Very severely obese patients have a high prevalence of type 2 diabetes mellitus and cardiovascular disease

Postprandial Metabolite Profiles and Risk of Prediabetes in Young People: A Longitudinal Multicohort Study

OBJECTIVE

Prediabetes in young people is an emerging epidemic that disproportionately impacts Hispanic populations. We aimed to develop a metabolite-based prediction model for prediabetes in young people with overweight/obesity at risk for type 2 diabetes.

RESEARCH DESIGN AND METHODS

In independent, prospective cohorts of Hispanic youth (discovery; n = 143 without baseline prediabetes) and predominately Hispanic young adults (validation; n = 56 without baseline prediabetes), we assessed prediabetes via 2-h oral glucose tolerance tests. Baseline metabolite levels were measured in plasma from a 2-h postglucose challenge. In the discovery cohort, least absolute shrinkage and selection operator regression with a stability selection procedure was used to identify robust predictive metabolites for prediabetes. Predictive performance was evaluated in the discovery and validation cohorts using logistic regression.

RESULTS

Two metabolites (allylphenol sulfate and caprylic acid) were found to predict prediabetes beyond known risk factors, including sex, BMI, age, ethnicity, fasting/2-h glucose, total cholesterol, and triglycerides. In the discovery cohort, the area under the receiver operator characteristic curve (AUC) of the model with metabolites and known risk factors was 0.80 (95% CI 0.72-0.87), which was higher than the risk factor-only model (AUC 0.63 [0.53-0.73]; P = 0.001). When the predictive models developed in the discovery cohort were applied to the replication cohort, the model with metabolites and risk factors predicted prediabetes more accurately (AUC 0.70 [95% CI 40.55-0.86]) than the same model without metabolites (AUC 0.62 [0.46-0.79]).

CONCLUSIONS

Metabolite profiles may help improve prediabetes prediction compared with traditional risk factors. Findings suggest that medium-chain fatty acids and phytochemicals are early indicators of prediabetes in high-risk youth.

Increased circulating FGF21 level predicts the burden of metabolic demands and risk of vascular diseases in adults with type 2 diabetes

OBJECTIVES

Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder characterized by chronic hyperglycemia and metabolic stress, involved in the stepwise development of cardiovascular complications. Fibroblast growth factor 21 (FGF21) is a novel hepatokine involved in regulating glucose and lipid metabolism, and has been linked to the prediction, treatment, and improvement of prognosis in multiple cardiovascular diseases (CVDs). The aim of this study is to explore the relationship between FGF21 levels and vascular diseases (VDs) including carotid atherosclerosis (CAS) and hypertension (HP) in patients with T2DM.

METHODS

Baseline serum FGF21 was determined in a cross-sectional study of 701 patients with T2DM and 258 healthy control.

RESULTS

The morbidity of CAS was increased in T2DM patients with HP as compared with those without (p < 0.001). The average serum FGF21 level of healthy was [123.9 (67.2-219.3)]. Baseline FGF21 was significantly higher in those who developed CAS or HP than in those who did not [305.9 (177.2-508.4) vs. 197.2 (129.7-308.3) pg/mL, p < 0.001]. In addition, an elevated serum FGF21 was observed in T2DM patients with HP and CAS than that of T2DM patients with CAS or HP [550.5 (312.6-711.3) vs. 305.9 pg/mL, p < 0.001]. Serum FGF21 levels were positively correlated with body mass index and carotid intima media thicknes (p < 0.05), the association remained significant after adjusting for age and T2DM duration. Furthermore, the multinomial logistic regression showed that serum FGF21 was independently associated with CAS and HP in patients with T2DM after adjustment for demographic and traditional VDs risk factors (p < 0.001).

CONCLUSIONS

Baseline FGF21 is elevated in VDs during diabetes, changes of serum FGF21 levels were appropriately matched to metabolic stress. FGF21can be used as an independent predictor for diagnosing VDs and predicting prognosis.

The role of diabetes severity scores in predicting disease remission in patients with BMI > 50 kg/m2 undergoing Roux-En-Y gastric bypass and sleeve gastrectomy: a multi-centered study

BACKGROUND

Roux-En-Y gastric bypass (RYGB) and Sleeve Gastrectomy (SG) have shown to be two of the most effective interventions to enhance weight loss and associated type-2 diabetes mellitus (T2DM) remission. However, a significant number of patients, particularly with BMI ≥ 50 kg/m2, do not achieve T2DM remission after bariatric surgeries. The individualized metabolic surgery (IMS) and Robert et al. scores are two scores that characterize T2DM severity and predict disease remission after bariatric surgeries. We aim to assess the validity of these scores in predicting T2DM remission in our cohort of patients with BMI ≥ 50 kg/m2 with long-term follow-up.

METHODS

This is a retrospective cohort study of all patients with T2DM, have a BMI ≥ 50 kg/m2, and underwent RYGB or SG in two different US bariatric surgery centers of excellence. The study endpoints included validating the IMS and Robert et al. scores in our cohort and evaluating the presence of any significant differences between RYGB and SG in terms of T2DM remission predicted by each of these scores. Data are presented as mean (standard deviation).

RESULTS

A total of 160 patients (66.3% females, mean age 51.0 [11.8] years) had IMS score and 238 patients (66.4% females, age 50.8 [11.4] years) had Robert et al. score data. Both scores predicted T2DM remission in our patients with BMI ≥ 50 kg/m2 with ROC AUC 0.79 for the IMS score and 0.83 for Robert et al. score. Patients with lower IMS scores and higher Robert et al. scores had higher T2DM remission rates. RYGB and SG had similar T2DM remission rates over the long-term follow-up.

CONCLUSION

We demonstrate the ability of the IMS and Robert et al. scores to predict T2DM remission in patients with BMI ≥ 50 kg/m2. T2DM remission was shown to decrease with more severe IMS scores and lower Robert et al. scores.

Periodontitis in obese adults with and without metabolic syndrome: a cross-sectional study

BACKGROUND

Epidemiological studies support an association between obesity, metabolic syndrome (MetS), and periodontitis. Still, understanding of the effects of low-grade inflammation in obese subjects on periodontitis and influence of MetS remains incomplete. The aims of this cross-sectional study were to explore the association between obesity related variables and periodontitis, and assess if MetS is a risk indicator for periodontitis in a sample of obese adults.

METHODS

The study sample comprised 52 adults with a body mass index (BMI) of ≥ 30 kg/m2 referred for obesity therapy at the Obesity Centre at Haukeland University Hospital (HUH), Bergen, Norway. The subjects had prior to enrolment completed a 5-month lifestyle intervention course as part of a 2-year managing program. According to the revised National Cholesterol Education Program Adult Treatment Panel III (NCEP ATP III) classification of MetS, 38 subjects were recruited to the MetS group and 14 subjects to the non-MetS group. Medical data including peripheral blood samples were obtained from records at HUH at the time of enrolment. Probing depth, clinical attachment level, tooth mobility, furcation involvement, bleeding on probing (BoP) were recorded and intraoral bitewings evaluated at a full-mouth periodontal examination. Associations between risk variables for obesity/MetS and periodontitis were explored using linear and logistic regression models.

