Obesity epidemic: overview, pathophysiology, and the intensive care unit conundrum

Voluntary wheel running access produces opposite effects in male and female rats on both palatable diet consumption and associated ventral striatal opioid- and dopamine-related gene expression

The relationship between physical activity levels and feeding behaviors has been a focus of preclinical research for decades, yet this interaction has only recently been explored for potential sex differences. The aim of the present study was to isolate sex-dependent effects of voluntary wheel running (RUN) vs. sedentary locked wheel (SED) home cage conditions on palatability-driven feeding behavior using a 2-diet choice task between standard chow and a high-fat diet. The sex-dependent effects of physical activity on feeding behavior were examined following a within-subject novel reversal design of physical activity conditions (i.e., RUN > SED > RUN), to assess temporal sensitivity of the interaction. Following the final 2 weeks of reestablished and sustained RUN vs. SED conditions in separate groups of both males and females, reward-related opioid and dopamine gene expression within the nucleus accumbens (Acb) brain region were analyzed. Results demonstrated that the initial RUN > SED transition led to sex-dependent effects of SED condition, as males increased, and females decreased their high fat consumption, compared to their respective high fat consumption during previous RUN condition phase. Following reintroduction to the RUN condition, males decreased, and females increased their high fat consumption, compared to their separate SED control group. Last, sex-dependent shifts in ventral striatal opioid- and dopamine-related gene expression were observed to parallel the behavioral effects. The major findings of the study reveal that SED and RUN home cage conditions shift palatability-driven feeding in the opposite direction for males and females, these effects are sensitive to reversal, and these sex-dependent feeding behaviors track sex-dependent changes to critical reward-related gene expression patterns in the Acb. Considering the present high rates of sedentary behavior and obesity, furthering our understanding of the interaction between physical activity (or lack thereof) and feeding behavior should be a priority, especially in the context of these divergent sex-dependent outcomes.

Examining Obesity and Its Association With Burn Injury: A Secondary Analysis of the Transfusion Requirement in Burn Care Evaluation Study

INTRODUCTION

Literature examining the connection between obesity and burn injuries is limited. This study is a secondary analysis of a multicenter trial data set to investigate the association between burn outcomes and obesity following severe burn injury.

MATERIALS AND METHODS

Body mass index (BMI) was used to stratify patients as normal weight (NW; BMI 18.5-25), all obese (AO; any BMI>30), obese I (OI; BMI 30-34.9), obese II (OII; BMI 35-39.9), or obese III (OIII; BMI>40). The primary outcome examined was mortality. Secondary outcomes included hospital length of stay (LOS), number of transfusions, injury scores, infection occurrences, number of operations, ventilator days, intensive care unit LOS, and days to wound healing.

RESULTS

Of 335 patients included for study, 130 were obese. Median total body surface area (TBSA) was 31%, 77 patients (23%) had inhalation injury and 41 patients died. Inhalation injury was higher in OIII than NW (42.1% versus 20%, P = 0.03). Blood stream infections (BSI) were higher in OI versus NW (0.72 versus 0.33, P = 0.03). Total operations, ventilator days, days to wound healing, multiorgan dysfunction score, Acute Physiology and Chronic Health Evaluationscore, hospital LOS, and intensive care unit LOS were not significantly affected by BMI classification. Mortality was not significantly different between obesity groups. Kaplan-Meier survival curves did not significantly differ between the groups (χ2 = 0.025, P = 0.87). Multiple logistic regression identified age, TBSA, and full thickness burn as significant independent predictors (P < 0.05) of mortality; however, BMI classification itself was not predictive of mortality.

CONCLUSIONS

No significant association between obesity and mortality was seen after burn injury. Age, TBSA, and percent full- thickness burn were independent predictors of mortality after burn injury, while BMI classification was not.

Body Mass Index (BMI) Cutoffs and Racial, Ethnic, Sex, or Age Disparities in Patients Treated With Total Ankle Arthroplasty

Background

The rising prevalence of obesity among American adults has disproportionately affected Black adults and women. Furthermore, body mass index (BMI) has historically been used as a relative contraindication to many total joint arthroplasty (TJA) procedures, including total ankle arthroplasty. The purpose of this study was to investigate potential disparities in patient eligibility for total ankle arthroplasty based on race, ethnicity, sex, and age by applying commonly used BMI cutoffs to the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

Methods

Patients in the ACS-NSQIP database who underwent TAA from 2011 to 2020 were retrospectively reviewed in a cross-sectional analysis. BMI cutoffs of <50, <45, <40, and <35 were then applied. The eligibility rate for TAA was examined for each BMI cutoff, and findings were stratified by race, ethnicity, sex, and age. Independent t tests, chi-squared tests, and Fisher exact tests were performed to compare differences at an α = 0.05.

Results

A total of 1215 of 1865 TAA patients (65.1%) were included after applying the exclusion criteria. Black patients had disproportionately lower rates of eligibility at the most stringent BMI cutoff of <35 (P = .004). Hispanic patients had generally lower rates of eligibility across all BMI cutoffs. In contrast, Asian American and Pacific Islander patients had higher rates of eligibility at the BMI cutoffs of <35 (P = .033) and <40 (P = .039), and White non-Hispanic patients had higher rates of eligibility across all BMI cutoffs. Females had lower eligibility rates across all BMI cutoffs. Ineligible patients were also younger compared to eligible patients across all BMI cutoffs.

Conclusion

Stringent BMI cutoffs may disproportionately disqualify Black, female, and younger patients from receiving total ankle arthroplasty.

Level of Evidence

Level III, retrospective cross-sectional study.

An Update on the Management and Optimization of the Patient with Morbid Obesity Undergoing Hip or Knee Arthroplasty

The prevalence of obesity in the United States is at a record high of 42%. In 1999, the Centers for Disease Control and Prevention recognized the obesity epidemic as a national problem, spurring the first generation of interventions for obesity prevention and control. Despite billions of dollars in funding, legislative changes, and public health initiatives, the trajectory of American obesity has not waivered. Obesity is also strongly associated with the development of osteoarthritis. The growing population of young, obese, and sick patients presents a unique dilemma for orthopedic surgeons performing joint replacement, as obesity levels and the demand for joint replacement are only expected to rise further.

The use of cellulose, chitosan and hyaluronic acid in transdermal therapeutic management of obesity: A review

Obesity is a clinical condition with rising popularity and detrimental impacts on human health. According to the World Health Organization, obesity is the sixth most common cause of death worldwide. It is challenging to combat obesity because medications that are successful in the clinical investigation have harmful side effects when administered orally. The conventional approaches for treating obesity primarily entail synthetic compounds and surgical techniques but possess severe adverse effects and recurrences. As a result, a safe and effective strategy to combat obesity must be initiated. Recent studies have shown that biological macromolecules of the carbohydrate class, such as cellulose, hyaluronic acid, and chitosan, can enhance the release and efficacy of medications for obesity but due to their short biological half-lives and poor oral bioavailability, their distribution rate is affected. This helps to comprehend the need for an effective therapeutic approach via a transdermal drug delivery system. This review focuses on the transdermal administration, utilizing cellulose, chitosan, and hyaluronic acid via microneedles, as it offers a promising solution to overcome existing therapy limitations in managing obesity and it also highlights how microneedles can effectively deliver therapeutic substances through the skin's outer layer, bypassing pain receptors and specifically targeting adipose tissue.

Potential contributors to variation in weight-loss response to liraglutide

Obesity treatment requires a chronic state of negative energy balance. Obesity medications can help with this, increasing long-term dietary compliance by promoting satiety or reducing hunger. However, efficacy and safety of obesity medications vary for individuals. Early identification of non-responders to obesity medications may limit drug exposure while optimizing benefits for responders. This review summarizes factors that impact weight-loss response to liraglutide. Factors linked to greater weight loss on liraglutide include being female, not having diabetes, having relatively high baseline weight, and losing at least 4% of initial weight after 16 weeks of treatment. Other covariates that may predict treatment response but require further confirmation include central effects, nausea, gastric emptying of solids, and genotype. Baseline body mass index, race, and age seem less relevant for predicting weight-loss response to liraglutide. Lesser known and harder-to-measure factors such as cerebral blood flow, food cue reactivity, gut hormone levels, and dietary adherence possibly impact variability of response to liraglutide. This information should assist healthcare providers with establishing realistic weight-loss probability for individual patients. Future research should improve the ability to identify responders to liraglutide. Importantly, this review may provide a framework to identify responders to other obesity medications.

