Obesity paradox does exist

The All-Cause Mortality and a Screening Tool to Determine High-Risk Patients among Prevalent Type 2 Diabetes Mellitus Patients

AIMS

This study aims to determine the all-cause mortality and the associated risk factors for all-cause mortality among the prevalent type 2 diabetes mellitus (T2DM) patients within five years' period and to develop a screening tool to determine high-risk patients.

METHODS

This is a cohort study of T2DM patients in the national diabetes registry, Malaysia. Patients' particulars were derived from the database between 1st January 2009 and 31st December 2009. Their records were matched with the national death record at the end of year 2013 to determine the status after five years. The factors associated with mortality were investigated, and a prognostic model was developed based on logistic regression model.

RESULTS

There were 69,555 records analyzed. The mortality rate was 1.4 persons per 100 person-years. The major cause of death were diseases of the circulatory system (28.4%), infectious and parasitic diseases (19.7%), and respiratory system (16.0%). The risk factors of mortality within five years were age group (p < 0.001), body mass index category (p < 0.001), duration of diabetes (p < 0.001), retinopathy (p = 0.001), ischaemic heart disease (p < 0.001), cerebrovascular (p = 0.007), nephropathy (p = 0.001), and foot problem (p = 0.001). The sensitivity and specificity of the proposed model was fairly strong with 70.2% and 61.3%, respectively.

CONCLUSIONS

The elderly and underweight T2DM patients with complications have higher risk for mortality within five years. The model has moderate accuracy; the prognostic model can be used as a screening tool to classify T2DM patients who are at higher risk for mortality within five years.

Quantitative MRI evaluation of whole abdomen adipose tissue volumes in healthy volunteers-validation of technique and implications for clinical studies

OBJECTIVE

To explore "whole abdomen" MRI methods for quantifying adipose tissue volumes and to establish associations with body mass index (BMI) and measurement reproducibility-relative to existing "partial abdomen" methods.

METHODS

15 healthy volunteers were scanned on a 3T MRI scanner using a double-echo three-point-Dixon gradient echo sequence. Whole abdomen volumes were acquired via three separate scans ("supine 1", "supine 2" and "prone"). Segmentation was applied to derive (i) "whole abdomen" visceral (VAT) and subcutaneous adipose tissue (SCAT) volumes, and (ii) "partial abdomen" volumes at the lumbar spine (L3 to L5). Root-mean-square coefficients of variation (RMS CoV) were calculated to quantify the variability of each measurement.

RESULTS

"Whole abdomen" measurements were found to correlate better with BMI (r2max = 0.74) than "partial abdomen" volumes (r2max = 0.66). Total adipose tissue (TAT) measurements correlated better with BMI (r2max = 0.74) than SCAT (r2max = 0.43) or VAT (r2max = 0.33) for both methods. Scan-to-scan RMS CoV's for "whole abdomen" VAT and SCAT measurements were 4.16 and 3.61% compared to 6.31 and 5.07% for "partial abdomen" measurements.

CONCLUSION

"Whole abdomen" measures of abdominal adiposity are better correlated with BMI and demonstrate better scan-to-scan reproducibility than "partial abdomen" measures. It is recommended that "whole abdomen" measures be used in longitudinal MRI radiology investigations, where small volume changes may occur. Advances in knowledge: Whole abdomen adipose tissue volumes can be measured and quantified using commercial MRI sequences and post-processing software. These methods are better correlated with BMI and are more reproducible than partial abdomen measures.

Obesity and Aging in the Drosophila Model

Being overweight increases the risk of many metabolic disorders, but how it affects lifespan is not completely clear. Not all obese people become ill, and the exact mechanism that turns excessive fat storage into a health-threatening state remains unknown. Drosophila melanogaster has served as an excellent model for many diseases, including obesity, diabetes, and hyperglycemia-associated disorders, such as cardiomyopathy or nephropathy. Here, we review the connections between fat storage and aging in different types of fly obesity. Whereas obesity induced by high-fat or high-sugar diet is associated with hyperglycemia, cardiomyopathy, and in some cases, shortening of lifespan, there are also examples in which obesity correlates with longevity. Transgenic lines with downregulations of the insulin/insulin-like growth factor (IIS) and target of rapamycin (TOR) signaling pathways, flies reared under dietary restriction, and even certain longevity selection lines are obese, yet long-lived. The mechanisms that underlie the differential lifespans in distinct types of obesity remain to be elucidated, but fat turnover, inflammatory pathways, and dysregulations of glucose metabolism may play key roles. Altogether, Drosophila is an excellent model to study the physiology of adiposity in both health and disease.

Obesity, Diabetes, and the Risk of Invasive Group B Streptococcal Disease in Nonpregnant Adults in the United States

Background

Rates of invasive group B Streptococcus (GBS) disease, obesity, and diabetes have increased in US adults. We hypothesized that obesity would be independently associated with an increased risk of invasive GBS disease.

Methods

We identified adults with invasive GBS disease within Active Bacterial Core surveillance during 2010–2012 and used population estimates from the Behavioral Risk Factor Surveillance System to calculate invasive GBS incidence rates. We estimated relative risks (RRs) of invasive GBS using Poisson analysis with offset denominators, with obesity categorized as class I/II (body mass index [BMI] = 30–39.9 kg/m²) and class III (BMI ≥ 40.0 kg/m²).

Results

In multivariable analysis of 4281 cases, the adjusted RRs of invasive GBS disease were increased for obesity (class I/II: RR, 1.52; 95% confidence interval [CI], 1.14–2.02; and class III: RR, 4.87; 95% CI, 3.50–6.77; reference overweight) and diabetes (RR, 6.04; 95% CI, 4.77–7.65). The adjusted RR associated with class III obesity was 3-fold among persons with diabetes (95% CI, 1.38–6.61) and nearly 9-fold among persons without diabetes (95% CI, 6.41–12.46), compared with overweight. The adjusted RRs associated with diabetes varied by age and BMI, with the highest RR in young populations without obesity. Population attributable risks of invasive GBS disease were 27.2% for obesity and 40.1% for diabetes.

Conclusions

Obesity and diabetes were associated with substantially increased risk of infection from invasive GBS. Given the population attributable risks of obesity and diabetes, interventions that reduce the prevalence of these conditions would likely reduce the burden of invasive GBS infection.

Body mass index and the all-cause mortality rate in patients with type 2 diabetes mellitus

AIMS

The relationship between obesity and mortality rate among diabetic patients is a controversial topic. The aim of this study was to investigate the association between obesity and all-cause mortality risk in patients with type 2 diabetes.

METHODS

In this retrospective database study, 2383 patients with type 2 diabetes, who had been registered in the Isfahan Endocrine and Metabolism Research Center, Iran, were enrolled between 1992 and 2010. The mean (SD) of diabetes duration and follow-up period was 15.5 (8.0) and 7.8 (3.9) years. The main outcome was all-cause mortality. All-cause mortality rates were calculated for the body mass index (BMI) categories of underweight, normal, overweight and class I, II and III obese. Cox proportional hazard models were used to estimate the adjusted hazard ratio for BMI as categorical variable using BMI of 18.5-24.9 kg/m² as the reference group.

RESULTS

The mortality rate in patients with normal weight was higher than overweight patients (59.11 vs. 33.17 per 1000 person-years). The adjusted hazard ratios of all-cause mortality were 0.82 [95%CI 0.68-0.99; P = 0.037], 0.79 [95%CI 0.61-1.02; P = 0.069], 0.71 [95%CI 0.42-1.19; P = 0.191] and 1.36 [95%CI 0.55-3.33; P = 0.507] for overweight, class I, II and III obesity, respectively. When BMI was included in the Cox model as a time-dependent variable, the U-shaped relationship between BMI and all-cause mortality did not change.

CONCLUSIONS

The results show a U-shaped association of BMI with all-cause mortality in patients with type 2 diabetes with the lowest risk observed among the overweight patients.

