Expert Panel Report: Guidelines (2013) for the management of overweight and obesity in adults

Practical strategies to manage obesity in type 2 diabetes

The rising phenomenon of obesity, a major risk factor for the development and progression of type 2 diabetes, is a complex and multifaceted issue that requires a comprehensive and coordinated approach to be prevented and managed. Although novel pharmacological measures to combat obesity have achieved unprecedented efficacy, a healthy lifestyle remains essential for the long-term success of any therapeutic intervention. However, this requires a high level of intrinsic motivation and continued behavioural changes in the face of multiple metabolic, psychological and environmental factors promoting weight gain, particularly in the context of type 2 diabetes. This review is intended to provide practical recommendations in the context of a holistic, person-centred approach to weight management, including evidence-based and expert recommendations addressing supportive communication, shared decision-making, as well as nutritional and pharmacological therapeutic approaches to achieve sustained weight loss.

Association between insulin sensitivity and lean mass loss during weight loss

OBJECTIVE

The study objective was to assess the relationship between insulin sensitivity and changes in total lean mass (LM) and appendicular LM (ALM) during weight loss.

METHODS

Individuals were randomly assigned to either a standard or a moderately reduced carbohydrate diet for 16 weeks. Body composition was assessed using dual-energy x-ray absorptiometry and insulin sensitivity index (SI) using an intravenous glucose tolerance test. Multiple linear regression was used to determine whether baseline SI was predictive of changes in total LM and ALM.

RESULTS

Participants (n = 57; baseline BMI 32.1 ± 3.8 kg/m2) lost an average of 6.8 ± 3.2 kg of body weight (p < 0.001), with 1.5 ± 2.6 kg coming from LM (p < 0.05) and 0.5 ± 0.73 kg from ALM (p < 0.05). Multiple regression analysis demonstrated that SI was inversely associated with changes in total LM (kilograms; β = 0.481, p < 0.001), after adjusting for baseline LM, fat mass, acute insulin response to glucose, and weight loss. Similar results were seen when assessing ALM loss (β = 0.359, p < 0.05).

CONCLUSIONS

Identifying individuals with low insulin sensitivity prior to weight loss interventions may allow for a personalized approach aiming at minimizing LM loss.

Clinical practice guidelines for the management of overweight and obesity published internationally: A scoping review

With the increasing prevalence of obesity placing additional demands on healthcare systems, many jurisdictions and professional bodies have developed clinical practice guidelines to support practitioners in the management of people with overweight and obesity. This scoping review aimed to identify key features of contemporary guidelines for the clinical management of overweight and obesity. Searches of MEDLINE, Guidelines International Network's international guidelines library, and other grey literature sources identified 38 guidelines of 18 countries and one region published since 2010. Guidelines were developed by committees (n = 36, 95%) that comprised knowledgeable experts (n = 36, 95%) and were multidisciplinary (n = 33, 87%), with limited consumer representation (n = 11, 29%). Guideline documentation incorporated review questions (n = 23, 61%), systematic reviews (n = 25, 66%), evidence grading systems (n = 33, 87%), processes for reaching consensus (n = 19, 50%), and guideline review details (n = 28, 74%). Treatment approaches included in most guidelines were nutrition and physical activity (n = 38, 100%), psychology (n = 37, 97%), pharmacotherapy (n = 32, 84%), and bariatric surgery (n = 31, 82%). Most guidelines targeted populations based on age (n = 30, 79%). Guidelines contained recommendations for pregnancy (n = 12, 32%), older adults (n = 9, 24%), and people with eating disorders (n = 8, 21%). Future guidelines would benefit from involvement of consumers including groups known to be at increased risk of overweight and obesity, targeted guidance for at risk groups, and consideration of weight bias and stigma.

Preoperative dietitian-led Very Low Calorie Diet (VLCD) Clinic for adults living with obesity undergoing gynaecology, laparoscopic cholecystectomy and hernia repair procedures: a pilot parallel randomised controlled trial

Obesity can increase the risk of postoperative complications. Despite increased demand for patients living with obesity to lose weight prior to common surgical procedures, the impact of intentional weight loss on surgical outcomes is largely unknown. We aimed to conduct a pilot study to assess the feasibility of a full-scale randomised controlled trial (RCT) to examine the effect of preoperative dietitian-led Very Low Calorie Diet (VLCD) Clinic on surgical outcomes in gynaecology and general surgeries. Between August 2021 and January 2023, a convenience sample of adults living with obesity (BMI ≥ 30 kg/m2) awaiting gynaecology, laparoscopic cholecystectomy and ventral hernia repair procedures were randomised to dietitian-led VLCD (800-1000 kcal using meal replacements and allowed foods), or control (no dietary intervention), 2-12 weeks preoperatively. Primary outcome was feasibility (recruitment, adherence, safety, attendance, acceptability and quality of life (QoL)). Secondary outcomes were anthropometry and 30-d postoperative outcomes. Outcomes were analysed as intention-to-treat. Fifty-one participants were recruited (n 23 VLCD, n 28 control), mean 48 (sd 13) years, 86 % female, and mean BMI 35·8 (sd 4·6) kg/m2. Recruitment was disrupted by COVID-19, but other thresholds for feasibility were met for VLCD group: high adherence without unfavourable body composition change, high acceptability, improved pre/post QoL (22·1 ± 15 points, < 0·001), with greater reductions in weight (-5·5 kg VLCD v. -0·9 kg control, P < 0·05) waist circumference (-6·6 cm VLCD v. +0·6 control, P < 0·05) and fewer 30-d complications (n 4/21) than controls (n 8/22) (P > 0·05). The RCT study design was deemed feasible in a public hospital setting. The dietitian-led VLCD resulted in significant weight loss and waist circumference reduction compared with a control group, without unfavourable body composition change and improved QoL.

Mulberry and Hippophae-based solid beverage promotes weight loss in rats by antagonizing white adipose tissue PPARγ and FGFR1 signaling

Obesity, a multifactorial disease with many complications, has become a global epidemic. Weight management, including dietary supplementation, has been confirmed to provide relevant health benefits. However, experimental evidence and mechanistic elucidation of dietary supplements in this regard are limited. Here, the weight loss efficacy of MHP, a commercial solid beverage consisting of mulberry leaf aqueous extract and Hippophae protein peptides, was evaluated in a high-fat high-fructose (HFF) diet-induced rat model of obesity. Body component analysis and histopathologic examination confirmed that MHP was effective to facilitate weight loss and adiposity decrease. Pathway enrichment analysis with differential metabolites generated by serum metabolomic profiling suggests that PPAR signal pathway was significantly altered when the rats were challenged by HFF diet but it was rectified after MHP intervention. RNA-Seq based transcriptome data also indicates that MHP intervention rectified the alterations of white adipose tissue mRNA expressions in HFF-induced obese rats. Integrated omics reveals that the efficacy of MHP against obesogenic adipogenesis was potentially associated with its regulation of PPARγ and FGFR1 signaling pathway. Collectively, our findings suggest that MHP could improve obesity, providing an insight into the use of MHP in body weight management.

The Use of Fecal Microbiota Transplant in Overcoming and Modulating Resistance to Anti-PD-1 Therapy in Patients with Skin Cancer

While immune checkpoint inhibitors have evolved into the standard of care for advanced melanoma, 40-50% of melanoma cases progress while on therapies. The relationship between bacterium and carcinogenesis is well founded, such as in H. pylori in gastric cancers, and Fusobacterium in colorectal cancers. This interplay between dysbiosis and carcinogenesis questions whether changes in the microbiome could affect treatment. Thus, FMT may find utility in modifying the efficacy of anti-PD-1. This review aims to examine the use of FMT in treatment-resistant melanoma. A literature search was performed using the keywords "fecal microbiota transplant" and "skin cancer". Studies were reviewed for inclusion criteria and quality and in the final stage, and three studies were included. Overall objective responses were reported in 65% of patients who were able to achieve CR, and 45% who achieved PR. Clinical benefit rate of combined CR/PR with stable disease greater or equal to 6 months was 75%. Reported objective responses found durable stable disease lasting 12 months. Overall survival was 7 months, and overall PRS was 3 months. As for the evaluation of safety, many patients reported grade 1-2 FMT related AE. Only following the administration of anti-PD-1 therapy were there a grade 3 or higher AE.

Heart Rate Variability and Cognition: A Narrative Systematic Review of Longitudinal Studies

BACKGROUND

Heart rate variability (HRV) is a reliable and convenient method to assess autonomic function. Cross-sectional studies have established a link between HRV and cognition. Longitudinal studies are an emerging area of research with important clinical implications in terms of the predictive value of HRV for future cognition and in terms of the potential causal relationship between HRV and cognition. However, they have not yet been the objective of a systematic review. Therefore, the aim of this systematic review was to investigate the association between HRV and cognition in longitudinal studies.

METHODS

The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The Embase, PsycINFO and PubMed databases were searched from the earliest available date to 26 June 2023. Studies were included if they involved adult human subjects and evaluated the longitudinal association between HRV and cognition. The risk of bias was assessed with the Newcastle-Ottawa Scale for Cohort Studies. The results were presented narratively.

