Changing the endpoints for determining effective obesity management

'I'm a failure again, I can't do it': Attitudes towards, and experiences of, exercise participation in adults with class III obesity

OBJECTIVES

Living within a larger body brings unique challenges to exercise participation, which are poorly understood. This qualitative study explored the attitudes towards, and experiences of, exercise participation in adults with class III obesity.

DESIGN

Individual semi-structured qualitative interviews.

METHODS

We recruited 30 adults with class III obesity (body mass index: 45.8 ± 8.6 kg/m2) from a specialist multidisciplinary weight management service. Participants took part in semi-structured interviews while participating in a 6-month home-based aerobic and resistance exercise intervention. Open-ended questions were used flexibly to explore their views and experiences of exercise, encompassing barriers, motives and perceived benefits. Transcripts were analysed using reflexive thematic analysis.

RESULTS

Three themes were developed: (1) a web of barriers; (2) tailored exercise facilitates positive experiences; and (3) a desire to live a normal life. People with class III obesity perceived that they were unable to do exercise; a view that was attributed to perceived judgement, low physical function, pain during everyday activities and failed weight loss attempts. These complex physical and psychosocial barriers to exercise were described as contributing to exercise avoidance. High value was placed on tailored exercise that accommodates the unique needs of moving in a larger body. A desire to carry out everyday tasks underpinned motivations for exercise.

CONCLUSIONS

Our findings suggest that multi-component obesity interventions should move away from generic exercise prescriptions designed to maximize energy expenditure, and instead move towards addressing the unique physical and psychosocial needs of people who have class III obesity with tailored person-centred and weight-neutral exercise prescriptions.

The Role of Gut Microbiota, Nutrition, and Physical Activity in Depression and Obesity-Interdependent Mechanisms/Co-Occurrence

Obesity and depression are interdependent pathological disorders with strong inflammatory effects commonly found worldwide. They determine the health status of the population and cause key problems in terms of morbidity and mortality. The role of gut microbiota and its composition in the treatment of obesity and psychological factors is increasingly emphasized. Published research suggests that prebiotic, probiotic, or symbiotic preparations can effectively intervene in obesity treatment and mood-dysregulation alleviation. Thus, this literature review aims to highlight the role of intestinal microbiota in treating depression and obesity. An additional purpose is to indicate probiotics, including psychobiotics and prebiotics, potentially beneficial in supporting the treatment of these two diseases.

Mobile health (m-health) smartphone interventions for adolescents and adults with overweight or obesity

BACKGROUND

Obesity is considered to be a risk factor for various diseases, and its incidence has tripled worldwide since 1975. In addition to potentially being at risk for adverse health outcomes, people with overweight or obesity are often stigmatised. Behaviour change interventions are increasingly delivered as mobile health (m-health) interventions, using smartphone apps and wearables. They are believed to support healthy behaviours at the individual level in a low-threshold manner.

OBJECTIVES

To assess the effects of integrated smartphone applications for adolescents and adults with overweight or obesity.

SEARCH METHODS

We searched CENTRAL, MEDLINE, PsycINFO, CINAHL, and LILACS, as well as the trials registers ClinicalTrials.gov and World Health Organization International Clinical Trials Registry Platform on 2 October 2023 (date of last search for all databases). We placed no restrictions on the language of publication.

SELECTION CRITERIA

Participants were adolescents and adults with overweight or obesity. Eligible interventions were integrated smartphone apps using at least two behaviour change techniques. The intervention could target physical activity, cardiorespiratory fitness, weight loss, healthy diet, or self-efficacy. Comparators included no or minimal intervention (NMI), a different smartphone app, personal coaching, or usual care. Eligible studies were randomised controlled trials of any duration with a follow-up of at least three months.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methodology and the RoB 2 tool. Important outcomes were physical activity, body mass index (BMI) and weight, health-related quality of life, self-efficacy, well-being, change in dietary behaviour, and adverse events. We focused on presenting studies with medium- (6 to < 12 months) and long-term (≥ 12 months) outcomes in our summary of findings table, following recommendations in the core outcome set for behavioural weight management interventions.