The Evidence for an Obesity Paradox in Type 2 Diabetes Mellitus

Although overweight/obesity is a major risk factor for the development of type 2 diabetes mellitus, there is increasing evidence that overweight or obese patients with type 2 diabetes mellitus experience lower mortality compared with patients of normal weight. This paradoxical finding, known as the "obesity paradox," occurs in other chronic diseases, and in type 2 diabetes mellitus is particularly perplexing given that lifestyle intervention with one goal being weight reduction is an important feature of the management of this condition. We summarize in this review the findings from clinical and epidemiologic studies that have investigated the association between overweight and obesity (usually assessed using body mass index [BMI]) and mortality in type 2 diabetes mellitus and discuss potential causes of the obesity paradox. We conclude that most studies show evidence of an obesity paradox, but important conflicting findings still exist. We also evaluate if potential bias might explain the obesity paradox in diabetes, including, for example, the presence of confounding factors, measurement error due to use of BMI as an index of obesity, and reverse causation.

Weight loss and mortality risk in patients with different adiposity at diagnosis of type 2 diabetes: a longitudinal cohort study

BACKGROUND

Undiagnosed comorbid diseases that independently lead to weight loss before type 2 diabetes mellitus (T2DM) diagnosis could explain the observed increased mortality risk in T2DM patients with normal weight.

OBJECTIVES

To evaluate the impact of weight change patterns before the diagnosis of T2DM on the association between body mass index (BMI) at diagnosis and mortality risk.

METHODS

This was a longitudinal cohort study using 145,058 patients from UK primary care, with newly diagnosed T2DM from January 2000. Patients aged 18-70, without established disease history at diagnosis (defined as the presence of cardiovascular diseases, cancer, and renal diseases on or before diagnosis) were followed up to 2014. Longitudinal 6-monthly measures of bodyweight three years before (used to define groups of patients who lost bodyweight or not before diagnosis) and 2 years after diagnosis were obtained. The main outcome was all-cause mortality.

RESULTS

At diagnosis, mean (SD) age was 52 (12) years, 56% were male, 52% were current or ex-smokers, mean BMI was 33 kg/m², and 66% were obese. Normal weight and overweight patients experienced a small but significant reduction in body weight 6 months before diagnosis. Among all categories of obese patients, consistently increasing body weight was observed within the same time window. Among patients who did not lose body weight pre-diagnosis (n = 117,469), compared with the grade 1 obese, normal weight patients had 35% (95% CI of HR: 1.17, 1.55) significantly higher adjusted mortality risk. However, among patients experiencing weight loss before diagnosis (n = 27,589), BMI at diagnosis was not associated with mortality risk (all p > 0.05).

CONCLUSIONS

Weight loss before the diagnosis of T2DM was not associated with the observed increased mortality risk in normal weight patients with T2DM. This emphasises the importance of addressing risk factors post diagnosis for excess mortality in this group.

Adipose tissue inflammation in aging

Adipose tissue has traditionally been viewed as an organ of interest within studies of obesity and diet-associated metabolic disorders. However, as studies reveal the role white adipose tissue plays as an energy storage, a lipid metabolism site, and an adipokine secretor, it has become recognized as an organ of importance for metabolic health in both the young obese and the old obese. Within the realms of aging research, the pursuit of senolytics has taken the field's spotlight, where the clearance of senescent cells has shown to attenuate aspects of age-related disorders. More interestingly, these senolytics have also revealed that these senescent cells, specifically p16Ink4a cells, accumulate within adipose tissue, skeletal muscles, and eye (Baker et al., 2011). These results implicate the importance of adipose tissue inflammation in aging and widen the discussion on how senescent cells among other immune and non-immune cells cross paths to influence an organism's lifespan and healthspan.

Hospital-Based Case-Control Study of MDS Subtypes and Benzene Exposure in Shanghai

OBJECTIVE

Due to the sparse data on benzene exposure and myelodysplastic syndrome (MDS) subtypes, we studied this relationship in patients from 29 hospitals in Shanghai, China.

METHODS

We recruited 604 cases of MDS and 1193 controls matched on age, sex, and admission date. We interviewed subjects for information on workplace and lifestyle exposures, and developed semi-quantitative exposure estimates.

RESULTS

Benzene exposure showed a direct exposure-response pattern with refractory cytopenia with multilineage dysplasia, a less certain association with refractory cytopenia with unilineage dysplasia, and no association with other MDS subtypes. A different pattern was observed with farm residence and smoking, which was primarily related to refractory anemias.

CONCLUSIONS

This research demonstrates the importance of MDS subtype specification for more robust etiologic insights. Our data suggests that subtypes with non-erythroid dysplasia are associated with benzene exposure.

Association Between Exercise Frequency and Health Care Costs Among Employees at a Large University and Academic Medical Center

OBJECTIVE

The aim of this study was to evaluate the relationship between exercise frequency and health care costs associated with medical and pharmacy claims among a 10-year employee cohort.

METHODS

The relationship between self-reported exercise (days/week) and health care costs was analyzed with negative binomial regression, using an integrated database involving 32,044 person-years and linking employee demographics, health risk appraisal information, and health insurance claims.

RESULTS

An association demonstrating exercise frequency lowering health care costs was present in most medical and prescription drug categories and was strongest among employees reporting 2 to 3 and 4 to 5 days/week of exercise. Increased exercise was associated with statistically significant reductions in endocrine disease costs and gastrointestinal prescription drug costs.

CONCLUSIONS

This cohort demonstrates lower health care costs in employee populations when exercise frequency is increased. Employers may lower modifiable risk factors for chronic disease and reduce health care costs by promoting exercise among their employee population.

Body Mass Index and All-cause Mortality in Chronic Kidney Disease: A Dose-response Meta-analysis of Observational Studies

This article provides a dose-response meta-analysis to evaluate the relationship between body mass index (BMI) and all-cause and disease-specific mortality in chronic kidney disease (CKD) by pooling together early stage, hemodialysis, and peritoneal dialysis patients. We evaluated eligible studies that published between 1966 and December 2014 by searching in PubMed, Object View and Interaction Design (OVID), and the Scopus databases. We used random-effects generalized least squares spline models for trend estimation to derive pooled dose-response estimates. Nonlinear associations of BMI with all-cause mortality were observed (P-nonlinearity < .0001), with an increased rate of mortality with BMIs > 30 kg/m² in all stages of CKD together. However, reanalysis of data separately by stage of CKD (hemodialysis and peritoneal dialysis) showed that the risk of all-cause mortality decreased with a steep slope in individuals with BMIs > 30 kg/m². This meta-analysis indicates that higher BMI has protective effects with respect to all-cause mortality in patients with both type of dialysis.

Obesity and chronic kidney disease

PURPOSE OF REVIEW

To review recent advances in the epidemiology, pathophysiology, clinical features, and treatment of obesity-related kidney disease.

RECENT FINDINGS

Studies have confirmed that obesity is associated with increased risk of developing chronic kidney disease (CKD). This risk extends to those who are metabolically healthy, indicating that obesity per se contributes to CKD independent of the metabolic syndrome. Recent developments in the pathophysiology of obesity-related kidney disease indicate that chronic inflammation and abnormal lipid metabolism contribute to kidney cell injury. Children with severe obesity have increased prevalence of early kidney abnormalities, including albuminuria, decreased kidney function, and elevated biomarkers of early kidney injury. For these patients, bariatric surgery has emerged as a treatment option to consider. Longitudinal studies in children and adults have demonstrated that in patients with obesity-related kidney disease, kidney function and albuminuria improve following bariatric surgery.

SUMMARY

The injurious renal effects of obesity are present in childhood, although the natural history and clinical spectrum of obesity-related kidney disease in children are not known. In obese children with early kidney disease, identification of kidney injury, implementation of preventive strategies, and prompt treatment are essential to improving clinical outcomes.

Effect of non-surgical weight management on weight and glycaemic control in people with type 2 diabetes: A comparison of interventional and non-interventional outcomes at 3 years

AIMS

To examine the long-term effectiveness of lifestyle weight management interventions, recommended in clinical guidelines for patients with type 2 diabetes mellitus (T2DM) and obesity.

MATERIALS AND METHODS

Electronic health records were used to follow 23 208 patients with T2DM and obesity in Glasgow, UK, for up to 3 years between 2005 and 2014. Patients were stratified by referral to and attendance at a lifestyle weight management intervention, and by attainment of a target weight loss of ≥5 kg over 7 to 9 sessions ("successful completers"). Outcomes were change in weight, glycated haemoglobin (HbA1c) and diabetes medications.