RESULTS

Of 14,359 records screened, 12 studies were included in this systematic review, with a total of 24,390 participants. Two thirds of the studies were published from 2020 onwards. All studies found a longitudinal relationship between HRV and cognition. There was a consistent association between higher parasympathetic nervous system (PNS) activity and better cognition, and some association between higher sympathetic nervous system activity and worse cognition. Also, higher PNS activity persistently predicted better executive functioning, while data on episodic memory and language were more scant and/or controversial.

CONCLUSIONS

Our results support the role of HRV as a biomarker of future cognition and, potentially, as a therapeutic target to improve cognition. They will need confirmation by further, more comprehensive studies also including unequivocal non-HRV sympathetic measures and meta-analyses.

A complex relationship between intuitive eating and diet quality among university students

Intuitive Eating (IE) theory posits eating in response to internal hunger, and satiety cues minimize impulses to over-consume foods. To assess this relationship, 758 university students (55% male) completed the Intuitive Eating Scale 2 (IES-2) and the Diet History Questionnaire II (DHQ). The IES-2 includes a total score and four subscale scores; unconditional permission to eat (UPE), reliance on hunger and satiety cues (RHSC), eating for physical rather than emotional reasons (EPR), and body food choice congruence (BFCC). Using multiple regression analysis, IE total was not related to diet quality. EPR (ß =0.10, p ≤ .01) and BFCC (ß =0.29, p ≤ .001) were positively related to diet quality. UPE (ß = -0.15, p ≤ .001) and RHSC (ß = -0.08, p ≤ .05) were negatively related to diet quality. This study found an antipodal relationship between the subscales of IE and diet quality among university students.

Efficacy and safety of the dual GIP and GLP-1 receptor agonist tirzepatide for weight loss: a meta-analysis of randomized controlled trials

OBJECTIVES

Tirzepatide is a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist approved for type 2 diabetes. We performed a meta-analysis to assess tirzepatide's weight reduction efficacy and safety.

METHODS

We searched PubMed, Embase, and Cochrane for randomized controlled trials published from inception to July 2022, comparing tirzepatide with placebo for the co-primary endpoints of absolute and percent change in weight. Mean difference (MD) and odds ratio (OR) were calculated for continuous and binary outcomes, respectively. Review Manager 5.4.1 and RStudio were used for the statistical analysis, and RoB-2 (Cochrane) to assess the risk of bias.

RESULTS

Of 397 search results, 6 studies (4036 participants) ranging from 12 to 72 weeks were included. Pooled analysis showed that tirzepatide 5 mg, 10 mg, and 15 mg were more effective than placebo, with MD in body weight of -7.7 kg (95% CI -11.0, -4.4; p < 0.001), -11.6 kg (95% CI -18.8, -4.3; p = 0.002), and -11.8 kg (95% CI -17.4, -6.2; p < 0.001), respectively, and MD in percent change in weight of -8.1% (95% CI -11.0, -5.2; p < 0.001), -11.9% (95% CI -18.1, -5.6; p < 0.001), and -12.4% (95% CI -17.2, -7.5; p < 0.001), respectively. Tirzepatide also reduced BMI and waist circumference. Adverse events were more common with tirzepatide with respect to nausea (OR 4.2; 95% CI 2.4, 7.5; p < 0.001), vomiting (OR 7.0; 95% CI 4.3, 11.4; p < 0.001), and diarrhea (OR 2.8; 95% CI 1.6, 4.9; p < 0.001) (15 mg dose), when compared with placebo.

CONCLUSIONS

The results support that tirzepatide leads to substantial weight reduction and constitutes a valuable therapeutic option for weight management, despite an increase in gastrointestinal symptoms.

PROTOCOL REGISTRATION

CRD42022348576.

Experimental study on stabilometric complex for terrainkur in overweight people

Overweight and obesity is a multifactorial, multisystem disease declared a global epidemic by the World Health Organization (WHO) as early as in 1997. At least 30% of the working-age population in Russia is overweight. Only the use of physical activity as an integral (basic) part of obesity treatment and maintenance of the body weight achieved in the course of treatment can achieve durable and long-lasting treatment results as well as significant changes in the body structure (fat/non-fat body weight ratio). Terrainkur (therapeutic walking) is a method of spa treatment that combines climatotherapy and physical therapy. One of the problems in physical activity in obese people is the difficulty they experience in exercising due to the impaired walking pattern caused by imbalances in the muscle chains, including pelvic region, cervical region, which reduces endurance and commitment to physical activity. The study found that the exposure group (Terrainkur) showed lower values of "total fat", "metabolic age", "basic caloric value" compared to initial results and the control group; the exposure group (Terrainkur) showed a decrease in the deviation of the centre of body axis projection from the proper axis, the percentage of non-compliance with the proper fluctuations of the foot underextension. These changes contributed to the elimination of terrainkur restrictions and, as a result, improved the patient compliance during the terrainkur exercises.

Safety and Efficacy of Fecal Microbiota Transplantation in Treatment of Inflammatory Bowel Disease in the Pediatric Population: A Systematic Review and Meta-Analysis

Background and Aims: Fecal microbiota transplantation (FMT) has been increasingly studied in the inflammatory bowel disease (IBD) population. However, most studies have focused on the adult population, and the safety and efficacy of FMT in a pediatric population is less well understood. This systematic review and meta-analysis investigates the safety and efficacy of FMT in a pediatric IBD population. Methods: A comprehensive literature search of publications published prior to 30 June 2022 was undertaken. Safety data, IBD-related outcomes, and microbiome analysis were obtained from these studies when accessible. Individual estimates of each study were pooled, and sensitivity analysis was conducted. Results: Eleven studies satisfied our eligibility criteria. The calculated pooled rate of adverse events was 29% (95% confidence interval [CI]: 15.0%, 44.0%; p < 0.001; I2 = 89.0%, Q = 94.53), and the calculated pooled rate of serious adverse events was 10% (95% confidence interval [CI]: 6.0%, 14.0%; p = 0.28; I2 = 18.0%, Q = 9.79). One month after FMT, clinical response was achieved in 20/34 (58.8%) pediatric IBD patients, clinical remission was achieved in 22/34 (64.7%), and both clinical response and remission were achieved in 15/34 (44.1%) pediatric IBD patients. Conclusions: FMT can be a safe and effective treatment in the pediatric IBD population and may demonstrate improved safety and efficacy in the pediatric population compared to the adult population. However, our results are limited by a lack of established protocol as well as long-term follow-up for FMT in a pediatric IBD population.

Beyond BMI

This review examined the origins of the concept of the BMI in the work of Quetelet in the 19th century and its subsequent adoption and use in tracking the course of the pandemic of obesity during the 20th century. In this respect, it has provided a valuable international epidemiological tool that should be retained. However, as noted in this review, the BMI is deficient in at least three ways. First, it does not measure body fat distribution, which is probably a more important guide to the risk of excess adiposity than the BMI itself. Second, it is not a very good measure of body fat, and thus its application to the diagnosis of obesity or excess adiposity in the individual patient is limited. Finally, the BMI does not provide any insights into the heterogeneity of obesity or its genetic, metabolic, physiological or psychological origins. Some of these mechanisms are traced in this review.

Evaluation and Treatment of Obesity and Its Comorbidities: 2022 Update of Clinical Practice Guidelines for Obesity by the Korean Society for the Study of Obesity

The goal of the 8th edition of the Clinical Practice Guidelines for Obesity is to help primary care physician provide safe, effective care to patients with obesity by offering evidence-based recommendations to improve the quality of treatment. The Committee for Clinical Practice Guidelines comprised individuals with multidisciplinary expertise in obesity management. A steering board of seven experts oversaw the entire project. Recommendations were developed as the answers to key questions formulated in patient/problem, intervention, comparison, outcomes (PICO) format. Guidelines underwent multi-level review and cross-checking and received endorsement from relevant scientific societies. This edition of the guidelines includes criteria for diagnosing obesity, abdominal obesity, and metabolic syndrome; evaluation of obesity and its complications; weight loss goals; and treatment options such as diet, exercise, behavioral therapy, pharmacotherapy, and bariatric and metabolic surgery for Korean people with obesity. Compared to the previous edition of the guidelines, the current edition includes five new topics to keep up with the constantly evolving field of obesity: diagnosis of obesity, obesity in women, obesity in patients with mental illness, weight maintenance after weight loss, and the use of information and communication technology-based interventions for obesity treatment. This edition of the guidelines features has improved organization, more clearly linking key questions in PICO format to recommendations and key references. We are confident that these new Clinical Practice Guidelines for Obesity will be a valuable resource for all healthcare professionals as they describe the most current and evidence-based treatment options for obesity in a well-organized format.