Obesity Measured via Body Mass Index May Be Associated with Increased Incidence but Not Worse Outcomes of Immune-Mediated Diarrhea and Colitis

Obesity defined by high body mass index (BMI) has traditionally been associated with gastrointestinal inflammatory processes but has recently been correlated with better survival in patients receiving immune checkpoint inhibitors (ICI). We sought to investigate the association between BMI and immune-mediated diarrhea and colitis (IMDC) outcomes and whether BMI reflects body fat content on abdominal imaging. This retrospective, single-center study included cancer patients with ICI exposure who developed IMDC and had BMI and abdominal computed tomography (CT) obtained within 30 days before initiating ICI from April 2011 to December 2019. BMI was categorized as <25, ≥25 but <30, and ≥30. Visceral fat area (VFA), subcutaneous fat area (SFA), total fat area (TFA: VFA+SFA), and visceral to subcutaneous fat (V/S) ratio were obtained from CT at the umbilical level. Our sample comprised 202 patients; 127 patients (62.9%) received CTLA-4 monotherapy or a combination, and 75 (37.1%) received PD-1/PD-L1 monotherapy. Higher BMIs ≥ 30 were associated with a higher incidence of IMDC than BMIs ≤ 25 (11.4% vs. 7.9%, respectively; p = 0.029). Higher grades of colitis (grade 3-4) correlated with lower BMI (p = 0.03). BMI level was not associated with other IMDC characteristics or did not influence overall survival (p = 0.83). BMI is strongly correlated with VFA, SFA, and TFA (p < 0.0001). Higher BMI at ICI initiation was linked to a higher incidence of IMDC but did not appear to affect outcomes. BMI strongly correlated with body fat parameters measured by abdominal imaging, suggesting its reliability as an obesity index.

Load-to-strength ratio at the radius is higher in adolescent and young adult females with obesity compared to normal-weight controls

BACKGROUND

Among adolescents with extremity fractures, individuals with obesity have greater representation compared with individuals of normal-weight, despite having higher areal and volumetric bone mineral density (aBMD, vBMD) than their normal-weight counterparts. The relative increase in BMD in individuals with obesity may thus be insufficient to support the greater force generated upon falling. The load-to-strength ratio is a biomechanical approach for assessing the risk of fracture by comparing applied force to bone strength, with higher load-to-strength ratios indicating higher fracture risk.

OBJECTIVE

To assess the load-to-strength ratio at the distal radius in adolescent and young adult females with severe obesity (OB) compared with normal-weight healthy controls (HC). We hypothesized that OB have a higher load-to-strength ratio compared to HC.

METHODS

We examined bone parameters in 65 girls 14-21 years old: 33 OB and 32 HC. We used dual-energy X-ray absorptiometry (DXA) to assess body composition, high resolution peripheral quantitative CT (HR-pQCT) to estimate vBMD, and microfinite element analysis (μFEA) to assess bone strength at the distal radius. To quantify fracture risk, we computed the load-to-strength ratio, where the numerator is defined as the load applied to the outstretched hand during a forward fall and the denominator is the bone strength, as estimated by μFEA.

RESULTS

Although OB had higher total vBMD than HC (368.3 vs. 319.9 mgHA/cm3, p = 0.002), load-to-strength ratio at the radius was greater in OB than HC after controlling for age and race (0.66 vs. 0.54, p < 0.0001). In OB, impact force and load-to-strength ratio were associated negatively with % lean mass (r = -0.49; p = 0.003 and r = -0.65; p < 0.0001 respectively) and positively with visceral fat (r = 0.65; p < 0.0001 and r = 0.36; p = 0.04 respectively).

CONCLUSIONS

Adolescent and young adult females with obesity have higher load-to-strength ratio at the distal radius due to higher forces applied to bone in a fall combined with incomplete adaptation of bone to increasing body weight. This is differentially affected by lean mass, fat mass, and visceral fat mass.

Obesity Does Not Increase Perioperative Outcomes in Older Patients Undergoing Thoracoscopic Anatomic Lung Cancer Surgery

Objectives

To investigate the relationship between obesity status and perioperative outcomes in elderly patients undergoing thoracoscopic anatomic lung cancer surgery.

Methods

From January 2016 to December 2018, we performed a monocentric retrospective cohort study among 4164 consecutive patients aged 65 years or older who underwent thoracoscopic anatomic lung cancer surgery at Shanghai Chest Hospital. Two groups were stratified by body mass index (BMI): nonobese (BMI<28kg/m²) and obese status (BMI≥28kg/m²). Using a 1:1 propensity score matching (PSM) analysis to compare perioperative outcomes between two groups.

Results

4035 older patients were eventually enrolled, with a mean age of 69.8 years (range: 65-87), and 305 patients were eligible for obese status, with a mean BMI of 29.8 ± 1.7kg/m². Compared with nonobese patients, obese patients were more likely to have higher rates of intraoperative hypoxemia (1.2% vs 3.9%, P=0.001) and new-onset arrhythmia (2.3% vs 4.3%, P=0.034). The difference in intraoperative transfusion and conversion rates and postoperative outcomes regarding pulmonary complications, new-onset arrhythmia, transfusion, length of hospital stay, 30-day readmission and hospitalization costs between two groups were not significant (P>0.05). After a 1:1 PSM analysis, the difference in both intraoperative and postoperative complications among two groups were not significant (P>0.05). In subgroup analysis, patients with BMI≥30kg/m² had a similar incidence of perioperative complications compared to patients with BMI between 28 and 30 kg/m² (P>0.05).

Conclusions

Our research data support evidence for “obesity paradox” and also contribute the growing body of evidence that obesity in older patients should not exclude candidates for thoracoscopic anatomic lung cancer surgery.

Impact of body mass index on perioperative and oncological outcomes in elderly patients undergoing minimally invasive McKeown esophagectomy for esophageal squamous cell carcinoma

Background

The association between elevated body mass index (BMI) and perioperative and oncological outcomes among elderly patients undergoing minimally invasive McKeown esophagectomy (MIE) remains unclear.

Methods

We performed a single‐center retrospective analysis of 526 consecutive patients aged 65 years or older who underwent MIE for esophageal squamous cell carcinoma (SCC) between January 2016 and December 2019. Two groups were stratified by BMI: normal (18.5 ≤ BMI < 24 kg/m²) and elevated groups (BMI ≥ 24 kg/m²). A 1:1 propensity score matching (PSM) analysis was used to compare perioperative and oncological outcomes between the two groups.

Results

A total of 480 elderly patients were eventually enrolled, with a mean age of 70.2 years (range: 65–87), and 185 patients were eligible for elevated BMI, with a mean BMI of 26.3 ± 1.9 kg/m². Compared with the normal BMI group, the elevated BMI group had prolonged operation time (261.7 ± 57.2 vs. 278.9 ± 62.7 mins, p = 0.002) and increased incidence of intraoperative hypoxemia (12.2% vs. 21.6%, p = 0.006). The differences in intraoperative estimated blood loss, transfusion, new‐onset arrhythmia, and conversion rates and postoperative outcomes regarding pulmonary and surgical complications, intensive care unit and 30‐day readmissions, the length of hospital stay, and oncological outcomes regarding R0 dissection, and the number of dissected lymph nodes between two groups were comparable. After a 1:1 PSM analysis, there was no significant difference in both perioperative and oncological outcomes between two groups.

Conclusions

Among elderly patients undergoing MIE for esophageal SCC, there was insufficient evidence to demonstrate that elevated BMI could increase perioperative and oncological adverse outcomes.

Does obesity influence the preferred treatment approach for early-stage cervical cancer? A cost-effectiveness analysis

OBJECTIVE

Abdominal radical hysterectomy in early-stage cervical cancer has higher rates of disease-free and overall survival compared with minimally invasive radical hysterectomy. Abdominal radical hysterectomy may be technically challenging at higher body mass index levels resulting in poorer surgical outcomes. This study sought to examine the influence of body mass index on outcomes and cost effectiveness between different treatments for early-stage cervical cancer.

METHODS

A Markov decision-analytic model was designed using TreeAge Pro software to compare the outcomes and costs of primary chemoradiation versus surgery in women with early-stage cervical cancer. The study used a theoretical cohort of 6000 women who were treated with abdominal radical hysterectomy, minimally invasive radical hysterectomy, or primary chemoradiation therapy. We compared the results for three body mass index groups: less than 30 kg/m², 30-39.9 kg/m², and 40 kg/m² or higher. Model inputs were derived from the literature. Outcomes included complications, recurrence, death, costs, and quality-adjusted life years. An incremental cost-effectiveness ratio of less than $100 000 per quality-adjusted life year was used as our willingness-to-pay threshold. Sensitivity analyses were performed broadly to determine the robustness of the results.

RESULTS

Comparing abdominal radical hysterectomy with minimally invasive radical hysterectomy, abdominal radical hysterectomy was associated with 526 fewer recurrences and 382 fewer deaths compared with minimally invasive radical hysterectomy; however, abdominal radical hysterectomy resulted in more complications for each body mass index category. When the body mass index was 40 kg/m² or higher, abdominal radical hysterectomy became the dominant strategy because it led to better outcomes with lower costs than minimally invasive radical hysterectomy. Comparing abdominal radical hysterectomy with primary chemoradiation therapy, recurrence rates were similar, with more deaths associated with surgery across each body mass index category. Chemoradiation therapy became cost effective when the body mass index was 40 kg/m² or higher.

CONCLUSION

When the body mass index is 40 kg/m² or higher, abdominal radical hysterectomy is cost saving compared with minimally invasive radical hysterectomy and primary chemoradiation is cost effective compared with abdominal radical hysterectomy. Primary chemoradiation may be the optimal management strategy at higher body mass indexes.

