to body mass index (BMI). PCM was more common among patients with chronic gastrointestinal disease.(ABSTRACT TRUNCATED AT 250 WORDS)

The influence of physical training on glucose tolerance, insulin sensitivity, and lipid and lipoprotein concentrations in middle-aged hypertriglyceridaemic, carbohydrate intolerant men

The effects of 9 weeks of moderate intensity exercise training while on a weight-maintaining diet were studied in 19 untrained middle-aged, hypertriglyceridaemic, carbohydrate intolerant men. Initial mean maximum oxygen consumption was low (29.7 +/- 1.0 ml.min-1.kg-1; mean +/- SEM) and improved (34.2 +/- 1.4 ml.min-1.kg-1, p less than 0.01) with exercise training. Fasting glucose, insulin, lipid and lipoprotein concentrations did not change. While the abnormal glucose response to oral glucose did not change with training, insulin concentrations were significantly (p less than 0.05) lower at 90 and 120 min during the final oral glucose tolerance test. Insulin mediated glucose uptake did not change, indicating that the degree of exercise training failed to improve in vivo insulin sensitivity. Significant associations were found between the following parameters measured: fasting concentrations of triglycerides and insulin, very low density lipoprotein-triglycerides and glucose, and measures of in vivo insulin resistance and fasting insulin levels, suggesting that insulin resistance in these glucose intolerant subjects may play a role in their hypertriglyceridaemia. These data indicate that moderate increases in physical training alone are not sufficient to improve the carbohydrate, insulin and lipid metabolism of hypertriglyceridaemic, glucose intolerant men.

Usefulness of echocardiographically determined mitral leaflet motion for diagnosis of mitral valve prolapse in 17- and 18-year-old men

Mitral leaflet motion during systole was studied by echocardiography in 102 healthy young men. Mean posterior maximal leaflet motion was 2 +/- 1 mm behind the CD line on 2-dimensionally (2-D) directed M-mode examination. On the apical 4-chamber cross-sectional view a mean area of 0.34 +/- 0.24 mm2 was contained by the mitral leaflets above the plane of the mitral anulus. Elevated values on the M-mode view (greater than or equal to 4 mm) compared with the 2-D 4-chamber view (greater than or equal to 0.70 mm2) were discordant, with 90% (18 of 20) of the elevated values found in 1 view only. Thus, there is a wide spectrum of mitral leaflet motion in asymptomatic young men. The value of the echocardiogram in diagnosis of mitral valve prolapse is questionable because any cutoff point between normal and abnormal is arbitrary and the degree of motion has not been shown to correlate with morbidity or mortality.

Determining an individual's ideal body weight from skeletal measurements: a new method

Determining an individual's "ideal" body weight is fundamental in nutritional therapy. A simulation of the human body to a cylindrical volumetric model permits the calculation of the ideal body weight from the measured height, interacromioclavicular distance, and humeral length. A group of 189 healthy normal volunteers were assessed. The calculated "Pitt" ideal body weight correlated closely (r = 0.88 for males, r = 0.72 for women) with values obtained from the Metropolitan tables. The technique provides an estimate of ideal body weight based upon reproducible, easily obtained measurements of fixed bony landmarks.

Persistence of juvenile-onset obesity over eight years: the Bogalusa Heart Study

The persistence of obesity and overweight over eight years was assessed in a biracial (Black-White) cohort of 1,490 two-to 14-year-olds. Initial levels of triceps skinfold thickness (TRSF) and Rohrer index (weight/height3) were moderately predictive of subsequent levels: r = 0.54 and 0.67, respectively. However, TRSF and Rohrer index tended to track most strongly in Black females (r = 0.64 and 0.72) and less well in both White females (r = 0.45 and 0.57) and preschool children (r = 0.45 and 0.54). Based on elevated levels of TRSF or Rohrer index, children were classified as obese or overweight, respectively. Of the 222 children who were initially above the 85th percentile for TRSF, 43 per cent remained obese after eight years. Persistence of overweight was slightly greater at follow-up, with 50 per cent of initially overweight children staying above the 85th percentile for Rohrer index. Severe, initial obesity/overweight (greater than 95th percentile) and consecutively elevated levels increased the probability of remaining obese/overweight. Results indicate that moderate, juvenile-onset obesity is malleable, but that the child who is extremely obese over consecutive examinations is likely to become an obese adult.