Obesity and type 2 diabetes mellitus: connections in epidemiology, pathogenesis, and treatments

The prevalence of obesity and diabetes mellitus (DM) has been consistently increasing worldwide. Sharing powerful genetic and environmental features in their pathogenesis, obesity amplifies the impact of genetic susceptibility and environmental factors on DM. The ectopic expansion of adipose tissue and excessive accumulation of certain nutrients and metabolites sabotage the metabolic balance via insulin resistance, dysfunctional autophagy, and microbiome-gut-brain axis, further exacerbating the dysregulation of immunometabolism through low-grade systemic inflammation, leading to an accelerated loss of functional β-cells and gradual elevation of blood glucose. Given these intricate connections, most available treatments of obesity and type 2 DM (T2DM) have a mutual effect on each other. For example, anti-obesity drugs can be anti-diabetic to some extent, and some anti-diabetic medicines, in contrast, have been shown to increase body weight, such as insulin. Meanwhile, surgical procedures, especially bariatric surgery, are more effective for both obesity and T2DM. Besides guaranteeing the availability and accessibility of all the available diagnostic and therapeutic tools, more clinical and experimental investigations on the pathogenesis of these two diseases are warranted to improve the efficacy and safety of the available and newly developed treatments.

Nutrition and Emotional Health Education: The Use of Emotional Intelligence and a Plant-Based Diet to Reduce Cardiometabolic Risk

Background

For individuals living with chronic conditions like diabetes mellitus and obesity, there is a need for sustainable behavioral strategies and physiologic tools. These tools support identifying and addressing barriers to healthy eating, reducing body mass index (BMI), and building increased physical resilience in real time.

Objective

To evaluate whether a 12-week learning management system designed to combine nutritional intervention with education and coaching on improving emotional intelligence (EI) could alter cardiometabolic outcomes.

Methods

This pre-post prospective study enrolled 37 adult volunteers with BMI greater than 25 to participate in a 12-week learning management system. Primary (BMI, systolic blood pressure, diastolic blood pressure, low-density lipoprotein [LDL], high-density lipoprotein, and fasting glucose levels) and secondary self-reported outcomes were assessed at baseline, 12 weeks, and 6 months after enrollment using Short Form-36, Emotional Quotient Inventory (EQi), and Whole Health Index (WHI). Linear mixed-effects regression models with random effect were used to estimate changes in primary and secondary outcomes. We adjusted for multiple testing using Holm step-down method.

Results

BMI and LDL were the only primary endpoints lower at program completion and 6-month follow-up compared to baseline levels (-1.63 and -17.77 mg/dL, respectively; P < .001). Secondary outcomes showing statistically significant improvement from baseline to 6-month follow-up included energy/fatigue (Short Form-36), self-regard (EQi), decision-making (EQi), impulse control (EQi), stress management (EQi), Whole Brain - Form A (WHI), Whole Food - Form C (WHI), and Whole Body - Form D (WHI).

Conclusion

This study provides preliminary evidence that lifestyle programs combining nutritional interventions and EI can have a significant impact on BMI and LDL. Our study highlights the potential importance of both nutrition and EI in programs targeting diet and lifestyle modification.

Efficacy and safety of tirzepatide in patients with type 2 diabetes: A systematic review and meta-analysis

Purpose: A systematic review and meta-analysis was conducted to combine the data available from clinical trials and evaluate the clinical efficacy and safety of tirzepatide in people with type 2 diabetes (T2D). Methods: We systematically searched the MEDLINE, Embase, Cochrane Library, and clinical trials registries (https://clinicaltrials.gov) up to 25 March 2022 for randomized controlled trials (RCTs) that compared tirzepatide with placebo or active hypoglycemic drugs in subjects with T2D. Heterogeneity was judged by the I ² value and Cochran's Q test. The randomized effects model was adopted to calculate risk ratios and weighted mean differences (WMDs). The primary outcome was the change from baseline in HbA1c levels. Secondary efficacy endpoints were fasting serum glucose (FSG), change of body weight, blood pressure, fasting lipid profiles, and safety indexes. Results: Six trials comprising 6,579 subjects (4,410 in the tirzepatide group and 2,054 in the control group) fulfilled the pre-specified criteria and were included in the study. Tirzepatide treatment resulted in reducing HbA1c (WMD: -1.07%; 95% confidence intervals [CIs]: -1.44, -0.56), FSG (WMD, -21.50 mg/dl; 95% CI: -34.44, -8.56), body weight (WMD: -7.99 kg; 95% CI -11.36, -4.62), and blood pressure and ameliorated fasting lipid profiles, without increasing hypoglycemia, either as monotherapy or an add-on therapy. Tirzepatide increased the risk of gastrointestinal adverse events mainly in add-on therapy but not in terms of pancreatitis or cholelithiasis. Furthermore, tirzepatide presented a dose-response effect on the reduction in HbA1c and body weight and increase in nausea and vomiting. Conclusion: In patients with type 2 diabetes, tirzepatide shows superior blood glucose control and weight loss performance, without an increased risk of hypoglycemia. Systematic Review Registration: (https://www.crd.york.ac.uk/PROSPERO), identifier (CRD42022319442).

Exploratory analysis of one versus two-day intermittent fasting protocols on the gut microbiome and plasma metabolome in adults with overweight/obesity

Nutritional interventions are a promising therapeutic option for addressing obesity and cardiometabolic dysfunction. One such option, intermittent fasting (IF), has emerged as a viable alternative to daily caloric restriction and may beneficially modulate body weight regulation and alter the gut microbiome (GM) and plasma metabolome. This secondary analysis of a larger, registered trial (ClinicalTrials.gov ID: NCT04327141) examined the effect of a four-week intervention comparing one vs. two-consecutive days of IF in combination with protein pacing (IF-P; 4-5 meals/day, >30% protein/day) on the GM, the plasma metabolome, and associated clinical outcomes in overweight and obese adults. Participants (n = 20) were randomly assigned to either a diet consisting of one fasting day (total of 36 h) and six low-calorie P days per week (IF1-P, n = 10) or two fasting days (60 h total) and five low-calorie P days per week (IF2-P, n = 10). The fecal microbiome, clinical outcomes, and plasma metabolome were analyzed at baseline (week 0) and after four weeks. There were no significant time or interaction effects for alpha diversity; however, baseline alpha diversity was negatively correlated with percent body fat change after the four-week intervention (p = 0.030). In addition, beta-diversity for both IF groups was altered significantly by time (p = 0.001), with no significant differences between groups. The IF1-P group had a significant increase in abundance of Ruminococcaceae Incertae Sedis and Eubacterium fissicatena group (q ≤ 0.007), while the IF2-P group had a significant increase in abundance of Ruminococcaceae Incertae Sedis and a decrease in Eubacterium ventriosum group (q ≤ 0.005). The plasma metabolite profile of IF2-P participants displayed significant increases in serine, trimethylamine oxide (TMAO), levulinic acid, 3-aminobutyric acid, citrate, isocitrate, and glucuronic acid (q ≤ 0.049) compared to IF1-P. Fecal short-chain fatty acid concentrations did not differ significantly by time or between groups (p ≥ 0.126). Interestingly, gastrointestinal symptoms were significantly reduced for the IF2-P group but not for the IF1-P group. Our results demonstrate that short-term IF modestly influenced the GM community structure and the plasma metabolome, suggesting these protocols could be viable for certain nutritional intervention strategies.

Informal caregivers' self-identified roles in facilitating health-promoting behaviours for weight management in community-dwelling care recipients living with spinal cord injury in the United States

Health providers often focus on secondary conditions and spend less time prioritising overweight/obesity care. Informal caregivers are well positioned to facilitate health-promoting behaviours of healthy eating and physical activity among community-dwelling care recipients with spinal cord injury (SCI) for prevention and management of overweight/obesity. Literature has typically focused on caregiver adjustment post-injury and burden related to their roles in secondary condition care. The novel objective of this study was to describe informal caregivers' perspectives of their roles in facilitating health-promoting weight management behaviours, healthy eating and physical activity, for care recipients with SCI. This was a qualitative study that used semi-structured interviews with informal caregivers for data collection in 2019. Braun & Clarke's established thematic phases were used for analysis. Participants included informal caregivers of individuals with SCI living in the community (n = 24). Caregivers identified eight themes to describe their role in facilitating weight management for care recipients. Themes included: (1) meal planning/shopping, (2) meal preparation/cooking, (3) using portion control, (4) serving/feeding, (5) helping the care recipient with physical activity and/or leisure activities, (6) mutually participating in weight management activities, (7) providing motivation and encouragement and (8) being an information liaison. In summary, informal caregivers have an intimate understanding of care recipients' needs and have insights on obstacles and enablers to health-promoting behaviours, making their involvement in facilitating weight management in individuals with SCI vital. Caregivers self-identified several significant roles for promoting weight management. This is especially valuable for conditions such as overweight/obesity for which prevention and treatment involve health-promoting behaviours that need consistent attention in the community setting. It is important to ensure that informal caregivers and care recipients have the information required in order to facilitate healthy eating and physical activity in persons with SCI and have opportunities for mutual dyadic participation when both partners are interested.

Preventing Obesity in Midlife Women: A Recommendation From the Women's Preventive Services Initiative

DESCRIPTION

The Women's Preventive Services Initiative (WPSI), a national coalition of women's health professional organizations and patient advocacy representatives, developed a recommendation for counseling midlife women aged 40 to 60 years with normal or overweight body mass index (BMI; 18.5 to 29.9 kg/m²) to maintain weight or limit weight gain to prevent obesity with the long-term goals of optimizing health, function, and well-being. This recommendation is intended to guide clinical practice and coverage of clinical preventive health services for the Health Resources and Services Administration and other stakeholders. Clinicians providing preventive health care to women in primary care settings are the target audience for this recommendation.