Excessive fat expenditure in cachexia is associated with dysregulated circadian rhythm: a review

Cachexia is a progressive metabolic disorder characterized by the excessive depletion of adipose tissue. This hypermetabolic condition has catastrophic impacts on the survival and quality of life for patients suffering from critical illness. However, efficient therapies to prevent adipose expenditure have not been discovered. It has been established that the circadian clock plays an important role in modulating fat metabolic processes. Recently, an increasing number of studies had provided evidence showing that disrupted circadian rhythm leads to insulin resistance and obesity; however, studies analyzing the relationship between circadian misalignment and adipose tissue expenditure in cachexia are scarce. In the present review, we cover the involvement of the circadian clocks in the regulation of adipogenesis, lipid metabolism and thermogenesis as well as inflammation in white and brown adipose tissue. According to the present review, we conclude that circadian clock disruption is associated with lipid metabolism imbalance and elevated adipose tissue inflammation. Moreover, under cachexia conditions, lipid synthesis and storage processes lost rhythm and decreased, while lipolysis and thermogenesis activities remained high for 24 h. Therefore, disordered circadian clock may be responsible for fat expenditure in cachexia by adversely influencing lipid synthesis/ storage/lipolysis/utilization. Further study needs to be performed to explore the direct interaction between circadian clock and fat expenditure in cachexia, it will likely provide potential efficient drugs for the treatment of fat expenditure in cachexia.

Nitrogen balance in mechanically ventilated obese patients

ABSTRACT Objective This study aimed to evaluate if the protein intake recommendations for obese critically ill requiring mechanical ventilation are sufficient to promote a positive or neutral nitrogen balance. Methods Cross-sectional study that included 25 obese, ≥18 years old, undergoing mechanical ventilation and who were target to receive high-protein enteral nutrition therapy (2.0-2.5g/kg ideal body weight). Clinical, nutritional and biochemical variables were analyzed. Nitrogen balance was performed when patient was receiving full enteral nutrition therapy and was classified: positive when intake was greater than excretion; negative when excretion was greater than intake; neutral when both were equal. Results The characteristics of patients evaluated were 64.1±9.4 years old, clinical treatment 88%, body mass index 36.5±5.1kg/m2, nitrogen balance 0.3g/day (-5.3 to 4.8g/day), protein intake 2.1g/day (2.0-2.3g/kg) ideal body weight. Of individuals analyzed, 52% showed positive or neutral nitrogen balance with median of 4.23g/day 2.41 to 6.40g/day) in comparison to negative group with median of -5.27g/day (-10.38 to -3.86g/day). Adults had higher ratio of negative nitrogen balance (57.1%) than elderly (44.4%), with protein intake of 2.0 versus 2.1g/day, respectively. No correlation was found between nitrogen balance and variables assessed. Conclusion High-protein enteral nutrition therapy contributed to positive or neutral nitrogen balance for approximately half of obese ventilated individuals. With similar protein intake, elderly showed a higher proportion of positive or neutral nitrogen balance. Nitrogen balance can be influenced by various factors, so further studies are required to identify different protein needs in obese critically.

Does Weight Matter? Outcomes in Adult Patients on Venovenous Extracorporeal Membrane Oxygenation When Stratified by Obesity Class

BACKGROUND

Many believe obesity is associated with higher rates of mortality in the critically ill. The purpose of this retrospective observational study is to evaluate the association between body mass index (BMI) and survival in patients receiving venovenous (VV) extracorporeal membrane oxygenation (ECMO) for acute hypoxic or hypercarbic respiratory failure.

METHODS

All of the patients admitted to a dedicated VV ECMO unit were included. Patients <18 years of age, listed for lung transplant, or underweight were excluded. ECMO outcomes, including hospital length of stay and survival to discharge, were analyzed after stratification according to BMI. Multivariate logistic and linear regression techniques were used to assess variables associated with the outcomes of death and length of stay, respectively.

RESULTS

One hundred ninety-four patients with a median BMI of 35.7 kg/m (33-42 kg/m) were included. Obese patients were older, had higher creatinine levels, and required higher levels of positive end-expiratory pressure and mean airway pressure at time of cannulation. Survival to discharge in any group did not differ when stratified by BMI classification (P = .36). Multivariable regression did not reveal any association with greater odds of death or longer length of stay when controlling for BMI and other variables.

CONCLUSIONS

We did not detect an association between obesity and increased mortality in patients requiring VV ECMO for acute hypoxic or hypercarbic respiratory failure. These data suggest that obesity alone should not exclude candidacy for VV ECMO. Evidence for the "obesity paradox" in this population of VV ECMO patients may be supported by these data.

The relationship between obesity and nursing care problems in intensive care patients in Austria

OBJECTIVES

To describe the characteristics and nursing care problems of intensive care patients in Austria stratified by obesity.

BACKGROUND

Obese people in intensive care units (ICUs) present nurses with special challenges. Therefore, nurses need to receive education and training regarding how to treat obese patients to provide them with the best care. Most studies on obesity in ICU patients have not specifically addressed the problems and challenges from the nurses' perspective. This may be because nursing science programmes in Europe rarely introduce the topic of obesity.

DESIGN

This was a secondary data analysis of a longitudinal study.

METHODOLOGY

The "Nursing Quality Measurement 2.0" is the Austrian version of the "International Prevalence Measurement of Care problems". It is an annual cross-sectional study, which has been carried out since 2009. Data from all ICU patients for 2009 to 2018 were extracted and combined into one file (n = 460). The main outcome measures were obesity and various nursing care problems, including care dependency.

RESULTS

Of the ICU patients. 25% were obese. Obese ICU patients suffered significantly more often from diabetes mellitus and endocrine, nutritional, or metabolic diseases than non-obese patients. About 30% of the ICU patients were totally care dependent, and 85.6% of the ICU patients were at risk of developing pressure ulcers, whereas the risk was higher for non-obese than obese patients. ICU patients with a risk of pressure ulcer (measured with the Braden Scale) had a reduced risk of being obese (OR = 0.544).

CONCLUSION

Overall, the prevalence of nursing care problems found in this study was high. No significant differences in the prevalence of nursing care problems between obese and non-obese patients were found. However, because of the increase in the number of obese patients in all nursing settings, a stronger focus on obesity research in the area of nursing science is recommended.

Modulatory effect of methanandamide on gastric vagal afferent satiety signals depends on nutritional status

SIGNIFICANCE STATEMENT

Gastric vagal afferent responses to tension are dampened in high fat diet-induced obesity. Endocannabinoids are known to dose-dependently inhibit and excite gastric vagal afferents but their effect on gastric vagal afferents in diet-induced obesity are unknown. In individual gastric vagal afferent neurons of diet-induced obese mice the co-expression of components of the endocannabinoid system, including CB1, GHSR, TRPV1 and FAAH, was increased compared with lean mice. In high fat diet-induced obese mice, methanandamide only inhibited gastric vagal afferent responses to tension, possibly due to the observed change in the balance of receptors, hormones and breakdown enzymes in this system. Collectively, these data suggest that endocannabinoid signalling, by gastric vagal afferents, is altered in diet-induced obesity which may impact satiety and gastrointestinal function.

ABSTRACT

Gastric vagal afferents (GVAs) play a role in appetite regulation. The endocannabinoid anandamide (AEA) dose-dependently inhibits and excites tension-sensitive GVAs. However, it is also known that high fat diet (HFD) feeding alters GVA responses to stretch. The aim of this study was to determine the role of AEA in GVA signalling in lean and HFD-induced obese mice. Male C57BL/6 mice were fed (12 weeks) a standard laboratory diet (SLD) or HFD. Protein and mRNA expression of components of the cannabinoid system was determined in individual GVA cell bodies and the gastric mucosa. An in vitro GVA preparation was used to assess the effect of methanandamide (mAEA) on tension-sensitive GVAs and the second messenger pathways involved. In individual GVA cell bodies, cannabinoid 1 (CB1) and ghrelin (GHSR) receptor mRNA was higher in HFD mice than SLD mice. Conversely, gastric mucosal AEA and ghrelin protein levels were lower in HFD mice than SLD mice. In SLD mice, mAEA exerted dose-dependent inhibitory and excitatory effects on tension-sensitive GVAs. Only an inhibitory effect of mAEA was observed in HFD mice. The excitatory effect of mAEA was dependent on CB1, transient receptor potential vanilloid 1 (TRPV1) and the protein kinase C. Conversely, the inhibitory effect was dependent on CB1, growth hormone secretagogue receptor, TRPV1 and the protein kinase A. Endocannabinoids, acting through CB1 and TRPV1, have a pivotal role in modulating GVA satiety signals depending on the second messenger pathway utilised. In HFD mice only an inhibitory effect was observed. These changes may contribute to the development and/or maintenance of obesity.

Fad Diets: Hype or Hope?

PURPOSE OF REVIEW

Obesity continues to be a growing concern globally due to association with a number of comorbidities and contributing significantly to increase in health care expenditures. Despite availability of a number of treatment modalities, lifestyle modification with dietary modification and exercise continues to be the foundation. However, the standard model of lifestyle modification is not efficacious or sustainable for many patients leading them to seek alternative approaches. We conducted a comprehensive literature review to present the data regarding efficacy and sustainability of many common dietary approaches.

RECENT FINDINGS

Building upon previous work, recent randomized controlled trials have compared many popular diets head to head in varying patient populations. Along with the weight changes, studies have investigated the changes in metabolic parameters, inflammatory markers, and cardiac risk factor reduction. Though the studies do not show superiority of one diet compared to the other, the preventive benefits and other favorable metabolic changes of the diets make them worthy of consideration.