MAIN RESULTS

We included 18 studies with 2703 participants. Interventions lasted from 2 to 24 months. The mean BMI in adults ranged from 27 to 50, and the median BMI z-score in adolescents ranged from 2.2 to 2.5. Smartphone app versus no or minimal intervention Thirteen studies compared a smartphone app versus NMI in adults; no studies were available for adolescents. The comparator comprised minimal health advice, handouts, food diaries, smartphone apps unrelated to weight loss, and waiting list. Measures of physical activity: at 12 months' follow-up, a smartphone app compared to NMI probably reduces moderate to vigorous physical activity (MVPA) slightly (mean difference (MD) -28.9 min/week (95% confidence interval (CI) -85.9 to 28; 1 study, 650 participants; moderate-certainty evidence)). We are very uncertain about the results of estimated energy expenditure and cardiorespiratory fitness at eight months' follow-up. A smartphone app compared with NMI probably results in little to no difference in changes in total activity time at 12 months' follow-up and leisure time physical activity at 24 months' follow-up. Anthropometric measures: a smartphone app compared with NMI may reduce BMI (MD of BMI change -2.6 kg/m2, 95% CI -6 to 0.8; 2 studies, 146 participants; very low-certainty evidence) at six to eight months' follow-up, but the evidence is very uncertain. At 12 months' follow-up, a smartphone app probably resulted in little to no difference in BMI change (MD -0.1 kg/m2, 95% CI -0.4 to 0.3; 1 study; 650 participants; moderate-certainty evidence). A smartphone app compared with NMI may result in little to no difference in body weight change (MD -2.5 kg, 95% CI -6.8 to 1.7; 3 studies, 1044 participants; low-certainty evidence) at 12 months' follow-up. At 24 months' follow-up, a smartphone app probably resulted in little to no difference in body weight change (MD 0.7 kg, 95% CI -1.2 to 2.6; 1 study, 245 participants; moderate-certainty evidence). A smartphone app compared with NMI may result in little to no difference in self-efficacy for a physical activity score at eight months' follow-up, but the results are very uncertain. A smartphone app probably results in little to no difference in quality of life and well-being at 12 months (moderate-certainty evidence) and in little to no difference in various measures used to inform dietary behaviour at 12 and 24 months' follow-up. We are very uncertain about adverse events, which were only reported narratively in two studies (very low-certainty evidence). Smartphone app versus another smartphone app Two studies compared different versions of the same app in adults, showing no or minimal differences in outcomes. One study in adults compared two different apps (calorie counting versus ketogenic diet) and suggested a slight reduction in body weight at six months in favour of the ketogenic diet app. No studies were available for adolescents. Smartphone app versus personal coaching Only one study compared a smartphone app with personal coaching in adults, presenting data at three months. Two studies compared these interventions in adolescents. A smartphone app resulted in little to no difference in BMI z-score compared to personal coaching at six months' follow-up (MD 0, 95% CI -0.2 to 0.2; 1 study; 107 participants). Smartphone app versus usual care Only one study compared an app with usual care in adults but only reported data at three months on participant satisfaction. No studies were available for adolescents. We identified 34 ongoing studies.

AUTHORS' CONCLUSIONS

The available evidence is limited and does not demonstrate a clear benefit of smartphone applications as interventions for adolescents or adults with overweight or obesity. While the number of studies is growing, the evidence remains incomplete due to the high variability of the apps' features, content and components, which complicates direct comparisons and assessment of their effectiveness. Comparisons with either no or minimal intervention or personal coaching show minor effects, which are mostly not clinically significant. Minimal data for adolescents also warrants further research. Evidence is also scarce for low- and middle-income countries as well as for people with different socio-economic and cultural backgrounds. The 34 ongoing studies suggest sustained interest in the topic, with new evidence expected to emerge within the next two years. In practice, clinicians and healthcare practitioners should carefully consider the potential benefits, limitations, and evolving research when recommending smartphone apps to adolescents and adults with overweight or obesity.

Validation of the obesity paradox by body mass index and waist circumference in patients undergoing percutaneous coronary intervention

BACKGROUND

The paradoxical association of obesity with mortality, named the "obesity paradox", has been inconsistent, possibly due to a difference between body mass index (BMI) and central obesity, estimated by waist circumference (WC) as patterns of adiposity.

SUBJECTS/METHODS

We enrolled 8513 participants from the Kumamoto Intervention Conference Study, a multicenter registry that included consecutive patients undergoing percutaneous coronary intervention (PCI) at 18 centers between 2008 and 2017 in Japan. Patients were divided into quartiles in ascending order of the BMI or WC. The primary endpoints were all-cause mortality and cardiovascular death within a year.

RESULTS

There were 186 deaths (case fatality rate, 22.1/1000 person-years) during the follow-up period. The lowest group (1st quartile) of BMI or WC had the worst prognosis among the quartiles (1st quartile, 4.2%; 2nd quartile, 1.9%; 3rd quartile, 1.5%; 4th quartile, 1.1%; P < 0.001 (χ²) and 1st quartile, 4.1%; 2nd quartile, 2.3%; 3rd quartile, 1.2%; 4th quartile, 1.5%; P < 0.001 (χ²), respectively). Similar results were obtained for cardiovascular death. In a multivariable analysis adjusted by nine conventional factors, the lowest group (1st quartile) of BMI (hazards ratio, 2.748; 95% confidence interval [CI], 1.712-4.411) and WC (hazards ratio, 2.340; 95% CI, 1.525-3.589) were independent prognostic factors for all-cause mortality. By dividing the participants into two groups according to either the BMI or WC based on the National Cholesterol Education Program Adult Treatment Panel III and World Health Organization classification, the highest mortality was observed in the lower group. However, the C-statistic after adding BMI (quartile) to conventional factors was found to be slightly higher than BMI (two categories) and WC (two categories) (0.735 vs. 0.734).

CONCLUSIONS

The obesity paradox was observed in patients after PCI, and single-use of BMI (or WC) was sufficient to predict the prognosis of patients after PCI.