METHODS

The WPSI developed this recommendation after evaluating results of a systematic review of the effectiveness and harms of interventions to prevent weight gain and obesity in women aged 40 to 60 years without obesity. Seven randomized clinical trials including 51 638 participants and using various counseling and behavioral interventions were included. Trials indicated favorable weight changes with interventions that were statistically significantly different from control groups in 4 of 5 trials of counseling, but not in 2 trials of exercise. Few harms were reported.

RECOMMENDATION

The WPSI recommends counseling midlife women aged 40 to 60 years with normal or overweight BMI (18.5 to 29.9 kg/m²) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.

A 2.5-Year Weight Management Program Using Noom Health: Protocol for a Randomized Controlled Trial

BACKGROUND

Overweight and obesity are serious public health concerns. As the prevalence of excess weight among individuals continues to increase, there is a parallel need for inexpensive, highly accessible, and evidence-based weight loss programs.

OBJECTIVE

This weight loss trial will aim to examine the efficacy of the Noom weight loss program in comparison to a digital control after a 6-month intervention phase and a 24-month maintenance phase, with assessments continuing for 2 years beyond the intervention (to 30 months-after the baseline). The secondary outcomes include quality of life, psychosocial functioning, sleep quality, physical activity, diet, and health status. This trial will also examine the severity of obesity-related functional impairment, weight loss history, and demographic moderators, along with adherence and self-efficacy as mediators of the outcome.

METHODS

A total of 600 participants were randomized in a parallel-group, controlled trial to either Noom Healthy Weight Program (intervention) or Noom Healthy Weight Control (control) for a 6-month intervention. Both intervention and control groups include diet and exercise recommendations, educational content, daily logging capabilities, and daily weigh-in entries. The Noom Healthy Weight Program also includes a coach support for weight loss. Remote follow-up assessments of eating, physical activity, psychosocial factors, app use data, and weight will be conducted at 1, 4, 6, 12, 18, 24, and 30 months after baseline. Weight is measured at each follow-up point during a Zoom call using the participants' scales.

RESULTS

Enrollment began in March 2021 and the 6-month intervention phase ended in March 2022. Data collection for the final assessment will be completed in March 2024.

CONCLUSIONS

This study tests commercially available digital lifestyle interventions for individuals with overweight and obesity seeking weight loss support. Data obtained from the study will evaluate whether the Noom Healthy Weight Control Program can help individuals overcome weight loss, achieve long-term maintenance, adhere to lifestyle changes, and feature use barriers that are present in other traditional weight loss treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04797169; https://clinicaltrials.gov/ct2/show/NCT04797169.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/37541.

Targeting skeletal muscle mitochondrial health in obesity

Metabolic demands of skeletal muscle are substantial and are characterized normally as highly flexible and with a large dynamic range. Skeletal muscle composition (e.g., fiber type and mitochondrial content) and metabolism (e.g., capacity to switch between fatty acid and glucose substrates) are altered in obesity, with some changes proceeding and some following the development of the disease. Nonetheless, there are marked interindividual differences in skeletal muscle composition and metabolism in obesity, some of which have been associated with obesity risk and weight loss capacity. In this review, we discuss related molecular mechanisms and how current and novel treatment strategies may enhance weight loss capacity, particularly in diet-resistant obesity.

Competing paradigms of obesity pathogenesis: energy balance versus carbohydrate-insulin models

The obesity pandemic continues unabated despite a persistent public health campaign to decrease energy intake (“eat less”) and increase energy expenditure (“move more”). One explanation for this failure is that the current approach, based on the notion of energy balance, has not been adequately embraced by the public. Another possibility is that this approach rests on an erroneous paradigm. A new formulation of the energy balance model (EBM), like prior versions, considers overeating (energy intake > expenditure) the primary cause of obesity, incorporating an emphasis on “complex endocrine, metabolic, and nervous system signals” that control food intake below conscious level. This model attributes rising obesity prevalence to inexpensive, convenient, energy-dense, “ultra-processed” foods high in fat and sugar. An alternative view, the carbohydrate-insulin model (CIM), proposes that hormonal responses to highly processed carbohydrates shift energy partitioning toward deposition in adipose tissue, leaving fewer calories available for the body’s metabolic needs. Thus, increasing adiposity causes overeating to compensate for the sequestered calories. Here, we highlight robust contrasts in how the EBM and CIM view obesity pathophysiology and consider deficiencies in the EBM that impede paradigm testing and refinement. Rectifying these deficiencies should assume priority, as a constructive paradigm clash is needed to resolve long-standing scientific controversies and inform the design of new models to guide prevention and treatment. Nevertheless, public health action need not await resolution of this debate, as both models target processed carbohydrates as major drivers of obesity.

Current status of obesity treatment in Korea: based on the 2020 Korean Society for the Study of Obesity guidelines for obesity management

Background: Obesity is a complex disease, and its prevalence is gradually increasing globally. The increasing prevalence of obesity is shown to significantly affect the development of obesity-related comorbidities. This paper describes the recent updates on obesity treatment in Korea based on the 2020 Korean Society for the Study of Obesity guidelines for obesity management.Current Concepts: Accurate evaluation of obesity is important before treatment initiation. Obesity in Korean adults is defined as body mass index ≥25 kg/m2, and abdominal obesity is defined as waist circumference ≥90 cm for men and ≥85 cm for women. It is recommended that energy intake be reduced and that the degree of energy restriction be individualized based on patient characteristics and medical conditions. Guidelines recommend assessment of the exercise participation and health status before prescribing exercise therapy; aerobic exercise for at least 150 min/week or 3–5 times/week is advised to facilitate weight loss. Although nutrition and behavior therapy and increased physical activity constitute the mainstay of obesity treatment, pharmacotherapy is recommended concomitant with comprehensive lifestyle modification. Bariatric surgery should be actively considered in patients with severe obesity and in those with obesity-related comorbidities.Discussion and Conclusion: Obesity and the associated comorbidities result in an increased socioeconomic and medical burden. Multifactorial intervention using a team approach is warranted for optimal management of obesity. This guideline will benefit primary care physicians for safe and effective decision-making regarding obesity management and treatment.

Cost-effectiveness analysis of semaglutide 2.4 mg for the treatment of adult patients with overweight and obesity in the United States

BACKGROUND: The rising prevalence and associated public health burden of obesity has led to advancements in pharmaceuticals for weight management. Semaglutide 2.4 mg, an anti-obesity medication (AOM) recently approved by the US Food and Drug Administration, has demonstrated clinically relevant weight loss in its phase 3 clinical trials. Economic evaluation comparing semaglutide 2.4 mg with other available weight management therapies is essential to inform payers for decision-making. OBJECTIVES: To assess the cost-effectiveness of semaglutide 2.4 mg in the treatment of adult patients with obesity (ie, body mass index [BMI] ≥ 30) and adult patients who are overweight (ie, BMI 27-29.9) with 1 or more weight-related comorbidities from a US third-party payer perspective. METHODS: A cohort Markov model was constructed to compare semaglutide 2.4 mg with the following comparators: no treatment, diet and exercise (D&E), and 3 branded AOMs (liraglutide 3 mg, phentermine-topiramate, and naltrexone-bupropion). All AOMs, including semaglutide 2.4 mg, were assumed to be taken in conjunction with D&E. Changes in BMI, blood pressure, cholesterol level, experience of acute and chronic obesity-related complications, costs, and quality-adjusted life years (QALYs) were simulated over 30 years based on pivotal trials of the AOMs and other relevant literature. Drug and health care prices reflect 2021 standardized values. Cost-effectiveness was examined with a willingness-to-pay (WTP) threshold of $150,000 per QALY gained. Sensitivity analyses were conducted to test the robustness of the cost-effectiveness results to plausible variation in model inputs. RESULTS: In the base-case analysis, treatment with semaglutide 2.4 mg was estimated to improve QALYs by 0.138 to 0.925 and incur higher costs by $3,254 to $25,086 over the 30-year time horizon vs comparators. Semaglutide 2.4 mg is cost-effective against all comparators at the prespecified WTP threshold, with the incremental cost per QALY gained ranging from $23,556 to $144,296 per QALY gained. In the sensitivity analysis, extended maximum treatment duration, types of subsequent treatment following therapy discontinuation, and weight-rebound rates were identified as key drivers for model results. The estimated probability of semaglutide 2.4 mg being cost-effective compared with comparators ranged from 67% to 100% when varying model parameters and assumptions. CONCLUSIONS: As a long-term weight management therapy, semaglutide 2.4 mg was estimated to be cost-effective compared with no treatment, D&E alone, and all other branded AOM comparators under a WTP threshold of $150,000 per QALY gained over a 30-year time horizon. DISCLOSURES: Financial support for this research was provided by Novo Nordisk Inc. The study sponsor was involved in several aspects of the research, including the study design, the interpretation of data, the writing of the manuscript, and the decision to submit the manuscript for publication. Dr Kim and Ms Ramasamy are employees of Novo Nordisk Inc. Ms Kumar and Dr Burudpakdee were employees of Novo Nordisk Inc at the time this study was conducted. Dr Sullivan received research support from Novo Nordisk Inc for this study. Drs Wang, Song, Wu, Ms Xie, and Ms Sun are employees of Analysis Group, Inc, who received consultancy fees from Novo Nordisk Inc in connection with this study.