Selective beta 1-adrenergic receptor-blockade with atenolol enhances growth hormone releasing hormone and mediated growth hormone release in man

The growth hormone (GH) responses to a single bolus injection of the growth hormone releasing hormone (GRH) were examined in the basal state and in the presence of beta-adrenergic receptor blocking agents of different specificity in ten normal men. During a constant five-hour infusion of 56 micrograms/min of propranolol (nonselective beta-adrenergic receptor-blocker) in seven subjects studied, there was a significant augmentation of the GH release in response to exogenous GRH compared to the GH response during saline infusion, as measured by the peak serum GH concentrations after GRH (P = 0.019) and the integrated GH values (P = 0.019). A similar significant enhancement of GH responses to exogenous GRH as compared to the control day was observed with the specific beta 1-adrenergic receptor-blocker atenolol in all seven subjects studied (four of whom also participated in the propranolol study). Both the peak GH response to a GRH bolus and the integrated GH values were significantly greater with atenolol (P = 0.019 for both). There was no difference in serum GH concentrations after beta-adrenergic receptor-blocking drugs during a three-hour sampling period before GRH administration compared to placebo. Our results support the concept that beta-adrenergic receptors may modulate either the release or action of hypothalamic somatostatin in the control of GH secretion in man. We suggest the effect is mediated by specific beta 1-adrenergic receptors.

The Tromsø Heart Study: the relationship between food habits and the body mass index

Associations between food habits and body mass index (BMI) (kg/m2) were explored in a cross-sectional study with 7410 men and 7257 women. High BMI was most strongly associated with low bread consumption and use of low-fat milk. Weaker positive associations were seen for coffee, fish and ground meat consumption, and with use of table fat with a low P/S-ratio. Negative associations were seen for use of fruits and vegetables and amount of table fat at each slice of bread. Inconsistent relationships were noted for use of alcohol. The results suggest that individuals to some extent have changed their food habits in order to keep the BMI within limits they consider to be normal, and underline the need for adjustment for BMI when e.g. relationships between the diet and blood lipids are studied.

A preliminary anthropometric study (body weight, body height, body-mass index) of Ethiopian schoolchildren and college students

Body weight and height have been recorded in 261 schoolchildren and 283 college students from Gondar, North-western Ethiopia. The body-mass index has been calculated for different age-groups in males and females to provide reference data for the evaluation of the nutritional status.

Musculoskeletal capacity of employees aged 44 to 58 years in physical, mental and mixed types of work

The musculoskeletal capacity of 60 women and 69 men, average age 52.3 +/- 3.7 years was determined, including measurements of anthropometry, maximal isometric trunk flexion and extension, sit-ups, isometric hand grip strength and back mobility. According to the job and to cluster analysis, the subjects were divided into three dominating work groups; physical, mental, and mixed groups. The results showed significant differences in right hand grip strength of the women and in the number of sit-ups by men among the three work groups (p less than 0.05). The differences between the other tests were not significant, although the physical group in the women and either the physical or the mixed group in the men had systematically the lowest mean values in almost all tests. It is concluded that jobs with mainly physical demands do not guarantee superior musculoskeletal capacity in older employees.

Increased 2-hydroxylation of estradiol as a possible mechanism for the anti-estrogenic effect of cigarette smoking

Epidemiologic data indicate that cigarette smoking is associated with an important anti-estrogenic effect, and increased hepatic metabolism has been suggested as a possible mechanism. We examined the hypothesis that cigarette smoking in women induces an increase in estradiol 2-hydroxylation. This irreversible metabolic pathway yields 2-hydroxyestrogens, which possess minimal peripheral estrogenic activity and are cleared rapidly from the circulation. We found a significant increase in estradiol 2-hydroxylation in premenopausal women who smoked at least 15 cigarettes per day. The extent of the reaction (mean +/- SEM) was 53.6 +/- 2.2 percent among 14 smokers and 35.1 +/- 1.8 percent among 13 nonsmoking controls--an increase of approximately 50 percent (P less than 0.001). The extent of 2-hydroxylation among five smokers did not vary during the follicular and luteal phases of their menstrual cycles. In addition, urinary excretion of estriol relative to estrone was significantly decreased among smokers (P less than 0.01), providing evidence that the smoking-induced increase in 2-hydroxylation diminishes the competing metabolic pathway involving 16 alpha-hydroxylation. This study demonstrates that smoking exerts a powerful inducing effect on the 2-hydroxylation pathway of estradiol metabolism, which is likely to lead to decreased bioavailability at estrogen target tissues. Elucidation of the mechanism responsible for smoking-induced changes in 2-hydroxylation may be useful in the development of strategies to reduce the risk of hormone-dependent tumors.