Health at Every Size®-Based Interventions May Improve Cardiometabolic Risk and Quality of Life Even in the Absence of Weight Loss: An Ancillary, Exploratory Analysis of the Health and Wellness in Obesity Study

We examined whether weight loss following HAES®-based interventions associates with changes in cardiometabolic risk factors and quality of life of women with obesity. This was an exploratory, ancillary analysis of a 7-month, mixed-method, randomized controlled trial. Fifty-five women (age: 33.0 ± 7.2; BMI: 30–39.9 kg/m²) were included in this study. Body weight, cardiovascular risk factors, clustered cardiometabolic risk, and quality of life were assessed before (Pre) and after HAES®-based interventions (Post). Delta scores (Post-Pre) were calculated for each outcome and used in linear regression models. After adjusting by potential confounders, weight loss was associated with improvements in waist circumference (β = 0.83, p <0.001), fasting glycemia (β = 0.45, p = 0.036), total cholesterol (β = 1.48, p = 0.024), LDL (β = 1.33, p = 0.012), clustered cardiometabolic risk (β = 0.18, p = 0.006), and quality of life (β = −1.05, p = 0.007). All participants but one who reduced body weight (n = 11) improved clustered cardiometabolic risk and quality of life. Of relevance, 34% and 73% of the participants who maintained or gained weight improved clustered cardiometabolic risk and quality of life, respectively, although the magnitude of improvements was lower than that among those who lose weight. Improvements in cardiovascular risk factors and quality of life following HAES®-based interventions associated with weight loss as expected. However, most of the participants who maintained or even gained weight experienced benefits to some extent. This suggests that weight-neutral, lifestyle-modification interventions may improve wellness and health-related outcomes, even in the absence of weight loss.

Racial and ethnic disparities in cardiometabolic disease and COVID-19 outcomes in White, Black/African American, and Latinx populations: Social determinants of health

Racial and ethnic-related health disparities in the United States have been intensified by the greater burden of Coronavirus Disease 2019 (COVID-19) in racial and ethnic minority populations. Compared to non-Hispanic White individuals, non-Hispanic Black and Hispanic/Latinx individuals infected by COVID-19 are at greater risk for hospitalization, intensive care unit admission, and death. There are several factors that may contribute to disparities in COVID-19-related severity and outcomes in these minority populations, including the greater burden of cardiovascular and metabolic diseases as discussed in our companion review article. Social determinants of health are a critical, yet often overlooked, contributor to racial and ethnic-related health disparities in non-Hispanic Black and Hispanic/Latinx individuals relative to non-Hispanic White individuals. Thus, the purpose of this review is to focus on the essential role of social factors in contributing to health disparities in chronic diseases and COVID-19 outcomes in minority populations. Herein, we begin by focusing on structural racism as a social determinant of health at the societal level that contributes to health disparities through downstream social level (e.g., occupation and residential conditions) and individual level health behaviors (e.g., nutrition, physical activity, and sleep). Lastly, we conclude with a discussion of practical applications and recommendations for future research and public health efforts that seek to reduce health disparities and overall disease burden.

The Effect of Pre-operative Exercise Intervention on Patient Outcomes Following Bariatric Surgery: a Systematic Review and Meta-analysis

This systematic review aimed to assess the effect of a pre-operative exercise intervention on short- and long-term health and clinical outcomes for adult patients undergoing bariatric surgery (BS). We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), SPORTDiscus and reference lists of relevant papers, through March 2021. Five randomised controlled trials were included (n = 199 patients). Modest increases in cardiorespiratory fitness (VO2max) were found at both pre-operative (0.73 mL kg-1 min-1, P ≤ 0.001) and maximum follow-up time points (0.98 mL kg-1 min-1, P ≤ 0.04). There was no significant effect of an exercise intervention on percentage total weight loss (%TWL). Pre-operative exercise can induce significant short- and long-term improvements in fitness in individuals with obesity. There is insufficient evidence to determine whether pre-operative training impacts other post-operative clinical outcomes.

Development and Validation of a Lifestyle Behavior Tool in Overweight and Obese Women through Qualitative and Quantitative Approaches

There is a paucity of effective intervention tools for overweight/obese women to assess, guide and monitor their eating behavior. This study aimed to develop a lifestyle intervention tool, assess its acceptability and usefulness, and verify its construct validity in overweight/obese women. The 6P tool (Portion, Proportion, Pleasure, Phase, Physicality, Psychology) was developed and 15 women with a body mass index (BMI) ≥ 25 kg/m2 were interviewed to assess its perceived acceptability and usefulness. Subsequently, the revised 6P tool was tested in 46 women with a BMI ≥ 25 kg/m2. The Three-Factor Eating Questionnaire (TFEQ), International Physical Activity Questionnaire-Short (IPAQ), and weight were measured at baseline and one-month. Most participants were satisfied with the presentation of the 6P tool (86.8%), and agreed it was useful in guiding healthy eating (81.6%) and raising awareness of eating behavior (97.4%). There were significant improvements in cognitive restraint (p = 0.010) and disinhibition (p = 0.030) (TFEQ), portion size (P1), pleasure behaviors (P3), and total composite 6P score (p < 0.001). However, there was no significant reduction in weight or increase in physical activity. The 6P tool is acceptable and presents with good validity for assessing lifestyle behaviors.