Fecal Microbiota Transplantation in Decompensated Cirrhosis: A Systematic Review on Safety and Efficacy

Background and Aims: Due to increasing knowledge of the “gut–liver axis”, there has been growing interest regarding the use of fecal microbiota transplant in the management of chronic liver disease. There are limited data available and current guidelines are mostly based on expert opinions. We aim to perform the first systematic review investigating safety and efficacy of fecal microbiota transplant particularly among high-risk decompensated cirrhosis patient populations. Methods: Literature search was performed using variations of the keywords “fecal microbiota transplant” and “cirrhosis” on PubMed/Medline from inception to 3 October 2021. The resulting 116 articles were independently screened by two authors. In total, 5 qualifying studies, including 2 randomized control trials and 3 retrospective case series, were found to meet established eligibility criteria and have adequate quality of evidence to be included in this review. Results: Of the total 58 qualifying patients, there were 2 deaths post fecal microbiota transplant, 1 of which could not rule out being related (1.7%). Among the remaining 56 participants, 8 serious adverse events were reported, of which 2 could not rule out being related (3.6%). The success rate of fecal microbiota transplantation in treating recurrent Clostridioides difficile infection among patients with decompensated cirrhosis was 77.8%. The success rate when used as investigational treatment for hepatic encephalopathy was 86.7%, with multiple studies reporting clinically significant improvement in encephalopathy testing scores. Conclusions: We found a marginally higher rate of deaths and serious adverse events from fecal microbiota transplant in our patient population compared with the average immunocompetent population, where it was previously found to have 0 deaths and SAE rate of 2.83%. The efficacy when used for recurrent C.difficile infection was 77.8% and 87% in the decompensated cirrhotic and general populations, respectively. Studies on efficacy in novel treatment of hepatic encephalopathy have been promising. This study concludes that fecal microbiota transplant use in decompensated cirrhosis patients should be used with caution and preferably be limited to research purposes until better data are available.

A bibliometric analysis of research on herbal medicine for obesity over the past 20 years

BACKGROUND

The aim of this study was to analyze published papers on the use of herbal medicine in obesity research over the past 20 years using bibliometric methods and present an overview of global research trends.

METHODS

English articles on herbal medicine for obesity published from 2001 to 2020 were retrieved from the Web of Science Core Collection database using the search terms "herbal" AND "obesity". Microsoft Office Excel was used to sort and analyze the statistical data. Bibliographic analysis and data visualization were performed using visualization of similarities viewer based on publication year, country of publication, journal, research area, author, affiliated institution, and keywords.

RESULTS

A total of 463 English articles were retrieved, and we observed a trend in which the number of publications on herbal medicine for obesity has gradually increased over the past 20 years. The most productive countries and research organizations in this field were Korea and Kyunghee University, respectively. Many papers have been published in research areas, such as pharmacology pharmacy and integrative complementary medicine, and the journals with the most published articles in this field were Journal of Ethnopharmacology and Evidence-Based Complementary and Alternative Medicine. The main research keywords formed 3 clusters, and keywords with the most occurrences were "obesity," "adipose-tissue," and "insulin resistance."

CONCLUSION

This study presents an overview of the global research trend of herbal medicine for obesity from the bibliographic analysis. An increased understanding of the recently changing research topics provides a new perspective on future research directions. This study may help guide the research in the field of obesity in the future.

A Systematic Review of the Efficacy and Safety of Fecal Microbiota Transplantation in the Treatment of Hepatic Encephalopathy and Clostridioides difficile Infection in Patients With Cirrhosis

The microbiome of the human gut and liver coexists by influencing the health and disease state of each system. Fecal microbiota transplantation (FMT) has recently emerged as a potential treatment for conditions associated with cirrhosis, such as hepatic encephalopathy and recurrent/refractory Clostridioides difficile infection (rCDI). We have conducted a systematic review of the safety and efficacy of FMT in treating hepatic encephalopathy and rCDI. A literature search was performed using variations of the keywords "fecal microbiota transplant" and "cirrhosis" on PubMed/MEDLINE from inception to October 3, 2021. The resulting 116 articles were independently reviewed by two authors. Eight qualifying studies were included in the systematic review. A total of 127 cirrhotic patients received FMT. Hepatic encephalopathy was evaluated by cognitive tests, such as the Psychometric Hepatic Encephalopathy Score (PHES) and EncephalApp Stroop test. Not only was there an improvement in the cognitive performance in the FMT cohort, but the improvement was also maintained throughout long-term follow-up. In the treatment of rCDI, the FMT success rate is similar between cirrhotic patients and the general population, although more than one dose may be needed in the former. The rate of serious adverse events and adverse events in the cirrhotic cohort was slightly higher than that in the general population but was low overall. We found evidence that supports the therapeutic potential and safety profile of FMT to treat hepatic encephalopathy and rCDI in cirrhotic patients. Further research will be beneficial to better understand the role of FMT in cirrhosis.

Effect of an Interdisciplinary Weight Loss and Lifestyle Intervention on Obstructive Sleep Apnea Severity: The INTERAPNEA Randomized Clinical Trial

IMPORTANCE

Obesity is the leading cause of obstructive sleep apnea (OSA); however, the effects of weight loss and lifestyle interventions on OSA and comorbidities remain uncertain.

OBJECTIVE

To evaluate the effect of an interdisciplinary weight loss and lifestyle intervention on OSA and comorbidities among adults with moderate to severe OSA and overweight or obesity.

DESIGN, SETTING, AND PARTICIPANTS

The Interdisciplinary Weight Loss and Lifestyle Intervention for OSA (INTERAPNEA) study was a parallel-group open-label randomized clinical trial conducted at a hospital-based referral center in Granada, Spain, from April 1, 2019, to October 23, 2020. The study enrolled 89 Spanish men aged 18 to 65 years with moderate to severe OSA and a body mass index (calculated as weight in kilograms divided by height in meters squared) of 25 or greater who were receiving continuous positive airway pressure (CPAP) therapy. The sole inclusion of men was based on the higher incidence and prevalence of OSA in this population, the differences in OSA phenotypes between men and women, and the known effectiveness of weight loss interventions among men vs women.

INTERVENTIONS

Participants were randomized to receive usual care (CPAP therapy) or an 8-week weight loss and lifestyle intervention involving nutritional behavior change, aerobic exercise, sleep hygiene, and alcohol and tobacco cessation combined with usual care.

MAIN OUTCOMES AND MEASURES

The primary end point was the change in the apnea-hypopnea index (AHI) from baseline to the intervention end point (8 weeks) and 6 months after intervention. Secondary end points comprised changes in other OSA sleep-related outcomes, body weight and composition, cardiometabolic risk, and health-related quality of life.

RESULTS

Among 89 men (mean [SD] age, 54.1 [8.0] years; all of Spanish ethnicity; mean [SD] AHI, 41.3 [22.2] events/h), 49 were randomized to the control group and 40 were randomized to the intervention group. The intervention group had a greater decrease in AHI (51% reduction; change, -21.2 events/h; 95% CI, -25.4 to -16.9 events/h) than the control group (change, 2.5 events/h; 95% CI, -2.0 to 6.9 events/h) at the intervention end point, with a mean between-group difference of -23.6 events/h (95% CI, -28.7 to -18.5 events/h). At 6 months after intervention, the reduction in AHI was 57% in the intervention group, with a mean between-group difference of -23.8 events/h (95% CI, -28.3 to -19.3 events/h). In the intervention group, 18 of 40 participants (45.0%) no longer required CPAP therapy at the intervention end point, and 6 of 40 participants (15.0%) attained complete OSA remission. At 6 months after intervention, 21 of 34 participants (61.8%) no longer required CPAP therapy, and complete remission of OSA was attained by 10 of 34 participants (29.4%). In the intervention vs control group, greater improvements in body weight (change, -7.1 kg [95% CI, -8.6 to -5.5 kg] vs -0.3 kg [95% CI, -1.9 to 1.4 kg]) and composition (eg, change in fat mass, -2.9 kg [95% CI, -4.5 to -1.3 kg] vs 1.4 kg [95% CI, -0.3 to 3.1 kg]), cardiometabolic risk (eg, change in blood pressure, -6.5 mm Hg [95% CI, -10.3 to -2.6 mm Hg] vs 2.2 mm Hg [95% CI, -2.1 to 6.6 mm Hg]), and health-related quality of life (eg, change in Sleep Apnea Quality of Life Index, 0.8 points [95% CI, 0.5-1.1 points] vs 0.1 points [95% CI, -0.3 to 0.4 points]) were also found at the intervention end point.

CONCLUSIONS AND RELEVANCE

In this study, an interdisciplinary weight loss and lifestyle intervention involving Spanish men with moderate to severe OSA and had overweight or obesity and were receiving CPAP therapy resulted in clinically meaningful and sustainable improvements in OSA severity and comorbidities as well as health-related quality of life. This approach may therefore be considered as a central strategy to address the substantial impact of this increasingly common sleep-disordered breathing condition.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03851653.

