Obesity as a disease: a white paper on evidence and arguments commissioned by the Council of the Obesity Society

Assessing the state of obesity care: Quality, access, guidelines, and standards

Background

An international panel of obesity medicine experts from multiple professional organizations examined patterns of obesity care and current obesity treatment guidelines to identify areas requiring updating in response to emerging science and clinical evidence.

Aims

The panel focused on multiple medical health and societal issues influencing effective treatment of obesity and identified several unmet needs in the definition, assessment, and care of obesity.

Methods

The panel was held in Leesburg, Virginia in September 2019.

Results

The panelists recommended addressing these unmet needs in obesity medicine through research, education, evaluation of delivery and payment of care, and updating clinical practice guidelines (CPG) to better reflect obesity's pathophysiological basis and heterogeneity, as well as the disease's health, sociocultural, and economic complications; effects on quality of life; need for standards for quantitative comparison of treatment benefits, risks, and costs; and the need to more effectively integrate obesity treatment guidelines into routine clinical practice and to facilitate more direct clinician participation to improve public understanding of obesity as a disease with a pathophysiological basis. The panel also recommended that professional organizations working to improve the care of people with obesity collaborate via a working group to develop an updated, patient-focused, comprehensive CPG establishing standards of care, addressing identified needs, and providing for routine, periodic review and updating.

Conclusions

Unmet needs in the definition, assessment and treatment of obesity were identified and a blueprint to address these needs developed via a clinical practice guideline that can be utilized worldwide to respond to the increasing prevalence of obesity.

Digital Biohacking Approach to Dietary Interventions: A Comprehensive Strategy for Healthy and Sustainable Weight Loss

The rising obesity epidemic requires effective and sustainable weight loss intervention strategies that take into account both of individual preferences and environmental impact. This study aims to develop and evaluate the effectiveness of an innovative digital biohacking approach for dietary modifications in promoting sustainable weight loss and reducing carbon footprint impact. A pilot study was conducted involving four participants who monitored their weight, diet, and activities over the course of a year. Data on food consumption, carbon footprint impact, calorie intake, macronutrient composition, weight, and energy expenditure were collected. A digital replica of the metabolism based on nutritional information, the Personalized Metabolic Avatar (PMA), was used to simulate weight changes, plan, and execute the digital biohacking approach to dietary interventions. The dietary modifications suggested by the digital biohacking approach resulted in an average daily calorie reduction of 236.78 kcal (14.24%) and a 15.12% reduction in carbon footprint impact (-736.48 gCO2eq) per participant. Digital biohacking simulations using PMA showed significant differences in weight change compared to actual recorded data, indicating effective weight reduction with the digital biohacking diet. Additionally, linear regression analysis on real data revealed a significant correlation between adherence to the suggested diet and weight loss. In conclusion, the digital biohacking recommendations provide a personalized and sustainable approach to weight loss, simultaneously reducing calorie intake and minimizing the carbon footprint impact. This approach shows promise in combating obesity while considering both individual preferences and environmental sustainability.

Describing the views of Canadian post-secondary students in health-related disciplines on the recognition of obesity as a chronic disease

OBJECTIVE

This cross-sectional study examined students' perspectives on the ramifications of obesity being recognized as a chronic disease in Canada.

PARTICIPANTS

Undergraduate and graduate students (n = 150) in health-related programs at a major Canadian university.

METHODS

An online survey featured open-ended questions to capture student perspectives on recognizing obesity as a disease. Data were evaluated using content analysis methods.

RESULTS

Positive themes identified included: (a) treatment accessibility; (b) improved healthcare provider attitudes; (c) de-stigmatization of obesity; (d) promotion of health behaviors; and (e) greater research/funding. Negative themes included potential: (a) healthcare system burdens; (b) perpetuation of obesity stigma; (c) medicalization of obesity; and (d) de-emphasis on modifiable risk factors as contributing to obesity.

CONCLUSIONS

There is a need to increase students' understanding of the multifaceted nature of obesity and the prevention of obesity-related stigma within healthcare. Findings may inform post-secondary health curricula and obesity initiatives.

Age-related disgust responses to signs of disease

Previous studies found similarities in adults' disgust responses to benign (e.g. obesity) and actual disease signs (e.g. influenza). However, limited research has compared visual (i.e. benign and actual) to cognitive (i.e. disease label) disease cues in different age groups. The current study investigated disgust responses across middle childhood (7-9 years), late childhood (10-12 years), adolescence (13-17 years), and adulthood (18+ years). Participants viewed individuals representing a benign visual disease (obese), sick-looking (staphylococcus), sick-label (cold/flu), and healthy condition. Disgust-related outcomes were: (1) avoidance, or contact level with apparel the individual was said to have worn, (2) disgust facial reactions, and (3) a combination of (1) and (2). Avoidance was greater for the sick-looking and sick-label than the healthy and obese conditions. For facial reaction and combination outcomes, middle childhood participants responded with greater disgust to the sick-looking than the healthy condition, while late childhood participants expressed stronger disgust towards the sick-looking and obese conditions than the healthy condition. Adolescents and adults exhibited stronger disgust towards sick-label and sick-looking than obese and healthy conditions. Results suggest visual cues are central to children's disgust responses whereas adolescents and adult responses considered cognitive cues.

Predicting short-term thromboembolic risk following Roux-en-Y gastric bypass using supervised machine learning

BACKGROUND

Roux-en-Y gastric bypass (RYGB) is a widely recognized bariatric procedure that is particularly beneficial for patients with class III obesity. It aids in significant weight loss and improves obesity-related medical conditions. Despite its effectiveness, postoperative care still has challenges. Clinical evidence shows that venous thromboembolism (VTE) is a leading cause of 30-d morbidity and mortality after RYGB. Therefore, a clear unmet need exists for a tailored risk assessment tool for VTE in RYGB candidates.

AIM

To develop and internally validate a scoring system determining the individualized risk of 30-d VTE in patients undergoing RYGB.

METHODS

Using the 2016-2021 Metabolic and Bariatric Surgery Accreditation Quality Improvement Program, data from 6526 patients (body mass index ≥ 40 kg/m2) who underwent RYGB were analyzed. A backward elimination multivariate analysis identified predictors of VTE characterized by pulmonary embolism and/or deep venous thrombosis within 30 d of RYGB. The resultant risk scores were derived from the coefficients of statistically significant variables. The performance of the model was evaluated using receiver operating curves through 5-fold cross-validation.

RESULTS

Of the 26 initial variables, six predictors were identified. These included a history of chronic obstructive pulmonary disease with a regression coefficient (Coef) of 2.54 (P < 0.001), length of stay (Coef 0.08, P < 0.001), prior deep venous thrombosis (Coef 1.61, P < 0.001), hemoglobin A1c > 7% (Coef 1.19, P < 0.001), venous stasis history (Coef 1.43, P < 0.001), and preoperative anticoagulation use (Coef 1.24, P < 0.001). These variables were weighted according to their regression coefficients in an algorithm that was generated for the model predicting 30-d VTE risk post-RYGB. The risk model's area under the curve (AUC) was 0.79 [95% confidence interval (CI): 0.63-0.81], showing good discriminatory power, achieving a sensitivity of 0.60 and a specificity of 0.91. Without training, the same model performed satisfactorily in patients with laparoscopic sleeve gastrectomy with an AUC of 0.63 (95%CI: 0.62-0.64) and endoscopic sleeve gastroplasty with an AUC of 0.76 (95%CI: 0.75-0.78).

CONCLUSION

This simple risk model uses only six variables to assist clinicians in the preoperative risk stratification of RYGB patients, offering insights into factors that heighten the risk of VTE events.

Can eating behaviour traits be explained by underlying, latent factors? An exploratory and confirmatory factor analysis

Eating Behaviour Traits (EBTs) are psychological constructs developed to explain patterns of eating behaviour, including factors that motivate people to (over or under) eat. There is a need to align and clarify their unique contributions and harmonise the understanding they offer for human eating behaviour. Therefore, the current study examined whether 18 commonly cited EBTs could be explained by underlying, latent factors (domains of eating behaviour). An exploratory factor analysis (EFA) was used to identify latent factors, and these factors were validated using a confirmatory factor analysis (CFA). 1279 participants including the general public and members of a weight management programme were included in the analysis (957 females, 317 males, 3 others, 2 prefer not to say), with a mean age of 54 years (median = 57 years, SD = 12.03) and a mean BMI of 31.93 kg/m2 (median = 30.86, SD = 6.00). The participants completed 8 questionnaires which included 18 commonly cited EBTs and the dataset was split at random with a 70/30 ratio to conduct the EFA (n = 893) and CFA (n = 383). The results supported a four-factor model which indicated that EBTs can be organised into four domains: reactive, restricted, emotional, and homeostatic eating. The four-factor model also significantly predicted self-reported BMI and weight change. Future research should test whether this factor structure is replicated in more diverse populations, and including other EBTs, to advance these domains of eating as a unifying framework for studying individual differences in human eating behaviour.