Low Muscularity as Assessed by Abdominal Computed Tomography on Intensive Care Unit Admission Is Associated With Mortality in a Critically Ill Asian Population

BACKGROUND

Low muscularity (LM) is associated with high mortality in the Caucasian critically ill population. Muscularity can be accurately measured by the skeletal muscle index (SMI; cm² /m² ) generated by computed tomography (CT). This study aimed to establish the overall and sex-specific cutoff values that predict hospital mortality in an Asian critically ill population.

METHODS

This single-center, retrospective, observational study included patients aged ≥18 years with an abdominal CT conducted within 72 hours of admission to the intensive care unit. SMI generated from CT images at the level of the mid-third lumbar vertebra were extracted from the medical records. Area under the receiver operating characteristic curves (AUC) was generated to determine the SMI cutoff values for hospital mortality. Association between LM (defined by SMI cutoff value) and hospital mortality was further evaluated by multivariable logistic regression.

RESULTS

In a sample of 228 patients, the overall SMI cutoff value (cm² /m² ) for hospital mortality was 42.0 (AUC: 0.637; sensitivity: 66.7%, specificity: 56.8%), whereas it was 46.5 in males and 35.3 in females. More males than females had LM (51.4% vs 37.5%), and >40% of overweight/obese patients had LM. Patients with LM were older and had a longer duration of mechanical ventilation and hospitalization. After adjusting for known confounders, LM independently predicted hospital mortality in the overall sample (adjusted odds ratio: 2.42; 95% CI 1.16-5.03; P = 0.003) and in both sexes.

CONCLUSION

This study established a set of SMI cutoff values that predict hospital mortality. LM is independently associated with hospital mortality.

The paradox prevails: Outcomes are better in critically ill obese patients regardless of the comorbidity burden

During critical illness, obese patients have better outcomes compared to patients with normal BMI, and this is known as the obesity paradox. The difference in comorbidity burden have been implied to be responsible for the paradox. We performed a retrospective review from 2001 to 2012 of critically ill patients from the Medical Information Mart for Intensive Care database. We included 11,433 patients and classified them according to body mass index (BMI) and comorbidity burden (Elixhauser comorbidity measure). The odds of inpatient mortality were lower in obese patients compared to patients with normal BMI; in group with the least comorbidity score (Elixhauser <0) [OR: 0.47, CI (0.28-0.80), p-value 0.006] and higher comorbidity scores, (Elixhauser 1-5) [(OR: 0.66, CI (0.46-0.95), p-value 0.02)] and (Elixhauser 6-13) [OR: 0.69, CI (0.53-0.92), p-value 0.01]. 30-day mortality was also significantly lower in obese patients, in groups with the lowest (Elixhauser <0) [OR:49, CI (0.31-0.77), p-value 0.002] as well as the highest comorbidity burden (Elixhauser >14) [OR:0.59, CI (0.45-0.77), p-value <.001]. Subgroup analysis in patients with various comorbidities showed better outcomes in obese patients. These findings show that the decreased odds of mortality in critically ill obese patients is independent of the comorbidity burden or type of comorbidity.

Effect of lorcaserin in different age groups: a post hoc analysis of patients from the BLOOM, BLOSSOM and BLOOM-DM studies

INTRODUCTION

The elderly population is projected to be the fastest growing group of individuals with obesity group in the United States. As such, there is merit in examining factors that contribute to healthy aging and weight management. The effects of newer weight loss medications approved after 2013 have been studied but are not often assessed specifically in older persons.

METHODS

This post hoc analysis evaluated the magnitude of weight loss in adults across age quartiles with lorcaserin, a serotonin (5-HT) 2C receptor agonist indicated as an adjunct to a reduced-caloric diet and increased physical activity for chronic weight management. Data from three lorcaserin pivotal phase 3 studies were used in this analysis. Data for patients with overweight/obesity without type 2 diabetes (T2D; BLOOM/BLOSSOM; body mass index [BMI] 27.0-29.9 kg/m2 and ≥1 comorbidity or BMI 30.0-45.0 kg/m2) and patients with overweight/obesity with T2D (BLOOM-DM; BMI 27.0-45.0 kg/m2) were used. Patients were randomized to receive lorcaserin 10 mg twice daily or placebo in addition to diet and exercise for 52 weeks. Age quartiles between the studies differed as the T2D population was on average, 9 years older.

RESULTS

This analysis shows that lorcaserin was associated with improved weight loss relative to placebo regardless of age. Importantly, these results were consistent for patients with and without T2D. Interestingly, the magnitude of weight loss for lorcaserin appeared to increase with increasing age. In patients without T2D, odds of achieving ≥5% and ≥10% reduction in body weight at 52 weeks were significantly higher for patients >36 years. Lorcaserin was well tolerated in all patients across all quartiles including the oldest quartile.

CONCLUSIONS

In summary, this post hoc analysis demonstrates that lorcaserin treatment in patients with and without T2D was safe and effective at reducing weight across all age groups analysed. Weight loss appeared to be greater for older patients; additional analyses are warranted to confirm these findings and to better understand the factors for improved weight loss.

The impact of body mass index on resource utilization and outcomes of children admitted to a pediatric intensive care unit

Introduction:

Obesity is associated with poor health outcomes but may be protective in intensive care unit patients. The objective of this study is to describe the characteristics of underweight, normal weight, and obese children, and to compare their length of stay, resource utilization, and mortality.

Methods:

The charts of 1447 patients who were admitted to a tertiary-level pediatric intensive care unit during 1 calendar year were reviewed. Patients were divided into three groups: underweight (<5th percentile), normal (5th–95th percentiles), and obese (>95th percentile). Body mass index for age percentile was used for children older than age 2 years, and weight-for-height percentile was used for children younger than age 2 years. Demographic data, Pediatric Index of Mortality 2 score, Pediatric Index of Mortality 2 risk of mortality, hospital mortality, hospital length of stay, the use and duration of ventilator support, hemodynamic support, and dialysis were determined.

Results:

Fifteen percent of children were underweight, while 61.5% were normal weight and 23.5% were obese; 54.9% of the patients were male. The overall mortality was 1.87%, with no significant difference between the three weight groups. The racial distribution, prevalence, and duration of invasive and noninvasive ventilation, and the use of vasopressors, central venous lines, and dialysis were similar between three groups. Tube feeding and parenteral nutrition were used more often in the underweight group. Pediatric intensive care unit and hospital lengths of stays were higher in underweight children. Underweight children were younger when compared to normal or obese children. Pediatric Index of Mortality 2 scores and Pediatric Index of Mortality 2 risk of mortality scores were higher in underweight children.

Conclusion:

There were no significant differences between the three weight groups in mortality. Underweight children were younger and sicker, and received tube feeding and parenteral nutrition more frequently.

ASSOCIATION OF THE HUMAN PPARγ2 PRO12ALA POLYMORPHISM WITH OBESITY IN A POPULATION FROM TURKEY

BACKGROUND

There have been a number of reports on the relationship between the PPARγ2 Pro12Ala genotype and the development of obesity.

OBJECTIVE

A case-control survey was designed to investigate the potential association between a Pro12Ala polymorphism in the PPARγ2 gene and obesity and/or obesity-related phenotypes in a population from Turkey.

MATERIALS AND METHODS

The polymerase chain reaction and restriction enzyme digestion were used to genotype the Pro12Ala polymorphism of the PPARγ2 gene in 149 unrelated obese and 105 non-obese control subjects from Turkey. The data were analyzed statistically.

RESULTS

We found that the overall minor allele frequency was 0.12 in cases and 0.095 in controls. In terms of genotype distribution and allele frequencies among the cases versus controls in the population studied, only the gender-stratified analysis revealed a significantly higher frequency of Pro/Ala genotype within males. The polymorphism was associated with significantly higher weight, height, waist circumference, central adiposity (waist-to-hip ratio, WHR), lean body weight as well as dry body weight, but not overall adiposity (total body fat percentage, TBF) in cases carrying Ala allele (Pro/Ala or Ala/Ala). However, in the subjects carrying Ala allele of the control group, WHR values were found significantly lower.

CONCLUSION

Our results showed that the Pro12Ala polymorphism in the PPARγ2 gene is associated with obesity in the studied adult population from Turkey. These data suggest that the Pro12Ala polymorphism in PPARγ2 may be a potential genetic risk factor for central obesity.

Higher BMI is associated with reduced mortality but longer hospital stays following ICU discharge in critically ill Asian patients

BACKGROUND & AIMS

Asians with similar body mass index (BMI) as the Caucasians are at higher health risk as compared to their counterparts. Although the mean weight of patients admitted to the intensive care unit (ICU) is increasing but the relation between BMI with 28-day mortality and length of stay (LOS) following ICU discharge in Asian patients is not well studied.

METHODS

We included all adult patients admitted to the ICU of a tertiary hospital who received mechanical ventilation (MV) for at least 48 hours between October 2013 and September 2014. Demographics, BMI, MV, comorbidities, ICU scores (Acute Physiology And Chronic Health Evaluation (APACHE) II and sequential organ failure assessment (SOFA)), use of vasopressor, renal replacement therapy and calorie supplementation were collected from the ICU database. BMI was categorized into four groups according to the World Health Organization's Asian BMI recommendation. Post-ICU LOS (days) was calculated from ICU discharge to hospital discharge in hospital survivors. We used multivariable logistic regression to identify factors associated with 28-day mortality and post-ICU LOS of more than 7 days.