Clearance defects in primary chylomicronemia: a study of tissue lipoprotein lipase activities

Tissue and postheparin lipoprotein lipase (LPL) activities were assayed in a heterogeneous group of eight chylomicronemic subjects ranging in age from 15 years to 55 years. Three patients, presenting with the classical genetic and clinical features of type I hyperlipoproteinemia, had virtually absent adipose tissue LPL activity and markedly reduced muscle LPL activity (between 5% and 20% of normal). A fourth patient, with a similar but more benign lipoprotein and clinical phenotype, showed reduced adipose tissue LPL activity (10% of control) but retained essentially normal muscle enzyme. This patient represents a variant form of familial LPL deficiency. Two of the four remaining patients presented with typical features of adult type V hyperlipoproteinemia associated with familial hypertriglyceridemia (type IV and V phenotypes) in first-degree relatives. Adipose tissue LPL activities were 25% to 35% of the control mean in these patients, but muscle activities were normal or elevated. A third patient had suggestively similar tissue enzyme levels, but a family study could not be carried out. The eighth patient presented with a brittle type V phenotype, normolipidemia in the two first-degree relatives available for study and normal lipolytic activity in adipose tissue, muscle, and postheparin plasma assayed against a 14C-triolein substrate. An oral fat load in this patient, however, led to a marked but transient increase in light scattering suggesting defective clearance. Mixing experiments in vitro using a chylomicron substrate strongly suggested an extrinsic defect of lipolysis due to the inhibitory effect of excess very low density lipoprotein peptides, presumably apo C-III.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of a low-energy diet associated with egg supplementation on plasma cholesterol and lipoprotein levels in normal subjects: results of a cross-over study

1. The influence of a low-energy diet when associated with high-cholesterol intake was investigated in seventeen normal men during an 8-week cross-over study. The subjects were given a daily supplement of two whole eggs and two egg yolks (approximately 1 g cholesterol) either with their usual diet for 4 weeks or with a low-energy diet for 4 weeks. Each subject took part randomly in both dietary periods. 2. During the first part of the study, no changes occurred in the plasma cholesterol of the subjects with egg supplementation of the usual diet. 3. In contrast, the low-energy diet and associated weight loss markedly decreased tolerance to high-cholesterol intake resulting in increased plasma cholesterol. The mean rise was 22.7% but with wide individual variations in the response. This was almost completely normalized when the subjects returned to their usual energy intake indicating the involvement of weight reduction in the increase observed. 4. Changes in low-density-lipoprotein (LDL) cholesterol were parallel to those of total plasma cholesterol with an increase following the low-energy diet and normalization after body-weight recovery. 5. The opposite effect was shown with the low-energy diet after previous adaptation to the consumption of four eggs per day. This dietary regimen resulted in a decrease in plasma cholesterol although it was not significant. Moreover, the lipoprotein profile was improved with a decrease in very-low-density-lipoprotein (VLDL) cholesterol and an increase in high-density-lipoprotein (HDL) cholesterol. 6. High-cholesterol intake induced significant changes in lipoprotein composition whatever the energy ration. LDL and HDL were enriched in cholesterol esters as early as the 1st month of egg supplementation of the diet. 7. Taken together, the results emphasize the possible adverse effect of slimming diets when associated with high-cholesterol intake. The existence of 'high-responders' to these dietary conditions calls for special attention to be paid to the cholesterol content of restricted diets.

Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes?

Self-monitoring of blood glucose levels is currently being recommended for obese patients with type II diabetes to improve weight loss and glycemic control. To determine whether self-monitoring of blood glucose levels improves dietary compliance in these patients, 50 obese patients with type II diabetes were randomly assigned either to a standard behavioral weight control program or to a weight control program that included self-monitoring of blood glucose levels and focused on the weight-blood glucose relationship. Both groups lost significant amounts of weight and maintained their losses for at least one year; reductions in medication could be made for 70 percent of patients. These data suggest that the behavioral weight control used in this study may be of benefit to patients with type II diabetes. However, there was no evidence that the addition of self-monitoring of blood glucose levels to the treatment program improved the outcome in terms of weight loss, reduction in medication, dietary compliance, or mood state.

