Life Years Lost Associated with Obesity-Related Diseases for U.S. Non-Smoking Adults

Late reproduction is associated with extended female survival but not with familial longevity

RESEARCH QUESTION

Are age at last childbirth and number of children, as facets of female reproductive health, related to individual lifespan or familial longevity?

DESIGN

This observational study included 10,255 female participants from a multigenerational historical cohort, the LINKing System for historical family reconstruction (LINKS), and 1258 female participants from 651 long-lived families in the Leiden Longevity Study (LLS). Age at last childbirth and number of children, as outcomes of reproductive success, were compared with individual and familial longevity using the LINKS dataset. In addition, the genetic predisposition in the form of a polygenic risk score (PRS) for age at menopause was studied in relation to familial longevity using the LLS dataset.

RESULTS

For each year increase in the age of the birth of the last child, a woman's lifespan increased by 0.06 years (22 days; P = 0.002). The yearly risk for having a last child was 9% lower in women who survived to the oldest 10% of their birth cohort (hazard ratio 0.91, 95% CI 0.86-0.95). Women who came from long-living families did not have a higher mean age of last childbirth. There was no significant association between familial longevity and genetic predisposition to age at menopause.

CONCLUSIONS

Female reproductive health associates with a longer lifespan. Familial longevity does not associate to extended reproductive health. Other factors in somatic maintenance that support a longer lifespan are likely to have an impact on reproductive health.

Aging, Equality and the Human Healthspan

John Davis (New Methuselahs: The Ethics of Life Extension, The MIT Press, Cambridge, 2018) advances a novel ethical analysis of longevity science that employs a three-fold methodology of examining the impact of life extension technologies on three distinct groups: the "Haves", the "Have-nots" and the "Will-nots". In this essay, I critically examine the egalitarian analysis Davis deploys with respect to its ability to help us theorize about the moral significance of an applied gerontological intervention. Rather than focusing on futuristic scenarios of radical life extension, I offer a rival egalitarian analysis that takes seriously (1) the health vulnerabilities of today's aging populations, (2) the health inequalities of the "aging status quo" and, (3) the prospects for the fair diffusion of an aging intervention over the not-so-distant future. Despite my reservations about Davis's focus on "life-extension" vs. increasing the human "healthspan", I agree with his central conclusion that an aging intervention would be, on balance, a good thing and that we should fund such research aggressively. But, I make an even stronger case and conjecture that an intervention that slows down the rate of molecular and cellular decline from the inborn aging process will likely be one of the most important public health advancements of the twenty-first century. This is so because aging is the most prevalent risk factor for chronic disease, frailty and disability, and it is estimated that there will be over 2 billion persons age > 60 by the year 2050.

Effects of electroacupuncture on obesity: A systematic review and meta-analysis

BACKGROUND

This systematic review and meta-analysis evaluated the efficacy of electroacupuncture for the treatment of obesity.

METHODS

We searched 8 electronic databases for articles published between 2005 and 2021, including only randomized controlled trials (RCTs) in the review. The intervention groups received either electroacupuncture alone or electroacupuncture with standard care, whereas the control groups received sham electroacupuncture, standard care, or no treatment. The primary outcome was the body mass index (BMI), and the secondary outcomes were the body weight (BW), waist circumference (WC), hip circumference, waist-to-hip ratio (WHR), body fat mass, body fat percentage, and adverse effects. Continuous outcome data are presented as mean differences (MDs) with 95% confidence intervals (CIs).

RESULTS

This systematic review and meta-analysis included 13 RCTs involving 779 participants. Results revealed that the BMI (MD: -0.98; 95% CI: -1.35 to -0.61), BW (MD: -1.89; 95% CI: -2.97 to -0.80), WC (MD: -2.67; 95% CI: -4.52 to -0.82), and WHR (MD: -0.03; 95% CI: -0.06 to -0.01) were significantly improved in the intervention groups compared with those in the control groups. Adverse effects were reported in 5 studies. The most commonly used acupoint in the abdomen was ST25, whereas the most commonly used acupoints in other regions were ST36 and SP6 for the treatment of obesity. ST25 was the most commonly used acupoint connected by electroacupuncture.