Obesity treatment: Weight loss versus increasing fitness and physical activity for reducing health risks

We propose a weight-neutral strategy for obesity treatment on the following grounds: (1) the mortality risk associated with obesity is largely attenuated or eliminated by moderate-to-high levels of cardiorespiratory fitness (CRF) or physical activity (PA), (2) most cardiometabolic risk markers associated with obesity can be improved with exercise training independent of weight loss and by a magnitude similar to that observed with weight-loss programs, (3) weight loss, even if intentional, is not consistently associated with lower mortality risk, (4) increases in CRF or PA are consistently associated with greater reductions in mortality risk than is intentional weight loss, and (5) weight cycling is associated with numerous adverse health outcomes including increased mortality. Adherence to PA may improve if health care professionals consider PA and CRF as essential vital signs and consistently emphasize to their patients the myriad benefits of PA and CRF in the absence of weight loss.

Physical activity, diet, and weight loss in patients recruited from primary care settings: An update on obesity management interventions

BACKGROUND

Obesity and related comorbidities are the most common chronic conditions in North America where behavior modification including the adoption of physical activity (PA) and a healthful diet are primary treatment strategies. Patients are more likely to engage in behavior modification if encouraged by their physician; however, behavioral counseling in primary care rarely occurs due to lack of training and resources. A more effective method may be to refer patients from clinical settings to other health professionals.

OBJECTIVE

This systematic review examines the effectiveness of behavior-based counseling for obesity management among participants referred from clinical settings.

METHODS

PubMed, CINAHL, and EMBASE were used to identify randomized clinical trials (2014-2020) for weight loss with the following inclusion criteria: trial duration ≥12 months, included a control or usual care group, recruited adults with overweight or obesity from primary care and/or treated in the primary care setting, and the intervention included counseling on PA and diet.

RESULTS

Seventeen studies, encompassing 21 different intervention groups with 6185 unique participants (56% female) met the inclusion criteria. All participants had overweight or obesity, with a body mass index between 28.2 and 41.0 kg/m2. In 11 (52%) of the intervention groups, significant weight loss in the intervention group was observed compared to usual care (mean weight loss: 4.9[2.1] kg vs. 1.0[0.9] kg). In 13 out of 18 interventions (72%) reporting weight loss at two time points, weight regain was observed by 12 months. Statistically significant weight loss was observed in one intervention (of two total) that was longer than 12 months.

CONCLUSIONS

Sustained weight loss regardless of the behavior-based, intervention strategy remains a challenge for most adults. Given the established benefits of routine PA and a healthful diet, prioritizing the adoption of healthy behaviors regardless of weight loss may be a more effective strategy for ensuring long-term health benefit.

Constraints of Weight Loss as a Marker of Bariatric Surgery Success: An Exploratory Study

Purpose

The aim of this exploratory study was to investigate whether the degree of weight loss properly reflects improvements in cardiometabolic health among patients who underwent Roux-en-Y gastric bypass.

Methods

In this ancillary analysis from a clinical trial, patients were clustered into tertiles according to the magnitude of the percentage weight loss (1st tertile: “higher weight loss”: −37.1 ± 5.8%; 2nd tertile: “moderate weight loss”: −29.7 ± 1.4%; 3rd tertile: “lower weight loss”: −24.2 ± 2.3%). Delta changes (9 months after surgery-baseline) in clustered cardiometabolic risk (i.e., blood pressure index, fasting glucose, high-density lipoprotein [HDL] and triglycerides [TG]), glycated hemoglobin (HbA1c), homeostasis model assessment (HOMA-IR), and C-reactive protein (CRP) were calculated.

Results

A total of 42 patients who had complete bodyweight data (age = 40 ± 8 year; BMI = 47.8 ± 7.1 kg/m²) were included. Surgery led to substantial weight loss (−37.9 ± 11.3 kg, P < 0,001), and clinically significant improvements in blood pressure index (−17.7 ± 8.2 mmHg, P < 0.001), fasting glucose (−36.6 ± 52.5 mg/dL, P < 0.001), HDL (9.4 ± 7.1 mg/dL, P < 0.001), TG (−35.8 ± 44.1 mg/dL P < 0,001), HbA1c (−1.2 ± 1.6%, P < 0.001), HOMA-IR (−4.7 ± 3.9 mg/dL, P < 0.001) and CRP (−8.5 ± 6.7 μg/mL P < 0.001). Comparisons across tertiles revealed no differences for cardiometabolic risk score, fasting glucose, HbAc1, HOMA-IR, blood pressure index, CRP, HDL, and TG (P > 0.05 for all). Individual variable analysis confirmed cardiometabolic improvements across the spectrum on weight-loss. There were no associations between weight loss and any dependent variable.

Conclusion

Weight loss following bariatric surgery does not correlate with improvements in cardiovascular risk factors. These findings suggest that weight loss alone may be insufficient to assess the cardiometabolic success of bariatric surgery, and the search for alternate proxies that better predict surgery success are needed.