Antisperm antibodies and circulating immune complexes of vasectomized men with and without coronary events

We compared antisperm antibody and circulating immune complex (CIC) levels in serum samples from 101 vasectomized and 101 normal age-matched nonvasectomized men; 31 of each group had histories of coronary heart disease (CHD). Vasectomy and CHD status were treated as categorical independent variables in the two-way analysis of variance. Elevations of both systolic and diastolic blood pressures were significantly associated with age and body mass index but not vasectomy. Antisperm antibodies (immobilizing and agglutinating) were significantly associated with vasectomy (P less than or equal to .001); the incidences were similar in men with and without CHD. The CICs were significantly associated with vasectomy in a Staphylococcus aureus (FcSa) CIC assay (P less than or equal to .001) and a Raji cell CIC assay (P less than or equal to .05). A third CIC assay, the Clq binding assay, did not reveal a difference between any subgroups. Generally, CICs occurred more frequently in the CHD group by the FcSa assay and particularly the Raji cell assay (P less than or equal to .001). In summary, vasectomized men had a higher incidence and higher levels of circulating antisperm autoantibodies and CICs than did age-matched controls.

A prospective study of treatment techniques to minimize the volume of pelvic small bowel with reduction of acute and late effects associated with pelvic irradiation

The volume, distribution, and mobility of opacified pelvic small bowel (PSB) were determined by fluoroscopy and orthogonal radiographs in 150 consecutive patients undergoing pelvic irradiation. Various techniques including uteropexy, omental transposition, bladder distention, inclining the patient, and anterior abdominal wall compression in the supine and prone treatment position were studied for their effect on the volume and location of small bowel within the pelvis. Abdominal wall compression in the prone position combined with bladder distention was selected for further investigation because of its simplicity, reproducibility, patient comfort, and ability to displace the small bowel. Factors correlating with the volume of pelvic small bowel (PSB) included prior pelvic surgery, pelvic irradiation (XRT), and body mass index. After pelvic surgery, especially following abdominoperineal resection (APR), there was a greater volume of PSB which was also less mobile. The severity of acute gastrointestinal effects positively correlated with the volume of irradiated small bowel. Overall, 67% of patients experienced little or no diarrhea, 30% developed mild diarrhea, and no patient required treatment interruption. Late gastrointestinal effects correlated with the prior pelvic surgery and with the volume of small bowel receiving greater than 45 Gy. Small bowel obstruction was not observed in 75 patients who had no previous pelvic surgery. However, following pelvic surgery excluding APR, 2/50 patients and following APR, 3/25 patients developed small bowel obstruction.

Relationship between body mass indices and measures of body adiposity

We examined the relationship between various body mass indices (BMIs), skinfold measures, and laboratory measures of body fat in 474 males aged 20-70 years. Evaluations included height, weight, skinfold thickness, and hydrostatic measurements of adiposity. The weight-height ratio (W/H), Quetelet index (W/H2), Khosla-Lowe index (W/H3), and Benn index (W/HP) were calculated. The correlations among the various BMIs were high, ranging from 0.91 to 0.99, and all were strongly correlated with weight (rs = 0.81 - 0.98), while only W/H2 (r = -.03) and W/HP (r = -.01) were not correlated with height. The W/H2 and W/HP had the strongest correlation with hydrostatic and skinfold measurements, although all the BMIs were significantly correlated with these measurements. Results suggest that the Benn index and the Quetelet index are equally valid estimates of body fat in respect to their relationship with hydrostatic measures.

The ear lobe crease sign and coronary artery disease in aortic stenosis

Ear lobe creases have been proposed as useful indirect markers of coronary artery disease. To test such a hypothesis, this physical sign was evaluated in 100 patients with symptomatic aortic stenosis undergoing cardiac catheterization to establish the hemodynamic severity of the obstruction and the degree of coronary artery involvement. This is a disorder where the coexistence of cardiac ischemia may play an important part in diagnosis and management. Criteria were established for the degree of ear lobe involvement with a grading of mild (Grade 1), moderate (Grade 2), and severe (Grade 3). Significant coronary artery disease was defined as narrowing greater than or equal to 50% and a coronary score was established. Sensitivity, specificity, positive and negative predictive values were calculated, using Bayesian analysis for three levels of assumed coronary artery disease prevalence. An ear lobe crease score was correlated with a coronary artery disease score, taking into account the variables of age, sex, and body mass index. No useful statistical correlations were found and it is concluded that this physical sign is of little practical value in this clinical setting.