RESULTS

In the present sample 79% of the subjects were diagnosed with periodontitis. The prevalence of stage III/IV periodontitis was 42.9% in the non-MetS group vs. 36.8% in the MetS group (p = 0.200). In the non-MetS group 29.8% of the sites displayed BoP vs. 23.5% in the MetS group (p = 0.048). For stage III/IV periodontitis, the effect of age appeared to be significant for obesity related variables and MetS (p = 0.006, p = 0.002, respectively). None of the other analyses showed significant association with the outcome variables.

CONCLUSION

In the present sample of obese subjects, periodontitis occurred independently of MetS. Reaching a certain BMI level, suggested association between MetS and periodontitis might be non-significant due to the dominating impact of obesity related variables undermining the effect of other systemic factors.

TRIAL REGISTRATION

The principal clinical trial, entitled "Obesity and Oral Diseases", was prospectively registered in ClinicalTrials.gov with registration NCT04602572 (20.10.2020).

Diabetes Mellitus Remission in Patients with BMI > 50 kg/m2 after Bariatric Surgeries: A Real-World Multi-Centered Study

INTRODUCTION

Type 2 diabetes mellitus (T2DM) is a common comorbidity associated with obesity, particularly in patients with body mass index (BMI) ≥ 50 kg/m². We aim to study real-world T2DM long-term remission in patients with BMI ≥ 50 kg/m² following Roux-En-Y gastric bypass (RYGB) or sleeve gastrectomy (SG).

METHODS

This was a retrospective study of the electronic medical records of all patients with BMI ≥ 50 kg/m², T2DM, and have undergone RYGB or SG at three tertiary referral centers in the United States. We assessed the change in T2DM outcomes after bariatric surgery using a matched paired t-test for continuous variables and Bowker and Pearson test for categorical variables. We performed a multivariate logistic regression to determine predictors of remission.

RESULTS

A total of 279 patients with T2DM (65% females, mean age 51.0 ± 11.7 years, 89% white, BMI 56.6 ± 5.9 kg/m²) were analyzed. Long-term T2DM remission (≥ 5 years) was demonstrated in 47% of patients. The duration of T2DM (p < 0.0001), number of T2DM medications (p = 0.003) and weight loss (p = 0.048) were the only independent factors for long-term T2DM remission.

CONCLUSIONS

In this cohort of patients with BMI ≥ 50 kg/m², RYGB and SG demonstrated significant and similar long-term T2DM remission rates and weight loss outcomes.

Outcome of Sleeve Gastrectomy Versus Roux-en-Y Gastric Bypass for Patients with Super Obesity (Body Mass Index > 50 kg/m2)

PURPOSE

With increasing BMI, the complexity of treating patients with obesity rises. The focus of this study is to investigate the effects of sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) on perioperative morbidity and remission of comorbidities at 3 years in patients with a BMI > 50 kg/m².

MATERIALS AND METHODS

A retrospective multicenter analysis of a prospectively maintained database was performed to enroll patients with a 3-year follow-up after SG or RYGB between 2005 and 2019 and a BMI of > 50 kg/m² preoperatively. Patients' BMI and comorbidity status were recorded preoperatively.

RESULTS

We analyzed data from 2939 patients who had at least a preoperative BMI > 50 kg/m². A total of 1278 patients underwent RYGB surgery, and 1661 underwent SG. The distribution of sex, BMI, hypertension, reflux, and sleep apnea was significant between the two groups. Three years after surgery, the percent excess weight loss (%EWL) was 62.21% in RYGB and 55.87% in SG (p < 0.001). The change in hypertension (p < 0.001) and reflux (p < 0.001) was significantly in favor of RYGB. The change in diabetes mellitus was not significant between the two groups (p > 5%). There was a minimal difference in sleep apnea in favor of SG (p < 0.001). Mortality and overall complication rates were not significant in either group.

CONCLUSION

Both procedures positively affected comorbidities, BMI, and %EWL in patients with super obesity 3 years after surgery. In some categories, RYGB was better than SG. Nevertheless, the decision between the two methods remains a matter of the surgeon's experience and the patient's general condition.

Five Years of MBSAQIP Data: Characteristics, Outcomes, and Trends for Patients with Super-obesity

PURPOSE

Incidence of super obesity (SO; BMI ≥ 50 kg/m²) is growing rapidly and confers worse metabolic complications than non-SO (BMI 30-50 kg/m²). We aim to characterize bariatric surgery patients with SO, their postoperative complications, and treatment trends over the last 5 years in hopes of informing SO-specific treatment protocols.

MATERIALS AND METHODS

The MBSAQIP database was analyzed, and two cohorts were compared, those with SO and non-SO. Univariate analysis was performed to determine between-group differences. Multivariable logistic regression analysis was performed to determine if SO was independently associated with serious complications or mortality.

RESULTS

We evaluated 751,952 patients with 173,110 (23.0%) having SO. Patients with SO were younger (42.2 ± 11.8 SO vs 45.1 ± 12.0 years non-SO, p < 0.001) and less likely to be female (74.8% vs 81.1%, p < 0.001). While comorbidities seem to be decreasing overall in bariatric surgery patients, those with SO have worse functional capacity and more endocrine, pulmonary, and vascular comorbidities. Patients with SO also have worse 30-day postoperative complications, and SO was independently associated with severe complications (OR 1.08; CI 1.05-1.11, p < 0.001) and mortality (OR 2.49; CI 2.12-2.92, p < 0.001) CONCLUSIONS: Patients with SO have significantly increased preoperative comorbidities resulting in worse postoperative outcomes. SO remains an independent risk factor for serious complications and the greatest independent risk factor for 30-day postoperative mortality. Considering the expected increase in patients with SO, substantial work is required to optimize bariatric surgery strategies specific to these patients.

In severe obesity, subcutaneous adipose tissue cell-derived cytokines are early markers of impaired glucose tolerance and are modulated by quercetin

BACKGROUND

Excessive adiposity provides an inflammatory environment. However, in people with severe obesity, how systemic and local adipose tissue (AT)-derived cytokines contribute to worsening glucose tolerance is not clear.

METHODS

Ninty-two severely obese (SO) individuals undergoing bariatric surgery were enrolled and subjected to detailed clinical phenotyping. Following an oral glucose tolerance test, participants were included in three groups, based on the presence of normal glucose tolerance (NGT), impaired glucose tolerance (IGT), or type 2 diabetes (T2D). Serum and subcutaneous AT (SAT) biopsies were obtained and mesenchymal stem cells (MSCs) were isolated, characterized, and differentiated in adipocytes in vitro. TNFA and PPARG mRNA levels were determined by qRT-PCR. Circulating, adipocyte- and MSC-released cytokines, chemokines, and growth factors were assessed by multiplex ELISA.