RESULTS

A total of 3471 potentially eligible patients were referred to the service, and fewer than half of these attended (n = 1537). Of those who attended 7 to 9 sessions, >40% successfully completed and achieved 5-kg weight loss (334/808). Successful completers maintained greater weight loss (change at 3 years -8.03 kg; 95% confidence interval [CI] -9.44 to -6.62) than the non-completers (-3.26 kg; 95% CI -4.01 to -2.51; P < .001) and those not referred to the service (-1.00 kg; 95% CI -1.15 to -0.85; P < .001). Successful completers were the only patient group who did not increase their use of diabetes medication and insulin over 3 years. In adjusted models, successful completers had a clinically significant reduction in HbA1c (-3.7 mmol/mol; 95% CI -5.82 to -1.51) after 3 years; P ≤ .001) compared with non-completers and unsuccessful completers.

CONCLUSIONS

A real-life structured weight management intervention in patients with diabetes can reduce weight in the medium term, result in improved glycaemic control with fewer medications, and may be more effective than pharmacological alternatives. Challenges include getting a higher proportion of patients referred to and engaged with interventions.

Cardiovascular and Metabolic Heterogeneity of Obesity: Clinical Challenges and Implications for Management

The prevalence of obesity has increased globally over the last 2 decades. Although the body mass index has been a convenient and simple index of obesity at the population level, studies have shown that obesity defined by body mass index alone is a remarkably heterogeneous condition with varying cardiovascular and metabolic manifestations across individuals. Adipose tissue is an exquisitely active metabolic organ engaged in cross-talk between various systems; perturbation of adipose tissue results in a pathological response to positive caloric balance in susceptible individuals that directly and indirectly contributes to cardiovascular and metabolic disease. Inadequate subcutaneous adipose tissue expansion in the face of dietary triglycerides leads to visceral and ectopic fat deposition, inflammatory/adipokine dysregulation, and insulin resistance. Conversely, preferential fat storage in the lower body depot may act as a metabolic buffer and protect other tissues from lipotoxicity caused by lipid overflow and ectopic fat. Translational, epidemiological, and clinical studies over the past 30 years have clearly demonstrated a strong link between visceral and ectopic fat and the development of a clinical syndrome characterized by atherogenic dyslipidemia, hyperinsulinemia/glucose intolerance, hypertension, atherosclerosis, and adverse cardiac remodeling/heart failure. This relationship is even more nuanced when clinical entities such as metabolically healthy obesity phenotype and the obesity paradox are considered. Although it is clear that the accumulation of visceral/ectopic fat is a major contributor to cardiovascular and metabolic risk above and beyond the body mass index, implementation of fat distribution assessment into clinical practice remains a challenge. Anthropometric indexes of obesity are easily implemented, but newer imaging-based methods offer improved sensitivity and specificity for measuring specific depots. Lifestyle, pharmacological, and surgical interventions allow a multidisciplinary approach to overweight/obesity that may improve outcomes and align with a public health message to combat the growing epidemic of obesity worldwide and to build healthier lives free of cardiovascular diseases.

Skipping breakfast, overconsumption of soft drinks and screen media: longitudinal analysis of the combined influence on weight development in primary schoolchildren

BACKGROUND

Regular breakfast and well-balanced soft drink, and screen media consumption are associated with a lower risk of overweight and obesity in schoolchildren. The aim of this research is the combined examination of these three parameters as influencing factors for longitudinal weight development in schoolchildren in order to adapt targeted preventive measures.

METHODS

In the course of the Baden-Württemberg Study, Germany, data from direct measurements (baseline (2010) and follow-up (2011)) at schools was available for 1733 primary schoolchildren aged 7.08 ± 0.6 years (50.8% boys). Anthropometric measurements of the children were taken according to ISAK-standards (International Standard for Anthropometric Assessment) by trained staff. Health and lifestyle characteristics of the children and their parents were assessed in questionnaires. A linear mixed effects regression analysis was conducted to examine influences on changes in waist-to-height-ratio (WHtR), weight, and body mass index (BMI) measures. A generalised linear mixed effects regression analysis was performed to identify the relationship between breakfast, soft drink and screen media consumption with the prevalence of overweight, obesity and abdominal obesity at follow-up.

RESULTS

According to the regression analyses, skipping breakfast led to increased changes in WHtR, weight and BMI measures. Skipping breakfast and the overconsumption of screen media at baseline led to higher odds of abdominal obesity and overweight at follow-up. No significant association between soft drink consumption and weight development was found.

CONCLUSION

Targeted prevention for healthy weight status and development in primary schoolchildren should aim towards promoting balanced breakfast habits and a reduction in screen media consumption. Future research on soft drink consumption is needed. Health promoting interventions should synergistically involve children, parents, and schools.

TRIAL REGISTRATION

The Baden-Württemberg Study is registered at the German Clinical Trials Register (DRKS) under the DRKS-ID: DRKS00000494 .

Malnutrition, poor food intake, and adverse healthcare outcomes in non-critically ill obese acute care hospital patients

BACKGROUND & AIMS

Obesity, defined as a BMI ≥ 30 kg/m², has demonstrated protective associations with mortality in some diseases. However, recent evidence demonstrates that poor nutritional status in critically ill obese patients confounds this relationship. The purpose of this paper is to evaluate if poor nutritional status, poor food intake and adverse health-related outcomes have a demonstrated association in non-critically ill obese acute care hospital patients.

METHODS

This is a secondary analysis of the Australasian Nutrition Care Day Survey dataset (N = 3122), a prospective cohort study conducted in hospitals from Australia and New Zealand in 2010. At baseline, hospital dietitians recorded participants' BMI, evaluated nutritional status using Subjective Global Assessment (SGA), and recorded 24-h food intake (as 0%, 25%, 50%, 75%, and 100% of the offered food). Post-three months, participants' length of stay (LOS), readmissions, and in-hospital mortality data were collected. Bivariate and regression analyses were conducted to investigate if there were an association between BMI, nutritional status, poor food intake, and health-related outcomes.

RESULTS

Of the 3122 participants, 2889 (93%) had eligible data. Obesity was prevalent in 26% of the cohort (n = 750; 75% females; 61 ± 15 years; 37 ± 7 kg/m²). Fourteen percent (n = 105) of the obese patients were malnourished. Over a quarter of the malnourished obese patients (N = 30/105, 28%) consumed ≤25% of the offered meals. Most malnourished obese patients (74/105, 70%) received standard diets without additional nutritional support. After controlling for confounders (age, disease type and severity), malnutrition and intake ≤25% of the offered meals independently trebled the odds of in-hospital mortality within 90 days of hospital admission in obese patients.

CONCLUSION

Although malnourished obese experienced significantly adverse health-related outcomes they were least likely to receive additional nutritional support. This study demonstrates that BMI alone cannot be used as a surrogate measure for nutritional status and warrants routine nutritional screening for all hospital patients, and subsequent nutritional assessment and support for malnourished patients.

Obesity paradox in heart failure: statistical artifact, or impetus to rethink clinical practice?

The "obesity paradox" in heart failure (HF) is a phenomenon of more favorable prognosis, especially better survival, in obese versus normal-weight HF patients. Various explanations for the paradox have been offered; while different in their details, they typically share the premise that obesity per se is not actually the cause of reduced mortality in HF. Even so, there is a lingering question of whether clinicians should refrain from, or at least soft-pedal on, encouraging weight loss among their obese HF patients. Against the backdrop of recent epidemiological analysis by Banack and Kaufman, which speculates that collider stratification bias may generate the obesity paradox, we seek to address the aforementioned question. Following a literature review, which confirms that obese HF patients are demographically and clinically different from their normal-weight counterparts, we present four hypothetical data sets to illustrate a spectrum of possibilities regarding the obesity-mortality association. Importantly, these hypothetical data sets become indistinguishable from each other when a crucial variable is unmeasured or unreported. While thorough, the discussion of these data sets is intended to be accessible to a wide audience, especially including clinicians, without a prerequisite of familiarity with advanced epidemiology. We also furnish intuitive visual diagrams which depict a version of the obesity paradox. These illustrations, along with reflection on the distinction between weight and weight loss (and, furthermore, between voluntary and involuntary weight loss), lead to our recommendation for clinicians regarding the encouragement of weight loss. Finally, our conclusion explicitly addresses the questions posed in the title of this article.