Physical activity is favorably associated with arterial stiffness in patients with obesity and elevated metabolic risk

OBJECTIVES

Physical activity and cardiorespiratory fitness (CRF) are relevant modifiers of cardiovascular risk. Their independent effects on arterial stiffness have not been assessed in people with obesity. This study aimed to assess the independent effects of light (LPA) and moderate-to-vigorous (MVPA) physical activity and CRF on Pulse wave velocity (PWV).

METHODS

Brachial-ankle PWV (baPWV) was measured cross-sectionally in 55 subjects (43.0 ± 13.8 years; 66% women) with moderate cardiovascular risk. Body composition was assessed with bioelectrical impedance-analysis. Daily minutes of LPA and MVPA were measured by accelerometry and CRF (peak oxygen uptake [VO₂ peak]) with spiroergometry. Independent effects of LPA, MVPA, and VO₂ peak on baPWV were analyzed in an age-, sex-, body fat mass-, and blood pressure-adjusted ANOVA.

RESULTS

Every 10 minutes increase of daily MVPA was associated with a 2.8% (0.32m/s [-0.64 to 0.001 m/s], P = .05) reduction of baPWV, whereas LPA and VO₂ peak had only a little or no relevant effects on baPWV.

CONCLUSIONS

Higher MVPA is associated with lower composite arterial stiffness independent of CRF and the number of metabolic risk factors in patients with obesity and further metabolic risk factors. Thus, lifestyle interventions should aim for an increase in MVPA. BaPWV may improve the monitoring of favorable effects of MVPA, even if an improvement of VO₂ peak cannot be obtained.

Mobile health (m‐health) smartphone interventions for overweight or obese adolescents and adults

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the effects of smartphone‐based m‐health interventions for overweight or obese adolescents and adults.

Why people engage in a weight loss intervention at their workplace - a stratified case study

Background

The prevalence of obesity has increased significantly worldwide within the last decade. As obesity is recognised as a contributing factor when developing various health threatening chronic diseases, prevention initiatives focusing on weight loss are becoming more important. Because of the time spent at the workplace, workplaces can be optimal arenas for weight loss programs and these programs have been effective to decrease body weight. Thus, reasons for engaging in weight loss interventions needs exploring, in order to engage more workplaces in weight loss interventions. Such information provides important knowledge that may help to inform decisions of municipalities, employers and other public health decision makers, when and if implementing weight loss interventions. The aim of this study was therefore to explore reasons for employee engagement in weight loss projects at the workplace and the incentives a municipality, a manager at a home-care centre, and a project manager have to launch such project.

Methods

A stratified case study was conducted. A representative from the municipality, the manager at a home-care centre, the project manager of the weight loss intervention and six health-care workers were interviewed at the end of a one-year weight loss intervention at the workplace. Data were analysed using Systematic Text Condensation.

Results

Analysis identified different views and considerations for engaging in a weight loss intervention at the workplace. For the representative of the municipality the possible economical gain of the project was in focus. The project manager and the manager of the home-care centre both reflected mainly on improvement of the healthcare workers health. For the project manager, achieving good scientific results was highlighted as well. However, the employees were influenced by several factors, such as their own health and weight loss, the pressure from the environment and their struggle for recognition.

Conclusions

This study concluded that if targeting the increasing worldwide obesity problem through workplace initiated weight loss programs, the sales pitch to managements and employers have to be tailored in order to increase the participation and the motivation for the initiative.

Trial registration

ClinicalTrial.gov: NCT01015716, registration data 14.12.2010 (Prospectively registered).

In BMI We Trust: Reframing the Body Mass Index as a Measure of Health

Recent work in medical sociology has provided critical insights into distinguishing between obesity as a condition with severe individual- and population-level health consequences, and obesity as a socially undesirable, stigmatizing construct opposing thinness as the healthy ideal. Less often considered is the role of Body Mass Index (BMI) as the standard by which obesity and healthy weight are measured and defined. Addressing this issue, I begin by distinguishing between BMI as an empirical, objective measure of health, and BMI as an arbitrary, subjective label for categorizing the population. I further consider how BMI is empowered as a measurable quantity through the lens of medicalization and evidence-based medicine, and introduce the "performativity" of BMI as a superior framework for confronting the measure's conceptual limitations. Emphasizing key parallels between BMI and self-rated health as measures with high predictive validity, yet unspecified mechanisms of action, I propose an epistemological shift away from classifying BMI as a biomarker and toward a more flexible view of the measure as a holistic appraisal of health. In closing, I argue that researchers may continue to leverage BMI's ease of collection and interpretation, provided they are attuned to its definitional ambiguity across diverse research methods and contexts.