RESULTS

In a cohort of 273 patients (male 62%, mean age 58.4 ± 17 years), the prevalence of overweight/obesity was 53%. In the bivariate analysis, 28-day mortality was lower (p = 0.014) and post-ICU LOS longer (p = 0.01) in the overweight/obese groups. In the multivariable logistic regression analysis, APACHE II (Odds ratio, OR 1.10, CI 1.05-1.16), SOFA (OR 1.17, CI 1.05-1.31), duration of MV (days, OR 1.14, CI 1.05-1.25) were associated with increased and higher BMI groups (p < 0.001) with decreased 28-day mortality. Further analysis of 196 hospital survivors showed age (OR 1.04, CI 1.02-1.06), duration of MV (days, OR 1.14, CI 1.02-1.27) and higher Asian BMI (p = 0.042) were associated with longer post-ICU LOS. The odds of longer post-ICU LOS amongst overweight and obese patients were 1.27 (CI 0.59-2.73) and 1.62 (CI 0.69-3.81) times that of those with normal BMI respectively.

CONCLUSION

In multiethnic critically ill Asian patients, the prevalence of overweight/obesity was high. Although higher BMI was associated with reduced risk of 28-day mortality, obese patients stayed significantly longer in the hospital following ICU discharge.

Challenging obesity, diabetes, and addiction: the potential of lorcaserin extended release

Obesity is a global epidemic that is a leading cause of preventable death. In addition to lifestyle modification, there are numerous obesity treatments for clinicians to consider, including medications. Lorcaserin immediate release/extended release (IR/XR) is a US Food and Drug Administration approved medication for overweight and obese patients to be used with lifestyle modifications. Lorcaserin is thought to reduce weight by targeting the serotonin (5HT2c) system to induce satiety. Lorcaserin IR has been shown to be effective in reducing weight in overweight (body mass index [BMI] > 27 kg/m2) and obese (BMI > 30 kg/m2) participants in three large Phase III trials. In addition, lorcaserin has been shown to reduce post-cessation weight gain and improved smoking cessation in a randomized placebo-controlled trial. A recent meta-analysis suggested in overweight diabetic patients lorcaserin may be added to first-line oral hypoglycemic medications to enhance reduction in glycated hemoglobin. Lorcaserin is generally well tolerated with the most common side effect being headache, which is typically self-limiting. Lorcaserin XR (once daily) was recently approved and has been shown to be bioequivalent to lorcaserin IR (twice daily) in a pivotal study. Lorcaserin XRs, main advantage over the IR formulation is the once daily dosing regimen, which likely would lead to improved adherence and thus improved clinical effectiveness. The present review will evaluate the lorcaserin clinical studies (obesity, diabetes, and addiction), XR bioequivalence studies, pharmacogenomics of the serotonin (5HT2c) system, and adherence data in once daily versus twice daily medications.

Differential Effects of High Sugar, High Lard or a Combination of Both on Nutritional, Hormonal and Cardiovascular Metabolic Profiles of Rodents

BACKGROUND

Dietary interventions in rodents can induce an excess of adipose tissue and metabolic disorders that resemble human obesity. Nevertheless, these approaches are not standardized, and the phenotypes may vary distinctly among studies. The aim of this study was to investigate the effects of different dietary interventions on nutritional, metabolic, biochemical, hormonal, and cardiovascular profiles, as well as to add to development and characterization of an experimental model of obesity.

METHODS

Male Wistar rats were randomized into four groups: control diet (C), high-sugar (HS), high-fat (HF), or high-sugar and high-fat (HFHS). Weekly measurements of body weight, adiposity, area under the curve (AUC) for glucose, blood pressure (BP) and serum triglycerides, total cholesterol level, and leptin were performed.

RESULTS

HF and HFHS models were led to obesity by increases in adipose tissue deposition and the adiposity index. All hypercaloric diets presented systolic BP increases. In addition, the AUC for glucose was greater in HF and HFHS than in C, and only the HF group presented hyperleptinemia.

CONCLUSIONS

HF and HFHS diet approaches promote obesity and comorbidities, and thus represent a useful tool for studying human obesity-related disorders. By contrast, the HS model did not prove to be a good model of obesity.

Overfed but undernourished: recognizing nutritional inadequacies/deficiencies in patients with overweight or obesity

Overweight and obesity are highly prevalent throughout the world and can adversely affect the nutritional status of individuals. Studies have shown that many people with obesity have inadequate intake of iron, calcium, magnesium, zinc, copper, folate and vitamins A and B₁₂, likely as a result of poor diet quality. Nutritional inadequacies or deficiencies may also occur due to altered pharmacokinetics in the individual with obesity and due to interactions in those with overweight or obesity with various pharmaceuticals. However, it has been demonstrated that the adult population in the United States as a whole is deficient in certain micronutrients as a result of the availability and overconsumption of high-calorie, low-nutrient processed foods. Poor nutrition may contribute to the development of certain chronic conditions, such as type 2 diabetes, which is already more prevalent in those with obesity. Clinicians need to be aware of these gaps, particularly in those individuals with obesity who are undergoing bariatric surgery or taking pharmaceutical products long term to facilitate weight loss. Patients with overweight or obesity likely struggle to achieve a balanced diet and may benefit from consultation with a dietitian. Along with providing recommendations for healthy eating and exercise, supplementation with specific micronutrients or multivitamins should be considered for individuals at the highest risk for or with established deficiencies. Further research is needed to understand the factors underlying nutritional inadequacies in individuals with overweight or obesity, as well as the outcomes of treatment strategies employed to address them.

The Impact of a Multi-Level Multi-Component Childhood Obesity Prevention Intervention on Healthy Food Availability, Sales, and Purchasing in a Low-Income Urban Area

The multifactorial causes of obesity require multilevel and multicomponent solutions, but such combined strategies have not been tested to improve the community food environment. We evaluated the impact of a multilevel (operating at different levels of the food environment) multicomponent (interventions occurring at the same level) community intervention. The B’more Healthy Communities for Kids (BHCK) intervention worked at the wholesaler (n = 3), corner store (n = 50), carryout (n = 30), recreation center (n = 28), household (n = 365) levels to improve availability, purchasing, and consumption of healthier foods and beverages (low-sugar, low-fat) in low-income food desert predominantly African American zones in the city of Baltimore (MD, USA), ultimately intending to lead to decreased weight gain in children (not reported in this manuscript). For this paper, we focus on more proximal impacts on the food environment, and measure change in stocking, sales and purchase of promoted foods at the different levels of the food system in 14 intervention neighborhoods, as compared to 14 comparison neighborhoods. Sales of promoted products increased in wholesalers. Stocking of these products improved in corner stores, but not in carryouts, and we did not find any change in total sales. Children more exposed to the intervention increased their frequency of purchase of promoted products, although improvement was not seen for adult caregivers. A multilevel food environment intervention in a low-income urban setting improved aspects of the food system, leading to increased healthy food purchasing behavior in children.

In Defense of Flossing: Part II-Can We Agree It's Premature to Claim Flossing Is Ineffective to Help Prevent Periodontal Diseases?

Periodontal diseases are complex, multifactorial disorders. Effective daily plaque control promotes gingival/periodontal health. Recent meta-analyses and other reviews have found inconclusive evidence to support that tooth flossing promotes gingival/periodontal health. Ideally, the claim should have been that, "at present, we do not have high-quality evidence from well-designed randomized clinical trials to determine whether flossing lowers the risk for periodontal diseases." Rather than "not proven to be effective," the lay public may now think that flossing is "almost entirely unhelpful and/or unnecessary." How does the dental community communicate the nuances of this topic? Herein, we examine the key structural issues underlying this area of research. We assert that effective flossing between specific teeth can promote gingival/periodontal health. Furthermore, we explore the nuances for whom this may be true and untrue, why our evidence is lacking, and what can be done to clarify the effectiveness of flossing on clinical outcomes.

Novel Nonsurgical Endoscopic Approaches for the Treatment of Obesity

Globally, obesity is a leading cause of preventable death and is associated with >60 comorbid medical conditions, including 10 types of cancer that are strongly associated with body mass index. There are a number of traditional obesity treatments-for example, lifestyle management (eg, decreased caloric intake and increased expenditure), pharmacotherapy, and bariatric surgery. Recently, endoscopic approaches have emerged as a viable alternative for weight loss. Endoscopically placed intragastric balloons were introduced in the early 1980s for the treatment of medically complicated obesity but, unfortunately, had high rates of complications, such as premature deflation leading to obstruction. Despite these shortcomings, these devices have experienced a renewal, with a second generation of improved devices being approved for clinical use in 2015. In addition to the intragastric balloons, there are a number of other endoscopic approaches to weight loss that are either Food and Drug Administration approved or undergoing evaluation (aspiration therapy, duodenal jejunal bypass sleeve). The current review examines the literature available and discusses the practical clinical considerations involved.