RESULTS

Serum levels of IL-9, IL-13, and MIP-1β were increased in SO individuals with T2D, as compared with those with either IGT or NGT. At variance, SAT samples obtained from SO individuals with IGT displayed levels of TNFA which were threefold higher compared to those with NGT, but not different from those with T2D. Elevated levels of TNFα were also found in differentiated adipocytes, isolated from the SAT specimens of individuals with IGT and T2D, compared to those with NGT. Consistent with the pro-inflammatory milieu, IL-1β and IP-10 secretion was significantly higher in adipocytes from individuals with IGT and T2D. Moreover, increased levels of TNFα, both mRNA and secreted protein were detected in MSCs obtained from IGT and T2D, compared to NGT SO individuals. Exposure of T2D and IGT-derived MSCs to the anti-inflammatory flavonoid quercetin reduced TNFα levels and was paralleled by a significant decrease of the secretion of inflammatory cytokines.

CONCLUSION

In severe obesity, enhanced SAT-derived inflammatory phenotype is an early step in the progression toward T2D and maybe, at least in part, attenuated by quercetin.

Outcomes of Bariatric Surgery: Patients with Body Mass Index 60 or Greater

Introduction:

Perioperative outcomes of bariatric surgery in patients with super super obesity (SSO) (BMI ≥ 60 kg/m²) merit further investigation.

Methods:

A retrospective review was conducted of patients with SSO who underwent surgery from Jun 2005 through Jun 2018 at a Metabolic and Bariatric Surgery Center of Excellence. Quantitative demographic data was summarized using descriptive statistics; categorical variables were compared using Fisher’s exact test.

Results:

Two hundred fourteen procedures were performed, of which 208 were eligible for inclusion. Majority were female (65.4%). The mean age and BMI was 43 (17–68 years) and 65.9 kg/m² (60 95 kg/m²), respectively. Comorbidities included: obstructive sleep apnea (74%), hypertension (59%), gastro-esophageal reflux disease (43%), osteoarthritis (41%), and diabetes mellitus (30%). Surgical approach: 97 Roux-en-Y gastric bypasses (46%), 88 laparoscopic sleeve gastrectomies (42%), and 23 adjustable gastric bands (11%). Additional subset included: primary (87%), conversion (7.7%), and revision (5.3%); majority being laparoscopic (75%) and robotic (24%). Complications via Clavien-Dindo classification: one Grade I, one Grade II, three Grade IIIa, three Grade IIIb, and three Grade IVa. Thirty-day events: 11 complications (5.3%; one leak [0.5%], one deep vein thrombosis [0.5%]), six re-admissions (3%), four re-operations (2%): repair of staple-line leak, repair of incisional hernia, uterine dilation and curettage, and cholecystectomy. No mortalities occurred. Complications occurred in 14.8% of conversion/revision cases, 3.9% in primary cases (p = 0.0395) with no difference observed between laparoscopic (4.5%) and robotic (6.1%) modalities (p = 0.7051).

Conclusion:

Bariatric surgery is feasible in patients with SSO. Revision procedures may increase risk of operative complications.

Effect of different limb lengths on quality of life, eating patterns and gastrointestinal symptoms after Roux-en-Y gastric bypass in superobese patients: randomized study

BACKGROUND

Distal Roux-en-Y gastrojejunal bypass (DRYGJB) gives better weight reduction than standard Roux-en-Y gastric bypass (RYGB) but at the risk of increased malnutrition side-effects. This study compared the effects of RYGB and DRYGJB on gastrointestinal symptoms, eating patterns and health-related quality of life (QoL).

METHODS

This was a single-blind RCT from a university-affiliated obesity centre. Patients with a BMI of 50 kg/m2 or above were invited to participate. Treatment arms were standard gastric bypass with an alimentary limb of 150 cm and a biliopancreatic limb of 60 cm, with a variable common channel length, or DRYGJB with biliopancreatic limb of 200 cm, common channel limb of 150 cm and variable alimentary limb length. Baseline and follow-up data to 5 years on quality of life, obesity-related problems and gastrointestinal symptoms were collected using prospectively created and validated questionnaires.

RESULTS

Some 140 patients were included. Those with a DRYGJB had better weight loss at 5 years (mean(s.d.) 68·3(21·8) kg versus 55·7(19·8) kg for standard RYGB; P = 0·011). Eating patterns improved, with no difference between the groups. Gastrointestinal symptoms (diarrhoea, indigestion) worsened significantly in both groups, but only patients with DRYGJB had significantly worse diarrhoea at the end of the study than at baseline (P = 0·006). Both groups had improved perceived generic QoL over baseline, and obesity-related problems were markedly reduced.

CONCLUSION

Standard RYGB and both improved generic and disease-specific QoL and eating behavioural pattern. Diarrhoea was increased more following DRYGJB than after RYGB. Registration number: NCT01514799 (https://clinicaltrials.gov).

Type 2 Diabetes Mellitus in Class II and III Obesity: Prevalence, Associated Factors, and Correlation between Glycemic Parameters and Body Mass Index

Despite the worldwide growth of class II and III obesity, the factors associated with type 2 diabetes mellitus (T2DM) in these obese individuals are not widely understood. Moreover, no study has investigated these associations in South America. Our study aimed to investigate the prevalence of T2DM and its associated factors, with an emphasis on biochemical parameters and eating habits, in class II and III obese individuals. We also aimed to analyze the correlation between glycemic parameters and body mass index (BMI). Baseline data from a randomized clinical trial (DieTBra Trial) of 150 class II and III obese individuals (BMI > 35 kg/m2) was used. An accelerometer, Food Frequency Questionnaire, and bioimpedance analysis were used to assess physical activity levels, eating habits, and body composition, respectively. Blood was collected after 12 h of fasting. Hierarchical multivariate Poisson regression was performed, and prevalence ratios (PRs) were calculated. Correlations between glycemic parameters (fasting blood glucose, glycosylated hemoglobin, homeostasis model assessment of insulin resistance (HOMA-IR), and insulin) and BMI were also analyzed. The prevalence of T2DM was 40.0% (95% CI, 32.1-48.3), high fasting blood glucose level was 19.33% (95% CI, 13.3-26.6), and high glycosylated hemoglobin was 32.67% (95% CI, 25.2-40.8). Age ≥ 50 years (PR = 3.17, 95% CI, 1.26-7.98) was significantly associated with T2DM; there was a positive linear trend between age and T2DM (p = 0.011). Multivariate analysis showed an association with educational level (PR = 1.49, 1.07-2.09, p = 0.018), nonconsumption of whole grains daily (PR = 1.67, 1.00-2.80, p = 0.049), and high HOMA-IR (PR = 1.54, 1.08-2.18, p = 0.016). We found a high prevalence of T2DM and no significant correlations between BMI and glycemic parameters.

Limb Length in Gastric Bypass in Super-Obese Patients-Importance of Length of Total Alimentary Small Bowel Tract

BACKGROUND

In super-obese patients, rates of weight loss failure and weight regain are high after RYGB. In order to improve weight loss, lengthening of the biliopancreatic limb is vital. In this study, efficacy and safety of two types of RYGB with 2-m BP-limb were assessed in improving weight loss and in the resolution of comorbidities compared with standard RYGB in a long-term follow-up.