Revisiting donor risk over two decades of single-center experience: More attention on the impact of overweight

OBJECTIVE

Morbidity rates after living donor hepatectomy vary greatly among centers. Donor morbidity in a tertiary center over the past two decades was revisited.

METHODS

Clinical data and grading of complications were reviewed by a nontransplant surgeon based on Clavien 5 tier grading. Risk factors were analyzed.

RESULTS

In total, 473 consecutive living liver donors from 1997 to 2016 were included for analysis; 305 were right liver donors and 168 left liver donors, and the corresponding morbidity rates were 27.2% and 9.5%. The majority (81/99, 81.2%) of complications were grade I and II. Donors with morbidity compared with those without were significantly younger, nonoverweight body figure (BMI < 25), more as the right liver donors, and longer length of hospital stay. Right liver donation had significantly higher morbidity rates than did left liver donation in earlier periods (before 2011), but not thereafter. Multivariate modeling revealed that right lobe donation and overweight (BMI ≥ 25 kg/m²) were significant factors associated with donor morbidity, with adjusted hazard ratios HR (95% confidence interval) of 3.401 (1.909-6.060) and 0.550 (0.304-0.996), respectively. Further, overweight was a paradoxical risk factor in right donor hepatectomy with HR 0.422 (0.209-0.851), but the effect was nonsignificant in left liver donors. Most complications in overweight donors were grade I and not specific to liver surgery.

CONCLUSIONS

The overall complication rate was 20.9%. Overweight might be protective against morbidity in right hepatectomy and warrants further deliberation.

Association of muscle mass and fat mass with insulin resistance and the prevalence of metabolic syndrome in Korean adults: a cross-sectional study

Relationship of muscle mass and fat mass with insulin resistance and metabolic syndrome remains uncertain, especially among Asian population. We performed a cross-sectional study with 14,807 adult participants aged between 18 and 65 in the fourth and fifth Korea National Health and Nutrition Examination Survey with Dual Energy X-ray Absorptiometry (DEXA) data to investigate whether muscle mass and fat mass are associated with insulin resistance and metabolic syndrome. DEXA records were used to categorize the participants into four categories (low muscle/low fat, low muscle/high fat, high muscle/ low fat, and high muscle/high fat). Least square means and incidence rate ratios (IRR) were used to assess the associations of muscle mass and fat mass with insulin resistance and metabolic syndrome. After adjustment for potential confounders, high muscle/low fat was associated with significantly lower insulin resistance (P < 0.001) compared to low muscle/low fat. Low muscle/high fat (IRR: 1.90; 95% confidence interval [CI]:1.44-2.50, P < 0.001) and high muscle/high fat (IRR: 2.30; 95% CI:1.76-3.00, P < 0.001) were significantly associated with the prevalence of metabolic syndrome. Our study suggests that protective association of muscle mass with metabolic syndrome is attenuated by high fat mass in Korean adults.

DR, Lee DH. Persistent Organic Pollutants and Type 2 Diabetes: A Critical Review of Review Articles

Low dose persistent organic pollutants (POPs) have emerged as a new risk for type 2 diabetes (T2D). Despite substantial evidence from human and experimental studies, there are several critical issues which have not been properly addressed by POPs researchers. First, as POPs exist as mixtures, findings about POPs from human studies should be interpreted from the viewpoint of lipophilic chemical mixtures which include both measured and unmeasured POPs. Second, as POPs can directly reduce insulin secretion of beta cells, the role of POPs may be more prominent in the development of beta-cell dysfunction-dominant T2D rather than insulin resistance-dominant T2D. Third, there are multidimensional interrelationships between POPs and adipose tissue. Even though POPs are now considered as a new risk factor for T2D, independent of obesity, POPs and obesity are mechanistically linked to each other. POPs are involved in key mechanisms linking obesity and T2D, such as chronic inflammation of adipose tissue and lipotoxicity with ectopic fat accumulation. Also, POPs can explain puzzling human findings which suggest benefits of obesity because healthy adipose tissue can be protective by reducing the amount of POPs reaching other organs. Fourth, non-linear dose-response relationships between POPs and T2D are biologically possible. Although POPs are well-known endocrine disrupting chemicals (EDCs), mitochondrial dysfunction may be a more plausible mechanism due to unpredictability of EDC mixtures. As adipose tissue plays a role as an internal exposure source of POPs, how to manage POPs inside us may be essential to protect against harms of POPs.

The Impact of Weight Gain During HIV Treatment on Risk of Pre-diabetes, Diabetes Mellitus, Cardiovascular Disease, and Mortality

Since the introduction of combined antiretroviral therapy (cART) and more effective treatments for AIDS, there has been a dramatic shift from the weight loss and wasting that characterised HIV/AIDS (and still does in countries where cART is not readily available or is initiated late) to healthy weight, or even overweight and obesity at rates mirroring those seen in the general population. These trends are attributable to several factors, including the "return to health" weight gain with reversal of the catabolic effects of HIV-infection following cART-initiation, strategies for earlier cART-initiation in the course of HIV-infection which have prevented many people living with HIV-infection from developing wasting, in addition to exposure to the modern obesogenic environment. Older cART regimens were associated with increased risk of body fat partitioning disorders (lipodystrophy) and cardiometabolic complications including atherothrombotic cardiovascular disease (CVD) and diabetes mellitus. Whilst cART now avoids those medications implicated in causing lipodystrophy, long-term cardiometabolic data on more modern cART regimens are lacking. Longitudinal studies show increased rates of incident CVD and diabetes mellitus with weight gain in treated HIV-infection. Abdominal fat gain, weight gain, and rising body mass index (BMI) in the short-term during HIV treatment was found to increase incident diabetes risk. Rising BMI was associated with increased risk of incident CVD, however the relationship varied depending on pre-cART BMI category. In contrast, a protective association with mortality is evident, predominantly in the underweight and in resource-poor settings, where weight gain reflects access to cART and virological suppression. The question of how to best evaluate, manage (and perhaps constrain) weight gain during HIV treatment is of clinical relevance, especially in the current climate of increasingly widespread cART use, rising overweight, and obesity prevalence and growing metabolic and cardiovascular disease burden in people living with HIV-infection. Large prospective studies to further characterise the relationship between weight gain during HIV treatment and risk of diabetes, CVD and mortality are required.

Effect of Body Weight, Waist Circumference and Their Changes on Mortality: a 10-Year Population-based Study

OBJECTIVES

To investigate the effect of body weight, waist circumference and their changes on all-cause and cardiovascular mortality.

DESIGN

A nationwide population-based cohort study.

PARTICIPANTS

627 community-dwelling older adults.

MEASUREMENTS

Participants were interviewed for demographic and anthropometric data collected. Blood were drawn for testing biochemistry data. Central obesity was defined as waist circumference is greater than 80 cm for women and 90 cm for men. Obesity, overweight, normal and underweight were defined as BMI ≥27 kg/m2 , ≥24 kg/m2 ,18.5-24 kg/m2 and < 18.5 kg/m2. Cox proportion hazard model was used to explore the impact of body weight and its change on mortality.

RESULTS

The distribution of weight changes and mortality was right skewed, but U-shape of waist change for all-cause mortality was observed. Compared to normal BMI at baseline, the association between underweight (HR: 1.7, 95% CI: 0.7-4.0), overweight (HR:0.7, 95% CI:0.4-1.2) and obesity (HR:1.3,95% CI:0.8-2.3) showed insignificantly associated with all-cause mortality. The HR of those weight loss >5% (HR: 1.7, 95% CI: 1.1-2.8) and waist decrease >5% (HR: 1.7, 95% CI: 1.0-2.8) were higher than those of stable weight/waist +/- 5% over a 6-year period. Compared to those stable weight/waist, the mortality risk was similar in those of weight gain or waist increase (HR 0.7,95%CI: 0.4-1.5 and HR:0.9, 95%CI:0.4-1.6).

CONCLUSION

Weight loss and waist decrease were significantly associated with long-term mortality risk, a life-course approach for body weight management is needed to pursuit the most optimal health benefits for the middle-aged and older adults.