A novel computed tomography method to detect normal from abnormal psoas muscle: a pilot feasibility study

Background: Sarcopenia is a syndrome characterized by progressive loss of skeletal muscle which can be detected by computed tomography (CT) by estimating total psoas muscle cross-sectional area (CSA).  Relying on total psoas CSA alone takes into account abnormal muscle and intramuscular fat, both of which may be increased in sarcopenic obesity.  We developed a novel CT-method to identify the proportion of normal to abnormal psoas muscle at the third lumbar (L3) level.  The primary objective of our pilot study was to measure inter-observer agreement between measuring total psoas CSA and proportion of normal and abnormal psoas muscle using a novel CT-method.  We hypothesized total psoas CSA and proportion of normal and abnormal psoas muscle would be reliably quantifiable.Methods: CT abdomen images were obtained for 20 adults.  Two radiologists independently identified and traced the L3 psoas muscle circumference to estimate CSA.  Hounsfield units were applied to the tracing to identify proportion of normal muscle, abnormal muscle, and fat.  Inter-observer agreement was assessed using Pearson’s correlation coefficient.Results: Of the 20 patients, 13 were male and six were obese.  Mean age was 66 years.  Correlation coefficient was excellent for total psoas CSA (r=0.93,p-value<0.00001) and proportion of normal psoas muscle (r=0.94,p-value<0.0001).  Correlation was excellent between BMI and abnormal muscle (r=0.67, p-value=0.001).  Correlation was poor between total psoas CSA and body mass index (BMI) (r=0.369,p-value=0.108) and negative between proportion of normal muscle and BMI (r= -0.50,p-value=0.025).Conclusions: Our study findings demonstrate that total psoas CSA and proportion of normal and abnormal psoas can be reliably quantified.  Our CT-method may be superior to total psoas CSA in identifying sarcopenic obesity, the results of which can be used to explore clinical outcomes.

Body Mass Index and Intensive Care Unit Outcomes in African American Patients

PURPOSE

We sought to determine whether body mass index (BMI) is associated with worse intensive care unit (ICU) outcomes among Black patients.

METHODS

Patients admitted to the medical ICU during 2012 were categorized into six BMI groups based on the World Health Organization criteria. ICU mortality, ICU and hospital length of stay (LOS), need for and duration of mechanical ventilation and organ failure rate were assessed.

RESULTS

A total of 605 patients with mean age 58.9 ± 16.0 years were studied. Compared with those with normal BMI, obese patients had significant higher rates of hypertension, diabetes mellitus and obstructive sleep apnea diagnoses (P<.001 for all). A total of 100 (16.5%) patients died during their ICU stay. Obesity was not associated with increased odds of ICU mortality (OR=.58; 95% CI, .16-2.20). Moreover, improved survival was observed for class II obese patients (OR, .031; 95% CI, .001-.863). There were no differences in the need for and duration of mechanical ventilation between the BMI groups. However, ICU and hospital LOS were significantly longer in patients with obesity.

CONCLUSION

Obesity was not associated with increased ICU mortality; however, obesity was associated with increased comorbid illness and with significant longer ICU and hospital length of stay.

Indole Derivatives Isolated from Brown Alga Sargassum thunbergii Inhibit Adipogenesis through AMPK Activation in 3T3-L1 Preadipocytes

Seaweed, a popular and abundant food ingredient mainly consumed in Asian countries, is a good source of bioactive compounds with anti-obesity effects. However, the anti-obesity effects of Sargassum thunbergii have not yet been established. In this study, we isolated six indole derivatives (STCs)-indole-2-carboxaldehyde (STC-1), indole-3-carboxaldehyde (STC-2), indole-4-carboxaldehyde (STC-3), indole-5-carboxaldehyde (STC-4), indole-6-carboxaldehyde (STC-5), and indole-7-carboxaldehyde (STC-6)-from S. thunbergii and evaluated their inhibitory effects on adipocyte differentiation in 3T3-L1 cells. We found that STC-1 and STC-5 resulted in non-toxic inhibition of the differentiation of 3T3-L1 adipocytes and thus selected these compounds for further study. STC-1 and STC-5 significantly inhibited lipid accumulation and downregulated the expression of peroxisome proliferator-activated receptor-γ (PPARγ), CCAAT/enhancer-binding protein α (C/EBPα), and sterol regulatory element-binding protein 1c (SREBP-1c) in a dose-dependent manner. The specific mechanism mediating the effects of STC-1 and STC-5 was shown to be AMP-activated protein kinase (AMPK) activation. Our results demonstrated the inhibitory effect of STC-1 and STC-5 on adipogenesis through the activation of the AMPK signal pathway. Together, these findings suggested that STC-1 and STC-5 may be effective candidates for the prevention of obesity or obesity-related diseases.

Effect of an obesogenic environment and health behaviour-related social support on body mass index and body image of adolescents

Aim:

The purpose of this study was to examine the effect of an obesogenic environment and social support for health behaviours on body mass index and body image in adolescents.

Methods:

This methodological and descriptive study was conducted in a city centre in Turkey. Interviews were made with the Provincial Directorate for National Education, and the schools in the city centre were divided into three regions according to socioeconomic levels; three schools were then determined among the regions by drawing lots. The data collection was performed with 270 students randomly selected from the three schools. A student information form, an obesogenic environment evaluation form, body cathexis scale, body mass index (BMI) and the Child and Adolescent Social Support Scale for Healthy Behaviours were used to collect data. Percentage distributions, correlations, chi-square tests, analyses of variance and independent samples t-tests were used in the data analysis.

Results:

According to the data acquired, 10.7% of adolescents in the study group were overweight and 3.0% were obese. There was a positive relationship between the obesogenic environment and BMI, and as the obesogenic environmental features of adolescents increased, the BMI increased, and the body image scores decreased. As social support for the adolescents’ health behaviours increased from their mothers, fathers, teachers, classmates, and close friends, BMI decreased and they were more likely to be satisfied satisfied with their bodies.

Conclusion:

Our results demonstrate that, while an obesogenic environment contributed to increased BMI in adolescents and decreased their body satisfaction, social support given for health behaviours had a positive effect on BMI and body perception.

Nutritional Assessment in Primary Care

Alterations in nutritional status are common and can be associated with increased morbidity and mortality. However, for healthcare providers, the definition of malnutrition is vague, insensitive, and poorly standardized. In contrast, nutrition risk is more easily defined, and recognizes that both poor nutritional status and disease severity contribute to increased morbidity and mortality. Clinicians need to identify patients who may already have evidence of nutrient deficiencies or have disease processes that affect nutrition risk. This article reviews risk assessment tools and provides practical tips to screen patients and identify those whose nutrition risk warrants specialized nutrition therapy.

Irisin improves perivascular adipose tissue dysfunction via regulation of the heme oxygenase-1/adiponectin axis in diet-induced obese mice

AIMS

To determine whether irisin could improve perivascular adipose tissue (PVAT) dysfunction via regulation of the heme oxygenase-1 (HO-1)/adiponectin axis in obesity.

MATERIALS AND METHODS

C57BL/6 mice were given chow or a high-fat diet (HFD) with or without treatment with irisin. The concentration-dependent responses of the thoracic aorta with or without PVAT (PVAT+ or PVAT-) to phenylephrine were studied in an organ bath. Protein levels of HO-1 and adiponectin were determined by western blot. UCP-1, Cidea, and TNF-α gene expression in PVAT were analyzed by real-time PCR.

RESULTS

Treatment of obese mice with irisin improved glucose and lipid metabolism, reduced plasma levels of TNF-α and malondialdehyde, and increased plasma adiponectin levels (P<0.01). The anti-contractile effects of PVAT were attenuated in HFD mice and this attenuation was restored in HFD mice treated with irisin (P<0.05). Incubation of aortas (PVAT+) with the HO-1 inhibitor and adiponectin receptor blocking peptide in irisin-treated HFD mice abolished the beneficial effects of irisin on PVAT function. The same results were also observed in HFD mice treated with irisin ex vivo. Treatment of HFD mice with irisin significantly enhanced protein levels of HO-1 and adiponectin, and reduced superoxide production and TNF-α expression in PVAT. Irisin treatment enhanced brown adipocyte markers UCP-1 and Cidea expression in PVAT from HFD mice.

CONCLUSION

Irisin improved the anti-contractile properties of PVAT from the thoracic aorta in diet-induced obese mice. The mechanism for protective effects of irisin appeared to be related to upregulation of the HO-1/adiponectin axis in PVAT and browning of PVAT.

The Critical Care Obesity Paradox and Implications for Nutrition Support

Obesity is a leading cause of preventable death worldwide. The prevalence of obesity has been increasing and is associated with an increased risk for other co-morbidities. In the critical care setting, nearly one third of patients are obese. Obese critically ill patients pose significant physical and on-physical challenges to providers, including optimization of nutrition therapy. Intuitively, obese patients would have worse critical care-related outcome. On the contrary, emerging data suggests that critically ill obese patients have improved outcomes, and this phenomenon has been coined "the obesity paradox." The purposes of this review will be to outline the historical views and pathophysiology of obesity and epidemiology of obesity, describe the challenges associated with obesity in the intensive care unit setting, review critical care outcomes in the obese, define the obesity-critical care paradox, and identify the challenges and role of nutrition support in the critically ill obese patient.

Rates and Predictors of Obesity Among African American Sexual Minority Women

PURPOSE

The purpose of this study is to examine rates of and risk factors for obesity in a community sample of African American sexual minority women (SMW).

METHODS

Data were collected using self-administered paper-and-pencil survey questionnaires (n = 219).