METHODS

This is a retrospective cohort analysis on 671 super-obese patients operated in a 10-year period. Patients were classified into three groups: (1) 155 patients; roux limb 150 cm, BP-limb 60 cm; (2) 230 patients; roux limb 60 cm, BP-limb 200 cm; and (3) 286 patients; roux limb 150 cm, BP-limb 200 cm. EWL, TWL, BMI, failure, weight regain, comorbidity resolution, nutritional status, and complications were assessed.

RESULTS

Total alimentary limb length was shortened with 60 cm in group 1 and with 200 cm in groups 2 and 3. EWL, BMI change, and TWL were higher in the 2-m BP-limb groups vs group 1. No differences in complication rates were found, except higher frequency of marginal ulcers in patients with a shorter roux limb. EWL failure was higher in group 1 (10.3%) vs the other groups (4.3%; 5.2%). Group 3 had significantly less weight regain (26.6%). Remission of comorbidities was higher in the 2-m BP-limb groups at expense of nutritional and vitamin deficiencies (3.9%; 5.9%). No difference in hypoalbuminemia was noted.

CONCLUSION

Lengthening of the BP-limb gives significantly higher weight loss, lower rate of EWL failure, and lesser weight regain along with better resolution of obesity-associated comorbidities.

Enrichment of Tc1 cells and T cell resistance to suppression are associated with dysglycemia in the visceral fat in human obesity

OBJECTIVE

Insulin resistance, defined as tissue inflammation leading to type 2 diabetes, is a feature of obesity. The immune system has been implicated in its pathogenesis, but the role of adaptive immunity in humans remains uncertain. Here, we aim to determine whether specific phenotypic and functional properties of visceral adipose tissue (VAT)-derived CD4 conventional T cells (Tconv) and CD8 T cells are associated with dysglycemia in human obesity.

RESEARCH DESIGN AND METHODS

Peripheral blood and the stromal vascular fraction of obese patients without dysglycemia (n=23), with impaired fasting glucose or type 2 diabetes (n=17), and non-diabetic lean controls (n=11) were studied. Characterization of memory, activation profile, cytokine production, proliferative capacity, cytotoxic potential and transforming growth factor-β-mediated suppression of CD4 Tconv and CD8 T cells was performed. Correlation between anthropometric/metabolic parameters and VAT-derived T cell subsets was determined.

RESULTS

In the VAT of the overall obese population, reduced frequency of interferon-γ-producing or tumor necrosis factor-α-producing CD4 (ie, T helper 1, Th1) and CD8 (ie, cytotoxic type 1, Tc1) T cells, as well as interleukin-17-producing CD8 T cells (ie, Tc17), was evident when compared with lean controls. However, enrichment of Tc1 cells, together with the impaired ability of CD4 and CD8 T cells to be suppressed, distinguished the visceral fat of obese patients with dysglycemia from the one of non-diabetic obese patients. Moreover, accumulation of Th1 and Tc1 cells in the VAT correlated with anthropometric and metabolic parameters.

CONCLUSIONS

Here, we define the VAT-specific characteristics of T cells in human obesity, showing that accumulation of Tc1 cells and T cell resistance to suppression can be harmful to the development of obesity-induced diabetes. These findings open new directions to investigate immunological targets in the obesity setting.

Class 3 Obesity in a Multidisciplinary Metabolic Weight Management Program: The Effect of Preexisting Type 2 Diabetes on 6-Month Weight Loss

INTRODUCTION

Class 3 obesity (BMI ≥ 40 kg/m²) is a growing health problem worldwide associated with considerable comorbidity including Type 2 diabetes mellitus (T2DM). The multidisciplinary medical management of obesity can be difficult in T2DM due to potential weight gain from medications including sulphonylureas and insulin. However, newer weight-neutral/losing diabetes medications can aid additional weight loss. The aim of this study was to compare weight loss outcomes of patients with and without T2DM, and in patients with T2DM, to compare diabetes outcomes and change in medications at 6 months.

METHODS

All patients entering a multidisciplinary weight management metabolic program in a publicly funded hospital clinic in Sydney between March 2018 and March 2019, with BMI ≥ 40 kg/m² and aged ≥18 years were included. Data was collected from patient clinical and electronic notes at baseline and 6 months.

RESULTS

Of the 180 patients who entered the program, 53.3% had T2DM at baseline. There was no difference in percentage weight loss in those with or without T2DM (4.2 ± 4.9% vs. 3.6 ± 4.7%, p = 0.35). Additionally, T2DM patients benefited from a 0.47% reduction in HbA1c (p < 0.01) and a reduction in the number of medications from baseline to 6 months (1.8 ± 1.0/patient vs. 1.0 ± 1.2/patient, p < 0.001). T2DM patients who started on weigh-neutral/losing medications in the program lost more weight than those started on weight-gaining medications (7.7 ± 5.3% vs. 2.4 ± 3.8%, p = 0.015).

CONCLUSIONS

Patients with class 3 obesity had significant weight loss at 6 months in this program. Patients with T2DM at baseline had comparable weight loss at 6 months, a significant improvement in glycaemic control, and a reduction in diabetes medication load. Additionally, patients with T2DM who were started on weight-neutral/losing medications lost significantly more weight than those started on weight-gaining medications, and these medications should be preferentially used in class 3 obesity and comorbid T2DM.

Predictive values of obesity categories for cardiovascular disease risk factors in Chinese adult population

OBJECTIVE

Whether obesity categories can be used to predict cardiovascular disease (CVD) in Chinese adults remains unclear. This aim of this study was to examine the predictive values of obesity categories for CVD risk factors in Chinese adults.

METHODS

This study comprised a sample size of 3480 men and 6364 women aged ≥25 years (age range 25-89 years), from the medical health check-up center of Lianyungang First People's Hospital. The following CVD risk factor outcomes were used: hypertension, diabetes, dyslipidemia, insulin resistance, and metabolic syndrome (Mets). Framingham risk scores were used to evaluate the CVD. Four categories of obesity were used, based on body mass index (BMI) and waist circumference: no risk, increased risk, high risk, and very high risk. Predictive abilities were determined by calculating the odds ratios (OR) of CVD risk.

RESULTS

A graded linear relationship between obesity categories and CVD risk was observed across the categories, except for dyslipidemia. The people in the very high-risk category had the highest OR of having more unfavorable CVD risk factors compared with those in the lower risk category. For example, the OR of diabetes increased with the increase in risk category (OR, 1.13, 1.36, and 1.83, respectively, for increased, high, and very high risk categories in men and OR, 1.52, 1.80, and 2.78, respectively, for increased, high, and very high risk category in women).

CONCLUSIONS

These findings suggest that obesity categories provide clinical insights into identifying multiple CVD risk factors in Chinese adults.

Altered tricarboxylic acid cycle flux in primary myotubes from severely obese humans

BACKGROUND/OBJECTIVE

The partitioning of glucose toward glycolytic end products rather than glucose oxidation and glycogen storage is evident in skeletal muscle with severe obesity and type 2 diabetes. The purpose of the present study was to determine the possible mechanism by which severe obesity alters insulin-mediated glucose partitioning in human skeletal muscle.