Body Mass and Physical Activity Uniquely Predict Change in Cognition for Aging Adults

BACKGROUND

Physical activity and body mass predict cognition in the elderly. However, mixed evidence suggests that obesity is associated with poorer cognition, while also protecting against cognitive decline in older age.

PURPOSE

We investigated whether body mass independently predicted cognition in older age and whether these associations changed over time.

METHODS

A latent curve structural equation modeling approach was used to analyze data from a sample of aging adults (N = 8442) split into two independent subsamples, collected over 6 years.

RESULTS

Lower baseline Body Mass Index (BMI) and higher physical activity independently predicted greater baseline cognition (p < 0.001). Decreases in BMI and physical activity independently predicted greater decline in the slope of cognition (p < 0.001).

CONCLUSIONS

Our results support the obesity paradox in cognitive aging, with lower baseline body mass predicting better cognition, but less decline over time protecting against cognitive decline. We discuss how weight loss in the elderly may serve as a useful indicator of co-occurring cognitive decline, and we discuss implications for health care professionals.

Incidence of diabetes and its mortality according to body mass index in South Koreans aged 40-79 years

Purpose

The purpose of this study was to assess diabetes incidence and all-cause mortality according to baseline body mass index (BMI) and to compare relative risks of mortality associated with incident diabetes across various BMI classes in a cohort of South Korean adults.

Patients and methods

Based on data from the National Health Insurance database of Korean individuals aged 40-79 years without preexisting diabetes, we calculated BMI at the baseline health examination. We estimated the relative risk of mortality associated with incident diabetes using time-dependent Cox models and considering the time of diabetes diagnosis.

Results

We noted 29,307 incident diabetes cases and 22,940 deaths during an 8-year follow-up of the initial cohort (n=436,692) and 73,756 incident diabetes cases and 57,556 deaths during a 10-year follow-up of the replication cohort (n=850,282). Regarding all-cause mortality, time-dependent Cox models revealed statistically significant interactions between diabetes status and baseline BMI class (P=0.018 and P<0.001 in the initial and replication cohorts, respectively). In separately conducted analyses for each BMI class, diabetes-associated relative risks for BMI values of 16.0-18.4, 18.5-22.9, 23.0-24.9, 25.0-29.9, and 30.0-34.9 kg/m² were 1.50 (95% confidence interval [CI], 1.09-2.07), 1.39 (95% CI, 1.26-1.54), 1.20 (95% CI, 1.08-1.35), 1.18 (95% CI, 1.07-1.30), and 0.97 (95% CI, 0.74-1.28) in the initial cohort, and 1.44 (95% CI, 1.18-1.74), 1.33 (95% CI, 1.26-1.41), 1.24 (95% CI, 1.16-1.31), 1.11 (95% CI, 1.05-1.17), and 0.99 (95% CI, 0.85-1.16) in the replication cohort. The increasing trend of relative risk with decreasing BMI persisted mostly among subgroups stratified according to age or sex and smoking status.

Conclusion

Incident diabetes was associated with a greater increase in all-cause mortality risk in adults with lower BMI relative to those with higher BMI. This emphasizes the importance of treatment and prevention of type 2 diabetes among normal weight or underweight adults, particularly in Asia.

Associations of changes in body mass index with all-cause and cardiovascular mortality in healthy middle-aged adults

Background

Conflicting data exist regarding the association of body mass index (BMI) changes with all-cause and cardiovascular (CV) mortality. The current study investigated the association between changes in BMI and all-cause, CV, and non-CV mortality in a large cohort of middle-aged adults.

Methods

A total of 379,535 adults over 40 years of age without pre-existing CV disease or cancer at baseline were enrolled to undergo a series of at least three health examinations of biennial intervals. Changes in BMI between baseline, midpoint follow-up, and final health examination during mean 9.3 years were defined according to the pattern of BMI change as follows: stable, sustained gain, sustained loss, and fluctuation. The relationship between BMI change category and mortality was assessed by multivariate Cox regression reporting hazard ratio (HR) with 95% confidence interval (95% CI).

Results

During a mean follow-up of 10.7 years for mortality, 12,378 deaths occurred from all causes, of which 2,114 were CV and 10,264 were non-CV deaths. Sustained BMI gain was associated with the lower risk of all-cause (HR 0.89, 95% CI: 0.83–0.95), CV (HR 0.84, 95% CI 0.72–0.98), and non-CV mortality (HR 0.90, 95% CI 0.84–0.96) compared with stable BMI. Conversely, sustained BMI loss (HR 1.25, 95% CI 1.19–1.32) and fluctuation (HR 1.13, 95% CI 1.08–1.19) displayed a higher risk of all-cause mortality compared with stable BMI, which was mainly attributable to the increase in non-CV mortality.

Conclusion

Sustained BMI gains were associated with reduced risk of all-cause, CV, and non-CV mortality in middle-aged healthy adults.

Taming the Flames: Targeting White Adipose Tissue Browning in Hypermetabolic Conditions

In this era of increased obesity and diabetes prevalence, the browning of white adipose tissue (WAT) has emerged as a promising therapeutic target to induce weight loss and improve insulin sensitivity in this population. The browning process entails a shift in the WAT from primarily storing excess energy to the dissipation of energy as heat. However, this idealistic view of WAT browning being the savior of the metabolic syndrome has been criticized by studies in burn and cancer patients that have shown browning to be detrimental rather than beneficial. In fact, in the context of hypermetabolic states, the browning of WAT has presented with substantial clinical adverse outcomes related to cachexia, hepatic steatosis, and muscle catabolism. Therefore, the previous thought construct of understanding browning as an all-beneficial physiologic event has now been met with skepticism. In this review, we focus on current knowledge of browning of WAT and its adverse metabolic alterations during hypermetabolic states. We also discuss the regulators and signaling pathways involved in the browning process and their potential for being targeted by new or existing drugs to inhibit or alleviate browning, potentially leading to decreased hypermetabolism and improved clinical outcomes. Lastly, the imminent clinical applications of pharmacological agents are explored in the perspective of attenuating WAT browning and its associated adverse side effects reported in burn patients.

Development and validation of anthropometric prediction equations for lean body mass, fat mass and percent fat in adults using the National Health and Nutrition Examination Survey (NHANES) 1999-2006

Quantification of lean body mass and fat mass can provide important insight into epidemiological research. However, there is no consensus on generalisable anthropometric prediction equations to validly estimate body composition. We aimed to develop and validate practical anthropometric prediction equations for lean body mass, fat mass and percent fat in adults (men, n 7531; women, n 6534) from the National Health and Nutrition Examination Survey 1999-2006. Using a prediction sample, we predicted each of dual-energy X-ray absorptiometry (DXA)-measured lean body mass, fat mass and percent fat based on different combinations of anthropometric measures. The proposed equations were validated using a validation sample and obesity-related biomarkers. The practical equation including age, race, height, weight and waist circumference had high predictive ability for lean body mass (men: R 2=0·91, standard error of estimate (SEE)=2·6 kg; women: R 2=0·85, SEE=2·4 kg) and fat mass (men: R 2=0·90, SEE=2·6 kg; women: R 2=0·93, SEE=2·4 kg). Waist circumference was a strong predictor in men only. Addition of other circumference and skinfold measures slightly improved the prediction model. For percent fat, R 2 were generally lower but the trend in variation explained was similar. Our validation tests showed robust and consistent results with no evidence of substantial bias. Additional validation using biomarkers demonstrated comparable abilities to predict obesity-related biomarkers between direct DXA measurements and predicted scores. Moreover, predicted fat mass and percent fat had significantly stronger associations with obesity-related biomarkers than BMI did. Our findings suggest the potential application of the proposed equations in various epidemiological settings.