RESULTS

Participants were primarily middle aged (M = 40.1; standard deviation [SD] = 10.5 years), well educated (56.9% with a college education and above), insured (82.3%), and had a median income range from $30,000 to $39,999. The mean body mass index (BMI) of the sample was 31.6 (SD = 8.0). Based on BMI scores, over half of the participants were identified as obese (53.9%) and 25.6% were overweight. A number of comorbid illnesses were reported that could be exacerbated by excess weight, including arthritis (21.3%), adult-onset diabetes (4.9%), back problems (23.2%), high cholesterol (15.3%), high blood pressure (19.2%), and heart disease (12%). Multiple risk factors for obesity were observed, including infrequent exercise (<3 times/week = 50.9%), low levels of fruit/vegetable consumption (≤1 serving daily = 39.9%), and frequent consumption of red meat (≥3 times/week = 21.2%). Psychosocial risk factors were also reported, including "eating in response to stress" (46.0%). Depression scores predicted eating in response to stress. One-third of the sample reported interest in weight management interventions.

CONCLUSIONS

African American SMW report high rates of obesity, chronic health conditions exacerbated by weight, and health and dietary behaviors that increase risk for weight-related health disparities. These study findings have implications for additional research and intervention development.

Irisin improves endothelial function in obese mice through the AMPK-eNOS pathway

Irisin is a novel hormone secreted by myocytes. Lower levels of irisin are independently associated with endothelial dysfunction in obese subjects. The objective of this study was to explore whether irisin exerts a direct vascular protective effect on endothelial function in high-fat-diet-induced obese mice. Male C57BL/6 mice were given chow or a high-fat diet with or without treatment with irisin. Aortic endothelial function was determined by measuring endothelium-dependent vasodilatation (EDV). Nitric oxide (NO) in the aorta was determined. The effect of irisin on the levels of AMP-activated protein kinase (AMPK), Akt, and endothelial NO synthase (eNOS) phosphorylation in endothelial cells was determined. Human umbilical vein endothelial cells were used to study the role of irisin in the AMPK-eNOS pathway. Acetylcholine-stimulated EDV was significantly lower in obese mice compared with control mice. Treatment of obese mice with irisin significantly enhanced EDV and improved endothelial function. This beneficial effect of irisin was partly attenuated in the presence of inhibitors of AMPK, Akt, and eNOS. Treatment of obese mice with irisin enhanced NO production and phosphorylation of AMPK, Akt, and eNOS in endothelial cells. These factors were also enhanced by irisin in human umbilical vein endothelial cells in vitro. Suppression of AMPK expression by small interfering RNA blocked irisin-induced eNOS and Akt phosphorylation and NO production. We have provided the first evidence that irisin improves endothelial function in aortas of high-fat-diet-induced obese mice. The mechanism for this protective effect is related to the activation of the AMPK-eNOS signaling pathway.

Childhood obesity: a (re) programming disease?

The aim of our article was to review the current literature on the effects of metabolic (re) programming on childhood obesity. PubMed/MEDLINE was the data source used to track the studies. Descriptors applied: children obesity, epigenetic, metabolic programming, exercise and nutrition. The focus was to analyze and discuss the international findings on the theme. The gathering of the papers was performed between June and August 2014. The search of articles with the descriptors used found 33.054 studies. In all, 5.709 studies were selected by crossing chosen keywords. Among these, after careful reading of the titles, 712 papers were considered potential as references. After applying inclusion/exclusion criteria, 50 studies were selected from 132 eligible abstracts. Most studies linked the development and treatment of obesity from epigenetically stimulated metabolic programming during the early stages of pregnancy and life. This review provides theoretical basis to the understanding that the programmed development of childhood obesity may be linked to early exposure to environmental factors, such as (nutrition and regular practice of exercise) and stimulus can epigenetically alter the modulation of the obesogenic metabolic behavior during pregnancy and the developmental stages of children and/or postpone the pathophysiologic disease stage to adulthood.

Uncoupling protein 2 gene (UCP2) 45-bp I/D polymorphism is associated with adiposity among Malaysian women

This study investigated the association of Uncoupling Protein 2 gene (UCP2) 45-bp I/D polymorphism with obesity and adiposity in 926 Malaysian subjects (416 males;265 obese; 102/672/152 Malays/Chinese/Indians). The overall minor allele frequency (MAF) was 0.14, while MAFs according to Malay/Chinese/Indian were 0.17/0.12/0.21. The polymorphism was associated with ethnicity, obesity and overall adiposity (total body fat percentage, TBF), but not gender and central adiposity (waist-hip ratio, WHR). Gender- and ethnicity-stratified analysis revealed that within males, the polymorphism was not associated with ethnicity and anthropometric classes. However, within females, significantly more Indians, obese and those with high TBF carried I allele. Logistic regression analysis among females further showed the polymorphism was associated with obesity and overall adiposity; however, when adjusted for age and ethnicity, this association was abolished for obesity but remained significant for overall adiposity [Odds Ratio (OR) for ID genotype = 2.02 (CI=1.18, 3.45; p=0.01); I allele =1.81 (CI=1.15, 2.84; p=0.01)]. Indeed, covariate analysis controlling for age and ethnicity also showed that those carrying ID genotype or I allele had significantly higher TBF than the rest. In conclusion, UCP2 45-bp I/D polymorphism is associated with overall adiposity among Malaysian women.

Renal protective effects of induction of haem oxygenase-1 combined with increased adiponectin on the glomerular vascular endothelial growth factor-nitric oxide axis in obese rats

What is the central question of this study? This study aimed to investigate whether induction of haem oxygenase-1 (HO-1) can protect the kidneys of obese rats by regulating the glomerular vascular endothelial growth factor-nitric oxide (VEGF-NO) axis by increasing the adiponectin concentrations. What is the main finding and its importance? Induction of HO-1 reduces the degree of microalbuminuria and has renal protective effects by improving endothelial function and regulating the uncoupled glomerular VEGF-NO axis in diet-induced obese rats. The mechanism may be related to increased activation of the HO-1-adiponectin axis. The glomerular vascular endothelial growth factor-nitric oxide (VEGF-NO) axis plays a critical role in maintenance of normal kidney function in obesity. Induction of haem oxygenase-1 (HO-1) may result in a parallel increase in adiponectin secretion. The aim of this study was to investigate whether induction of HO-1 could protect the kidneys of obese rats by regulating the glomerular VEGF-NO axis by increasing adiponectin levels. Rats received high-fat diets and were injected with either cobalt protoporphyrin to induce HO-1 or stannous protoporphyrin to inhibit HO-1. Blood and urine samples were collected. Endothelial function was determined by measuring the endothelium-dependent vasodilatation of the aorta. Renal tissues were collected for CD34 immunohistochemistry. The glomerular VEGF-NO axis and the AMP kinase-phosphoinositide 3-kinase (PI3K)/Akt-endothelial nitric oxide synthase pathway were measured. Induction of HO-1 by cobalt protoporphyrin decreased microalbuminuria, plasma free fatty acids, serum high-sensitivity C-reactive protein and malondialdehyde levels and increased serum adiponectin levels compared with the untreated obese rats. Severe impairment of endothelium-dependent vasodilatation was observed in the obese rats, which was improved to some extent by HO-1 induction. Induction of HO-1 reduced glomerular CD34 expression and production of reactive oxygen species in obese rats. Obese rats showed increased glomerular VEGF expression and reduced NO levels. This uncoupling of the glomerular VEGF-NO axis was improved to some extent by induction of HO-1, with enhancement of p-AMP kinase, p-Akt and phospho-endothelial nitric oxide synthase in obese rats. These results indicate that induction of HO-1 with cobalt protoporphyrin reduces the degree of microalbuminuria and has renal protective effects by improving endothelial dysfunction and regulating the glomerular VEGF-NO axis in diet-induced obese rats by increasing adiponectin levels.

Designation of obesity as a disease: lessons learned from alcohol and tobacco

Obesity is a leading cause of preventable death in the USA. The American Medical Association recently recognized obesity as meeting the definition of a chronic disease. This declaration had the intention of improving screening and long-term treatment and is historically similar to the designation of tobacco and alcohol dependence as a chronic disease. Nevertheless, it has ignited a nationwide debate in both academia and public opinion. The current article reviews the implications of treating obesity as a chronic disease, comparing the similarities in pathophysiology of obesity and other addictions, and discusses the pros and cons of this designation as it pertains to health care workers and patients.

Validation of the Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition Recommendations for Caloric Provision to Critically Ill Obese Patients: A Pilot Study

BACKGROUND

The Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN) recommend that obese, critically ill patients receive 11-14 kcal/kg/d using actual body weight (ABW) or 22-25 kcal/kg/d using ideal body weight (IBW), because feeding these patients 50%-70% maintenance needs while administering high protein may improve outcomes. It is unknown whether these equations achieve this target when validated against indirect calorimetry, perform equally across all degrees of obesity, or compare well with other equations.

METHODS

Measured resting energy expenditure (MREE) was determined in obese (body mass index [BMI] ≥30 kg/m(2)), critically ill patients. Resting energy expenditure was predicted (PREE) using several equations: 12.5 kcal/kg ABW (ASPEN-Actual BW), 23.5 kcal/kg IBW (ASPEN-Ideal BW), Harris-Benedict (adjusted-weight and 1.5 stress-factor), and Ireton-Jones for obesity. Correlation of PREE to 65% MREE, predictive accuracy, precision, bias, and large error incidence were calculated.