Scoliosis and fractures in young ballet dancers. Relation to delayed menarche and secondary amenorrhea

In a survey of 75 dancers (mean age, 24.3 years) in four professional ballet companies, we found that the prevalence of scoliosis was 24 percent and that it rose with increases in age at menarche. Fifteen of 18 dancers (83 percent) with scoliosis had had a delayed menarche (14 years or older), as compared with 31 of 57 dancers (54 percent) without scoliosis (P less than 0.04). The dancers with scoliosis had a slightly higher prevalence of secondary amenorrhea (44 percent vs. 31 percent), the mean (+/- SD) duration of their amenorrhea was longer (11.4 +/- 18.3 vs. 4.1 +/- 7.4 months; P less than 0.05), and they scored higher on a questionnaire that assessed anorectic behavior. The incidence of fractures was 61 percent (46 of 75 dancers), and it rose with increasing age at menarche. Sixty-nine percent of the fractures that were described were stress fractures (mostly in the metatarsals), and their occurrence had an even stronger correlation with increased age at menarche. The incidence of secondary amenorrhea was twice as high among the dancers with stress fractures (P less than 0.01), and its duration was longer (P less than 0.05). In 7 of 10 dancers in whom endocrine studies were performed, the amenorrheic intervals were marked by prolonged hypoestrogenism. These data suggest that a delay in menarche and prolonged intervals of amenorrhea that reflect prolonged hypoestrogenism may predispose ballet dancers to scoliosis and stress fractures.

Drug disposition in obese humans. An update

Drug disposition for many drugs has now been studied in obese individuals and some general conclusions can be drawn. Absorption of drugs evaluated to date is unchanged due to obesity. Apparent volume of distribution is greatly increased for some drugs including most benzodiazepines, thiopentone, phenytoin, verapamil and lignocaine (lidocaine). Modest increases in volume of distribution have been noted for methylxanthines, aminoglycosides, vancomycin, ibuprofen, prednisolone and heparin. Distribution of digoxin, cimetidine and procainamide is unchanged in obesity. The mechanism for the increased distribution of some drugs and unchanged distribution of others in obesity is unclear at present. It may be in part due to the lipophilic character of the drug molecule; however, other complex and as yet poorly understood factors contribute to the variability in drug distribution in obese patients. Protein binding of drugs bound to albumin is not dramatically changed in obesity. In contrast, some studies report that drugs bound to alpha 1-acid glycoprotein (AAG) may have increased binding that is related to increased serum AAG concentration; however, this is not a consistent finding. Oxidative drug biotransformation is minimally changed in obesity with the exceptions of ibuprofen and prednisolone, for which clearance increases as a highly correlated function of total bodyweight. Drug conjugation uniformly increases as a function of bodyweight in obesity, with paracetamol (acetaminophen), lorazepam and oxazepam having been studied. Drug acetylation may be unchanged in obesity, with only procainamide evaluated at this time. High clearance drugs, including lignocaine, verapamil and midazolam, have no change in clearance in obese individuals compared to normal bodyweight controls. Renal clearance of drugs is little changed for some drugs evaluated (digoxin, cimetidine), and increased for others (aminoglycosides, unmetabolised procainamide). Characterisation of appropriate animal models of obesity is underway to clarify the mechanisms for these in vivo pharmacokinetic observations in obese man. Two models, the Zucker obese and the obese cafeteria-fed male Sprague-Dawley rat, have provided preliminary physiological pharmacokinetic data with evaluations of theophylline, phenobarbitone and verapamil.(ABSTRACT TRUNCATED AT 400 WORDS)

Injury prediction in female gymnasts

In order to identify injury-proneness in female competitive gymnasts, 20 measures of flexibility, hypermobility, spinal posture and anthropometry were performed on 40 competitive gymnasts and injury scores were derived from the severity and extent of previous gymnastic injury and inherent hypermobility traits. Results were compared between contrasting groups of "low" and "high" injury gymnasts respectively (both N = 10). Nine variables demonstrated significant differences between the "low" and "high" injury risk status groups namely, weight (p less than 0.001), height (p less than 0.001), age (p less than 0.001), mesomorphy (p less than 0.01), Quetelet Index (p less than 0.01), shoulder flexion (p less than 0.05) and lumbar extension (p less than 0.05), standing lumbar curvature and total peripheral flexibility score (both p less than or equal to 0.05). Multiple regression analysis was applied to determine the relative contribution of these variables to the estimation of injury-proneness as evidenced by previous history of injury and hypermobility traits. Using 9 independent variables, multiple regression yielded a multiple correlation coefficient (R) = 0.840, accounting for over 70% of the observed variance (R2 = 0.706) in injury scores among the total group of gymnasts. However, a subset of five variables, (weight, mesomorphy, standing lumbar curvature, age and height) yielded a multiple correlation coefficient (R) = 0.834 accounting for almost 70% of the observed variance (R2 = 0.696). This was not significantly different from the larger subset. Using injury classification system of "low", "medium", and "high" risk categories, comparisons were made between predicted and observed injury scores in the respective risk categories. In "high" risk and "low" risk gymnasts, injury scores could be classified correctly with 70% and 79% accuracy respectively, so that relative risk status could be determined from simple physical tests which may be employed by practitioners in the field.