Central and peripheral effects of physical exercise without weight reduction in obese and lean mice

To investigate the central (hypothalamic) and peripheral effects of exercise without body weight change in diet-induced obesity (DIO). Twelve-week-old male C57Bl/6 mice received a control (C) or a high-fat diet (H). Half of them had free access to running wheels for 5 days/week for 10 weeks (CE) and HE, respectively). Hypothalamic expression of genes related to energy homeostasis, and leptin (Stat3 and p-Stat3) and insulin (Akt and p-Akt) signaling were evaluated. Glucose and leptin tolerance, peripheral insulin sensitivity, and plasma insulin, leptin and adiponectin were determined. Perigonadal and retroperitoneal fat depots were increased by diet but reduced by exercise despite lack of effect of exercise on body weight. Blood glucose during intraperitoneal glucose tolerance test (ipGTT) was higher and glucose decay during intraperitoneal insulin tolerance test (ipITT) was lower in H and HE compared with C and CE. Exercise increased liver p-Akt expression and reduced fast glycemia. High-fat diet increased plasma insulin and leptin. Exercise had no effect on insulin but decreased leptin and increased adiponectin. Leptin inhibited food intake in all groups. Hypothalamic total and p-Stat3 and Akt were similar amongst the groups despite higher plasma levels of leptin and insulin in H and HE mice. High-fat diet modulated gene expression favoring a positive energy balance. Exercise only marginally changed the gene expression. Exercise induced positive changes (decreased fast glycemia and fat depots; increased liver insulin signaling and adiponectin concentration) without weight loss. Thus, despite reducing body weight could bring additional benefits, the effects of exercise must not be overlooked when weight reduction is not achieved.

The role of increased body mass index in outcomes of sepsis: a systematic review and meta-analysis

Background

The role of increased body mass index (BMI) in sepsis is controversial. We aimed to evaluate the associations between overweight (25 kg/m² < BMI ≤ 29.9 kg/m²), obese (30 kg/m² < BMI ≤ 39.9 kg/m²) and morbidly obese (BMI > 40 kg/m²) BMIs and outcomes in septic patients.

Methods

We searched the PubMed, Embase, Web of Science, Cochrane Library and ClinicalTrials.gov databases for studies published by December 1, 2016. Electronic database searches yielded 3713 articles, eight of which were included in this meta-analysis. Data were independently extracted by two reviewers, and a third reviewer participated in making decisions as needed. We used Review Manager to conduct the analysis, and the outcomes were reported with odds ratios (ORs) or mean differences (MDs). The primary outcome was mortality, and the secondary outcome was length of stay (LOS) in the intensive care unit (ICU) or the hospital.

Results

Data from eight studies involving a total of 9696 patients were pooled in our final analysis. Compared with patients with normal BMI (18.5 kg/m² < BMI ≤ 24.9 kg/m²), patients with BMI ≥ 25 kg/m² exhibited decreased mortality (OR 0.81; 95% confidence interval (CI), 0.74–0.89, P < 0.0001). In subgroup analysis, compared with normal-weight patients, overweight patients had lower mortality (OR 0.87; 95% CI 0.77–0.97, P = 0.02), whereas obese (OR 0.89, 95% CI 0.72–1.10, P = 0.29) and morbidly obese (OR 0.64, 95% CI 0.38–1.08, P = 0.09) patients did not exhibit significantly reduced mortality.

Conclusions

In sepsis cases, overweight, but not obesity or morbid obesity, was associated with lower mortality. Further prospective studies are needed to clarify this relationship.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-017-0405-4) contains supplementary material, which is available to authorized users.

Interaction of Physical Activity and Body Mass Index on Mortality in Coronary Heart Disease: Data from the Nord-Trøndelag Health Study

OBJECTIVE

The role of physical activity in the relationship between body mass index (BMI) and survival in coronary heart disease is unclear. Our aim was to examine the isolated and combined associations among BMI, physical activity, and mortality in subjects with coronary heart disease.

METHODS

A total of 6493 participants (34.4% were women) with coronary heart disease from the Nord-Trøndelag Health Study, with examinations in 1986, 1996, and 2007, were followed to the end of 2014. We calculated hazard ratios (HRs) for all-cause and cardiovascular disease mortality, estimated using Cox proportionate hazard regression adjusted for age, smoking, diabetes, hypertension, self-reported health status, and alcohol.

RESULTS

A total of 3818 patients died (62.1% of cardiovascular disease) during 30 (median 12.5) years of follow-up. Compared with a BMI of 18.5 to 22.4 kg/m², BMI categories of 25.0 to 27.4 kg/m², 27.5 to 29.9 kg/m², and 30.0 to 34.9 kg/m² had reduced all-cause mortality risk: HR, 0.80; 95% confidence interval (CI), 0.72-0.90; HR, 0.80; 95% CI, 0.71-0.90; HR, 0.83; 95% CI, 0.74-0.95, respectively. The BMI categories 25.0 to 27.4 kg/m² and 27.5 to 29.9 kg/m² had reduced cardiovascular disease mortality risk: HR, 0.81; 95% CI, 0.70-0.94; HR, 0.83; 95% CI, 0.71-0.96, respectively. Compared with physically inactive, all levels of physical activity were associated with reduced all-cause and cardiovascular disease mortality risk. In physically inactive, all BMI categories >25.0 kg/m² had reduced all-cause mortality risk (HRs across BMI categories: 0.77, 0.79, 0.79, 0.74), whereas in subjects who were following or exceeding the recommended level of physical activity, BMI was not associated with survival.

CONCLUSIONS

Overweight and obese subjects with coronary heart disease had reduced all-cause and cardiovascular disease mortality, but such an obesity paradox was seen only in participants who did not adhere to current recommendations of physical activity.