RESULTS

All equations were significantly correlated with 65% MREE but had poor predictive accuracy, had excessive large error incidence, were imprecise, and were biased in the entire cohort (N = 31). In the obesity cohort (n = 20, BMI 30-50 kg/m(2)), ASPEN-Actual BW had acceptable predictive accuracy and large error incidence, was unbiased, and was nearly precise. In super obesity (n = 11, BMI >50 kg/m(2)), ASPEN-Ideal BW had acceptable predictive accuracy and large error incidence and was precise and unbiased.

CONCLUSIONS

SCCM/ASPEN-recommended body weight equations are reasonable predictors of 65% MREE depending on the equation and degree of obesity. Assuming that feeding 65% MREE is appropriate, this study suggests that patients with a BMI 30-50 kg/m(2) should receive 11-14 kcal/kg/d using ABW and those with a BMI >50 kg/m(2) should receive 22-25 kcal/kg/d using IBW.

New pharmacological treatments for the management of obesity

Obesity is quickly becoming the leading preventable cause of death in the USA. Over 60 obesity-related comorbidities exist which increase the complexity and cost of medical care in obese patients. Even a moderate weight loss of 5 % can reduce morbidity associated with these conditions. Lifestyle modification through caloric restriction and enhanced exercise and physical activity remain the first line treatment for obesity. The development of pharmacologic agents for the treatment of obesity has been challenged by both lack of efficacy and serious adverse side effects leading to their removal from market. Two new agents were recently approved by the US Food and Drug Administration to complement lifestyle modification in obese (BMI ≥30 kg/m(2)) and overweight patients (BMI ≥27 kg/m(2) and one obesity-related comorbidity). Lorcaserin is a novel serotonin 5-HT2C selective agonist which has been shown in three phase III studies to significantly reduce weight and cardiovascular risk factors such as diabetes. Phentermine/topiramate extended release (ER) is a novel combination of two agents which have individually been shown to significantly reduce weight. The combination agent phentermine/topiramate ER has been shown to reduce weight in overweight and obese subjects in a number of studies. This article reviews the pharmacology, clinical efficacy, and safety of these new agents compared to past and other presently available medications for the treatment of obesity.

Self-perceived vs actual and desired weight and body mass index in adult ambulatory general internal medicine patients: a cross sectional study

BACKGROUND

No study has compared patients' self-reported heights and weights (and resultant self-reported body mass indexes [BMIs]) with their actual heights, weights, and BMIs; their self-perceived BMI categories; and their desired weights and BMIs and determined rates of clinicians' documented diagnoses of overweight and obesity in affected patients in a single patient group. The objectives of this study were to make these comparisons, determine patient factors associated with accurate self-perceived BMI categorization, and determine the frequency of clinicians' documented diagnoses of overweight and obesity in affected patients.

RESULTS

A total of 508 consecutive adult general internal medicine outpatients (257 women, 251 men; mean age, 62.9 ± 14.9 years) seen at Mayo Clinic in Rochester, Minnesota, between November 9 and 20, 2009, completed a questionnaire in which they reported their heights, weights, self-perceived BMI categories ("underweight," "about right," "overweight," or "obese"), and desired weights. These self-reported data were compared to actual heights, actual weights, and actual BMI categories (measured after the questionnaire was completed). Overall, 70% of the patients were overweight or obese. The average self-reported weight was significantly lower than the average actual weight (80.3 ± 20.1 kg vs 81.9 ± 21.1 kg; P < .001). The average self-reported BMI was significantly lower than the average actual BMI (27.6 ± 5.7 kg/m(2) vs 28.3 ± 6.1 kg/m(2); P < .001). Overall, 32% of patients had obesity; however, only 6% perceived they were obese. Accuracy of self-perceived BMI category decreased with higher actual BMI category (P < .001 for trend). Female sex, higher education level, smoking status, and lower BMI were associated with higher accuracy of self-perceived BMI category. Desired weight loss increased with higher self-perceived and actual BMI categories (P < .001 for trends). Of the 165 patients who actually were obese, only 40 (24%) had obesity documented as a diagnosis in their medical records by their clinicians. Statistical tests used were the paired t test, the Pearson χ2 test, the Cochrane-Armitage trend test, the Wald test of marginal homogeneity, analysis of variance, and univariate and multivariate logistic regression.

CONCLUSIONS

Many obese patients inaccurately perceive their BMI categories; accuracy decreases with increasing BMI. Clinicians should inform patients of their BMIs and prescribe treatment plans for those with overweight and obesity.

Leptin influences estrogen metabolism and accelerates prostate cell proliferation

AIM

The present study was designed to investigate the effect of leptin on estrogen metabolism in prostatic cells.

MAIN METHODS

Malignant (PC-3) and benign (BPH-1) human prostate cells were treated with 17-β-hydroxyestradiol (1 μM) alone or in combination with leptin (0.4, 4, 40 ng/ml) for 72 h. Cell proliferation assay, immunocytochemical staining of estrogen receptor (ER), liquid chromatography-tandem mass spectrometry method (LC-MS) and semi-quantitative reverse transcriptase polymerase chain reaction (RT-PCR) were used.

KEY FINDINGS

Cell proliferation assay demonstrated that leptin caused significant growth potentiation in both cells. Immunocytochemical staining showed that leptin significantly increased the expression of ER-α and decreased that of ER-β in PC-3 cells. LC-MS method revealed that leptin increased the concentration 4-hydroxyestrone and/or decreased that of 2-methoxyestradiol, 4-methoxyestradiol and 2-methoxyestrone. Interestingly, RT-PCR showed that leptin significantly up-regulated the expression of aromatase and cytochrome P450 1B1 (CYP1B1) enzymes; however down-regulated the expression of catechol-o-methyltransferase (COMT) enzyme.

SIGNIFICANCE

These data indicate that leptin-induced proliferative effect in prostate cells might be partly attributed to estrogen metabolism. Thus, leptin might be a novel target for therapeutic intervention in prostatic disorders.

Perirenal fat associated with microalbuminuria in obese rats

PURPOSE

To determine whether perirenal fat is associated with increased urinary albumin excretion and whether perirenal fat affects renal vascular endothelial function in obese rats.

METHODS

Wistar rats were randomly divided into normal and obesity group, which were fed with normal and high-fat diet, respectively. Blood and urine samples were collected. Endothelial function of the aorta was determined by measuring endothelium-dependent vasodilatation. Renal tissues were collected for CD34 immunohistochemistry and free fatty acids (FFA) measurement. Levels of glomerular nitric oxide (NO) and reactive oxygen species (ROS) were measured.

RESULTS

After 24 weeks, plasma FFA, high-sensitivity C-reactive protein, and malondialdehyde levels were elevated and were significantly higher in renal venous blood than in jugular venous blood in obese rats. Urinary albumin/creatinine ratio, glomerular CD34 expression, glomerular ROS level, and renal cortex FFA levels were higher in obese rats. Endothelial dysfunction was more severe in the infra-renal aorta than in the thoracic aorta in obese rats. Plasma adiponectin and glomerular NO levels were lower in obese rats.

CONCLUSION

Perirenal fat is associated with increased urinary albumin excretion in obese rats. The mechanism may be renal vascular endothelial dysfunction caused by increased oxidative stress and activation of inflammatory molecular pathways due to elevated FFA and low adiponectin levels.

Non-alcoholic fatty pancreas disease pathogenesis: a role for developmental programming and altered circadian rhythms

OBJECTIVES

Emerging evidence suggests that maternal obesity (MO) predisposes offspring to obesity and the recently described non-alcoholic fatty pancreas disease (NAFPD) but involved mechanisms remain unclear. Using a pathophysiologically relevant murine model, we here investigated a role for the biological clock--molecular core circadian genes (CCG) in the generation of NAFPD.

DESIGN

Female C57BL6 mice were fed an obesogenic diet (OD) or standard chow (SC) for 6 weeks, prior to pregnancy and throughout gestation and lactation: resulting offspring were subsequently weaned onto either OD (Ob_Ob and Con_Ob) or standard chow (Ob_Con and Con_Con) for 6 months. Biochemical, pro-inflammatory and pro-fibrogenic markers associated with NAFPD were then evaluated and CCG mRNA expression in the pancreas determined.

RESULTS

Offspring of obese dams weaned on to OD (Ob_Ob) had significantly increased (p≤0.05): bodyweight, pancreatic triglycerides, macrovesicular pancreatic fatty-infiltration, and pancreatic mRNA expression of TNF-α, IL-6, α-SMA, TGF-β and increased collagen compared to offspring of control dams weaned on to control chow (Con_Con). Analyses of CCG expression demonstrated a phase shift in CLOCK (-4.818, p<0.01), REV-ERB-α (-1.4,p<0.05) and Per2 (3.27,p<0.05) in association with decreased amplitude in BMAL-1 (-0.914,p<0.05) and PER2 (1.18,p<0.005) in Ob_Ob compared to Con_Con. 2-way ANOVA revealed significant interaction between MO and post-weaning OD in expression of CLOCK (p<0.005), PER1 (p<0.005) and PER2 (p<0.05) whilst MO alone influenced the observed rhythmic variance in expression of all 5 measured CCG.

CONCLUSIONS

Fetal and neonatal exposure to a maternal obesogenic environment interacts with a post-natal hyper-calorific environment to induce offspring NAFPD through mechanisms involving perturbations in CCG expression.