Association between the number of natural teeth and diabetic retinopathy among type 2 diabetes mellitus: The Korea national health and nutrition examination survey

The aim of this study was to investigate the relationship between the number of teeth and diabetic retinopathy among Korean population.This was a retrospective analysis using data of total 45,811 individuals who participated in the Korea National Health and Nutrition Examination Survey (KNHANES) 2008 to 2012. Among these, 2593 (5.7%) participants were identified as having type 2 diabetes mellitus. After excluding participants without ophthalmic evaluation or other variables, 2078 (80%) participants were included. Demographic factors including dental status were analyzed and compared between participants with and without diabetic retinopathy.Among the 2078 type 2 diabetes, 358 (17.2%) had diabetic retinopathy. Type 2 diabetes with fewer teeth were more likely to have diabetic retinopathy (P < .001). Multivariate analysis showed that type 2 diabetes with < 20 teeth had an 8.7-fold risk of having vision-threatening diabetic retinopathy when compared with type 2 diabetes with ≥28 teeth (95% confidence interval: 2.69-28.3) after adjusting for age, sex, body mass index, smoking, drinking, exercise, hypertension, diabetes mellitus duration, and glycated hemoglobin level.The number of teeth was found to be an independent risk factor for diabetic retinopathy. Thus, a comprehensive approach of dentists and ophthalmologists is needed to minimize the complications of diabetes mellitus. Whether the teeth number reflects microvascular changes of the retina among type 2 diabetes warrants further investigation.

Higher Adiposity Is Associated With Slower Cognitive Decline in Hypertensive Patients: Secondary Analysis of the China Stroke Primary Prevention Trial

BACKGROUND

Obesity is a risk factor for many diseases. However, the potential association between adiposity and cognitive decline in hypertensive patients is inconclusive. We performed a secondary data analysis of the CSPPT (China Stroke Primary Prevention Trial) to examine whether adiposity is correlated with longitudinal cognitive performance in hypertensive adults.

METHODS AND RESULTS

The analysis included 16 791 patients in the CSPPT who received at least 2 cognitive assessments by the Mini-Mental State Examination (MMSE) during the follow-up (median, 4.5 years; interquartile range, 4.2-4.8 years). Outcomes included changes in MMSE scores and cognitive impairment (defined as MMSE score less than education-specific cutoff point). A marked reduction in MMSE scores at the final (compared with at the 1-year) follow-up was apparent in both men (n=4838; mean [SD] score, 0.41 [3.62]) and women (n=7190; mean [SD] score, 1.07 [4.61]; both P<0.001). Analysis using a mixed-effects model revealed an association between higher body mass index with less MMSE decline, even after controlling for demographics and comorbidities (men, β=0.0134 [SE, 0.0036]; women, β=0.0133 [SE, 0.0034]; both P<0.001). A total of 1037 men (15.3%) and 3317 women (33.1%) developed cognitive impairment. In multivariable Cox regression analyses, being obese in men (11.3% versus 18.0%; hazard ratio, 0.75; 95% confidence interval, 0.60-0.94) and women (30.1% versus 36.5%; hazard ratio, 0.82; 95% confidence interval, 0.74-0.91) was a protective factor against cognitive impairment compared with normal body mass index.

CONCLUSIONS

Higher adiposity is independently associated with slower cognitive decline in Chinese hypertensive adults.

CLINICAL TRIAL REGISTRATION

URL: http://www.clinicaltrials.gov. Unique identifier: NCT00794885 CSPPT.

Age-Related Anabolic Resistance of Myofibrillar Protein Synthesis Is Exacerbated in Obese Inactive Individuals

CONTEXT

A diminished muscle anabolic response to protein nutrition may underpin age-associated muscle loss.

OBJECTIVE

To determine how chronological and biological aging influence myofibrillar protein synthesis (MyoPS).

DESIGN

Cross-sectional comparison.

SETTING

Clinical research facility.

PARTICIPANTS

Ten older lean [OL: 71.7 ± 6 years; body mass index (BMI) ≤25 kg ⋅ m-2], 7 older obese (OO: 69.1 ± 2 years; BMI ≥30 kg ⋅ m-2), and 18 young lean (YL) individuals (25.5 ± 4 years; BMI ≤25 kg ⋅ m-2).

INTERVENTION

Skeletal muscle biopsies obtained during a primed-continuous infusion of l-[ring-13C6]-phenylalanine.

MAIN OUTCOME MEASURES

Anthropometrics, insulin resistance, inflammatory markers, habitual diet, physical activity, MyoPS rates, and fiber-type characteristics.

RESULTS

Fat mass, insulin resistance, inflammation, and type II fiber intramyocellular lipid were greater, and daily step count lower, in OO compared with YL and OL. Postprandial MyoPS rates rose above postabsorptive values by ∼81% in YL (P < 0.001), ∼38% in OL (P = 0.002, not different from YL), and ∼9% in OO (P = 0.11). Delta change in postprandial MyoPS from postabsorptive values was greater in YL compared with OL (P = 0.032) and OO (P < 0.001). Absolute postprandial MyoPS rates and delta postprandial MyoPS change were associated with step count (r2 = 0.33; P = 0.015) and leg fat mass (r2 = 0.4; P = 0.006), respectively, in older individuals. Paradoxically, lean mass was similar between groups, and muscle fiber area was greater in OO vs OL (P = 0.002).

CONCLUSION

Age-related muscle anabolic resistance is exacerbated in obese inactive individuals, with no apparent detriment to muscle mass.

Observational study of vascular dementia in the Spanish elderly population according to type 2 diabetes status: trends in incidence, characteristics and outcomes (2004-2013)

OBJECTIVES

To examine trends overtime in the incidence and in-hospital outcomes of vascular dementia (VaD) hospitalisations in patients aged 70 years or over suffering and not suffering from type 2 diabetes mellitus (T2DM) between 2004 and 2013 in Spain.

DESIGN

Retrospective study.

SETTING

Spain.

PARTICIPANTS

National hospital discharge data were used; patients aged ≥70, discharged from a hospital with VaD as a primary diagnosis, were selected.

MAIN OUTCOME MEASURES

Overall incidence, therapeutic and diagnostic procedures, comorbidities, infectious complications, duration of hospital stays and in-hospital mortality (IHM).

RESULTS

In total, 170 607 admissions for VaD (34.3% with T2DM) were identified. We found a significant upward linear trend in the incidence of VaD for men and women with and without diabetes between 2004 and 2013. The adjusted incidence was higher among people with T2DM over the study period. We found a higher incidence in men than women in all years under study. A positive association between T2DM and VaD hospitalisation was found among both men (IRR 2.14, 95% CI 2.11 to 2.16) and women (incidence rate ratio (IRR) 2.22; 95% CI 2.19 to 2.25). Pneumonia was significantly associated with a higher mortality (OR 2.59, 95% CI 2.52 to 2.67). We found that percutaneous endoscopic gastrostomy was associated with lower IHM (OR 0.37, 95% CI 0.31 to 0.45), while parenteral nutrition had the opposite effect (OR 1.29, 95% CI 1.18 to 1.41). There was no association between diabetes and higher IHM (OR 0.99, 95% CI 0.93 to 1.06). The time-trend analyses of the entire sample showed a significant reduction in mortality in patients with VaD (OR 0.98, 95% CI 0.97 to 0.99).

CONCLUSIONS

Incidence rates for VaD hospitalisations were twice as high in patients with diabetes compared with those without. Men had significantly higher incidence rates than women, regardless of diabetes status. In both groups studied, pneumonia and parenteral nutrition were associated with mortality while percutaneous endoscopic gastrostomy was associated with survival. Having diabetes was not associated with higher IHM after hospitalisation with VaD.

Obesity and its Association with Food Consumption, Diabetes Mellitus, and Acute Myocardial Infarction in the Elderly

Background

Obesity affects a large part of elderly individuals worldwide and is considered a risk predictor for the development of chronic diseases such as cardiac diseases, the leading causes of death in the elderly population.

Objective

To investigate the prevalence of obesity and associated factors, with emphasis on the occurrence of other diseases and on food consumption in elderly individuals treated at the Brazilian Unified Health System (Sistema Único de Saúde, SUS).

Methods

Cross-sectional sampling study performed in the city of Goiânia (Brazil) including elderly individuals (≥ 60 years) receiving primary care. During home visits, we performed anthropometric measurements and applied a structured, standardized, and pre-tested questionnaire assessing socioeconomic, demographic and lifestyle conditions, occurrence of diseases, and food consumption. We performed multiple Poisson regression analysis using a hierarchical model and adopting a significance level of 5%.