Consensus on pharmacological treatment of obesity in Latin America

A panel of 10 experts in obesity from various Latin American countries held a Zoom meeting intending to reach a consensus on the use of anti-obesity medicines and make updated recommendations suitable for the Latin American population based on the available evidence. A questionnaire with 16 questions was developed using the Patient, Intervention, Comparison, Outcome (Result) methodology, which was iterated according to the modified Delphi methodology, and a consensus was reached with 80% or higher agreement. Failure to reach a consensus led to a second round of analysis with a rephrased question and the same rules for agreement. The recommendations were drafted based on the guidelines of the American College of Cardiology Foundation/American Heart Association Task Force on Practice. This panel of experts recommends drug therapy in patients with a body mass index of ≥30 or ≥27 kg/m2 plus at least one comorbidity, when lifestyle changes are not enough to achieve the weight loss objective; alternatively, lifestyle changes could be maintained while considering individual parameters. Algorithms for the use of long-term medications are suggested based on drugs that increase or decrease body weight, results, contraindications, and medications that are not recommended. The authors concluded that anti-obesity treatments should be individualized and multidisciplinary.

Diagnosing social ills: Theorising social determinants of health as a diagnostic category

Medicine, as an institution and discipline, has embraced social determinants of health as a key influence on clinical practice and care. Beyond simply acknowledging their importance, most recent versions of the International Classification of Diseases explicitly codify social determinants as a viable diagnostic category. This diagnostic shift is noteworthy in the United States, where 'Z-codes' were introduced to facilitate the documentation of illiteracy, unemployment, poverty and other social factors impacting health. Z-codes hold promise in addressing patients' social needs, but there are likely consequences to medicalising social determinants. In turn, this article provides a critical appraisal of Z-codes, focussing on the role of diagnoses as both constructive and counterproductive sources of legitimacy, knowledge and responsibility in our collective understanding of health. Diagnosis codes for social determinants are powerful bureaucratic tools for framing and responding to psychosocial risks commensurate with biophysiological symptoms; however, they potentially reinforce beliefs about the centrality of individuals for addressing poor health at the population level. I contend that Z-codes demonstrate the limited capacity of diagnoses to capture the complex individual and social aetiology of health, and that sociology benefits from looking further 'upstream' to identify the structural forces constraining the scope and utility of diagnoses.

Comparisons of Explicit Weight Bias Across Common Clinical Specialties of US Resident Physicians

BACKGROUND

Patients with high body weight are persistently stigmatized in medical settings, with studies demonstrating that providers endorse negative stereotypes of, and have lower regard for, higher-weight patients. Very little is known about how this weight bias varies across specialties.

OBJECTIVE

The purpose of this study is to examine how explicit weight bias varies between resident providers among sixteen of the largest residency specialties in the USA. The identification of these differences will guide the prioritization and targeting of interventions.

DESIGN

The current study utilized cross-sectional, observational data.

PARTICIPANTS

Forty-nine allopathic medical schools were recruited to participate in this national, longitudinal study. The current study utilized data from 3267 trainees in Year 2 of Residency among those who specialized in one of the most common sixteen residency programs in 2016.

MAIN MEASURES

Participants reported demographic information and residency specialties and completed three sets of measures pertaining to explicit weight bias.

KEY RESULTS

A significant minority (13-48%) of residents reported slight-to-strong agreement with each anti-fat statement. There was a significant relationship between residency specialty and anti-fat blame (F(15, 3189 = 12.87, p < .001), η2 = .06), anti-fat dislike (F(15, 3189 = 7.01, p < .001), η2 = .03), and attitudes towards obese patients (F(15, 3208 = 17.78, p < .001), η2 = .08). Primary care residents (e.g., family medicine, pediatrics) consistently reported lower levels of weight bias than those in specialty programs (e.g., orthopedic surgery, anesthesiology).

CONCLUSIONS

This study is the first to report on weight bias in a large, heterogeneous sample of US resident physicians. Problematic levels of weight bias were found in all specialties, with residents in specialty programs generally reporting more bias than those in primary care residencies. Future research should examine which factors contribute to these differences to guide intervention.

Collaborative Prescribing Practice in Managing Patients Post-Bariatric Surgery in a Tertiary Centre in Singapore

Background: A collaborative prescribing (CP) practice model, established by the endocrinologists, pharmacists, and advanced practice nurses, aims to provide for the postoperative monitoring and medical and nutritional management of stable patients after bariatric surgery. Method: Under the CP agreement, endocrinologists refer patients who have undergone bariatric surgery with stable medical conditions to CP practitioners, comprising senior pharmacists and advanced practice nurses. CP practitioners review the patient's weight loss progress, blood test results and vitals, the sufficiency of micronutrient repletion, adherence to supplements and medications, and chronic disease control. CP practitioners can prescribe and adjust the medications and supplements, in accordance with a clinical evaluation and standard guidance. Patients who require immediate attention due to complications or red flags are referred to the primary endocrinologist for further management. Results: From 5 May 2020 to 30 September 2023, CP practitioners provided 672 consultations. At least 68% and 80% of patients achieved appropriate weight loss post-surgery during the acute and maintenance phases, respectively. Less than 10% of the patients presented with anaemia and iron deficiency, and vitamin B12, folate and vitamin D deficiency. More than 80% of patients achieved a HbA1c of less than 7%. Conclusions: The CP practice framework provides a sustainable and viable model to facilitate optimal outcomes after bariatric surgery.

Psychological interventions for weight reduction and sustained weight reduction in adults with overweight and obesity: a scoping review protocol

INTRODUCTION

Overweight and obesity are growing public health problems worldwide. Both diet and physical activity have been the primary interventions for weight reduction over the past decade. With increasing rates of overweight and obesity, it is evident that a primary focus on diet and exercise has not resulted in sustained obesity reduction within the global population. There is now a case to explore other weight management strategies, focusing on psychological factors that may underpin overweight and obesity. Psychological therapy interventions are gaining recognition for their effectiveness in addressing underlying emotional factors and promoting weight loss. However, there is a dearth of literature that has mapped the types of psychological interventions and the characteristics of these interventions as a means of achieving weight reduction and sustained weight reduction in adults with overweight or obesity.

METHODS AND ANALYSIS

The review will combine the methodology outlined by Arksey and O'Malley with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. A total of six databases will be searched using a comprehensive search strategy. Intervention studies will be included if participants are 18 years and over, classified as overweight or obese (body mass index ≥25 kg/m2), and have received a psychological therapy intervention. The review will exclude studies that are not available in English, not full text, none peer reviewed or combine a lifestyle and/or pharmacological intervention with a psychological intervention. Data will be synthesised using a narrative synthesis approach.

ETHICS AND DISSEMINATION

Ethical approval is not required to conduct this scoping review. The findings will be disseminated through journal publication(s), social media and a lay summary for key stakeholders.

Identification of hits as anti-obesity agents against human pancreatic lipase via docking, drug-likeness, in-silico ADME(T), pharmacophore, DFT, molecular dynamics, and MM/PB(GB)SA analysis

Obesity, characterized by excessive fat accumulation, is a major health concern. Inhibition of human pancreatic lipase, an enzyme involved in fat digestion, offers a potential strategy for weight loss and obesity treatment. This study aimed to identify polyphenols capable of forming stable complexes with human pancreatic lipase to block its activity. Molecular docking, density functional theory (DFT), molecular dynamics (MD) simulations, and MMPBGBSA calculations were employed to evaluate ligand binding, stability, and energy profiles. Pharmacophore modeling was also performed to identify key structural features for effective inhibition. Virtual screening identified ZINC000015120539, ZINC000000899200, ZINC000001531702, and ZINC000013340267 as potential candidates, exhibiting favorable binding and stable interactions over 100 ns MD simulations. These findings provide insights into the inhibitory potential of selected polyphenols on human pancreatic lipase and support further experimental investigations for obesity treatment.Communicated by Ramaswamy H. Sarma.