Polyphenol Levels Are Inversely Correlated with Body Weight and Obesity in an Elderly Population after 5 Years of Follow Up (The Randomised PREDIMED Study)

Overweight and obesity have been steadily increasing in recent years and currently represent a serious threat to public health. Few human studies have investigated the relationship between polyphenol intake and body weight. Our aim was to assess the relationship between urinary polyphenol levels and body weight. A cross-sectional study was performed with 573 participants from the PREDIMED (Prevención con Dieta Mediterránea) trial (ISRCTN35739639). Total polyphenol levels were measured by a reliable biomarker, total urinary polyphenol excretion (TPE), determined by the Folin-Ciocalteu method in urine samples. Participants were categorized into five groups according to their TPE at the fifth year. Multiple linear regression models were used to assess the relationships between TPE and obesity parameters; body weight (BW), body mass index (BMI), waist circumference (WC), and waist-to-height ratio (WHtR). After a five years follow up, significant inverse correlations were observed between TPE at the 5th year and BW (β = −1.004; 95% CI: −1.634 to −0.375, p = 0.002), BMI (β = −0.320; 95% CI: −0.541 to −0.098, p = 0.005), WC (β = −0.742; 95% CI: −1.326 to −0.158, p = 0.013), and WHtR (β = −0.408; 95% CI: −0.788 to −0.028, p = 0.036) after adjustments for potential confounders. To conclude, a greater polyphenol intake may thus contribute to reducing body weight in elderly people at high cardiovascular risk.

Obesity and Physical Activity

Some clinical manifestations of obesity include nonalcoholic fatty liver disease, type 2 diabetes, and cardiovascular disease. Calorie restriction may aid in weight loss in the short term. Exercise and physical activity are other means of weight loss. However, the efficacy of exercise and physical activity in weight reduction in obese populations is still unknown. In this review, we discuss the effects of exercise and physical activity in obese and overweight populations. We also discuss the effects of aerobic exercise and/or resistance training in weight loss and maintenance.

Healthy Living Medicine in the Workplace: More Work to Do

Non-communicable diseases (NCDs) are five of the top ten causes of death for Americans: cardiovascular disease (CVD), cancer, lower respiratory disease, stroke and diabetes mellitus. Risk factors for these NCDs and for CVD are tobacco use, poor diet quality, physical inactivity, increase body mass index, increased blood pressure, increased blood cholesterol, and glucose intolerance. Depression, depressive symptoms and anxiety also contribute to CVD risk. There is also evidence work stress itself contributes to CVD risk. By 2024 there is expected to be approximately 164 million workers in the US labor force and the share of older workers will likewise increase. Currently, about 25 million of those are over the age of 55, the age at which many diseases of lifestyle become clinically apparent. Furthermore, Americans spend as much as half of their waking hours at work. This makes the worksite an important target for the delivery of healthy living medicine.

Physical activity and obesity: what we know and what we need to know

Creating a negative energy balance by decreasing caloric consumption and increasing physical activity is a common strategy used to treat obesity. A large number of review and original research papers have considered the role of physical activity in weight loss and maintenance. However, their conclusions are at times conflicting. In this review, we have critically evaluated the findings of systematic reviews and meta-analyses and supplemented their conclusions with recently published, high-quality clinical trials. We have eliminated studies that were methodologically flawed in an attempt to reduce the ambiguity in the literature. We further sought, through selective review of these publications, to isolate the effects of various types of exercise, independent of dietary interventions, to further clarify their independent contributions. Thus, our review describes (i) combined calorie restriction with physical activity interventions, (ii) physical activity interventions without calorie restriction and (iii) the role of physical activity on maintenance of weight loss. Through this critical examination of the literature, we have provided conclusions to address certain ambiguities regarding the role of physical activity in obesity treatment that will inform clinical practice. We have also identified several long-standing gaps in knowledge that will inform future research.

Beliefs, Barriers and Facilitators to Physical Activity in Bariatric Surgery Candidates

BACKGROUND

Bariatric surgery candidates engage in less physical activity (PA) and spend longer periods in sedentary behaviour (SB) when compared to the general adult population. The aim of this study was to explore the beliefs about PA and perceived barriers and facilitators to PA in obese adults scheduled for bariatric surgery.

METHODS

Nineteen obese adults (15 females), with a mean (SD) age of 41.6 (12.1) years, weight of 119.2 (20.5) kg and body mass index of 41.6 (6.7) kg/m(2) participated in a one-on-one in-depth qualitative interview before undergoing bariatric surgery. Data were analysed using inductive thematic analysis.

RESULTS

Most participants believed that engaging in regular PA confers important health benefits, however reported insufficient PA levels to obtain those benefits. The perceived barriers to PA reported by participants were both obesity related (e.g. bodily pain, physical limitation and self-presentational concerns) and non-obesity related (e.g. lack of motivation, environment and restricted resources). All participants stated weight loss to be the main perceived facilitator to PA, together with social factors, better time management and access to financial resources.

CONCLUSIONS

In bariatric surgery candidates, many of the perceived barriers and facilitators to PA are not obesity related and are therefore unlikely to change as a result of bariatric surgery. This may explain why earlier research shows little change in PA or SB following surgery. It is likely that an approach that aims to address the barriers and facilitators identified in this study is needed to change the inactive lifestyle adopted in this population.