Resveratrol for Weight Loss in Obesity: An Assessment of Randomized Control Trial Designs in ClinicalTrials.gov

Resveratrol is a polyphenol that may improve weight loss outcomes in obese individuals. However, assessing the effectiveness of resveratrol supplementations as an appropriate intervention for weight loss in obesity across randomized control trials (RCTs) has been complicated by variability in their design. This study aims to evaluate design elements across RCTs of resveratrol interventions in obesity with weight loss as an end-point outcome, as recorded in ClinicalTrials.gov. We found discrepancies in participant inclusion criteria (sample size, age ranges, sex, BMI, medical conditions), interventional design (delivery modalities, dosages, duration) and primary outcomes measured (anthropomorphic, blood biomarkers). We identified a near three-fold variation in study sample size, two-fold variation in minimum inclusion age, five modalities of therapeutic resveratrol delivery with interventional durations ranging from two weeks to six months. Weight loss was only identified as a primary outcome in three of the seven studies evaluated. In conclusion, heterogeneity in trial design using resveratrol suggests that weight-loss-related outcomes are difficult to interpret and cross-validate. Indeed, conclusions drawn from human studies have been inconsistent, which may be attributed to study design heterogeneity including major differences in sample population, age, sex, BMI, underlying health conditions and end-point measures.

Lifestyle Modifications for Migraine Management

Migraine is a disabling disease that inflicts a heavy burden on individuals who suffer from it. Significant advances are being made in understanding the pathophysiology and treatment of the disease. The role of lifestyle modifications has become increasingly predominant. We reviewed the current and available data on the role of a healthy lifestyle in the management of migraine. Physical activity, management of obesity, a healthy diet, and a better lifestyle, such as adequate sleep and avoidance of drug abuse, significantly contribute to reducing the frequency and severity of attacks. It is important to consider these factors in the overall management strategies for migraine sufferers.

Salbutamol Increases Leg Glucose Uptake and Metabolic Rate but not Muscle Glycogen Resynthesis in Recovery From Exercise

CONTEXT

Exercise blunts the effect of beta2-agonists on peripheral glucose uptake and energy expenditure. Whether such attenuation extends into recovery is unknown.

OBJECTIVE

To examine the effect of a beta2-agonist on leg glucose uptake and metabolic rate in recovery from exercise.

METHODS

Using leg arteriovenous balance technique and analyses of thigh muscle biopsies, we investigated the effect of a beta2-agonist (24 mg of oral salbutamol) vs placebo on leg glucose, lactate, and oxygen exchange before and during quadriceps exercise, and 0.5 to 5 hours in recovery from quadriceps exercise, as well as on muscle glycogen resynthesis and activity in recovery. Twelve healthy, lean, young men participated.

RESULTS

Before exercise, leg glucose uptake was 0.42 ± 0.12 and 0.20 ± 0.02 mmol × min-1 (mean ± SD) for salbutamol and placebo (P = .06), respectively, while leg oxygen consumption was around 2-fold higher (P < .01) for salbutamol than for placebo (25 ± 3 vs 14 ± 1 mL × min-1). No treatment differences were observed in leg glucose uptake, lactate release, and oxygen consumption during exercise. But in recovery, cumulated leg glucose uptake, lactate release, and oxygen consumption was 21 mmol (95% CI 18-24, P = .018), 19 mmol (95% CI 16-23, P < .01), and 1.8 L (95% CI 1.6-2.0, P < .01) higher for salbutamol than for placebo, respectively. Muscle glycogen content was around 30% lower (P < .01) for salbutamol than for placebo in recovery, whereas no treatment differences were observed in muscle glycogen resynthesis or glycogen synthase activity.

CONCLUSION

Exercise blunts the effect of beta2-agonist salbutamol on leg glucose uptake, but this attenuation diminishes in recovery. Salbutamol increases leg lactate release in recovery, which may relate to glycolytic trafficking due to excessive myocellular glucose uptake.

Mitigating Breast Cancer Disparities by Addressing the Obesity Epidemic

Purpose of Review

Obese breast cancer patients have poorer outcomes compared to non-obese patients. The intent of this review is to discuss recent studies and analyses regarding the status of the obesity epidemic and its effect on breast cancer incidence and outcomes. Subsequently, we will introduce a program implemented at a New York City hospital to reduce the morbidity and mortality of breast cancer patients with obesity.

Recent Findings

The prevalence of obesity among adult Americans is 42%, spanning all racial and socioeconomic groups. Importantly, obesity is associated with multiple chronic diseases including cancer. Among breast cancer patients, obesity is linked to higher mortality and poorer clinical outcomes, including but not limited to distant recurrence and secondary malignancies.

Summary

Current treatment of breast cancer patients does not address the link between obesity and poorer prognosis. Here, we present a general strategy for reducing the morbidity and mortality of obese breast cancer patients by addressing the obesity epidemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12609-022-00460-4.

Radiological stent placement of post sleeve gastrectomy leak: efficacy, imaging features and post-procedure complications

Laparoscopic sleeve gastrectomy (SG) is the most commonly performed bariatric procedure. The primary and insidious early post-SG complication is the gastric leak (GL). In literature, there are many studies describing the endoscopic stent placement as treatment of GL and few studies about stent placement performed by interventional radiology under fluoroscopic guide. Our aims were to describe the radiological stent placement technique, to compare endoscopic and radiological stent placement, to illustrate normal diagnostic features and summarise the incidence of complications after stent placement, removal, and their imaging features. This was a single centre retrospective study of 595 patients who underwent SG between 2011 and 2019. Inclusion criteria: patients who developed GL after SG and treated with gastro-oesophageal stent placement by endoscopy or interventional radiology; availability of medical history and imaging studies; follow-up time after stent removal (1 year). The rates of technical success, clinical success and complications after stent placement and removal were collected and compared between the two methods of stent positioning. A total of 17/595 (2.8%) patients developed a radiologically diagnosed GL after SG. The type II-III GLs (15/17) were treated with endoscopic or radiological stent placement. 9/15 (60%/Group A) patients underwent gastro-oesophageal stenting by interventional radiology and 6/15 (40%/Group B) were treated with endoscopic stent placement. The technical and clinical success rate was 100% for both groups. Stent migration occurred in 22% and 27% for Group A and B respectively. Post-extraction stenosis was the main late complication, occurring in 22% in Group A and 0% in Group B. Gastro-esophageal stent placement performed by interventional radiologists is a valid "mini-invasive" treatment for GL. This procedure is not inferior to endoscopic positioning regarding efficacy, periprocedural and postprocedural complication rate. It's necessary to be familiar with radiological findings after stent placement and removal. Computed tomography (CT) scan is the main radiological technique to identify stent placement complications. Upper gastrointestinal (UGI) series are the first radiological procedures used to detect late complications after stent removal.

Time-Restricted Eating in Metabolic Syndrome-Focus on Blood Pressure Outcomes

PURPOSE OF THE REVIEW

Time-restricted eating (TRE) is a promising dietary intervention for weight loss and improvement of cardiometabolic risk factors. We aim to provide a critical review of blood pressure outcomes reported in clinical TRE studies in adults with metabolic syndrome, in the context of the proposed mechanisms that underlie the relationship between timing of eating and blood pressure.

RECENT FINDINGS

Clinical TRE studies report mixed results pertaining to blood pressure outcomes, likely due to significant heterogeneity in study design and TRE protocols. Mechanistically, TRE's metabolic benefits have been speculated to be mediated by alignment of meal timing with circadian regulation of metabolic processes and/or enhancement of catabolism as a result of prolonging the fasting period. TRE protocols that start and end earlier appear to have more pronounced blood pressure lowering effects. Blood pressure also tends to be lower with narrower eating windows. Concurrent weight loss is not consistently linked to blood pressure reduction, while lower insulin levels may be an important factor for blood pressure reduction. Notably, no published studies have reported 24-h blood pressure profiles or data on blood pressure variability. Blood pressure has only been examined in limited TRE studies, measured at a single time point. Given the clinical relevance of blood pressure's diurnal variability and the mechanistic evidence underlying timing of eating and blood pressure effects, more studies are needed to investigate TRE's effects on the diurnal variability of blood pressure.

Providing lifestyle advice to women with PCOS: an overview of practical issues affecting success

Polycystic Ovary Syndrome (PCOS) is a common endocrine disorder affecting up to 13 % of women. Lifestyle interventions are first-line treatments, however attrition in women with PCOS is high. This review summarises current evidence on barriers to lifestyle management in PCOS and suggested strategies for overcoming these challenges, mapped to the Capability, Opportunity, Motivation and Behaviour model.Physical capability for lifestyle changes may be impacted by altered gut hormone regulation and energy expenditure in PCOS. This may contribute to difficulties with weight management. The higher prevalence of eating disorders, disordered eating, fatigue and sleep disturbances are further barriers. Psychological capability may be reduced due psychological symptoms and lack of critical health literacy. Women with PCOS face similar challenges in terms of Opportunity to make lifestyle changes as other women of reproductive age. However, these are complicated by features more common in PCOS including body dissatisfaction. Motivation to adopt healthy lifestyles may be impacted by suboptimal risk perception and intrinsic motivation.To address these barriers, screening for and management of eating disorders, disordered eating, depression, and Obstructive Sleep Apnoea should be undertaken as per international evidence-based guidelines. A weight-neutral approach may be appropriate with disordered eating. Building capability among health professionals to better partner with women with PCOS on their management is essential in addressing health literacy gaps. Behavioural strategies that target risk perception and build intrinsic motivation should be utilised. More research is required to understand optimal self-management strategies, risk perception, energy homeostasis and overcoming attrition in women with PCOS.