SUBJECTS/METHODS

Primary human skeletal muscle cells (HSkMC) were isolated from lean (BMI = 23.6 ± 2.6 kg/m2, n = 9) and severely obese (BMI = 48.8 ± 1.9 kg/m2, n = 8) female subjects. Glucose oxidation, glycogen synthesis, non-oxidized glycolysis, pyruvate oxidation, and targeted TCA cycle metabolomics were examined in differentiated myotubes under basal and insulin-stimulated conditions.

RESULTS

Myotubes derived from severely obese subjects exhibited attenuated response of glycogen synthesis (20.3%; 95% CI [4.7, 28.8]; P = 0.017) and glucose oxidation (5.6%; 95% CI [0.3, 8.6]; P = 0.046) with a concomitant greater increase (23.8%; 95% CI [5.7, 47.8]; P = 0.004) in non-oxidized glycolytic end products with insulin stimulation in comparison to the lean group (34.2% [24.9, 45.1]; 13.1% [8.6, 16.4], and 2.9% [-4.1, 12.2], respectively). These obesity-related alterations in glucose partitioning appeared to be linked with reduced TCA cycle flux, as 2-[14C]-pyruvate oxidation (358.4 pmol/mg protein/min [303.7, 432.9] vs. lean 439.2 pmol/mg protein/min [393.6, 463.1]; P = 0.013) along with several TCA cycle intermediates, were suppressed in the skeletal muscle of severely obese individuals.

CONCLUSIONS

These data suggest that with severe obesity the partitioning of glucose toward anaerobic glycolysis in response to insulin is a resilient characteristic of human skeletal muscle. This altered glucose partitioning appeared to be due, at least in part, to a reduction in TCA cycle flux.

Impact of Successful Weight Loss Maintenance on Serum Lipids and Glucose Concentrations of Previous Participants of a Weight Loss Programme in Accra, Ghana

BACKGROUND AND AIM

There is a need to investigate the long-term impact of successful weight loss maintenance on blood lipids and glucose concentrations in populations within Africa, where obesity and cardiovascular disease (CVD) rates are increasingly becoming a public health threat. The aim of this study was to compare the serum lipid and glucose concentrations of successful and unsuccessful weight loss maintainers who previously participated in the Nutriline Weight Loss Programme (NWLP) in Accra, Ghana.

METHODS

112 participants were randomly selected to participate in this cross-sectional study. Baseline and end of weight loss programme anthropometric and programmatic data were accessed via the NWLP archival database. On follow-up, anthropometric data, physical activity, dietary behaviour, serum lipid, and glucose indices were taken. Successful weight loss maintainers (SWLM) were defined as those achieving at least 5% weight loss below the baseline weight at follow-up, otherwise unsuccessful (UWLM).

RESULTS

The adjusted serum total cholesterol (TC) concentration was significantly lower for SWLM (5.17 ± 0.99 mmol/L) compared to UWLM (5.59 ± 1.06 mmol/L). Serum low-density lipoprotein (LDL), high-density lipoprotein (HDL), fasting blood glucose (FBG), and glycosylated haemoglobin (HbA1c) concentrations for SWLM versus UWLM did not differ significantly and were as follows: 3.58 ± 0.92 mmol/L versus 3.87 ± 0.99 mmol/L, 1.22 ± 0.38 mmol/L versus 1.17 ± 0.32 mmol/L, 4.48 ± 0.72 mmol/L versus 4.73 ± 1.00 mmol/L, and 5.52 ± 0.39% versus 5.59 ± 0.59%, respectively. Triglyceride (TG) concentration was significantly (P < 0.001) lower for SWLM (0.79 ± 0.28 mmol/L) compared to UWLM (1.17 ± 0.51 mmol/L). After adjusting for covariates, it was no longer significant. Additionally, there was no significant association between weight loss maintenance success and having a normal status for selected lipids and glucose parameters.

CONCLUSION

SWLM had a significantly lower serum TC compared to UWLM. In addition, a greater proportion of SWLM had normal values for TC, TG, HbA1c, and LDL out of the six parameters measured although not statistically significant.

Perceived oral health in patients after bariatric surgery using oral health-related quality of life measures

Obesity is an increasing problem of the 21st century. A frequent intervention is bariatric surgery. The impact of bariatric surgery on oral health is largely unknown. The aim of the present case-control study was to survey the perceived oral health amongst individuals that had undergone bariatric surgery and compare the measures with two cohorts consisting of healthy individuals with respectively at or below versus above a body mass index score of 30. Study volunteers were recruited from interest group on the Internet. The study participants completed online a validated oral health-related quality of life scale, that is, OHIP-S. The three cohorts consisted of individuals that had undergone bariatric surgery (OS, n = 77) and the healthy obese (ONS, n = 45) and nonobese individuals (HNS, n = 71). Nonparametric Kruskal-Wallis rank sum tests were used to estimate likelihood of nondifference amongst the three cohorts. Individuals that had undergone bariatric surgery reported significant more oral health problems than the study participants in with the two other cohorts. Their perception of oral health-related quality of life was higher or similar to the obese study participants and lower than for nonobese study participants. Perceived oral health problems appear to be more frequent amongst individuals that have undergone bariatric surgery in comparison with healthy obese and nonobese individuals. Bariatric surgery may be consider a risk marker for impaired oral health.

Thiamine deficiency and cardiovascular disorders

BACKGROUND AND AIM

Thiamine, also known as vitamin B1, functions as a cofactor in the metabolism of carbohydrates and amino acids. Thiamine deficiency has been suggested to be associated with many cardiovascular diseases (CVDs) and risk factors including type 1 and type 2 diabetes (T1D and T2D, respectively), obesity, chronic vascular inflammation, dyslipidemia, heart failure (HF), myocardial infarction (MI) and conduction defects, and depression. The aim of this review was to explore the evidence of thiamine deficiency among subjects with CVDs or risk factors, illustrate the theories explaining the thiamine-CVDs associations, and describe the effect of thiamine supplementation.

METHODS

Human and animal studies were collected from various scientific databases following the PRISMA guidelines without limitation regarding the publication year. Studies investigating the prevalence of thiamine deficiency among patients with CVDs and the effect of thiamine supplementation on their conditions were summarized.

RESULTS AND CONCLUSIONS

Thiamine deficiency could have a role in the development of CVDs. Future studies should focus on the impact of thiamine supplementation on reversing CVDs and risk factors associated with its deficiency.

Phenotypic and genetic analysis of an adult cohort with extreme obesity

CONTEXT

Adult extreme obesity (EO) is a growing health concern. The prevalence of known obesity associated co-morbidities namely cardio-metabolic and neuro-psychiatric disease in EO is not fully established. The contribution of pathogenic genetic variants, previously implicated in early childhood onset obesity, to adult EO is also not established.

OBJECTIVE

We undertook phenotypic and genetic analysis of adult patients with extreme obesity (EO, BMI > 50). Specifically, we assessed the prevalence of eating disorders, cardio-metabolic, and neuro-psychiatric disease and the presence of pathogenic variants in known monogenic obesity genes.

DESIGN

A total of 55 patients with EO from a single site bariatric surgery referral program were assessed for the presence of eating disorders, cardio-metabolic, and neuro-psychiatric disease. The 54 obese (O) patients with a BMI < 50 from the same program were identified for phenotypic comparison. The 45 EO patients underwent whole exome sequencing to identify deleterious variants in known monogenic obesity genes.