From the BMI paradox to the obesity paradox: the obesity-mortality association in coronary heart disease

Despite a strong association between body weight and mortality in the general population, clinical evidence suggests better clinical outcome of overweight or obese individuals with established coronary heart disease. This finding has been termed the 'obesity paradox', but its existence remains a point of debate, because it is mostly observed when body mass index (BMI) is used to define obesity. Inherent limitations of BMI as an index of adiposity, as well as methodological biases and the presence of confounding factors, may account for the observed findings of clinical studies. In this review, our aim is to present the data that support the presence of a BMI paradox in coronary heart disease and then explore whether next to a BMI paradox a true obesity paradox exists as well. We conclude by attempting to link the obesity paradox notion to available translational research data supporting a 'healthy', protective adipose tissue phenotype. © 2016 World Obesity.

The CHANGE trial: no superiority of lifestyle coaching plus care coordination plus treatment as usual compared to treatment as usual alone in reducing risk of cardiovascular disease in adults with schizophrenia spectrum disorders and abdominal obesity

Life expectancy in patients with schizophrenia is reduced by 20 years for men and 15 years for women compared to the general population. About 60% of the excess mortality is due to physical illnesses, with cardiovascular disease being dominant. CHANGE was a randomized, parallel-group, superiority, multi-centre trial with blinded outcome assessment, testing the efficacy of an intervention aimed to improve cardiovascular risk profile and hereby potentially reduce mortality. A total of 428 patients with schizophrenia spectrum disorders and abdominal obesity were recruited and centrally randomized 1:1:1 to 12 months of lifestyle coaching plus care coordination plus treatment as usual (N=138), or care coordination plus treatment as usual (N=142), or treatment as usual alone (N=148). The primary outcome was 10-year risk of cardiovascular disease assessed post-treatment and standardized to age 60. At follow-up, the mean 10-year risk of cardiovascular disease was 8.4 ± 6.7% in the group receiving lifestyle coaching, 8.5 ± 7.5% in the care coordination group, and 8.0 ± 6.5% in the treatment as usual group (p=0.41). We found no intervention effects for any secondary or exploratory outcomes, including cardiorespiratory fitness, physical activity, weight, diet and smoking. In conclusion, the CHANGE trial did not support superiority of individual lifestyle coaching or care coordination compared to treatment as usual in reducing cardiovascular risk in patients with schizophrenia spectrum disorders and abdominal obesity.

Addition of Cardiorespiratory Fitness Within an Obesity Risk Classification Model Identifies Men at Increased Risk of All-Cause Mortality

OBJECTIVE

Guidelines for identification of obesity-related risk which stratify disease risk using specific combinations of body mass index and waist circumference. Whether the addition of cardiorespiratory fitness, an independent predictor of disease risk, provides better risk prediction of all-cause mortality within current body mass index and waist circumference categories is unknown. The study objective was to determine whether the addition of cardiorespiratory fitness improves prediction of all-cause mortality risk classified by the combination of body mass index and waist circumference.

METHODS

We performed a prospective observational study using data from the Aerobics Center Longitudinal Study. A total of 31,267 men (mean age, 43.9 years; standard deviation, 9.4 years) who completed a baseline medical examination between 1974 and 2002 were included. The main outcome measure was all-cause mortality. Participants were grouped using body mass index- and waist circumference-specific threshold combinations: normal body mass index: 18.5 to 24.9 kg/m(2), waist circumference threshold of 90 cm; overweight body mass index: 25.0 to 29.9 kg/m(2), waist circumference threshold of 100 cm, and obese body mass index: 30.0 to 34.9 kg/m(2), waist circumference threshold of 110 cm. Participants were classified using cardiorespiratory fitness as unfit or fit, where unfit was the lowest fifth of the age-specified distribution of maximal exercise test time on the treadmill among the entire Aerobics Center Longitudinal Study population.

RESULTS

A total of 1399 deaths occurred over a follow-up of 14.1 ± 7.4 years, for a total of 439,991 person-years of observation. Men who were unfit and had normal body mass index with waist circumference <90 cm and ≥90 cm had 95% (hazard ratio [HR], 1.95; 95% confidence interval [CI], 1.34-2.83) and 163% (HR, 2.63; 95% CI, 1.58-4.40) higher mortality risk than men who were fit, respectively (P <.05). Men who were unfit and overweight had 41% (HR, 1.41; 95% CI, 1.04-1.90) higher mortality risk with a waist circumference <100 cm (P <.05), but were at no greater risk (HR, 1.30; 95% CI, 0.92-1.84) if their waist circumference was ≥100 cm (P = .14). Men who were unfit and obese were not at increased mortality risk (HR, 1.37; 95% CI, 0.90-2.09) with a waist circumference <110 cm (P = .14), but were at 111% (HR, 2.11; 95% CI, 1.31-3.42) increased risk with a waist circumference ≥110 cm (P <.05).

CONCLUSIONS

For most of the body mass index and waist circumference categories, inclusion of cardiorespiratory fitness allowed for improved identification of men at increased mortality risk.