Results

We evaluated 418 elderly patients with a mean age of 70.7 ± 7 years. Their body mass indices had a mean value of 27.0 kg/m² and were higher in women than in men (27.4 kg/m² versus 26.1 kg/m², respectively, p = 0.017). Obesity had a prevalence of 49.0%, a risk 1.87 times higher between the ages of 60-69 years and 70-79 years, and a rate 1.4 times higher among individuals with more than four morbidities. On multivariate analysis, the factors associated with obesity were age 60-69 and 70-79 years, inadequate consumption of whole-wheat grains and adequate consumption of fruit, musculoskeletal diseases, diabetes mellitus, and acute myocardial infarction.

Conclusions

Obesity had a high prevalence in the evaluated elderly population and was associated with food consumption, musculoskeletal disease, diabetes mellitus, and acute myocardial infarction.

Obese But Fit: The Relationship of Fitness to Metabolically Healthy But Obese Status among Sexual Minority Women

PURPOSE

The purpose of this study was to describe fitness characteristics of metabolically healthy sexual minority women who are obese.

METHODS

As part of the Healthy Weight in Lesbian and Bisexual Women Initiative funded by the U.S. Office on Women's Health, one site enrolled self-identified lesbian or bisexual women age 40 and older in a randomized controlled trial that evaluated interventions to improve health. Women with waist-to-height ratio of 0.5 or greater were classified as obese. Women without diabetes or cardiovascular disease and with normal range fasting blood level measurements of glucose, triglycerides, high-density cholesterol, and blood pressure were classified as metabolically healthy but obese (MHO). Otherwise, women were classified as metabolically unhealthy obese (MUHO). Fitness measurements included predicted VO2 maximum, 1-minute heart rate recovery, and strength (single maximal leg lift and chest press). Self-reported demographic and physical activity level data were obtained by standardized questionnaires.

RESULTS

Of the 53 participants who completed the eligibility screener in Columbia, Missouri, 47 were enrolled in the study (89% participation proportion) with 45 categorized as obese. Approximately one-third (38%) were MHO. The majority of MHO and MUHO participants ranked poor or very poor on a composite fitness score that included measures of strength, flexibility, and aerobic fitness (75.0% and 77.8%, respectively). In the logistic regression models, better 1-minute heart rate recovery after peak exercise performance was significantly associated with MHO individuals (odds ratio, 2.92; 95% CI, 1.13-9.10) compared with MUHO. No other fitness measure was significantly different between the two groups.

CONCLUSION

Consistent with other studies, we identified more than one-third of our obese sexual minority women as MHO. Fitness measures may be potential predictors of MHO status because one measure, heart rate recovery, was significantly associated with MHO status. With the population prevalence of obesity high and even higher among lesbian or bisexual women, sexual minority women are an ideal population for a longitudinal study to better understand MHO characteristics.

The FTO rs9939609 polymorphism is associated with short leukocyte telomere length in nonobese individuals

The fat mass and obesity-associated (FTO) rs9939609 polymorphism have been associated with the increased metabolic risk and mortality, irrespective of obesity. The mechanism underlying this association is not known. We aimed to evaluate whether the FTO rs9939609 risk variant is independently associated with metabolic risk factors and/or leukocyte telomere length (LTL). We further aimed to investigate whether this relationship is modified by obesity status.A total of 2133 participants were recruited from the Korean Genome and Epidemiology Study. LTL was measured using the real-time quantitative polymerase chain reaction methodology. The FTO rs9939609 polymorphism was genotyped using DNA samples collected at baseline.The proportions of the TT, TA, and AA genotypes were 76.7%, 21.5%, and 1.8%, respectively, and obese subjects comprised 44.5% of the total subjects. Among the 1184 nonobese subjects, body mass index, waist circumference, and visceral fat area were higher in subjects with the FTO risk allele than in noncarriers. In contrast, only high-sensitive C-reactive protein level was associated with the FTO risk allele in the obese subjects. LTL was significantly shorter in carriers of the FTO risk allele compared with noncarriers after controlling for several confounding factors (P < .01). Of particular note, this significant association between the FTO risk allele and LTL appeared only in nonobese subjects (P = .03). Multivariate linear regression analyses identified older age, low high-density lipoprotein cholesterol level, and the presence of the FTO risk allele as independent risk factors affecting LTL. This finding was evident only in nonobese subjects.The FTO rs9939609 polymorphism is an independent risk factor for obesity and also for biological aging in the nonobese population.

The Effects of a Health Partner Program on Improving Health Status Among Overweight/Obese Individuals With and Without Prediabetes

The purpose of this study was to compare baseline health status in overweight/obese adults with and without prediabetes and to determine whether a health partner program improved health status at 1-year follow-up from 2010 to 2011. Sociodemographic information, body composition, blood work, and health status were obtained from both baseline and 1-year follow-up visit. Healthy overweight/obese participants with prediabetes were likely to self-report poorer physical functioning compared with those without prediabetes at baseline. At the 1-year follow-up visit, compared with participants without prediabetes, participants with prediabetes had the greatest improvements in physical functioning. Although participants without prediabetes had a significant improvement in mental functioning, there were no significant differences in changes in mental functioning between those with and without prediabetes. Early interventions to improve health status are important, and provider advice and preventive measures aimed at improving health status should be integrated into clinical practice.

Low body weight and clinical outcomes in acute coronary syndrome patients: results of the ACHILLES Registry

BACKGROUND

Being overweight increases the risk of cardiovascular diseases and mortality. However, among high-body-weight patients with established acute coronary syndrome (ACS) this evidence is not clear. In this scenario, a low body weight (LBW) has been proposed to confer higher prognostic risk and higher bleeding risk with new P2Y₁₂ inhibitors.

AIMS

We aimed to examine differences in mortality, catheterizations/revascularizations, antiplatelet therapy and ischemic/bleeding adverse events between ACS patients with LBW.

METHODS

This is a multicenter registry involving 1576 consecutive ACS patients (ST-elevation myocardial infarction (STEMI), non-STEMI, or unstable angina) from three tertiary institutions. Patients were divided into two groups: LBW (weight < 60 kg, n = 176) and non-LBW (weight ⩾ 60 kg, n = 1400). During 12 months follow-up, we recorded management (catheterizations/revascularizations), antiplatelet therapy, major adverse cardiovascular events (MACEs), bleeding events (BARC classification), and mortality.

RESULTS

Catheterizations (86.4% vs. 93.4%; p = 0.001) and revascularizations (64.8% vs. 76.1%; p = 0.001) were significantly lower in the LBW group. At discharge, prescription of new P2Y₁₂ inhibitors was also lower in LBW patients (24.4% vs. 37.8%; p = 0.001). After 12-month follow-up, the incidence of MACE (HR 1.61 (95% CI 1.03-2.50]; p = 0.038) and mortality (HR 2.18 (95% CI 1.33-3.58); p = 0.002) was higher in LBW patients compared with non-LBW. In contrast, there were no significant differences for bleeding events.

CONCLUSIONS

LBW in ACS patients was associated with higher incidence of MACE and mortality. In this group of patients less catheterizations and coronary revascularizations were performed. Despite there being no differences in bleeding rates, new P2Y₁₂ inhibitors were less prescribed in LBW patients.

Body-Brain Connections: The Effects of Obesity and Behavioral Interventions on Neurocognitive Aging

Obesity is a growing public health problem in the United States, particularly in middle-aged and older adults. Although the key factors leading to a population increase in body weight are still under investigation, there is evidence that certain behavioral interventions can mitigate the negative cognitive and brain ("neurocognitive") health consequences of obesity. The two primary behaviors most often targeted for weight loss are caloric intake and physical activity. These behaviors might have independent, as well as overlapping/synergistic effects on neurocognitive health. To date obesity is often described independently from behavioral interventions in regards to neurocognitive outcomes, yet there is conceptual and mechanistic overlap between these constructs. This review summarizes evidence linking obesity and modifiable behaviors, such as physical activity and diet, with brain morphology (e.g., gray and white matter volume and integrity), brain function (e.g., functional activation and connectivity), and cognitive function across the adult lifespan. In particular, we review evidence bearing on the following question: Are associations between obesity and brain health in aging adults modifiable by behavioral interventions?