CONCLUSION

This systematic review and meta-analysis suggested that electroacupuncture is an effective and safe therapy for simple obesity. To increase the reliability of this study, further detailed, long-term studies should be conducted on the effects of electroacupuncture on obesity.

Exercise and bariatric surgery: A systematic review and meta-analysis of the feasibility and acceptability of exercise and controlled trial methods

This systematic review and meta-analysis assessed the feasibility and acceptability of exercise and controlled trial methods in adults awaiting or having undergone bariatric surgery (BS). Search methods used to identify relevant articles were inclusion of articles identified in a systematic review, new database search of articles published 2019-2021, and hand searching reference lists. Titles/abstracts and full-texts were screened by two reviewers independently against inclusion criteria: adults awaiting or having undergone BS, controlled trial, exercise group compared with a comparison group without exercise. Twenty-eight articles were reviewed; most interventions were supervised, performed after BS, and lasted ≤13 weeks. Pooled data for exercise intervention attendance and dropout rates were 84% (k = 10) and 5% (k = 19), respectively, though possibly misestimated due to poor/selective reporting. Median study and recruitment duration were 18 weeks and 24 months, respectively, with a pooled enrollment rate of 2.5 participants/month. Pooled data for refusal to participate, enrollment, and retention rates were 23% (k = 16), 43% (k = 18), and 87% (k = 26), respectively. Despite the lack of data available in studies included, exercise and controlled trial methods seem feasible and acceptable for adults awaiting or having undergone BS. To better identify methodological or practical challenges, and assess bias, better reporting of feasibility and acceptability indicators is needed in future studies.

Recent advances in therapies utilizing superabsorbent hydrogel technology for weight management: A review

Long‐term therapeutic benefit of treatments for weight management in patients with overweight (also termed preobesity) or obesity may be limited by variable safety, tolerability, and efficacy profiles, and patient adherence to treatment regimens. There is a medical need for nonsystemic treatments that promote weight loss in patients with overweight or early obesity. This report reviews four different approaches of utilizing superabsorbent hydrogel technology for weight management at varying stages of preclinical and clinical development. The first is a nonsystemic, oral superabsorbent hydrogel created from naturally derived building blocks used in foods (cellulose‐based), designed to mix homogenously with and change the properties of the ingested meal throughout the gastrointestinal tract (stomach and small intestine). This is the first‐in‐class to be cleared by the Food and Drug Administration (FDA) to aid in weight‐management for adults with BMI of 25–40 kg/m² in conjunction with diet and exercise. In contrast, the other three approaches in development utilize superabsorbent hydrogel technologies to support an intragastric balloon‐like structure, solely occupying space in the stomach and displacing the meal: (1) a pufferfish‐inspired device; (2) Epitomee, a pH‐sensitive self‐expanding hydrogel device; and (3) a light‐degradable hydrogel used to control balloon deflation. These new approaches that utilize superabsorbent hydrogel technology offer a wide range of clinical applicability and have the potential to broaden the weight management treatment landscape. Over time, increasing the number of patients treated with superabsorbent hydrogel technologies will provide important information on long‐term efficacy and safety.

Effects of electroacupuncture for obesity: A protocol for systematic review and meta-analysis

BACKGROUND

Obesity-a public health problem that negatively affects the quality of life-is associated with various diseases, and its prevalence is on the rise. Although drugs and surgical interventions are used to treat obesity, they have adverse effects and limitations. Electroacupuncture is a widely used method for treating obesity in which electrical stimulation is transmitted to the body through acupuncture needles. This systematic review and meta-analysis will evaluate the efficacy of electroacupuncture in treating obesity.

METHODS

MEDLINE/PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, 3 Korean databases (Oriental Medicine Advanced Searching Integrated System, ScienceON, and KoreaMed), 1 Japanese database (Citation Information by the National Institute of Informatics), and 1 Chinese database (Chinese National Knowledge Infrastructure) will be searched from their inception to December 2021. The primary outcome will be body mass index, and the secondary outcomes will be body weight, waist and hip circumference, waist-to-hip ratio, body fat percentage, body fat mass, and adverse effects.