Change in the food environment and measured adiposity in adulthood in the Christchurch Health and development birth cohort, Aotearoa, New Zealand: A birth cohort study

This study investigated associations between change in the food environment and change in measured body mass index (BMI) and waist circumference (WC) in the Christchurch Health and Development Study (CHDS) birth cohort. Our findings suggest that cohort members who experienced the greatest proportional change towards better access to fast food outlets had the slightly larger increases in BMI and WC. Contrastingly, cohort members who experienced the greatest proportional change towards shorter distance and better access to supermarkets had slightly smaller increases in BMI and WC. Our findings may help explain the changes in BMI and WC at a population level.

Integrated bioinformatics and statistical approach to identify the common molecular mechanisms of obesity that are linked to the development of two psychiatric disorders: Schizophrenia and major depressive disorder

Obesity is a chronic multifactorial disease characterized by the accumulation of body fat and serves as a gateway to a number of metabolic-related diseases. Epidemiologic data indicate that Obesity is acting as a risk factor for neuro-psychiatric disorders such as schizophrenia, major depression disorder and vice versa. However, how obesity may biologically interact with neurodevelopmental or neurological psychiatric conditions influenced by hereditary, environmental, and other factors is entirely unknown. To address this issue, we have developed a pipeline that integrates bioinformatics and statistical approaches such as transcriptomic analysis to identify differentially expressed genes (DEGs) and molecular mechanisms in patients with psychiatric disorders that are also common in obese patients. Biomarker genes expressed in schizophrenia, major depression, and obesity have been used to demonstrate such relationships depending on the previous research studies. The highly expressed genes identify commonly altered signalling pathways, gene ontology pathways, and gene-disease associations across disorders. The proposed method identified 163 significant genes and 134 significant pathways shared between obesity and schizophrenia. Similarly, there are 247 significant genes and 65 significant pathways that are shared by obesity and major depressive disorder. These genes and pathways increase the likelihood that psychiatric disorders and obesity are pathogenic. Thus, this study may help in the development of a restorative approach that will ameliorate the bidirectional relation between obesity and psychiatric disorder. Finally, we also validated our findings using genome-wide association study (GWAS) and whole-genome sequence (WGS) data from SCZ, MDD, and OBE. We confirmed the likely involvement of four significant genes both in transcriptomic and GWAS/WGS data. Moreover, we have performed co-expression cluster analysis of the transcriptomic data and compared it with the results of transcriptomic differential expression analysis and GWAS/WGS.

Pharmaceutical Therapies for the Treatment of Obesity: A Network Meta-analysis

PURPOSE

Despite the introduction of various pharmaceutical therapies for treating obesity, selecting the optimal treatment remains challenging for both patients and physicians. Therefore, in this network meta-analysis (NMA), we aim to simultaneously compare the available drugs for treating obesity to determine the most effective treatment options.

METHODS

International databases, including PubMed, Web of Science, Scopus, Cochrane Library, and Embase, were searched for studies published from database inception to April 2023. The consistency assumption was evaluated using by the loop-specific and design × treatment interaction approaches. The effects of treatment in the NMA were summarized using mean differences based on a change score analysis. The random-effects model was used to report the results. Results were reported with 95% CIs.

FINDINGS

Of 9519 retrieved references, 96 randomized controlled trials, including 68 with both men and women, 23 with women only, and 5 with men only, met the eligibility criteria for this study. There were 4 treatment networks in the trials of both men and women, 4 in the trials of women only, and 1 in the trials of men only. The best-ranked treatments in the network in the trials of both men and women were (1) semaglutide, 2.4 mg (P-score = 0.99); (2) hydroxycitric acid, 4667 mg 3 times daily, supervised walking, and 2000-kcal/d diet (P-score = 0.92); (3) phentermine hydrochloride and behavioral therapy (P-score = 0.92); and (4) liraglutide plus advice to diet and exercise (P-score = 1.00). In women, the best-ranked treatments were beloranib (P-score = 0.98) and sibutramine, metformin, and hypocaloric diet (P-score = 0.90). In men, there was no significant difference among treatments.

IMPLICATIONS

According to the results of this NMA, semaglutide seems to be an effective treatment option for both men and women, whereas beloranib appears to be particularly effective for women with obesity and overweight, but its production has been stopped since 2016 and is not available.

What is Obesity?: Definition as a Disease, with Implications for Care

Advances in the understanding of weight regulation provide the framework for the recognition of obesity as a chronic disease. Lifestyle approaches are foundational in the prevention of obesity and should be continued while weight management interventions, including antiobesity medications and metabolic-bariatric procedures, are offered to eligible patients. Clinical challenges remain, however, including overcoming obesity stigma and bias within the medical community toward medical and surgical approaches, ensuring insurance coverage for obesity management (including medications and surgery), and promoting policies that reverse the upward worldwide trend in obesity and adiposity complications in populations.

Inflammatory biomarkers in overweight and obese Iranian women are associated with polyphenol intake

BACKGROUND

The evidence shows that obesity is associated with chronic inflammation in obese subjects. Polyphenols are a complex group of plant secondary metabolites that may play a role in reducing the risk of obesity and obesity-related diseases. Given the scarcity of evidence on the association between inflammatory markers and dietary polyphenols intake in overweight/obese Iranian women, the current study aims to investigate this link.

METHOD

The present cross-sectional study was conducted on 391 overweight and obese Iranian women aged 18-48 years (body mass index (BMI) ≥ 25 kg/m²). A 147-item food frequency questionnaire (FFQ) was used to assess dietary intake, as well as anthropometric indices including weight, height, waist circumference (WC), and hip circumference (HC) and biochemistry parameters including triglyceride (TG), total cholesterol (Chole), low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), serum glutamic pyruvic transaminase (SGPT), serum glutamic-oxaloacetic transaminase (SGOT), galactin-3 (Gal-3), monocyte chemoattractant protein-1 (MCP-1), transforming growth factor beta (TGF-β), interleukin-1 beta (IL_1β), plasminogen activator inhibitor-1 (PA-I), serum leptin concentrations, and C-reactive protein of high sensitivity (hs-CRP) in all participants. The inflammatory markers were assessed using the enzyme-linked immunosorbent assay (ELISA).

RESULT

The findings revealed a significant negative association between flavonoids intake and MCP-1 (P = 0.024), lignans intake and MCP-1 (P = 0.017), and Gal-3 (P = 0.032). These significant associations were observed between other polyphenols intake and IL_1β (P = 0.014). There was also a significant positive association between other polyphenol intake and TGF-β (P = 0.008) and between phenolic acid intake and TGF-β (P = 0.014).

CONCLUSION

Our findings suggest that a high polyphenol intake may help individuals to reduce systemic inflammation. Further large studies involving participants of different ages and genders are highly warranted.

Explaining adult obesity, severe obesity, and BMI: Five decades of change

Obesity rates have increased across all segments of society since the late 1970s, but the reason behind population-level increases in body weight remains unclear. We used the 1971-2020 NHANES data to examine whether the observed trend in obesity prevalence is attributable to changing public health behaviors (i.e., intracohort change) or changing publics (i.e., cohort replacement). We partitioned total change in mean BMI, and rates of obesity and severe obesity, into its IC and CR components using linear and algebraic decomposition methods. We found that the IC mechanism (i.e., broad sectors of individuals changing) plays a dominant role in the overall increase in mean BMI, and obesity and severe obesity prevalence. Birth cohort membership (i.e., the CR mechanism) is also influencing mean BMI, and rates of obesity and severe obesity, but in differing ways. Specifically, the large positive IC and the small positive CR effects are amplifying one another, thus creating a steep increase in the observed rates of severe obesity. Conversely, the large positive IC effect is offset by a small negative CR effect, which created a more gradual rise in mean BMI and rates of obesity. Furthermore, we computed total change for models that entered separately sociodemographic, lifestyle, nutritional, and physical activity measures to estimate differences in mean BMI, and rates of obesity and severe obesity, among cohorts and time periods. Adjustment for all the compositional differences among the cohorts during the study period indicate that a combination of a more pronounced IC and a less pronounced CR drove the observed increase in mean BMI, and rates of obesity and severe obesity. Thus, "universal prevention" (i.e., entire community) strategies for healthy weight promotion may need to be combined with "selective prevention" (i.e., at-risk groups) and/or "targeted prevention" (i.e., at-risk individuals) approaches in order to reverse the obesity epidemic.

Improvement in Nasal Obstruction and Quality of Life after Nasal Septoplasty with Turbinoplasty: A Pre- and Post-study

Introduction Septoplasty and turbinoplasty are common surgical interventions used to relieve nasal obstructive symptoms. Since it is difficult to measure the degree of nasal blockage, current literature wonders about the frequent performance of these procedures.