An adoption study of human obesity

We examined the contributions of genetic factors and the family environment to human fatness in a sample of 540 adult Danish adoptees who were selected from a population of 3580 and divided into four weight classes: thin, median weight, overweight, and obese. There was a strong relation between the weight class of the adoptees and the body-mass index of their biologic parents - for the mothers, P less than 0.0001; for the fathers, P less than 0.02. There was no relation between the weight class of the adoptees and the body-mass index of their adoptive parents. Cumulative distributions of the body-mass index of parents showed similar results; there was a strong relation between the body-mass index of biologic parents and adoptee weight class and no relation between the index of adoptive parents and adoptee weight class. Furthermore, the relation between biologic parents and adoptees was not confined to the obesity weight class, but was present across the whole range of body fatness - from very thin to very fat. We conclude that genetic influences have an important role in determining human fatness in adults, whereas the family environment alone has no apparent effect.

Spontaneous pneumothorax and mitral valve prolapse

We searched for mitral valve prolapse in patients with spontaneous pneumothorax to test the hypothesis that both may be part of a common disorder of connective tissue. Echocardiographic mitral valve prolapse was found in 11 (50 percent) of 22 patients who had suffered spontaneous pneumothorax compared to four (10 percent) of 40 age-matched control subjects (p less than 0.01). The body mass index (BMI) (weight/height2) was lower (p less than 0.001) in the group with pneumothorax; in five patients who were the thinnest in the study (BMI less than 2 standard deviations lower than mean normal value), mitral valve prolapse was present in four. The finding of a strong association of spontaneous pneumothorax with mitral valve prolapse, especially in subjects with an abnormal body build, suggests that in many patients, spontaneous pneumothorax may be a manifestation of a systemic abnormality of connective tissue.

Strategies for improving compliance in hypertensive patients

The results of the present trial, aimed at elucidating and improving the treatment situation of hypertensives, show that--within the domain of the Finnish community health centres--it continues to be unsatisfactory. The prevalence of the male hypertensives (those without treatment and with a permanent diastolic pressure level of at least 100 mmHg and those under treatment) aged 35 to 49 years, was 12.8%. Only half of them were receiving treatment and of these the treatment was adequate (diastolic pressure less than 90 mmHg) in only one case out of five. Overweight turned out to be common among hypertensives, 63.2% of them had at least 10% overweight (BMI greater than or equal to 27.0 kg/m2) while 15.7% had at least 30% overweight (BMI greater than or equal to 32.0 kg/m2). There were no differences worth noting in overweight between treated and untreated cases. With respect to tobacco smoking there was a clear difference in favour of the hypertensives receiving treatment, among whom only 26.1% were regular smokers, while the corresponding figure for untreated hypertensives were 41.7%. Within short time an improved, supervising physician-based treatment system could be seen to have led to favourable results in the treatment of hypertensive community health centre patients. The proportion of those receiving adequate treatment among subjects already under treatment prior to the screening, for instance, had become threefold within a few months.

Is fatness really a risk indicator of death? A 10-16-year prospective study of patients attending the primary health care services

A 10-16-year prospective study comprising more than 26 000 person-years was performed, to analyse whether or not patients receiving care within the primary health care services had a body mass index (BMI) related to mortality. When the mortality in the high and low BMI groups was compared with the medium one, the ratios did not differ significantly from one another. Thus, in this study, comprising patients attending primary health care, neither high BMI nor low BMI was found to be a risk indicator of death, thereby supporting earlier results from studies on BMI as a function of morbidity. BMI, or the degree of fatness, should therefore not be stressed as a general risk indicator of morbidity or mortality in patients attending the primary health care services.

Once-daily use of glyburide

Ideally, metabolic control with sulfonylureas should be maintained for 24 hours. To determine an optimal glyburide dosage schedule, the effects of glyburide once (every morning) or twice daily and chlorpropamide once daily (every morning) were compared in 18 men with non-insulin-dependent diabetes mellitus in a randomized, double-blind fashion. After discontinuation of previous hypoglycemic agents for 10 days, patients were admitted to a metabolic ward for two weeks (Study A). Glycemic measurements were performed on Day 14. Subjects were readmitted after 12 weeks of outpatient therapy for another two weeks (Study B), and glycemic determinations were repeated. Weight was kept constant during and between Studies A and B. Effective hypoglycemic action of each drug regimen was demonstrated. When six glycemic parameters were compared, there was no significant difference between groups. Thus, over a 14-week period, both glyburide regimens were similar and as effective as chlorpropamide once daily.