The Relationship Between Weight Loss Outcomes and Engagement in a Mobile Behavioral Change Intervention: Retrospective Analysis

Background

There is large variance in weight loss outcomes of digital behavior change interventions (DBCIs). It has been suggested that different patterns of engagement in the program could be responsible for this variance in outcomes. Previous studies have found that the amount of engagement on DBCIs, such as the number of meals logged or articles read, is positively associated with weight loss.

Objective

This retrospective study extends previous research by observing how important weight loss outcomes (high weight loss: 10% or greater body weight loss; moderate weight loss: between 5% to 10%; stable weight: 0 plus or minus 1%) are associated with engagement on a publicly available mobile DBCI (Noom) from 9 to 52 weeks.

Methods

Engagement and weight data for eligible participants (N=11,252) were extracted from the Noom database. Engagement measures included the number of articles read, meals logged, steps recorded, messages to coach, exercise logged, weigh-ins, and days with 1 meal logged per week. Weight was self-reported on the program. Multiple linear regressions examined how weight loss outcome (moderate and high vs stable) was associated with each engagement measure across 3 study time periods: 9-16 weeks, 17-32 weeks, and 33-52 weeks.

Results

At 9-16 weeks, among the 11,252 participants, 2594 (23.05%) had stable weight, 6440 (57.23%) had moderate weight loss, and 2218 (19.71%) had high weight loss. By 33-52 weeks, 525 (18.21%) had stable weight, 1214 (42.11%) had moderate weight loss, and 1144 (39.68%) had high weight loss. Regression results showed that moderate weight loss and high weight loss outcomes were associated with all engagement measures to a significantly greater degree than was stable weight (all P values <.001). These differences held across all time periods with the exception of exercise for the moderate weight loss category at 1 time period of 33-52 weeks. Exercise logging increased from 9 to 52 weeks regardless of the weight loss group.

Conclusions

Our results suggest that these clinically important weight loss outcomes are related to the number of articles read, meals logged, steps recorded, messages to coach, exercise logged, weigh-ins, and days with 1 meal logged per week both in the short-term and long-term (ie, 1 year) on Noom. This provides valuable data on engagement patterns over time on a self-directed mobile DBCI, can help inform how interventions tailor recommendations for engagement depending on how much weight individuals have lost, and raises important questions for future research on engagement in DBCIs.

Effects of Continuous Yoga on Body Composition in Obese Adolescents

Overweight/obesity is a pressing international health concern, and conventional treatments demonstrate poor long-term efficacy. Several studies have shown that yoga can control risk factors for cardiovascular disease, obesity, and psychosocial stress. The present study aimed to assess the effect of continuous yoga (asanas, pranayama, and Surya Namaskar yoga) on body composition in overweight participants. Forty adolescents with obesity were enrolled in this study. The study was conceived as a prospective, single-center, single-blinded randomized controlled trial. The participants were divided into 2 groups: the intervention group (n = 20), which undertook a continuous yoga practice, and the control group (n = 20). Body composition, including body weight (BW), body mass index (BMI), body fat mass (BFM), and muscle mass, was evaluated using tetrapolar bioelectrical impedance (BIA). Our results showed that the mean BMI and BFM of the yoga intervention group were significantly decreased at week 8 and week 12. The muscle mass of the yoga group continued to improve at a rate of 0.515 per week, which was statistically significant. In conclusion, a continuous yoga practice had a tendency to decrease BMI and BFM and increase muscle mass. These findings demonstrate intervention effectiveness similar to that observed in other clinical research and indicate that continuous yoga practice may be used as an alternative therapy for obesity prevention and health promotion in adolescents with obesity.

Exposure to Vicarious Social Defeat Stress and Western-Style Diets During Adolescence Leads to Physiological Dysregulation, Decreases in Reward Sensitivity, and Reduced Antidepressant Efficacy in Adulthood

A dramatic increase in the prevalence of major depression and diet-related disorders in adolescents has been observed over several decades, yet the mechanisms underlying this comorbidity have only recently begun to be elucidated. Exposure to western-style diet (WSD), high in both fats (45% kcal) and carbohydrates (35% kcal): e.g., high fat diet (HFD), has been linked to the development of metabolic syndrome-like symptoms and behavioral dysregulation in rodents, as similarly observed in the human condition. Because adolescence is a developmental period highlighted by vulnerability to both stress and poor diet, understanding the mechanism(s) underlying the combined negative effects of WSDs and stress on mood and reward regulation is critical. To this end, adolescent male C57 mice were exposed to vicarious social defeat stress (VSDS), a stress paradigm capable of separating physical (PS) versus psychological/emotional (ES) stress, followed by normal chow (NC), HFD, or a separate control diet high in carbohydrates (same sucrose content as HFD) and low in fat (LFD), while measuring body weight and food intake. Non-stressed control mice exposed to 5 weeks of NC or HFD showed no significant differences in body weight or social interaction. Mice exposed to VSDS (both ES and PS) gain weight rapidly 1 week after initiation of HFD, with the ES-exposed mice showing significantly higher weight gain as compared to the HFD-exposed control mice. These mice also exhibited a reduction in saccharin preference, indicative of anhedonic-like behavior. To further delineate whether high fat was the major contributing factor to these deficits, LFD was introduced. The mice in the VSDS + HFD gained weight more rapidly than the VSDS + LFD group, and though the LFD-exposed mice did not gain weight as rapidly as the HFD-exposed mice, both the VSDS + LFD- and VSDS + HFD-exposed mice exhibited attenuated response to the antidepressant fluoxetine. These data show that diets high in both fats and carbohydrates are responsible for rapid weight gain and reduced reward sensitivity; and that while consumption of diet high in carbohydrate and low in fat does not lead to rapid weight gain, both HFD and LFD exposure after stress leads to reduced responsiveness to antidepressant treatment.

[Nutraceutical correction in the complex non-drug treatment of metabolic syndrome]

The use of complex non-drug technologies at the stage of rehabilitation of metabolic syndrome (MS) includes multifactorial correction of its main manifestations: abdominal obesity, insulin resistance, arterial hypertension and dyslipidemia. A prospective randomized study on the use of low-calorie diet (LCD) and nutraceutical correction of the nutritional status of patients with MS was carried out.

OBJECTIVE

To study the effect of a non-drug complex including LCD, physical exercises, as well as correction of the gut microbiome and hepatic protection in relation to reduction of visceral fat volume in abdominal obesity and the dynamics of lipid and carbohydrate metabolism hormones in metabolic syndrome.

MATERIAL AND METHODS

120 patients with MS were randomized into 2 groups: Group 1 received LCD, physical exercises in the gym, and physical activity like daily walking up to 3-5 km/day. Group 2 received LCD, physical exercises in the gym, physical activity like daily walking up to 3-5 km/day, as well as nutraceutical correction of increased appetite, gut probiotic composition, hepatic protection. The treatment duration was 4 weeks. Anthropometric methods in order to control the body weight, waist and hip circumferences and bioimpedansometry were used.

RESULTS

As a treatment result, patients in group 1 represented a reduction in body weight, lean and active cell mass, a decrease in musculoskeletal mass and a decrease in total fluid due to extracellular fluid. A decrease in total cholesterol and blood triglyceride fraction was noted. Leptin decreased by 13.96%. Patients of the 2^nd group represented a decrease in body weight, fat mass, lean mass, total fluid and extracellular fluid. There was a statistically significant increase in active cell mass, skeletal muscle mass. There was a decrease in total cholesterol, triglycerides and transaminases. Due to weight loss and fat mass reduction a decrease in leptin expression by 29.85% and decrease in blood insulin levels by 11.2% were noted.

CONCLUSION

Thus, LCD accompanied by nutraceutical correction of the gut microbiota and hepatic protection can be effectively used in combination with physical training in order to reduce the fat mass without pre-sarcopenia development that was confirmed by positive dynamics of volume indices, bioimpedance measurements and reduction in leptin and insulin expression.

Obesity paradox and heart failure

BACKGROUND

There is scientific consensus that obesity increases the risk of cardiovascular diseases (CVD), including heart failure (HF). However, in CVD, many studies observed greater survival in overweight or class 1 obesity individuals. This counterintuitive observation was termed "obesity paradox" (OP).

OBJECTIVE AND METHODS

This article is a narrative overview of the relationship between OP and CVD, particularly HF. The sources used were MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from 2001 to 31 May 2020, exception for a 1983 work of historical importance. Studies reporting association and prognostic impact of obesity in HF and the impact of body composition on cardiac structure and myocardial function in obesity were also included in this review. In addition, we examined references from the retrieved articles and explored several related websites. Ultimately, we chose 79 relevant documents. Fifty-three were specifically focused on OP and HF.