OUTCOMES

(1) Presence of eating disorders, cardio-metabolic, and neuro-psychiatric disease in EO compared to O. (2) Onset of obesity in the EO group. (3) Presence of deleterious variants in genes previously implicated in monogenic obesity in the EO group.

RESULTS

The EO group had higher prevalence of lifetime neuro-psychiatric disease (67.3% vs. 37%, p = 0.001) and sleep apnea (74.6% vs. 51.9%, p = 0.01) but lower prevalence of type 2 diabetes (30.1% vs. 50%, p = 0.045) compared to O. There were no significant differences in binge eating, dyslipidemia, hypertension, and cardiac disease. In the EO group, we found previously unreported singleton variants in NTRK2 (pS667W, bio-informatically predicted to be deleterious) and BDNF (pE23K). No previously confirmed loss of function variants in monogenic obesity genes were found.

CONCLUSIONS

Adults with EO have significantly increased prevalence of neuro-psychiatric disease and a possibly lower burden of type 2 diabetes compared to less obese patients. Known monogenic causes of obesity were not highly prevalent in this cohort. Further studies are warranted to confirm these preliminary findings.

[Incretin secretion and glucose metabolism in morbidly obese patients in the early and late periods after biliopancreatic diversion]

AIM

To estimate the parameters of glucose metabolism and to assess the secretion of incretins in patients after biliopancreatic diversion (BPD) for morbid obesity (MO) in the early and late postoperative periods.

SUBJECTS AND METHODS

The prospective part of the investigation included 22 patients with a body mass index of 35.8 to 68.4 kg/m2 and type 2 diabetes mellitus (T2DM). All the patients were examined before, 3 weeks and 3 months after BPD. The retrospective part covered 23 patients who were examined after BPD for MO; the postoperative period was 4.7 [2.3; 7.2] years. A control group consisted of 22 healthy, normal weight volunteers. A 75-g oral glucose tolerance test was carried out in all the groups to study the levels of glucose, immunoreactive insulin (IRI), glucagon-like peptide-1 (GLP-1), glucose-dependent insulinotropic polypeptide (GIP) and glucagon at 0, 30, 60, and 120 min.

RESULTS

T2DM patients showed improvement in glucose metabolism just 3 weeks after BPD; following 3 months, they had normalized fasting blood glucose levels (5.6 [5.0; 6.0] mmol/l). During 3 months, glycated hemoglobin decreased from 7.5 [6.6; 8.5] to 5.7 [5.3; 5.9]%. In the early period following BPD, there was an increase in basal and postprandial GLP-1 levels associated with the peak IRI concentration. In the late period after BPD, the enhanced secretion of IRI and GLP-1 persisted, which was followed by a reduction in postprandial glucose levels in 4 of the 23 patients.

CONCLUSION

T2DM remission does not depend on weight loss in the early period after BPD. In this period, the significant improvement of glucose metabolic parameters in patients with obesity and T2DM is associated with elevated GLP-1 levels. The altered incretin response is a stable effect of BPD and remains in its late period.

Associations of Circulating PYY3-36 Concentrations with Metabolic Syndrome in Extremely Obese Subjects

BACKGROUND

The gut hormone peptide YY_3-36 (PYY_3-36) plays major roles in regulation of appetite and energy metabolism, mediates beneficial effects of bariatric surgery, and may be a potential weight-reducing and glucose-modulating therapy. Obesity may influence the metabolic expression of circulating PYY_3-36 and metabolic markers. We studied the relationship of PYY_3-36 concentrations with metabolic syndrome (MetSyn) components, lipids, insulin resistance, and inflammatory biomarkers in subjects with extreme obesity.

METHODS

We measured MetSyn components and PYY_3-36, lipids, hormones, homeostasis model assessment (HOMA) index, and inflammatory biomarkers in consecutively referred patients (180 women and 111 men) aged 18-78 years with body mass index (BMI) ≥40 kg/m². Associations of PYY_3-36 to components, insulin resistance, and biomarkers were examined with partial correlations and linear regression.

RESULTS

PYY_3-36 concentrations were not related to MetSyn components, HOMA index, or to inflammatory biomarker or leptin concentrations. PYY_3-36 concentrations correlated with systolic blood pressure (r = 0.21; P < 0.0001) after adjustment for age and gender. In linear regression analysis, PYY_3-36 concentrations were associated with systolic blood pressure after adjustment for age, gender, and central obesity in the entire sample (Beta 0.21; 95% CI 0.09-0.34) as well as in subjects not taking blood pressure-lowering medication (Beta 0.19; 95% CI 0.04-0.36). These associations were not statistically significant in the small subset of participants (22%) with type 2 diabetes.

CONCLUSIONS

In extremely obese patients, fasting PYY_3-36 concentrations were linked to systolic blood pressure, but not to other components of MetSyn, suggesting divergence between pathways of blood pressure and glucose/body weight regulation. However, this finding will need to be further investigated.

Preoperative Optimization of Total Joint Arthroplasty Surgical Risk: Obesity

Obesity is a problem that is increasing in prevalence in the United States and in other countries, and it is a common comorbidity in patients seeking total joint arthroplasty for degenerative musculoskeletal diseases. Obesity, as well as commonly associated comorbidities such as diabetes mellitus, cardiovascular disease, and those contributing to the diagnosis of metabolic syndrome, have been shown to have detrimental effects on total joint arthroplasty outcomes. Although there are effective surgical and nonsurgical interventions which can result in weight loss in these patients, concomitant benefit on arthroplasty outcomes is not clear. Preoperative optimization of surgical risk in obese total joint arthroplasty patients is an important point of intervention to improve arthroplasty outcomes.

Proportion of Obese Patients Presenting to Orthopedic Total Joint Arthroplasty Clinics

The purpose of this study is to demonstrate that the percentage of obese individuals initially presenting to total joint arthroplasty clinics in a public, tertiary hospital is greater than the proportion of obese individuals in the general population. In a retrospective, comparative study of patients seen in total joint replacement clinics at a public, tertiary hospital with an ICD-9 diagnosis of hip or knee osteoarthritis and documented body mass index, the proportion of obese individuals was compared with recent obesity data for the general population from the Centers for Disease Control and Prevention. Patients who had previously undergone hip or knee replacement surgery were excluded. Comorbid conditions, functional comorbidity index (FCI) scores, and Charlson comorbidity index scores were compared between obese and nonobese cohorts. The study included 499 patients aged 20 to 92 years (mean, 64.3 years), 58.9% of whom were female. Fifty-five percent of patients were obese, a significantly greater percentage than in the national (34.9%; P<.0005; odds ratio [OR]=2.23), regional (29.5%; P<.0005; OR=2.85), and state (31.1%; P<.0005; OR=2.64) populations. Obese patients had significantly more comorbid conditions (P<.002) and higher functional comorbidity index scores (P<.0009). The number of comorbidities and having Medicare/Medicaid insurance were predictive of obesity. This study highlights that the majority of patients presenting to orthopedic total joint arthroplasty clinics are obese and that they come with significantly more comorbidities. The total joint surgeon has a unique opportunity to facilitate weight loss in the obese osteoarthritic patient prior to joint replacement.