Smoking status at the time of acute myocardial infarction and subsequent prognosis

A population of 2955 patients admitted to the hospital with acute myocardial infarction (AMI) was followed for 1 year after AMI or until death. Smokers as compared to nonsmokers were over 10 years younger (p less than 0.001) and had a lower prevalence of hypertension (p less than 0.01), congestive heart failure (p less than 0.0001), angina pectoris (p less than 0.01), and diabetes (p less than 0.0001). They had less severe myocardial infarction evidenced, for example, by lower prevalence of pulmonary congestion on chest x-ray (p less than 0.01). Both early (1 month) and late (6 and 12 months) mortality rates were lower in the smoking population (p less than 0.0001 at 1 month, p less than 0.05 at 6 months, and p less than 0.01 at 1 year). Adjusting for age and other variables reduced but did not reverse the survival differential favoring smokers at 1 month, but adjusting for age alone eliminated the differences in mortality rates at 6 and 12 months. We conclude that while smoking is a risk factor for cardiovascular disease and may contribute to the occurrence of AMI at a younger age, smoking at the time of AMI does not appear to be an independent predictor of death during the first year after AMI.

Insulin and new bone formation in diffuse idiopathic skeletal hyperostosis

The tendency of patients with DISH towards obesity or an adult onset of diabetes has been reflected in marked hyperinsulinaemia following glucose challenge. It is hypothesized that insulin at prolonged and high physiologic levels promotes new bone growth, particularly in the entheseal regions. These areas are also subject to various mechanical forces. The resulting new bone produces the radiological changes which characterise DISH.

The impact of adjustment of a weight-height index (W/H2) for frame size on the prediction of body fatness

The impact of frame-size categories in weight-height tables was studied by comparing the efficiency of the body-mass index (weight/height2 (W/H2] and weight adjusted for body-height and a body-diameter, W/(H2Dp), in predicting body fatness. Body-weight, body-height, six body-diameters and four skinfold thicknesses were measured in ninety-five men and seventy women, aged between 23 and 35 years. Percentage of body fat was calculated from skinfold thicknesses using regression equations according to Durnin & Womersley (1974). The inclusion of a body-diameter increased the explained variation of body fatness from 57% to 62% (knee) and 63% (shoulder) in men and from 63% to 69% (knee) in women. It can be concluded that in the present population the efficiency of the prediction of percentage of body fat was not improved markedly by the inclusion of a body-diameter in the body-mass index, thus giving no support for the inclusion of frame-size categories in weight-height tables.

Ischaemic oculomotor nerve palsy. Clinical features and vascular risk factors in 23 patients

Of 61 patients with isolated third nerve palsy, 23 (38%) had the characteristic clinical features of an ischaemic oculomotor nerve palsy. The essential sign of this usually painful disorder of acute onset was a marked discrepancy between complete or severe paresis of the extraocular muscles innervated by the third nerve, and sparing of the pupillary sphincter. All patients had completely recovered within 3 months. Fourteen had a history or on follow-up had other cranial mononeuropathies. Except for two patients, all were above the age of 60 years. Of the 23 cases, 11 had diabetes mellitus and 8 an abnormal glucose tolerance test, while in 4 the latter was normal. Almost all had hypertension and were overweight, and half were smokers. In 18 patients, four or five vascular risk factors were present.

The independent contributions of socioeconomic status and health practices to health status

The objective of this study was to determine whether the much-repeated finding of a relationship between socioeconomic status and health status is explained by individuals' health practices. The investigation was carried out using data tapes from the 1977 Health Interview Survey in which a one-third subsample of adults was asked a series of questions related to the seven nonmedical health practices identified in the Alameda County Study. The group selected for analysis comprised 15,892 white, responding adults. With age controlled statistically, perceived health status was found to be associated with socioeconomic status, whether the indicator was educational level, family income, or occupation, and to number of positive health practices. When number of health practices, in addition to age and other socioeconomic indicators was controlled for, the association was still positive and significant. The finding of an independent contribution by socioeconomic status to health status emphasizes that individual health habits are not the only influence on health status.