RESULTS

In this review, we made a summary of the evidence coming from a series of studies investigating OP. Many of these studies do not take into consideration or underestimate some of the more important morpho-functional variables of patients suffering from HF: among these, body composition and visceral adiposity, sarcopenic obesity, muscle fitness (MF), and cardiorespiratory fitness (CRF). A high body mass index (BMI) represents a risk factor for HF, but it also seems to exert a protective effect under certain circumstances. Fat distribution, lean mass, and cardio fitness could play an essential role in determining the observed differences in the HF population.

CONCLUSION

BMI does not distinguish between the metabolically healthy and metabolically unhealthy obesity. The obesity impact on morbidity and premature mortality can be underestimated and, therefore, may lead to incorrect clinical courses.

LEVEL OF EVIDENCE

Level V, Narrative review.

Physical activity motives, barriers, and preferences in people with obesity: A systematic review

Background

Although the benefits of physical activity (PA) are well known, physical inactivity is highly prevalent among people with obesity. The objective of this systematic review was to i) appraise knowledge on PA motives, barriers, and preferences in individuals with obesity, and ii) quantify the most frequently reported PA motives, barriers and preferences in this population.

Methods

Six databases (Pubmed, CINAHL, Psyarticle, SportDiscus, Web of science and Proquest) were searched by independent reviewers to identify relevant quantitative or qualitative articles reporting PA motives, barriers or preferences in adults with body mass index ≥ 30 kg/m² (last searched in June 2020). Risk of bias for each study was assessed by two independent reviewers with the Mixed Methods Appraisal Tool (MMAT).

Results

From 5,899 papers identified, a total of 27 studies, 14 quantitative, 10 qualitative and 3 mixed studies were included. About 30% of studies have a MMAT score below 50% (k = 8). The three most reported PA motives in people with obesity were weight management, energy/physical fitness, and social support. The three most common PA barriers were lack of self-discipline/motivation, pain or physical discomfort, and lack of time. Based on the only 4 studies available, walking seems to be the preferred mode of PA in people with obesity.

Conclusions

Weight management, lack of motivation and pain are key PA motives and barriers in people with obesity, and should be addressed in future interventions to facilitate PA initiation and maintenance. Further research is needed to investigate the PA preferences of people with obesity.

2020 Korean Society for the Study of Obesity Guidelines for the Management of Obesity in Korea

Obesity is a prevalent and complex disease. The prevalence of obesity in Korea increased from 29.7% in 2010 to 35.7% in 2018, with the prevalence of abdominal obesity being 23.8% in 2018. Obesity contributes to medical costs and socioeconomic burden due to associated comorbidities. The treatment and management of obesity is changing based on new clinical evidence. The 2020 Korean Society for the Study of Obesity Guideline for the Management of Obesity in Korea summarizes evidence-based recommendations and treatment guidelines.

Nutrition in Physical Therapist Practice: Tools and Strategies to Act Now

It has been established that physical therapist practice includes screening for and providing information on diet and nutrition to patients, clients, and the community. Yet, an overwhelming amount of often contradictory diet and nutrition information poses a challenge for physical therapists to identify and maintain knowledge that they can rely on to screen for and discuss these topics with their patients, clients, and community members. The purposes of this perspective paper are to summarize the best known screening tools for general health, diet, and nutrition; provide intervention strategies that can be used to support behavior change related to diet and nutrition; and identify the most relevant resources and approaches from which physical therapist clinicians can build skill in addressing the nutritional needs of patients, clients, and the community.

The lifecycle of skeletal muscle mitochondria in obesity

Skeletal muscle possesses dramatic metabolic plasticity that allows for the rapid adaptation in cellular energy transduction to meet the demands of the organism. Obesity elicits changes in skeletal muscle structure and function, resulting in the accumulation of intramuscular lipids. The accumulation of intramuscular lipids in obesity is associated with impaired skeletal muscle mitochondrial content and function. Mitochondria exist as a dynamic network that is regulated by the processes of biogenesis, fusion, fission, and mitophagy. In this review, we outline adaptations in molecular pathways that regulate mitochondrial structure and function in obesity. We highlight the emerging role of dysregulated skeletal muscle macroautophagy and mitochondrial turnover in obesity. Future research should further elucidate the role of mitophagy in observed reductions in mitochondrial content and function during obesity.

Health provider identified barriers and facilitators to weight management for individuals with spinal cord injury

Study Design:

Qualitative descriptive study using semi-structured interviews

Objective:

The purpose of this study was to examine the barriers and facilitators of weight management in individuals with spinal cord injury (SCI) from the perspective of SCI health care providers.

Setting:

Veterans Health Administration and Midwest Regional SCI Care Systems

Methods:

Health care providers (n=25) who care for individuals with SCI completed semi-structured interviews. Thematic analysis methodology was used to identify emergent themes around barriers and facilitators to weight management in SCI.

Results:

Sixteen subthemes emerged for barriers and 7 subthemes emerged for facilitators for weight management in SCI. Barriers included individual-level factors (e.g., physical ability/mobility limitations, lack of interest, psychological obstacles, lack of knowledge, poor dietary strategies), socio-environmental factors (e.g., challenges with family support, lack of access to weight management resources, dependency on others, difficulties obtaining weight measurement), and organizational factors (e.g., lack of integration/ inconsistent weight management support from healthcare systems, pushing calorie intake early post-injury). Facilitators included individual-level factors (e.g., motivation, education/knowledge, participation in exercise and physical activity) and socio-environmental factors (e.g., positive support network, access to/use of healthy dietary strategies, access to exercise facilities/adaptive equipment, participating in weight management with others).

Conclusions:

Healthcare providers identified individual-level, socio-environmental, and organizational barriers and facilitators that influence weight management efforts in individuals with SCI. Future weight management resources and programs should consider addressing common barriers identified by healthcare providers, individuals with SCI, and their caregivers, and develop strategies to promote facilitators to enhance weight management in this population.

Dietary interventions for obesity: clinical and mechanistic findings

Dietary modification is central to obesity treatment. Weight loss diets are available that include various permutations of energy restriction, macronutrients, foods, and dietary intake patterns. Caloric restriction is the common pathway for weight reduction, but different diets may induce weight loss by varied additional mechanisms, including by facilitating dietary adherence. This narrative Review of meta-analyses and select clinical trials found that lower-calorie diets, compared with higher-calorie regimens, reliably induced larger short-term (<6 months) weight losses, with deterioration of this benefit over the long term (>12 months). Few significant long-term differences in weight loss were observed for diets of varying macronutrient composition, although some regimens were found to have short-term advantages (e.g., low carbohydrate versus low fat). Progress in improving dietary adherence, which is critical to both short- and long-term weight loss, could result from greater efforts to identify behavioral and metabolic phenotypes among dieters.

Obesity and Male Reproduction; Placing the Western Diet in Context

There is mounting evidence that obesity has negative repercussions for reproductive physiology in males. Much of this evidence has accumulated from rodent studies employing diets high in fat and sugar ("high fat" or "western" diets). While excessive fats and carbohydrates have long been considered major determinants of diet induced obesity, a growing body of research suggests that the relationships between diet composition and obesity are more complex than originally thought, involving interactions between dietary macronutrients. However, rodent dietary models have yet to evolve to capture this, instead relying heavily on elevated levels of a single macronutrient. While this approach has highlighted important effects of obesity on male reproduction, it does not allow for interpretation of the complex, interacting effects of dietary protein, carbohydrate and fat. Further, the single nutrient approach limits the ability to draw conclusions about which diets best support reproductive function. Nutritional Geometry offers an alternative approach, assessing outcomes of interest over an extended range of dietary macronutrient compositions. This review explores the practical application of Nutritional Geometry to study the effects of dietary macronutrient balance on male reproduction, including experimental considerations specific to studies of diet and reproductive physiology. Finally, this review discusses the promising use of Nutritional Geometry in the development of evidence-based pre-conception nutritional guidance for men.

Lipid-Lowering Effects of Concurrent Training and Green Tea Consumption in Overweight Women

Background

Exercise conducted simultaneously with the consumption of herbal supplements is one of the suggested methods for controlling obesity and its complications. The present study sought to investigate the lipid-lowering effects of concurrent training and green tea (GT) consumption in overweight women.

Methods

In this quasi-experimental study, 40 overweight women were selected and stratified into four groups: control (C), GT, concurrent training+placebo (TP), and concurrent training+GT (three tablets containing 500 mg of GT per week; T+GT) groups. Both the TP and T+GT groups performed exercise three sessions per week for 8 weeks. Fasting blood samples were collected before and 48 hours after the last training session.

Results

Low-density lipoprotein cholesterol levels in the T+GT (P=0.03) and TP (P=0.001) groups were significantly decreased relative to in the GT group and were significantly decreased in the T+GT group relative to in the TP group (P=0.001). Meanwhile, high-density lipoprotein cholesterol levels in the T+GT group were significantly increased as compared with in the GT (P=0.01), TP (P=0.03), and C (P=0.04) groups. Finally, total cholesterol levels in the T+GT group were decreased significantly as compared with in the TP, GT, and C groups (P=0.001) and triglyceride levels in the T+GT, TP, and GT groups were significantly increased as compared with in the C group (P=0.001).

Conclusion

Exercise performed simultaneously with GT consumption in comparison with either alone has a greater effect on improving the lipid profile in overweight women.