The role of lipid droplet formation in the protection of unsaturated fatty acids against palmitic acid induced lipotoxicity to rat insulin-producing cells

Background

Type 2 diabetes is associated with increased plasma concentrations of non-esterified fatty acids (NEFAs), which trigger pancreatic β-cell dysfunction and apoptosis. Only long-chain saturated NEFAs induced lipotoxicity in rat insulin-producing cells in in vitro experiments, whereas unsaturated NEFAs were not toxic. Some unsaturated NEFAs even protected against lipotoxicity. In former studies it was suggested that long-chain unsaturated NEFAs, which induce the formation of lipid droplets, can cause sequestration of palmitic acid into lipid droplets. In the present structure-activity-relationship study the correlation between lipid droplet formation and the protection against palmitic acid induced lipotoxicity by unsaturated NEFAs in rat insulin-producing cells was examined.

Methods

Rat insulin-producing RINm5F and INS-1E tissue culture cells were incubated in the presence of palmitic acid and unsaturated NEFAs with different chain lengths and different numbers of double bonds. The expression of the lipid droplet associated proteins perilipin 1 and 2 was repressed by the shRNA technique and the expression analyzed by qRT-PCR and Western blotting. Viability was measured by MTT assay and the accumulation of lipid droplets was quantified by fluorescence microscopy after Oil Red O staining.

Results

Long-chain unsaturated NEFAs strongly induce the formation of lipid droplets in rat insulin-producing RINm5F and INS-1E cells. In RINm5F cells incubated with 11-eicosenoic acid (C20:1) 27 % of the cell area was covered by lipid droplets corresponding to a 25-fold increase in comparison with control cells. On the other hand the saturated NEFA palmitic acid only induced minor lipid droplet formation. Viability analyses revealed only a minor toxicity of unsaturated NEFAs, whereas the cells were markedly sensitive to palmitic acid. Long-chain unsaturated NEFAs antagonized palmitic acid induced lipotoxicity during co-incubation, whereby no correlation existed between protection and the ability of lipid droplet formation. Perilipin 1 and 2 expression was decreased after incubation with C20:1 to about 80 % by shRNA. For the protective effect of long-chain unsaturated NEFAs against lipotoxicity of saturated NEFAs repression of perilipin was not of crucial importance.

Conclusions

Long-chain unsaturated fatty acids protected rat insulin-producing cells against lipotoxicity of saturated fatty acids. This protective effect was not dependent on lipid droplet formation. Thus lipid droplet formation is apparently not essential for the protective effect of unsaturated NEFAs against palmitic acid toxicity.

Electronic supplementary material

The online version of this article (doi:10.1186/s12986-016-0076-z) contains supplementary material, which is available to authorized users.

Impact of body weight on antidiabetic treatment and predictors of weight control under real-world conditions: a 2-year follow-up of DiaRegis cohort

AIMS

Treatment strategies for obese patients with type 2 diabetes mellitus aim to increase physical activity, reduce body weight, and improve glucose control using weight-beneficial antidiabetic drugs. The objective of this study was to determine whether these strategies are implemented, and to identify factors predictive of glucose control and body weight management in a large, real-world patient population.

METHODS

The prospective DiaRegis cohort study included 3807 patients with type 2 diabetes in whom the treating physician decided to intensify and optimize treatment because of insufficient glucose control.

RESULTS

Antidiabetic treatment of overweight and obese patients was compared with that of normal-weight patients over a 2-years follow-up period, and multivariate analyses were performed to identify predictors of body weight loss. Among the 3807 participants, 92.5 % were overweight or obese. Normal-weight participants were more often treated with sulfonylureas or insulin, and overweight and obese patients with metformin or glucagon-like peptide (GLP)-1 analogues. Predictors of weight loss were body mass index (BMI) ≥30 kg/m(2) and any reported physical activity.

CONCLUSIONS

DiaRegis study shows that under real-world conditions, antidiabetic drug therapy is performed dependent on body weight. This strategy results in adequate glucose control and moderate weight reductions in overweight and obese patients. Weight loss is affected by treatment with weight-beneficial drugs, but also by any reported physical activity. However, only a small subgroup of patients perform physical activity. Initiation and maintenance of a physically active lifestyle remains a significant challenge for physicians, and patients with type 2 diabetes.

Strong evidence of sexual dimorphic effect of adiposity excess on insulin sensitivity

AIMS

Our aims were to investigate in several large samples, with a wide range of adiposity, whether: (1) the effect of BMI on insulin sensitivity is different between sexes; (2) also waist circumference plays a sex-specific role on insulin sensitivity; and (3) serum adiponectin and resistin are mediators of such sex-dimorphic effect.

METHODS

Samples used were: Gargano study 1 (GS1), GS2 and Catania study (CS) comprising 3274 individuals. Adiponectin and resistin were measured by ELISA. Associations between variables were tested by linear models.

RESULTS

In all samples, relationship between BMI and HOMAIR was steeper in males than in females (BMI-by-sex interaction p = 0.04-0.0007). No interaction was observed on serum adiponectin and resistin (p = 0.40-059), which are therefore unlikely to mediate the sex-dimorphic effect of BMI on insulin resistance. Relationship between waist circumference and HOMAIR was similar between sexes in GS1 and GS2 but not in CS (waist-by-sex interaction p = 0.01), comprising much heavier individuals. This suggests that a sex-dimorphic effect of abdominal adiposity on insulin resistance is observable only in the context of high BMI.

CONCLUSIONS

Our findings represent a proof of concept that BMI and insulin sensitivity are associated in a sex-specific manner. This may explain why females are protected from diabetes and cardiovascular disease, compared to males of similar BMI.

Patient Understanding of Body Mass Index (BMI) in Primary Care Practices: A Two-State Practice-based Research (PBR) Collaboration

BACKGROUND

The concept of body mass index (BMI) may not be well understood by patients. The purpose of this study was to evaluate patients' knowledge of BMI in the primary care setting.

METHODS

Adult patients seen in 18 practices in West Virginia and New Jersey were invited to complete a voluntary survey. The survey assessed the patient's baseline knowledge of BMI as well as demographic information and whether the patient had known chronic conditions associated with increased BMI, including hypertension, hyperlipidemia, diabetes mellitus, and sleep apnea.

RESULTS

While the majority (59.9%) of primary care patients knew the meaning of BMI and that it is related to obesity, there was little knowledge of BMI cutoff values; more than 80% of responses were incorrect when asked to define specific BMI levels and their meaning. Self-awareness of obesity was limited as well, with only 16.4% aware of their own personal BMI. Furthermore, nearly 70% of patients could not recall having discussed BMI with their physician.

CONCLUSION

Findings indicate low comprehension of the term BMI. Increasing awareness of BMI may help patients address this key risk factor and significantly affect public health.