RESULTS AND CONCLUSION

This systematic review and meta-analysis will provide evidence for efficacy of electroacupuncture as a treatment method for obesity.

TRIAL REGISTRATION NUMBER

DOI 10.17605/OSF.IO/YU5XR (https://osf.io/yu5xr).

50 years of the "war on cancer": lessons for public health and geroscience

The year 2021 marks the 50th anniversary of the National Cancer Act of 1971 and President Richard Nixon's declaration of a "war on cancer". In 1971 cancer was the second leading cause of death in the USA, and today it is still the second leading cause of death with an estimated 606,520 Americans dying of cancer in the year 2020. The half a century campaign to eliminate cancer reveals at least two important public health lessons that must be heeded for the next 50 years of the war against the disease-(1) recognizing the limits of behaviour control and (2) recognizing the significance of rate (of ageing) control. These two lessons result in a somewhat paradoxical conclusion in that we must have both humility and ambition in our attitudes towards future preventative medicine for the world's ageing populations. Geroscience must become an integral part of public health if serious headway is to be made preventing not only cancer but most of the other chronic conditions of late life.

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

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

The state of nutrition in medical education in the United States

Despite the significant impact diet has on health, there is minimal nutrition training for medical students. This review summarizes published nutrition learning experiences in US medical schools and makes recommendations accordingly. Of 902 articles, 29 met inclusion criteria, describing 30 learning experiences. Nutrition learning experiences were described as integrated curricula or courses (n = 10, 33%), sessions (n = 17, 57%), or electives (n = 3, 10%). There was heterogeneity in the teaching and assessment methods utilized. The most common was lecture (n = 21, 70%), often assessed through pre- and/or postsurveys (n = 19, 79%). Six studies (26%) provided experience outcomes through objective measures, such as exam or standardized patient experience scores, after the nutrition learning experience. This review revealed sparse and inconsistent data on nutrition learning experiences. However, based on the extant literature, medical schools should build formal nutrition objectives, identify faculty and physician leadership in nutrition education, utilize preexisting resources, and create nutrition learning experiences that can be applied to clinical practice.

Obesity-related multimorbidity and risk of cardiovascular disease in the middle-aged population in the United States

To investigate the prevalence of obesity-related multimorbidity (co-occurrence of ≥2 obesity-related chronic diseases, ORCDs) and the risk of cardiovascular disease in the presence of multimorbidity in middle-aged adults in the United States. National Health and Nutrition Examination Survey data from 2007 to 2016 were used. Target ORCDs included hypertension (H), diabetes (D), coronary heart disease (C), and stroke (S). Age-standardized prevalence for obesity-related multimorbidity in its combination and permutation was calculated. Risk for cardiovascular disease (C or S) was estimated conditional on demographics, degree of obesity, and presence and duration of pre-existing ORCDs. Analyses were conducted at Washington University in 2019. The analytic sample included 14,243 individuals age 40-79 years, representing a population size of 110,003,550. Age-standardized prevalence for obesity-related multimorbidity was 12.3%. Hypertension was most commonly the first diagnosed ORCD for populations with 2-4 ORCDs, followed by diabetes for populations with 2-3 ORCDs. Compared with no pre-existing hypertension/diabetes/stroke, pre-existing hypertension in combination with diabetes/stroke significantly increased risk of coronary heart disease [H + S (multivariable-adjusted hazard ratio, aHR 27.6, 95% CI 10.9-70.2), D + H + S (aHR 20.3, 95% CI 7.9-52.2)]. Compared with no hypertension/diabetes/coronary heart disease, pre-existing hypertension in combination with diabetes/coronary heart disease significantly increased risk of stroke [C + D + H (aHR 32.6, 95% CI 12.2-87.1), C + H (aHR 25.4, 95% CI 12.1-53.6), D + H (aHR 5.3, 95% CI 2.6-10.8)]. Obesity-related multimorbidity is prevalent and highly associated with cardiovascular disease development. To reduce the detrimental health impact of multimorbidity, intervention strategies should target preventing increasing multimorbidity and detecting/managing diabetes and hypertension prior to the onset of cardiovascular disease.