Abdominal obesity and white matter microstructure in midlife

The aging U.S. population and the recent rise in the prevalence of obesity are two phenomena of great importance to public health. In addition, research suggests that midlife body mass index (BMI) is a risk factor for dementia, a particularly costly disease, in later life. BMI could influence brain health by adversely impacting cerebral white matter. Recently, greater BMI has been associated with lower white matter fractional anisotropy (FA), an index of tissue microstructure, as measured by diffusion-tensor imaging in midlife. The aim of this study was to investigate the role of abdominal obesity, the most metabolically active adipose tissue compartment, and white matter microstructure in midlife. Community dwelling participants (N = 168) between the ages of 40-62 underwent MRI scanning at 3T and a general health assessment. Inferences were made on whole brain white matter tracts using full-tensor, high-dimension normalization, and tract-based spatial statistics. Higher waist circumference was associated with higher FA, indicating more directional diffusion in several white matter tracts controlling for age, sex, triglycerides, systolic blood pressure, fasting glucose, and HDL-cholesterol. Post hoc analysis revealed that greater waist circumference was associated with lower axial diffusivity, indicating lower parallel diffusion; lower radial diffusivity, indicating lower perpendicular diffusion; and lower mean diffusivity, indicating restricted diffusion. This is the first study to report a positive relationship between obesity and FA, indicating a more complicated view of this relationship in the aging brain. Hum Brain Mapp 38:3337-3344, 2017. © 2017 Wiley Periodicals, Inc.

Skipping breakfast is detrimental for primary school children: cross-sectional analysis of determinants for targeted prevention

BACKGROUND

Skipping breakfast was found to be associated with abdominal obesity in primary school children. The aim of this research was to examine factors associated with skipping breakfast in primary school children in order to develop targeted preventive measures.

METHODS

Baseline data assessment (2010) of a cluster-randomized controlled trial for the evaluation of a school-based health promotion program in primary school children in the state of Baden-Württemberg, Germany. Anthropometric measures of 1,943 primary school children aged 7.1 ± 0.6 years (51.2% boys) were conducted according to ISAK-standards (International Standard for Anthropometric Assessment) by trained staff. Further information on the health and living conditions of the children and their parents were assessed in parental questionnaires. Generalized linear mixed regression analysis was calculated to define correlates for skipping breakfast in terms of odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

According to the final regression models, significant correlates of skipping breakfast can be divided into modifiable behavioral components (high consumption of soft drinks (OR 2.49, 95% CI 1.81; 3.43), screen media (OR 2.48, 95% CI 1.77; 3.46) and high levels of physical activity (OR 0.64, 95% CI 0.44; 0.93)) on the one hand, and more or less static socio-economic factors (migration background (OR 2.81, 95% CI 2.02; 3.91), single parenting (OR 2.13, 95% CI 1.34; 3.40), and high family education level (OR 0.42, 95% CI 0.28; 0.64)) on the other hand, and finally individual factors (female gender (OR 1.43, 95% CI 1.03; 1.99) and having a percentage of body fat at or above the 95th percentile (OR 1.47, 95% CI 1.00; 2.17)).

CONCLUSION

Targeted prevention should aim at health-related behaviors accompanying the habit of skipping breakfast. Focusing on vulnerable groups, characterized by not so easily modifiable socio-economic as well as individual factors, may improve results. Interventions should synergistically promote children's health and involve their parents in order to be successful. To reach all children and to avoid skipping breakfast, schools should offer regular breakfast at the start of a school day. Policy makers should support healthy eating habits at all times.

Lifestyle Factors and Early Clinical Outcome in Patients With Acute Stroke

Background and Purpose—

We examined the associations of individual and combined lifestyle factors with early adverse stroke outcomes.

Methods—

A total of 82 597 patients were identified from nationwide registries. Lifestyle factors at the time of stroke admission included body mass index (kg/m 2 ), smoking habits, and alcohol intake, which were grouped (healthy, moderately healthy, moderately unhealthy, and unhealthy). The associations between lifestyle and outcomes were examined using multivariable regression.

Results—

A total of 18.3% had a severe stroke, 7.8% pneumonia, 12.5% urinary tract infection, and 9.9% died within 30 days. The association between lifestyle, stroke severity, and mortality, respectively, differed according to sex. Unhealthy lifestyle was associated with lower risk of severe stroke (adjusted odds ratio [OR], 0.73; 95% confidence interval [CI], 0.63–0.84) and 30-day mortality among men (adjusted OR, 0.71; 95% CI, 0.58–0.87), but not among women (severe stroke: adjusted OR, 1.14; 95% CI, 0.85–1.55, and mortality: adjusted OR, 1.34; 95% CI, 0.90–1.99). No sex differences were found for pneumonia and urinary tract infection. Unhealthy lifestyle was not associated with a statistically significant increased risk of developing in-hospital pneumonia (adjusted OR, 1.30; 95% CI, 0.98–1.73) or urinary tract infection (adjusted OR, 0.98; 95% CI, 0.72–1.33). Underweight was associated with a higher 30-day mortality (men: adjusted OR, 1.71; 95% CI, 1.50–1.96, and women: adjusted OR, 1.46; 95% CI, 1.34–1.60).

Conclusions—

Healthy lifestyle was not associated with a lower risk of adverse stroke outcomes, in particularly among men. However, underweight may be a particular concern being associated with an increased risk of adverse outcomes among both sexes.

Association between diabetes mellitus and cirrhosis mortality: the Singapore Chinese Health Study

BACKGROUND & AIM

Diabetes mellitus has been linked to cirrhosis-related mortality in Western populations, but less is known about this relationship in Asian populations. We studied the impact of diabetes on the risk of cirrhosis mortality in a population-based cohort among Chinese in Singapore.

METHODS

We used data collected and analysed from the Singapore Chinese Health Study, a prospective community-based cohort of 63 275 subjects aged 45-74 years during enrolment between 1993 and 1998. Information on diet, lifestyle and medical history was collected via structured questionnaire. Mortality cases from cirrhosis in the cohort were identified via linkage with nationwide death registry up to 31 December 2014. Cox proportional regression models were used to estimate the associations with adjustment for risk factors of cirrhosis.

RESULTS

After a mean follow-up of 16.9 years, there were 133 deaths from cirrhosis. Diabetes was associated with an increased risk of cirrhosis mortality (hazard ratio [HR]: 2.80; 95% confidence interval [CI]: 2.04-3.83), and for both viral (HR: 2.20; 95% CI: 1.18-4.11) and non-viral hepatitis-related cirrhosis mortality (HR: 3.06; 95% CI: 2.13-4.41). The association between diabetes and non-viral hepatitis-related cirrhosis mortality was stronger among participants of body mass index (BMI) less than 23 kg/m² (HR: 7.11; 95% CI: 3.42-14.79) compared to heavier individuals (HR: 2.28; 95% CI: 1.20-4.35) (P_interaction =0.02).

CONCLUSION

Diabetes is a risk factor for cirrhosis mortality, especially for non-viral hepatitis-related cirrhosis in population with BMI considered low or normal in Asia.

Relationship between Regional Body Fat Distribution and Diabetes Mellitus: 2008 to 2010 Korean National Health and Nutrition Examination Surveys

BACKGROUND

The aim of this study was to investigate the association between regional body fat distribution, especially leg fat mass, and the prevalence of diabetes mellitus (DM) in adult populations.

METHODS

A total of 3,181 men and 3,827 postmenopausal women aged 50 years or older were analyzed based on Korea National Health and Nutrition Examination Surveys (2008 to 2010). Body compositions including muscle mass and regional fat mass were measured using dual-energy X-ray absorptiometry.

RESULTS

The odds ratios (ORs) for DM was higher with increasing truncal fat mass and arm fat mass, while it was lower with increasing leg fat mass. In a partial correlation analysis adjusted for age, leg fat mass was negatively associated with glycosylated hemoglobin in both sexes and fasting glucose in women. Leg fat mass was positively correlated with appendicular skeletal muscle mass and homeostasis model assessment of β cell. In addition, after adjusting for confounding factors, the OR for DM decreased gradually with increasing leg fat mass quartiles in both genders. When we subdivided the participants into four groups based on the median values of leg fat mass and leg muscle mass, higher leg fat mass significantly lowered the risk of DM even though they have smaller leg muscle mass in both genders (P<0.001).

CONCLUSION

The relationship between fat mass and the prevalence of DM is different according to regional body fat distribution. Higher leg fat mass was associated with a lower risk of DM in Korean populations. Maintaining leg fat mass may be important in preventing impaired glucose tolerance.