Feasibility of SPECT myocardial perfusion imaging in the super-obese using a multi-head semiconductor camera with attenuation correction

BACKGROUND

Obesity is not only associated with an increased risk of coronary artery disease, but also decreases the accuracy of many diagnostic modalities pertinent to this disease. Advances in myocardial perfusion imaging (MPI) have mitigated somewhat the effects of obesity, although the feasibility of MPI in the super-obese (defined as a BMI > 50) is currently untested. We undertook this study to assess the practicality of MPI in the super-obese using a multi-headed solid-state gamma camera with attenuation correction.

METHODS

We retrospectively identified consecutive super-obese patients referred for MPI at our institution. The images were interpreted by 3 blinded, experienced readers and graded for quality and diagnosis, and subjectively evaluated the contribution of attenuation correction. Clinical follow-up was obtained from review of medical records.

RESULTS

72 consecutive super-obese patients were included. Their BMI ranged from 50 to 67 (55.7 ± 5.1). Stress image quality was considered good or excellent in 45 (63%), satisfactory in 24 (33%), poor in 3 (4%), and uninterpretable in 0 patients. Rest images were considered good or excellent in 34 (49%), satisfactory in 23 (33%), poor in 13 (19%), and uninterpretable in 0 patients. Attenuation correction changed the interpretation in 34 (47%) of studies.

CONCLUSIONS

MPI is feasible and provides acceptable image quality for super-obese patients, although it may be camera and protocol dependent.

Association between class III obesity (BMI of 40-59 kg/m2) and mortality: a pooled analysis of 20 prospective studies

BACKGROUND

The prevalence of class III obesity (body mass index [BMI]≥40 kg/m2) has increased dramatically in several countries and currently affects 6% of adults in the US, with uncertain impact on the risks of illness and death. Using data from a large pooled study, we evaluated the risk of death, overall and due to a wide range of causes, and years of life expectancy lost associated with class III obesity.

METHODS AND FINDINGS

In a pooled analysis of 20 prospective studies from the United States, Sweden, and Australia, we estimated sex- and age-adjusted total and cause-specific mortality rates (deaths per 100,000 persons per year) and multivariable-adjusted hazard ratios for adults, aged 19-83 y at baseline, classified as obese class III (BMI 40.0-59.9 kg/m2) compared with those classified as normal weight (BMI 18.5-24.9 kg/m2). Participants reporting ever smoking cigarettes or a history of chronic disease (heart disease, cancer, stroke, or emphysema) on baseline questionnaires were excluded. Among 9,564 class III obesity participants, mortality rates were 856.0 in men and 663.0 in women during the study period (1976-2009). Among 304,011 normal-weight participants, rates were 346.7 and 280.5 in men and women, respectively. Deaths from heart disease contributed largely to the excess rates in the class III obesity group (rate differences = 238.9 and 132.8 in men and women, respectively), followed by deaths from cancer (rate differences = 36.7 and 62.3 in men and women, respectively) and diabetes (rate differences = 51.2 and 29.2 in men and women, respectively). Within the class III obesity range, multivariable-adjusted hazard ratios for total deaths and deaths due to heart disease, cancer, diabetes, nephritis/nephrotic syndrome/nephrosis, chronic lower respiratory disease, and influenza/pneumonia increased with increasing BMI. Compared with normal-weight BMI, a BMI of 40-44.9, 45-49.9, 50-54.9, and 55-59.9 kg/m2 was associated with an estimated 6.5 (95% CI: 5.7-7.3), 8.9 (95% CI: 7.4-10.4), 9.8 (95% CI: 7.4-12.2), and 13.7 (95% CI: 10.5-16.9) y of life lost. A limitation was that BMI was mainly ascertained by self-report.

CONCLUSIONS

Class III obesity is associated with substantially elevated rates of total mortality, with most of the excess deaths due to heart disease, cancer, and diabetes, and major reductions in life expectancy compared with normal weight. Please see later in the article for the Editors' Summary.

Microvesicle-shuttled miR-130b reduces fat deposition in recipient primary cultured porcine adipocytes by inhibiting PPAR-g expression

Obesity is a worldwide epidemic, and a risk factor for cardiovascular disease and type 2 diabetes. Consequently, the development of safe and effective anti-obesity drugs is an area of ongoing clinical interest. MicroRNAs play a vital role in anti-obesity by inhibiting the expression of genes involved in adipogenesis and lipogenesis. However, the clinical application of miRNAs has been limited by a lack of appropriate delivery systems. The discovery of microvesicles (MVs) has shed new light on the search for more efficient drug transport tools. In a previous study, we demonstrated that miRNA-130b suppressed fat deposition by inhibiting PPAR-g expression. In order to demonstrate whether miRNA-130b can be packaged into MVs and function as an endogenous form of miRNA-130b in recipient cells, we transfected HeLa-229 cells with plasmid to overexpress miRNA-130b. This enabled HeLa-229 cells to selectively package miRNA-130b into MVs and actively secrete the miRNA-130b enriched MVs into the culture media. We further verified that MVs enriched with miRNA-130b contain elevated concentrations of Argonaute 2 and heat shock protein 90a which are known to protect the circulating miRNAs from degradation. Exposure of primary cultured porcine adipocytes to purified, miRNA-130b-enriched MVs resulted in a significant down-regulation of PPAR-g expression which was associated with reduced adipogenesis and lipogenesis. Taken together, our results suggest that MVs may provide an effective transport systems for the deliver of miRNAs for therapeutic use. We also showed that MV-shuttled miRNA-130b inhibited adipogenesis and lipogenesis, and reduced fat deposition in recipient adipocytes by targeting PPAR-g.

Racial and ethnic differences in obesity and overweight as predictors of the onset of functional impairment

OBJECTIVES

To examine racial and ethnic differences in the effects of body mass index (BMI) on the onset of functional impairment over 10 years of follow-up.

DESIGN

Longitudinal analyses of a cohort from a nationally representative survey of community-dwelling American adults.

SETTING

Six waves (1996-2006) of the Health and Retirement Study (HRS).

PARTICIPANTS

Two groups of HRS participants aged 50 and older without functional impairment at baseline (1996): 5,884 with no mobility difficulty and 8,484 with no activity of daily living (ADL) difficulty.

MEASUREMENTS

Mobility difficulty was a composite measure of difficulty walking several blocks, walking one block, climbing several flights of stairs, and climbing one flight of stairs. ADL difficulty was measured as difficulty in dressing, bathing or showering, eating, and getting in and out of bed without help. The association between baseline BMI and risk of developing functional impairment was estimated using generalized estimating equation models.

RESULTS

Overweight and obesity were significant predictors of functional impairment. Overweight and obese Hispanics were 41% and 91% more likely, respectively, to develop ADL disability than whites in the same BMI categories. Overweight and severely obese blacks were also more likely than their white counterparts to develop ADL disability. Risk of developing ADL difficulty was higher for Hispanics than for blacks in the obese category. No significant differences in onset of mobility difficulty were found between racial or ethnic groups within any BMI category.

CONCLUSION

Blacks and Hispanics were at higher risk than whites of ADL but not mobility impairment. In addition to weight control, prevention efforts should promote exercise to reduce functional impairment, especially for blacks and Hispanics, who are at higher risk.