"Tsunami of obesity" threatens all regions of world, researchers find

Obesity, metabolic syndrome, and inflammation: an update for anaesthetists caring for patients with obesity

Our understanding of chronic inflammation in obesity is evolving. Suggested mechanisms include hypoxia of adipose tissue and a subsequent increase in circulating cytokines. It is now known that adipose tissue, far from being an inert tissue, produces and secretes multiple peptides that influence inflammation and metabolism, including substrates of the renin-angiotensin-aldosterone system (RAAS). RAAS blocking antihypertensive medication and cholesterol-lowering agents are now being evaluated for their metabolic and inflammation-modulating effects. Surgery also has pro-inflammatory effects, which may be exacerbated in patients with obesity. This narrative review will summarise the recent literature surrounding obesity, metabolic syndrome, inflammation, and interplay with the RAAS, with evidence-based recommendations for the optimisation of patients with obesity, prior to surgery and anaesthesia.

Perioperative Blood Pressure Monitoring in Patients With Obesity

Blood pressure monitoring plays a key part in the preoperative, intraoperative, and postoperative care of all patients. In patients with obesity, hypertension indicates increased metabolic and surgical risk and may signal the presence of significant medical comorbidities, including obstructive sleep apnea. Avoidance of hypertension postoperatively is necessary to minimize bleeding risk after surgery. Hypotension in the postoperative period may be the first sign of significant complications that require urgent management. With the problem of being overweight or obese now affecting two-thirds of adults in Western countries, the proportion of patients with obesity in perioperative environments is similarly increasing. Detection of aberrations in blood pressure is contingent on the accuracy of blood pressure measurement methods. Patients with obesity tend to have a large arm circumference and "cone-shaped arms." Standard blood pressure cuffs fit such patients poorly, and this compromises the accuracy of measurements. Alternatives to arm blood pressure cuffs, some made specifically for individuals with obesity, have been evaluated but are not widely available to clinicians. This focused narrative review will discuss the relevance of hypertension management in the care of patients with obesity, highlight the currently available methods for perioperative monitoring of blood pressure, and explore the opportunities that exist to improve the perioperative blood pressure care in patients with obesity undergoing surgical procedures.

The combination of obesity and hypertension: a highly unfavorable phenotype requiring attention

PURPOSE OF REVIEW

Body habitus is a key lifestyle characteristic whose current status and future projections are disconcerting. The percentage of the global population who are either overweight or obese has substantially increased, with no indication that any country has a solution to this issue. Hypertension is a key unfavorable health metric that, like obesity, has disastrous health implications if left uncontrolled. Poor lifestyle characteristics and health metrics often cluster together to create complex and difficult to treat phenotypes. Excess body mass is such an example, creating an obesity-hypertension phenotype, which is the focus of this review.

RECENT FINDINGS

An increased risk for hypertension is clearly linked to obesity, indicating that the two conditions are intimately linked. The cascade of obesity-induced pathophysiologic adaptations creates a clear path to hypertension. Adopting a healthy lifestyle is a primary intervention for the prevention as well as treatment of the obesity-hypertension phenotype.

SUMMARY

The obesity-hypertension phenotype is highly prevalent and has disastrous health implications. A primordial prevention strategy, focused on lifelong healthy lifestyle patterns, is the optimal approach for this condition. For those individuals already afflicted by the obesity-hypertension phenotype, interventions must aggressively focus on weight loss and blood pressure control.

Are medical educators following General Medical Council guidelines on obesity education: if not why not?

BACKGROUND

Although the United Kingdom's (UK's) General Medical Council (GMC) recommends that graduating medical students are competent to discuss obesity and behaviour change with patients, it is difficult to integrate this education into existing curricula, and clinicians report being unprepared to support patients needing obesity management in practice. We therefore aimed to identify factors influencing the integration of obesity management education within medical schools.

METHODS

Twenty-seven UK and Irish medical school educators participated in semi-structured interviews. Grounded theory principles informed data collection and analysis. Themes emerging directly from the dataset illustrated key challenges for educators and informed several suggested solutions.

RESULTS

Factors influencing obesity management education included: 1) Diverse and opportunistic learning and teaching, 2) Variable support for including obesity education within undergraduate medical programmes, and 3) Student engagement in obesity management education. Findings suggest several practical solutions to identified challenges including clarifying recommended educational agendas; improving access to content-specific guidelines; and implementing student engagement strategies.

CONCLUSIONS

Students' educational experiences differ due to diverse interpretations of GMC guidelines, educators' perceptions of available support for, and student interest in obesity management education. Findings inform the development of potential solutions to these challenges which may be tested further empirically.