Objective To evaluate the perceived change in the nasal obstruction and the quality of life (QoL) of patients that underwent a septoplasty along with a turbinoplasty by applying subjective scales, to describe the correlation between those scales, and to study the impact of clinical factors in the postoperative outcomes.

Methods Prospective observational study. The Nasal Obstruction Symptom Evaluation (NOSE), the Visual Analog Scale (VAS), and the Glasgow Benefit Inventory (GBI) were assessed. The paired sample Wilcoxon test was used to evaluate the difference between the pre- and postoperative surveys. The correlation coefficient between the subjective scales was calculated. A quantile regression was performed to evaluate the effect of surgery on the results adjusted for clinical and demographic variables.

Results A total of 115 patients were interviewed. Postoperative NOSE scores were 45 points lower (95% confidence interval [CI]: - 53.53–- 35.46; p < 0.001) in comparison with the NOSE preoperative scores. Obesity was the only statistically significant factor associated with worse outcomes. Additionally, we found a high correlation between the NOSE and VAS scores and a negative correlation between the GBI and postoperative VAS scores.

Conclusion Nasal septoplasty, when paired with a turbinoplasty, decreases nasal obstruction and improves QoL. Obesity was associated with worse results. There was a strong correlation between the NOSE and the VAS results and between the GBI and postoperative VAS results.

Tirzepatide for the treatment of obesity: Rationale and design of the SURMOUNT clinical development program

OBJECTIVE

Obesity is a growing global concern compounded by limited availability of effective treatment options. The SURMOUNT development program aims to evaluate the efficacy and safety of tirzepatide as an adjunct to lifestyle intervention compared with placebo on chronic weight management in adults with BMI ≥ 27 kg/m² with or without type 2 diabetes.

METHODS

The SURMOUNT program includes four global phase 3 trials NCT04184622 (SURMOUNT-1), NCT04657003 (SURMOUNT-2), NCT04657016 (SURMOUNT-3), and NCT04660643 (SURMOUNT-4). Participants are randomized to once-weekly subcutaneous tirzepatide versus placebo in a double-blind manner. The primary end point in all trials is the percentage change in body weight from randomization to end of treatment. Results for the primary end point for SURMOUNT-1 were published recently and results for the other trials are expected in 2023.

RESULTS

Across trials, participants have a mean age of 44.9 to 54.2 years, are mostly female (50.7% to 69.7%), and have a mean BMI of 36.1 to 38.9.

CONCLUSIONS

The extensive assessment of once-weekly tirzepatide in the global SURMOUNT program will detail the clinical effects of this first-in-class glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 receptor agonist in chronic weight management.

Early Vascular Aging in Obese Individuals with Low Cardiovascular Health

INTRODUCTION

The American Heart Association updated the original recommendations for cardiovascular health (CVH) promotion, defining the Life's Essential 8 (L8).

AIM

the aim of this cross-sectional study was to compare vascular function, central hemodynamics and autonomic modulation in obese individuals with low and moderate CVH-L8.

METHODS

Both sexes, aged 40-70 years and Body Mass Index ≥ 30 and < 40 kg/m², were submitted to anthropometric and biochemical evaluation, assessment of heart rate variability, endothelial function by flow-mediated dilatation (FMD) and central parameters by oscillometry. The CVH-L8 score was determined using the eight metrics defined in the new classification.

RESULTS

Patients (n = 82) were divided according to CVH-L8 classification: moderate group (score CVH-L8 ≥ 50 ≤ 79 points, n = 47) and low group (score CVH-L8 ≤ 49 points, n = 35). Peripheral (119 ± 10 vs 125 ± 15 mmHg, p = 0.048) and central (111 ± 10 vs 118 ± 15 mmHg; p = 0.016) systolic blood pressures and pulse wave velocity (PWV) adequacy (- 0.08 ± 0.34 vs 0.15 ± 0.42 m/s, p = 0.008) were significantly higher in low CVH-L8 group. Brachial FMD (9.24 ± 5.41 vs 6.79 ± 4.74%, p = 0.043) were lower in this same group. Only in the low CVH-L8 group low frequency/high frequency (LF/HF) ratio was significantly correlated with PWV (r = 0.338, p = 0.047) and atherogenic index of plasma with Framingham risk score (r = 0.446, p = 0.008), even after adjustment for age and sex.

CONCLUSION

In this sample of obese individuals, low CVH-L8 was associated with higher peripheral and central blood pressures, and evidence of early vascular aging with arterial stiffness and endothelial dysfunction.

Acceptance and Commitment Therapy and Weight-Related Difficulties in Overweight and Obese Adults: A Systematic Review

Multiple studies have investigated the efficacy of acceptance and commitment therapy (ACT) in improving psychological flexibility among overweight and obese individuals. However, to date, no specific reviews have focused on ACT and weight-related difficulties in this population. This systematic review of the literature aims to identify and assemble all ACT interventions in randomized controlled trials (RCT) that address weight-related difficulties in the treatment of overweight and obese adults. The PRISMA 2020 framework was used for the systematic review, includes manual and computerized database searches. Five databases (Medline, PubMed, Scopus, PsycInfo, and Google) were utilized to gather all articles that: (a) published in English; (b) adopted the RCT design; (c) used ACT as an intervention; (d) included adult participants aged over 18 years with BMI of over 25 kg/m2, and (e) included weight-related difficulties and weight as outcome measures. The review identified seven studies comprising 698 overweight or obese participants of both genders. Improvements were reported in weight-related difficulties and percentage of weight loss in the ACT group and the non-ACT group. The present review supports ACT as an effective intervention that can help adults with weight-related difficulties and excess body weight. Further studies should be conducted in various overweight or obese populations with a more systematic RCT research design to establish the effectiveness of ACT in this area.

How conceptualizing obesity as a disease affects beliefs about weight, and associated weight stigma and clinical decision-making in health care

OBJECTIVES

This study empirically investigated how conceptualizing obesity as a disease (i.e., pathologizing obesity) affects beliefs about weight, and weight stigma and discrimination among health professionals.

DESIGN

An experiment that manipulated the pathologization of obesity was completed by a multi-nation sample of health professionals from Australia, UK, and USA (N = 365).

METHODS

Participants were randomly assigned to one of two conditions where they were asked to conceptualize obesity as a disease or not a disease; then presented with a hypothetical medical profile of a patient with obesity who was seeking care for migraines. We measured biogenetic causal beliefs about obesity, endorsement of weight as a heuristic for health, negative obesity stereotypes, and treatment decisions.

RESULTS

Participants in the disease (vs. non-disease) condition endorsed biogenetic causal beliefs more strongly and made more migraine-related treatment recommendations. No effect of the manipulation was found for the remaining outcomes. Biogenetic causal beliefs about obesity were associated with less weight stigma. Endorsing weight as a heuristic for health was associated with greater weight stigma and differential treatment recommendations focused more on the patient's weight and less on their migraines.

CONCLUSIONS

Pathologizing obesity may reinforce biogenetic explanations for obesity. Evidence demonstrates complex associations between weight-related beliefs and weight stigma and discrimination. Biogenetic causal beliefs were associated with less weight stigma, while endorsing weight as a heuristic for health was associated with greater weight stigma and differential treatment. Further research is needed to inform policies that can promote health without perpetuating weight-based rejection in health care.

Managing the moral expansion of medicine

Science and technology have vastly expanded the realm of medicine. The numbers of and knowledge about diseases has greatly increased, and we can help more people in many more ways than ever before. At the same time, the extensive expansion has also augmented harms, professional responsibility, and ethical concerns. While these challenges have been studied from a wide range of perspectives, the problems prevail. This article adds value to previous analyses by identifying how the moral imperative of medicine has expanded in three ways: (1) from targeting experienced phenomena, such as pain and suffering, to non-experienced phenomena (paraclinical signs and indicators); (2) from addressing present pain to potential future suffering; and (3) from reducing negative wellbeing (pain and suffering) to promoting positive wellbeing. These expansions create and aggravate problems in medicine: medicalization, overdiagnosis, overtreatment, risk aversion, stigmatization, and healthism. Moreover, they threaten to infringe ethical principles, to distract attention and responsibility from other competent agents and institutions, to enhance the power and responsibility of professionals, and to change the professional-beneficiary relationship. In order to find ways to manage the moral expansion of medicine, four traditional ways of setting limits are analyzed and dismissed. However, basic asymmetries in ethics suggest that it is more justified to address people’s negative wellbeing (pain and suffering) than their positive wellbeing. Moreover, differences in epistemology, indicate that it is less uncertain to address present pain and suffering than future wellbeing and happiness. Based on these insights the article concludes that the moral imperative of medicine has a gradient from pain and suffering to wellbeing and happiness, and from the present to the future. Hence, in general present pain and suffering have normative priority over future positive wellbeing.