Effect of exercise training on glucose tolerance, in vivo insulin sensitivity, lipid and lipoprotein concentrations in middle-aged men with mild hypertriglyceridemia

The effects of 9 weeks of aerobic exercise training with maintenance of stable body weight upon insulin sensitivity and upon glucose, lipid, and lipoprotein concentrations were studied in 10 middle-aged men with mild hypertriglyceridemia. Following training, mean maximum oxygen consumption improved from 33.5 +/- 1.9 to 39.3 +/- 1.9 mL/kg/min (means +/- SEM), (P less than 0.01). Glucose concentrations, both fasting and during oral glucose tolerance testing, remained stable but both fasting insulin concentrations and insulin responses to oral glucose decreased (P less than 0.1 and less than 0.01, respectively). In vivo insulin sensitivity improved 25 +/- 6.1% (P less than 0.01) following training. Exercise training resulted in decreases in fasting serum triglyceride concentrations from 203 +/- 12.6 to 126 +/- 9.0 mg/dL (P less than 0.01), primarily as a result of the reduction in VLDL-triglycerides (P less than 0.01). The magnitude in percentage decrease of VLDL-triglycerides was found to be significantly correlated (r = 0.71, P less than 0.05) with the magnitude in percent increase in max VO2. Serum cholesterol levels declined from 211 +/- 8.9 to 193 +/- 11.9 mg/dL (P less than 0.01), and the ratio of HDL-cholesterol to total cholesterol was improved. This study demonstrates that exercise training at a level of intensity feasible for many middle-aged men has beneficial effects on several factors that have been associated with an increased risk of cardiovascular disease.

Distribution of risk factors in relation to the presence of cerebral angiographic lesions in TIA and minor stroke patients

In a series of patients with TIA or minor stroke we have investigated the possibility of a different distribution of risk factors according to the presence or absence of angiographic lesions of the cerebral arterial circulation. The differences observed, though not statistically significant, argue for a more severe and widespread atherosclerotic process in patients with positive angiography. A significant proportion of these patients present associated insufficiency of the coronary circulation, demonstrated indirectly by exercise testing. The exercise test presents a positive predictive power of 41% for cerebral angiographic lesions.

A 13-year review of jejunoileal bypass

One hundred and eighty patients had a jejunoileal bypass performed during the years 1971-1982. By leaving only 14 in. (35 cm) of intestine in continuity a mean weight loss of 34.4 per cent (s.d. = 8.5) was achieved over 2 years and, unless the operation had to be reversed for complications, this weight loss was maintained. The improvement in quality of life for a majority of patients should not be undervalued. Two-thirds of patients required admission for complications and eight patients died (4 per cent). Many of these problems were provoked by an inability to control eating. There have been no hospital deaths since 1976 which we attribute to better management of complications and a policy of early reversal for patients with excessive weight loss and signs of metabolic failure. Despite performing jejunoileal bypass less often in recent years we are still frequently reversing patients with electrolyte disturbances, metabolic failure, urinary calculi or arthritis. Thirty patients (16.7 per cent) have been reversed, half more than 5 years after bypass. Metabolic failure may occur even after many years of stable weight reduction. Because this is not well known the insidious onset of new weight loss and malaise may not be recognized, or not associated with the bypass many years before. Indefinite outpatient surveillance is mandatory. Changes in the operation have not significantly affected results. There has been no serious liver dysfunction in the 7:7:CJ group but this may reflect better management of lesser metabolic disturbances. Jejunoileal bypass remains the most effective operation for gross obesity and, with experience, can be performed safely. However, the complication rate and difficulty maintaining satisfactory follow-up on large numbers of young patients makes it an unacceptable procedure on any major scale.

Satiety responses in eating disorders

Appetite and satiety responses in a test meal paradigm were studied in six anorexia nervosa patients (four had bingeing and purging behaviors) and in nine normal control women. The anorexic patients were distinguished from normal controls by the amounts of food taken and by the pattern of the hunger and fullness responses to the test meal. Possible explanations for these findings are discussed.

Effect of obesity on esophageal transit

Esophageal transit time as measured by radionuclide scintigraphy using a swallowed technetium sulfur colloid bolus was measured in obese patients with gastroesophageal reflux, lean patients with reflux, and lean volunteers without reflux. The esophageal transit time was significantly prolonged in the obese group compared with both lean groups (p less than 0.001). Esophageal manometric measurement also confirmed that obese patients have an elevated gastroesophageal pressure gradient, presumably caused by increased intraabdominal pressure resulting from the mechanical burden of excess fat. The esophageal transit time is significantly related to the gastroesophageal pressure gradient. This finding, coupled with those in previous manometric investigations showing that esophageal muscle has a decreased maximum velocity with increasing afterload, explains in part why obese patients have delayed esophageal transit time. Therapy for reflux in obese patients should be aimed at improving esophageal transit.