A 15-year study of the changing demographics and infection risk in a new UK cardiac surgery unit

OBJECTIVES

National trends in cardiac surgery show a shift towards a higher preoperative risk profile and factors that might also be expected to increase the risk of postoperative infective complications. We document the changing patient demographics in the first 15 years of a new cardiac surgery unit and examine the impact of these and other changes in estate, staffing and clinical protocols, on the risks of common postoperative infections.

METHODS

Data recorded included patient age, sex and body mass index, type and number of operations, logistic EuroSCORE, mortality rate, urgency of operation, reoperation rate, requirement for intra-aortic balloon pump, incidence of diabetes and the incidence of common postoperative infections.

RESULTS

A total of 8449 cardiac operations were undertaken. The mean patient age increased from 62.71 to 65.82 years; procedural complexity increased with the proportion of isolated coronary artery bypass procedures falling from 72.8 to 54%; there were increases in the urgency of operation (11.3-26.9%), average patient body mass index (27.01-28.67), the incidence of diabetes (12.3-21.2%), logistic EuroSCORE (5.36-7.74) and intra-aortic balloon pump usage (6.4-15.6%). The incidence of superficial sternal infection reduced (3.9-1.4%); other wound infection rates were low and showed no overall trend with time. Urinary tract infection varied between 0 and 1.7%, but did show a significant increase over the last 3 years (P < 0.01).

CONCLUSIONS

This study demonstrates a change in the patient profile, yet despite an increase in infection risk factors, no increase in actual infection rates. The importance of non-patient factors in influencing the outcomes after cardiac surgery is discussed.

Preparing medical students to facilitate lifestyle changes with obese patients: a systematic review of the literature

PURPOSE

Doctors will increasingly encounter opportunities to support obese patients in lifestyle change efforts, but the extent to which medical schools prepare their students for this challenge is unknown. Further, despite evidence indicating theory-based techniques are effective in facilitating patients' behavioral changes, the methods taught to medical students and the means of content delivery are unclear. The authors reviewed the literature to investigate how effective educational interventions are in preparing medical students to facilitate lifestyle changes with obese patients.

METHOD

The authors systematically searched Excerpta Medica (EMBASE), PsycINFO, MEDLINE, and Scopus for educational interventions on obesity management for medical students published in English between January 1990 and November 2010 and matching PICOS (Population, Interventions, Comparators, Outcomes, Study design) inclusion criteria.

RESULTS

Results of a narrative synthesis are presented. Of 1,680 studies initially identified, 36 (2%) full-text articles were reviewed, and 12 (1%) were included in the final dataset. Eleven (92%) of these studies had quantitative designs; of these, 7 (64%) did not include control groups. Nine (75%) of the 12 studies were atheoretical, and 4 (33%) described behavior management strategies. Despite positive reported outcomes regarding intervention evaluations, procedures to control for bias were infrequently reported, and conclusions were often unsupported by evidence.

CONCLUSIONS

Evidence from this systematic review revealed data highly susceptible to bias; thus, intervention efficacy could not be determined. Additionally, evidence-based strategies to support patients' obesity-related behavior changes were not applied to these studies, and thus it remains unknown how best to equip medical students for this task.

Current challenges of behavior change talk for medical professionals and trainees

OBJECTIVE

To explore medical professionals' and trainees' experiences and views of behavior change talk in various health care settings to develop current understanding of the challenges that underlie this phenomenon.

METHODS

Qualitative, semi-structured interviews were conducted with medical professionals and trainees (n=29). Grounded theory principles informed sampling, data collection and analysis. To achieve maximum variance, participants with different levels of experience were purposively sampled from a range of primary and secondary care settings. Analysis was iterative, involving a constant comparative approach allowing emergent ideas to be tested in subsequent interviews until thematic saturation was reached.

RESULTS

Three emergent themes described reasons for not engaging in behavior change talk with patients: (1) 'personal challenges'; (2) 'somebody else's responsibility' and (3) 'prioritizing the doctor-patient relationship'.

CONCLUSION

Despite increasingly being recognized as a core aspect of medical practice and education, medical professionals and trainees remain unprepared to discuss health-related behavior change with patients and unclear of their roles within contemporary health care.

PRACTICE IMPLICATIONS

Formal training in theory-based behavior change techniques is likely to help empower doctors and mitigate many of the barriers found, particularly in relation to socially and emotionally uncomfortable topics that are perceived to threaten the doctor-patient relationship.