Psychometric properties and measurement invariance across gender of the Italian version of the tempest self-regulation questionnaire for eating adapted for young adults

The prevalence of overweight and obesity in young adults has increased dramatically in recent decades. The unhealthy eating habits that develop at this time can often lead to negative health consequences in the future. It is therefore important to learn about self-regulation and self-control strategies and help young adults to have healthy eating behaviours. This study aims to present an Italian version of the Tempest Self-Regulation Questionnaire for Eating (TESQ-E) adapted for young adults. The instrument assesses self-regulation and self-control strategies to counteract the desire and temptation to eat unhealthy food and to choose healthy foods. A total of 645 students (271 males and 374 females with an average age of 24.82 and SD = 4.34) took part in the study. The results of the confirmatory factor analysis supported the six first-order factors model concerning specific self-regulation strategies and a higher-order structure of the TESQ-E [χ² (152) = 336.480, p < 0.001; CFI = 0.95; RMSEA = 0.04; SRMR = 0.04]: three correlated second-order factors (addressing the temptation directly, addressing the psychological meaning of temptation, and addressing the goal directly) and one-third-order factor (self-regulatory competence). The results also confirmed the strong measurement invariance of the TESQ-E across gender. To have reliable comparisons across males and females, the latent mean differences tests were performed on the six specific self-regulation strategies. The analysis showed that females appear to prefer strategies that directly address the goal by expressing explicit intentions or plans to eat in a healthy way. Convergence validity was tested through correlations with Eating-Self-Efficacy Brief Scale (ESEBS), Emotional Eating Scale (EES), Scale of Attitudes towards Healthy Eating (SAHE), and Body Mass Index (BMI). In conclusion, the TESQ-E appears to be a psychometrically sound questionnaire that can be effectively used with young adults to measure self-regulation strategies in eating in order to plan personalised interventions for the prevention and control of the metabolic syndrome, and to reduce a wide range of diet-related diseases.

Sarcopenia: Body Composition and Gait Analysis

Background

Age-induced sarcopenia negatively affects walking stability and increases the risk of falls, which is the leading cause of accidental death in the elderly.

Objective

This study aimed to analyze and contrast body composition and gait characteristics in those with sarcopenia in relation to healthy controls to shed some light on the prevention of falls in elderly patients with sarcopenia.

Materials and Methods

In this study, 68 community dwellers were scanned by the Hologic QDR-4500A Dual-energy X-ray absorptiometry (DXA). The appendicular lean mass index (ALMI) results were used to distinguish the normal participants from those with sarcopenia: 24 in the sarcopenia group, and 44 into the normal group. The participants were asked to undergo gait analysis on a plantar pressure measurement system. Statistical analysis was conducted to contrast both groups' gait and butterfly parameters from their gait test, and then a gait forward dynamics method was performed to quantify the analysis for both groups.

Results

The ALMI of the female was not related to their age (r = 0.06) while that of the male was weakly related (r = 0.17). Body mass index (BMI) from both groups was normal, although with a statistically greater BMI from the normal group compared with sarcopenia (p &lt; 0.001). Greater values and significant differences were found in step length and stride length from the normal elderly group (p &lt; 0.01), and so was the length of the gait line and single support line (p &lt; 0.05). Gait forward dynamics analysis results showed no motor neural or musculoskeletal disorders in their gait performance from the sarcopenia group.

Conclusion

For the elderly, age did not largely affect the ALMI, BMI, or T-score, but BMI and ALMI were strongly correlated. In this study, significant differences were found in certain gait parameters between the elderly with sarcopenia and the normal elderly, which were related to absolute muscle strength, suggesting that sarcopenia was a disease mainly caused by decreased muscle mass. In addition, when abnormities were identified in step length, stride length, length of gait line, or length of single support line, it is proposed to take a DXA scan to confirm whether the elderly suffer from sarcopenia.

Is obesity in the brain? Parent perceptions of brain influences on obesity

Neuroimaging studies demonstrate associations of brain structure and function with children's eating behaviour and body weight, and the feasibility of integrating brain measures into obesity risk assessment and intervention is growing. However, little is known about lay perceptions of how the brain influences obesity. We investigated parent perceptions of brain contributions to obesity in three separate studies: 1) a study of mothers of adolescents recruited for neuroimaging research (n = 88), 2) a study of ethnically Chinese parents of 5-13 year olds participating in a parent feeding survey (n = 277), and 3) a study of parents of 3-15 year olds completing an online survey (n = 113). In general, parents believed that brain factors influence obesity, but considered them less influential than behaviours such as diet and exercise. Causal attributions for brain factors were correlated with attributions for genetic factors and biological factors (e.g., metabolism). Parents who perceived their child to be overweight or had a high concern about their child becoming overweight in the future rated brain factors as more important in determining their child's weight and more likely to lessen their child's ability to control their weight. Our results suggest that parents attribute obesity to the brain to a moderate degree, and that education or feedback regarding brain influences on obesity could be a promising obesity intervention component.

Acknowledging and addressing the many ethical aspects of disease

Diseases change the life of individuals, the social status of groups, the obligations of professionals, and the welfare of nations. Disease classifications function as a demarcation of access to care, rights, and duties. Disease also fosters social stigmatization and discrimination, and is a personal, professional, and political matter. It raises a wide range of ethical issues that are of utmost importance in patient communication and education. Accordingly, the objective of this article is to present and discuss a range of basic ethical aspects of this core concept of medicine and health care. First and foremost, disease evokes compassion for the person suffering and induces a moral impetus to health professionals and health policy makers to avoid, eliminate or ameliorate disease. The concept of disease has many moral functions, especially with respect to attributing rights and obligations. Classifying something as disease also has implications for the status and prestige of the condition as well as for the attitudes and behavior towards people with the condition. Acknowledging such effects is crucial for avoiding discrimination and good communication. Moreover, different perspectives on disease can create conflicts between patients, professionals and policy makers. While expanding the concept of disease makes it possible to treat many more people for more conditions - earlier, it also poses ethical challenges of doing more harm than good, e.g., in overdiagnosis, overtreatment, and medicalization. Understanding these ethical issues can be difficult even for health professionals, and communicating them to patients is challenging, but crucial for making informed consent. Accordingly, acknowledging and addressing the many specific ethical aspects of disease is crucial for patient communication and education.

Home Food Environment Changes and Dietary Intake during an Adolescent Behavioral Weight Loss Intervention Differ by Food Security Status

Behavioral weight loss (BWL) for pediatric obesity includes guidance on improving the home food environment and dietary quality; yet food insecurity presents barriers to making these changes. This study examined if home food environment, dietary quality, energy intake, and body weight changes during adolescent obesity treatment differed by food security status, and if changes in the home food environment were associated with changes in dietary quality and energy intake by food security status. Adolescents (n = 82; 13.7 ± 1.2 years) with obesity participated in a 4-month BWL treatment. Food insecurity, home food environment (Home Food Inventory [HFI]), dietary quality (Healthy Eating Index [HEI]), energy intake, and body mass index (BMI) were assessed at baseline and post-treatment. A reduced obesogenic home food environment and improved dietary quality were observed for food secure (ps < 0.01), but not insecure households (ps > 0.05) (mean difference, HFI: −6.6 ± 6.4 vs. −2.4 ± 7.4; HEI: 5.1 ± 14.4 vs. 2.7 ± 17.7). Energy intake and BMI decreased for adolescents in food secure and insecure households (ps < 0.03) (mean difference; energy intake: −287 ± 417 vs. −309 ± 434 kcal/day; BMI: −1.0 ± 1.4 vs. −0.7 ± 1.4). BWL yielded similar reductions in energy intake and body weight yet did not offer the same benefits for improved dietary quality and the home food environment for adolescents with food insecurity.

The Shades of Grey in Adipose Tissue Reprogramming

The adipose tissue (AT) has a major role in contributing to obesity-related pathologies through regulating systemic immunometabolism. The pathogenicity of the AT is underpinned by its remarkable plasticity to be reprogrammed during obesity, in the perspectives of tissue morphology, extracellular matrix (ECM) composition, angiogenesis, immunometabolic homoeostasis and circadian rhythmicity. Dysregulation in these features escalates the pathogenesis conferred by this endometabolic organ. Intriguingly, the potential to be reprogrammed appears to be an Achilles’ heel of the obese AT that can be targeted for the management of obesity and its associated comorbidities. Here, we provide an overview of the reprogramming processes of white AT (WAT), with a focus on their dynamics and pleiotropic actions over local and systemic homoeostases, followed by a discussion of potential strategies favouring therapeutic reprogramming. The potential involvement of AT remodelling in the pathogenesis of COVID-19 is also discussed.

Abdominal obesity phenotype is associated with COVID-19 chest X-ray severity score better than BMI-based obesity

PURPOSE

Chest X-ray (CXR) severity score and BMI-based obesity are predictive risk factors for COVID-19 hospital admission. However, the relationship between abdominal obesity and CXR severity score has not yet been fully explored.

METHODS

This retrospective cohort study analyzed the association of different adiposity indexes, including waist circumference and body mass index (BMI), with CXR severity score in 215 hospitalized patients with COVID-19.

RESULTS

Patients with abdominal obesity showed significantly higher CXR severity scores and had higher rates of CXR severity scores ≥ 8 compared to those without abdominal obesity (P < 0.001; P = 0.001, respectively). By contrast, patients with normal weight, with overweight and those with BMI-based obesity showed no significant differences in either CXR severity scores or in the rates of CXR severity scores ≥ 8 (P = 0.104; P = 0.271, respectively). Waist circumference and waist-to-height ratio (WHtR) correlated more closely with CXR severity scores than BMI (r = 0.43, P < 0.001; r = 0.41, P < 0.001; r = 0.17, P = 0.012, respectively). The area under the curves (AUCs) for waist circumference and WHtR were significantly higher than that for BMI in identifying a high CXR severity score (≥ 8) (0.68 [0.60-0.75] and 0.67 [0.60-0.74] vs 0.58 [0.51-0.66], P = 0.001). A multivariate analysis indicated abdominal obesity (risk ratio: 1.75, 95% CI: 1.25-2.45, P < 0.001), bronchial asthma (risk ratio: 1.73, 95% CI: 1.07-2.81, P = 0.026) and oxygen saturation at admission (risk ratio: 0.96, 95% CI: 0.94-0.97, P < 0.001) as the only independent factors associated with high CXR severity scores.

CONCLUSION

Abdominal obesity phenotype is associated with a high CXR severity score better than BMI-based obesity in hospitalized patients with COVID-19. Therefore, when visiting the patient in a hospital setting, waist circumference should be measured, and patients with abdominal obesity should be monitored closely. Level of evidence Cross-sectional descriptive study, Level V.

Disrupting Essentialism in Medical Genetics Education

Many traditional practices in medical genetics education need review to counteract messages of essentialism, or the belief in an underlying natural structure differentiating social categories. While genomics research increasingly disproves a genetic foundation for race, research from educational scholars demonstrates that current medical genetics instruction may actually reinforce racial bias in learners. In this monograph, we outline seven recommendations for medical educators to actively counteract essentialism, racial, and otherwise, in the genetics classroom. In particular, we emphasize the importance of engaging learners in nuanced discussions around stereotyping and its negative consequences for both accurate diagnoses and promoting health equity.

Not 'putting a name to it': Managing uncertainty in the diagnosis of childhood obesity

Childhood obesity is a challenging diagnosis. Children's body mass index (BMI) is an imprecise diagnostic of health, leading clinicians' interactions with patients and families to focus on the potential of future harm rather than the presence of infirmity or disease. This is complicated by emphasis on certainty in medical care; clinical diagnoses like childhood obesity are intended to help delineate good and bad health among patients. However, healthiness and wellbeing take on many meanings among individual children and families, especially in relation to weight. To better understand different forms of uncertainty and challenges in providing care, this study draws on 28 semi-structured interviews with U.S. health practitioners working with pediatric patients to examine strategies for communicating risk and defining success in the diagnosis and treatment of childhood obesity. Rather than focusing on patients' current BMIs or making the explicit diagnosis of obesity, clinicians turn to more optimistic prognoses emphasizing the gradual development of beliefs and behaviors that promote long-term physical, mental, and social health. This prognostic framework privileges the doctor-patient relationship over medical guidelines and protocols dictated by diagnoses, encouraging greater consideration of non-clinical factors shaping patients' health and weight. Clinicians expand their diagnostic framework and criteria to include information on the totality of patients' present and future lives, allowing for cognitively, emotionally, and socially attuned understanding of health and weight that is not focused on BMI. Critically, clinicians' awareness of the social etiology childhood obesity heightens their sense of futility about addressing it through clinical interventions, demonstrating the need for a diagnostic and treatment model that empowers doctors to look beyond the more proximate, biophysiological determinants of health.

The role of weight stigma in weight regain in bariatric surgery

Obesity is highly stigmatized, and individuals who undergo bariatric surgery are subject not only to weight stigma, but also to stigma related to the procedure itself. Patients lost to follow-up after surgery make estimating the amount of regain occurring after surgery difficult, and often patients fail to follow up due the shame of weight regain. Patients report difficulty following the diet necessary to maintain weight loss. Additionally, when they seek support after surgery, they often encounter stigmatizing messaging related to weight. Weight bias internalization, weight stigma, and stigma about having the surgery all contribute to feelings of social isolation, disordered eating, and reduced motivation to engage in physical activity. In this chapter, we present evidence for the impact of stigma on bariatric surgery outcomes and discuss the behavioral, physiological, and emotional processes that contribute to weight regain.

Fas signaling in adipocytes promotes low-grade inflammation and lung metastasis of colorectal cancer through interaction with Bmx

Obesity is a global public health issue. Obesity-related chronic low-grade inflammation (meta-inflammation) can lead to aberrant adipokine release and promote cardiometabolic diseases and obesity-related tumors. However, the mechanisms involved in the initiation of inflammatory responses in obesity and obesity-related tumors as well as metastasis are not fully understood. In this study, we found that the increased tumor necrosis factor-alpha (TNF-α) in adipocytes promoted the lung metastasis of MC38 colon cancer cells via Fas signaling. The release of TNF-α and interleukin (IL)-6 by Fas signaling in adipocytes was caused by the activation of the nuclear factor-kappa B (NF-κB) and mitogen-activated protein kinase (MAPK) pathways mediated by the interaction of Fas with Bmx, a non-receptor tyrosine kinase. Moreover, the Fas/Bmx complex is involved in the inflammation of adipocytes via Fas at the Tyr189 site and SH2 domain of Bmx. This is the first study to report the interaction between Fas and Bmx in adipocyte inflammation, which may provide clues for the development of potential new treatment strategies for obesity-related diseases.

Obesity is a chronic disease. Positioning statement of the Diabetes, Obesity and Nutrition Workgroup of the Spanish Society of Internal Medicine (SEMI) for an approach centred on individuals with obesity

BACKGROUND

Obesity is a chronic, complex and multifactorial metabolic disease involved in the development of chronic noncommunicable diseases such as type 2 diabetes mellitus, cardiovascular disease and cancer. The care of individuals with obesity is an essential part of the holistic approach provided by internal medicine to patients.

MATERIAL AND METHODS

Between September 2019 and January 2020, we distributed an online survey to the members of the Spanish Society of Internal Medicine. We prepared a Strengths, Weaknesses, Opportunities, and Threats analysis using the responses and, using the nominal group technique, developed the recommendations.

RESULTS

We obtained 599 responses. The respondents mean age was 44.4 ± 11 years, and 52.1% were women. Some 91.8% of the internists evaluate their patients to rule out the comorbidities associated with obesity, mainly type 2 diabetes mellitus (96.2%), cardiovascular disease (88.9%) and obesity-associated hypoventilation syndrome (73%), among others. Some 79.9% provided indications on lifestyle changes. Some 64.1% and 74.9% of the respondents knew the indications for the drugs and bariatric surgery, respectively. Some 93.8% and 83% of the respondents considered obesity and excess weight a chronic disease, and 88.7% considered it a disease of specific interest to internists, who should take an active and leading role in its treatment (85.3%).

CONCLUSIONS

The objective of the present document is to determine the degree of understanding and sensitivity of internists regarding the management of obesity and to develop a consensus of recommendations for the Spanish Society of Internal Medicine based on the scientific evidence and the opinion of its members.

The role of philosophy and ethics at the edges of medicine

BACKGROUND

The edge metaphor is ubiquitous in describing the present situation in the world, and nowhere is this as clearly visible as in medicine. "The edge of medicine" has become the title of books, scholarly articles, media headlines, and lecture series and seems to be imbued with hype, hope, and aversion. In order better to understand what is at stake at "the edge of medicine" this article addresses three questions: What does "the edge of medicine" mean in contemporary debates on modern medicine? What are the challenges "on the edge of medicine" (in these various meanings of "on the edge")? How can philosophy and ethics contribute with addressing these challenges?

METHODS

Literature searches in PubMed and Google Scholar are used to identify uses of the phrase "the edge of medicine" while conventional content analysis is used to analyze meanings of and challenges with "the edge of medicine." These results are then investigated with respect to how philosophy and ethics can address the identified challenges.

RESULTS

The literature reveals that "the edge of medicine" has many meanings, such as: Border; Margin (of life); Frontier; Forefront; Fringes; Plunge (abyss); Brink (verge); Conflict; and Balancing. In general, the various meanings address four basic challenges: setting limits, keeping control, make meaning, and handling conflicts or aporias. The analysis of each of the meanings of "the edge of medicine" identifies a wide range of important and urgent tasks for the humanities in general, and for philosophy and ethics in particular: 1) clarifying concepts; 2) clarifying assumptions and premises of arguments, methods, advice, and decisions; 3) elaborate new concepts and new theories; 4) conceptualize and handle uncertainty, moral regret, and residue; 5) reveal "the emperor's new clothes;" 6) identify trends and reflect on their implications; 7) demarcation; and 8) reflecting on goodness in medicine.

CONCLUSION

The phrase "the edge of medicine" expresses a wide range of challenges for modern health care. Together with other disciplines philosophy and ethics can and should make crucial contributions at "the edge of medicine," which is where the future of human beings and societies is created and formed.

Understanding the pathophysiologic pathways that underlie obesity and options for treatment

INTRODUCTION

Obesity is a chronic, multifactorial condition with devastating health consequences. It was thought that obesity could be controlled with discipline and lifestyle changes, but we now know that the underlying pathophysiology is a dysregulation of the body's energy balance system, controlled by a complex interplay of neural, hormonal, and metabolic pathways. Recognizing obesity as a chronic disease places a greater responsibility on all health care professionals to screen and identify patients at risk and develop long-term tailored treatment plans.

AREAS COVERED

This narrative review describes the central and peripheral pathways regulating obesity, the factors contributing to its development and how to effectively manage this disease.

EXPERT OPINION

Obesity is a disease with pathophysiologic mechanisms and should be treated accordingly to reduce the significant risk of morbidity and mortality. Lifestyle interventions remain the cornerstones of treatment; however, these measures alone are rarely enough for long-term maintenance of weight loss. Additional interventions, such as pharmacotherapy or bariatric surgery, are indicated for many patients and should be recommended. Treatment considerations should include assessment of comorbidities or risk factors, as many anti-obesity agents and bariatric surgeries also have beneficial effects on other weight-associated comorbidities.Plain language summary: This plain language summary highlights information from a recent scientific article about obesity. Obesity is a disease that leads to excess accumulation of body fat that may negatively affect health. People can check if they have obesity by measuring their body mass index (BMI for short). The BMI is a screening tool to see if you are at risk of obesity. Obesity is defined as a BMI of 30 kg/m2 or higher with lower cut-offs in Asian populations. Obesity is a chronic health condition that leads to a shorter life span. People with obesity have a higher chance of having other health conditions, such as type 2 diabetes, fatty liver disease, heart disease, kidney problems, osteoarthritis, and some types of cancer. It can be hard for people with obesity to lose weight for various reasons. The aim of this article is to help doctors who treat people with obesity understand more about the causes for obesity, as well as the available treatment options, which include lifestyle changes, medicines, and for some people, weight loss surgery.[Figure: see text][Figure: see text][Figure: see text][Figure: see text].

Obesity paradox and heart failure

BACKGROUND

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

OBJECTIVE AND METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

Level V, Narrative review.

Group Lifestyle Phone Maintenance for Weight, Health, and Physical Function in Adults Aged 65-80 Years: A Randomized Clinical Trial

BACKGROUND

Group lifestyle sessions with phone maintenance could improve weight, health, and function in vulnerable older adults.

METHODS

Community-dwelling adults (N = 322) with body mass index (BMI, kg/m2) ≥27 and additional risk factors received 12 one-hour in-person behavioral weight management group sessions then were randomized to 8 half-hour telephone sessions (n = 162) or newsletter control (n = 160) from 4 to 12 months with no treatment contact thereafter. Primary outcome was 0- to 12-month weight change. Cardiometabolic, short physical performance battery (SPPB), and self-reported activity changes were assessed at 12 and 24 months.

RESULTS

At baseline, the mean (SD) age was 71.2 (4.3) and BMI was 33.8 (5.1). Participants were 77% women, 13% Black, 85% retired, averaging 4 medical conditions, and taking blood pressure (67.4%) and lipid-lowering (51.6%) medications. At 12 months, a greater proportion of the phone group (66.0%) achieved ≥5% weight loss compared with newsletter control (53.2%; p = .02). Mean (95% CI) weight loss was greater for phone (-6.6 kg [-7.5, -5.8]) than newsletter (-5.1 kg [-7.2, -3.0]); p = .01. Modest lipid, glucose, and blood pressure improvements were found, but did not differ significantly between groups. Small SPPB and activity improvements were maintained at 12 and 24 months in both groups.

CONCLUSIONS

Brief phone contacts compared to newsletters enhanced weight loss maintenance among older high-risk adults at 1 year, but not cardiometabolic outcomes. Modest functional improvements were observed in both. Lower-intensity maintenance contacts (phone or newsletter) for weight, health, and physical function in older adults warrant further study.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03192475.

The composite alliance of FTO locus with obesity-related genetic variants

Obesity has become a genuine global pandemic due to lifestyle and environmental modifications, and is associated with chronic lethal comorbidities. Various environmental factors such as lack of physical activity due to modernization and higher intake of energy-rich diets are primary obesogenic factors in pathogenesis of obesity. Genome-wide association study has identified the crucial role of FTO (fat mass and obesity) in human obesity. A bunch of SNPs in the first intron of FTO has been identified and subsequently correlated to body mass index and body composition. Findings of in silico, in vitro, and in vivo studies have manifested the robust role of FTO in regulation of energy expenditure and food consumption. Numerous studies have highlighted the mechanistic pathways behind the concomitant functions of FTO in adipogenesis and body size. Current investigation has also revealed the link of FTO neighbouring genes i.e., RPGRIP1L, IRX3 and IRX5 and epigenetic factors with obesity phenotypes. The motive behind this review is to cite the consequences of FTO on obesity vulnerability.

Body mass index is just a number: Conflating riskiness and unhealthiness in discourse on body size

Despite the ubiquity of the body mass index (BMI) in discourse on health, there is ambiguity in its use as a biomarker of current abnormality versus future risk. This distinction is consequential for knowledge of the relationship between body size and health, as well as for individuals deemed to have abnormal and 'unhealthy' bodies. Consequently, the purposes of this review are threefold. The first is to differentiate this 'biomarker' perspective from extant critiques of BMI as a proxy for health behaviours or as the defining characteristic of obesity as a disease. The second is to highlight the shift towards treating BMI as a measure of attained unhealthiness, rather than a probabilistic indicator of risk. Finally, rather than call for the abolition of BMI, this paper argues that its continued use as 'just a number' is in keeping with the push for weight neutrality in research and practice. The review concludes by demonstrating how the riskiness and unhealthiness of body size is conflated in public health messaging on COVID-19. BMI is a marker of risk, but its use as a surrogate for COVID-19 severity equates body size with health, shaping beliefs about vulnerability and personal responsibility amid an ongoing pandemic.

Perception of Non-Alcoholic Fatty Liver Disease: Real-Life Experience From Pakistan

Introduction

Non-alcoholic fatty liver disease (NALFD) has become one of the most pervasive causes of hepatic pathology. Because of its marked association with metabolic syndrome, type II diabetes and cardiovascular disease, NAFLD has gained substantial focus recently. Its prevalence and incidence are on the rise in Pakistan. However, due to its indolent and mostly asymptomatic course, NAFLD is often overlooked. This reckless behavior towards a potentially deadly disease is influenced most notably by disinformation or flawed perception, although there are a number of other complex socioeconomic components to this as well. With respect to NAFLD, the gap between disease understanding and steps for management is growing in the Pakistani society. With this study, we hoped and aimed to evaluate just how far and wide these shortcomings were found and how was NAFLD perceived in the local populace via a self-administered survey.

Methods

This was a cross-sectional observational cohort study undertaken at the Department of Gastroenterology, Jinnah Postgraduate Medical Centre, and Medical Unit II, Dow University of Health Sciences, Ojha Campus, Karachi, Pakistan. All patients ≥18 years with a diagnosis of NAFLD were included in the study. NAFLD was diagnosed on the basis of sonographic evidence. All ultrasounds were done by a senior expert radiologist with at least 10 years of postgraduate experience. Ultrasounds were performed twice in all patients to rule out human error and bias. Perceptions regarding the knowledge of NAFLD were assessed using a self-administered survey questionnaire.

Results

The female-to-male ratio in our cohort was 3:1. The mean age and body mass index (BMI) recorded were 39.85 ± 9.79 years and 31.21 ± 3.6 kg/m², respectively. Sixty participants (26.4%) knew about their disease (NAFLD) while only 36 (15.9%) knew what NAFLD was and only 33 (14.5%) participants knew about the cardiovascular risk associated with it. Nearly two-thirds of the patients considered themselves overweight, while 180 (79.3%) of them were willing to lose weight. However, just about half of the cohort admitted the need for improved eating habits and increased physical activity/exercise in their daily lives. Fifty-seven (25.1%) patients admitted to using alternative or quack medications and only 45 (19.8%) patients considered them harmful.

Conclusions

Patients harboring NAFLD have little to no knowledge about the disease and its nature or the fact that they are suffering from it despite being diagnosed clinically. Furthermore, while the general populace is willing to accept being overweight and having unhealthy eating habits, their willingness in initiating real-life practical steps to manage NAFLD is lacking.

A detailed mapping of the food industry in the European single market: similarities and differences in market structure across countries and sectors

BACKGROUND

Food environments are influenced by food industries (packaged food and non-alcoholic beverage manufacturers; supermarkets and quick service restaurants). An important source of this influence is the significant market power held by a limited number of food companies. Market structure analysis, as part of a broader market power research agenda, has received limited attention from the public health community. The aim of this study was to analyse similarities and differences in market structure across countries and industries in the European Single Market.

METHODS

The companies with the largest market share at the national level for each industry were identified from Euromonitor sales data in 2017/18. The market structure was assessed by the following metrics: the number of global brand owners with ≥1% market share per country, the number of companies unique for one European Single Market member state, the most sold packaged food and non-alcoholic beverage categories, the number of quick-service restaurants and supermarkets per 1000 inhabitants and market concentration by means of the Herfindahl-Hirschman Index (HHI) and the four firm concentration ratio (CR4). CR4-values > 40% and HHI-values > 2000 indicate concentrated markets with limited competition.

RESULTS

The leading packaged food and non-alcoholic beverage manufacturers and the most sold food and beverage product categories were similar across countries in Europe. The observed levels of concentration were however different. Average CR4-values ranged from 21 to 72% among packaged food product markets and 60 to 76% for non-alcoholic beverage product markets. Average CR4-values for quick service restaurants and supermarkets were 50 and 60%, respectively. Across European countries the same leading quick-service restaurants were identified, while this was not the case for supermarkets.

CONCLUSIONS

This study forms an important basis to understand key aspects of market structure of the European food industry, observing clear differences between food industries and European Single Market member states. This has potential implications for the implementation of food environment policies at different levels of jurisdiction.

US Obesity Mortality Trends and Associated Noncommunicable Diseases Contributing Conditions Among White, Black, and Hispanic Individuals by Age from 1999 to 2017

This study aims to assess the effect of obesity as an underlying cause of death in association with four main noncommunicable diseases (NCDs) as contributing causes of mortality on the age of death in White, Black, and Hispanic individuals in the USA. To estimate mortality hazard ratios, we ran a Cox regression on the US National Center for Health Statistics mortality integrated datasets from 1999 to 2017, which included almost 48 million cases. The variable in the model was the age of death in years as a proxy for time to death. The cause-of-death variable allowed for the derivation of predictor variables of obesity and the four main NCDs. The overall highest obesity mortality HR when associated with NCD contributing conditions for the year 1999-2017 was diabetes (2.15; 95% CI: 2.11-2.18), while Whites had the highest HR (2.46; 95% CI: 2.41-2.51) when compared with Black (1.32; 95% CI: 1.27-1.38) and Hispanics (1.25; 95% CI: 1.18-1.33). Hispanics had lower mortality HR for CVD (1.21; 95% CI: 1.15-1.27) and diabetes (1.25; 95% CI: 1.18-1.33) of the three studied groups. The obesity death mean was 57.3 years for all groups. People who die from obesity are, on average, 15.4 years younger than those without obesity. Although Hispanics in the USA have a higher prevalence of diabetes and cardiovascular disease (CVD), they also have the lowest mortality HR for obesity as an underlying cause of death when associated with CVD and cancer. While there is no obvious solution for obesity and its complications, continued efforts to address obesity are needed.

Misperceptions and barriers to obesity management: Italian data from the ACTION-IO study

PURPOSE

Despite the increasing prevalence of obesity in Italy, it remains largely underdiagnosed and undertreated. We aimed to identify the perceptions, attitudes, behaviours and barriers to effective obesity care among people with obesity (PwO) and healthcare professionals (HCPs) in Italy.

METHODS

The ACTION-IO study was an online cross-sectional survey conducted in 11 countries from June to October 2018. Findings from the Italian cohort are reported here.

RESULTS

The survey was completed by 1501 PwO and 302 HCPs in Italy. Most PwO (84%) and HCPs (77%) acknowledged the large impact of obesity on overall health. However, fewer PwO (62%) than HCPs (91%) perceived obesity as a chronic disease. Most PwO (84%) assumed full responsibility for their weight loss. A median of 3 (mean 6) years elapsed between when PwO started struggling with obesity and when they first discussed their weight with an HCP. Many PwO expressed that they liked (80%) or would like (74%) their HCPs to initiate weight management conversations, and only 3% were offended by such a conversation. For 77% of HCPs, perceiving their patients as unmotivated or disinterested in losing weight prevented them from initiating these conversations. Short appointment times were also considered a limiting factor for 40% of HCPs.

CONCLUSIONS

Most PwO took complete responsibility for their own weight loss and waited considerable time before seeking help from an HCP. There is a need for improved education of both PwO and HCPs and for a more positive attitude from HCPs towards initiating weight discussions with PwO. Trial registration ClinicalTrials.gov: Awareness, Care & Treatment in Obesity Management - an International Observation (ACTION-IO). ClinicalTrials.gov: NCT03584191 LEVEL OF EVIDENCE: Level V, cross-sectional descriptive study.

Adverse Events and Complications with Intragastric Balloons: a Narrative Review (with Video)

Intragastric balloon (IGB) is a minimally invasive and reversible therapy for weight loss with a good efficacy and safety profile. Introduced in the 1980s, IGBs have significantly evolved in the last couple of decades. They mechanically act by decreasing the volume of the stomach and its reservoir capacity, delaying gastric emptying, and increasing satiety leading to a subsequent weight loss. Despite the low rates of complications and mortality associated with IGBs, adverse events and complications still occur and can range from mild to fatal. This review aims to provide an update on the current scientific evidence in regard to complications and adverse effects of the use of the IGB and its treatment. This is the first comprehensive narrative review in the literature dedicated to this subject.

Patients with Severe Obesity during the COVID-19 Pandemic: How to Maintain an Adequate Multidisciplinary Nutritional Rehabilitation Program?

BACKGROUND

The COVID-19 pandemic is spreading all over the world, particularly in developed countries where obesity is also widespread. There is a high frequency of increased BMI in patients admitted to intensive care for SARS-CoV-2 infection with a major severity in patients with an excess of visceral adiposity. Patients at risk of severe SARS-CoV-2 acute respiratory syndrome are characterised by the high prevalence of pre-existing diseases (high blood pressure and cardiovascular disease, diabetes, chronic respiratory disease, or cancer), most of them typically present in severely obese patients. Indeed, the biological role of adipose tissue in sustaining SARS-CoV-2 infection is not completely elucidated.

SUMMARY

The forced isolation due to pandemic containment measures abruptly interrupted the rehabilitation programs to which many patients with severe obesity were enrolled. People affected by obesity, and especially those with severe obesity, should continue clinical rehabilitation programs, taking extra measures to avoid COVID-19 infection and reinforcing the adoption of preventive procedures. In this review, the available data on obesity and COVID-19 are discussed along with evidence-based strategies for maintaining the necessary continuous rehabilitation programs. Key Messages: Greater attention is needed for obese and severely obese patients in the face of the current COVID-19 pandemic, which represents a huge challenge for both patients and healthcare professionals. The adoption of new strategies to guarantee adequate and continuous multidisciplinary nutritional rehabilitation programs will be crucial to control the severity of SARS-CoV-2 infection in high-risk populations as well as the worsening of obesity-linked complications. Health authorities should be urged to equip hospitals with tools for the diffusion of telemedicine to maintain physician-patient communication, which is fundamental in chronic and complicated obese patients.