Abdominal and pelvic adipose tissue distribution and risk of prostate cancer recurrence after radiation therapy

BACKGROUND

Fat distribution varies between individuals of similar body mass index (BMI). We hypothesized that visceral obesity is more strongly associated with poor prostate cancer outcomes than overall obesity defined by BMI.

MATERIALS AND METHODS

We quantified abdominal visceral and subcutaneous fat area (VFA and SFA), and pelvic periprostatic adipose tissue area (PPAT), using computed tomography scans from radiation-treated prostate cancer patients at the Durham North Carolina Veterans Administration Hospital. Multivariable-adjusted Cox regression examined associations between each adiposity measure and risk of recurrence, overall and stratified by race and receipt of androgen deprivation therapy (ADT).

RESULTS

Of 401 patients (59% black) treated from 2005 to 2011, 84 (21%) experienced recurrence during 9.3 years median follow-up. Overall, obesity defined by BMI was not associated with recurrence risk overall or stratified by race or ADT, nor was any measure of fat distribution related to the risk of recurrence overall or by race. However, higher VFA was associated with increased risk of recurrence in men who received radiation only (hazard ratio [HR], 1.79; 95% confidence interval [CI], 0.87-3.66), but inversely associated with recurrence risk in men treated with radiation and ADT (HR, 0.49; 95% CI, 0.24-1.03; P-interaction = .002), though neither association reached statistical significance. Similar patterns of ADT-stratified associations were observed for PPAT and SFA.

CONCLUSIONS

Associations between abdominal and pelvic adiposity measures and recurrence risk differed significantly by ADT receipt, with positive directions of association observed only in men not receiving ADT. If confirmed, our findings suggest that obesity may have varying effects on prostate cancer progression risk dependent on the hormonal state of the individual.

DNA methylation in genes of longevity-regulating pathways: association with obesity and metabolic complications

Aging is the main risk factor for most chronic diseases. Epigenetic mechanisms, such as DNA methylation (DNAm) plays a pivotal role in the regulation of physiological responses that can vary along lifespan. The aim of this research was to analyze the association between leukocyte DNAm in genes involved in longevity and the occurrence of obesity and related metabolic alterations in an adult population. Subjects from the MENA cohort (n=474) were categorized according to age (<45 vs 45>) and the presence of metabolic alterations: increased waist circumference, hypercholesterolemia, insulin resistance, and metabolic syndrome. The methylation levels of 58 CpG sites located at genes involved in longevity-regulating pathways were strongly correlated (FDR-adjusted< 0.0001) with BMI. Fifteen of them were differentially methylated (p<0.05) between younger and older subjects that exhibited at least one metabolic alteration. Six of these CpG sites, located at MTOR (cg08862778), ULK1 (cg07199894), ADCY6 (cg11658986), IGF1R (cg01284192), CREB5 (cg11301281), and RELA (cg08128650), were common to the metabolic traits, and CREB5, RELA, and ULK1 were statistically associated with age. In summary, leukocyte DNAm levels of several CpG sites located at genes involved in longevity-regulating pathways were associated with obesity and metabolic syndrome traits, suggesting a role of DNAm in aging-related metabolic alterations.

A Randomized, Double-Blind, Placebo-Controlled Trial of Intravenous Acetaminophen on Hospital Length of Stay in Obese Individuals Undergoing Sleeve Gastrectomy

BACKGROUND

Retrospective studies indicate that acetaminophen iv administration reduces hospital length of stay (LoS) and opiate consumption in patients undergoing bariatric surgery.

OBJECTIVE

This study sought to determine whether using acetaminophen iv in morbidly obese subjects undergoing sleeve gastrectomy decreased LoS and total hospital charges as compared to patients receiving saline placebo.

SETTING

Single-center university hospital METHODS: Using a randomized, double-blind, placebo-controlled design, subjects were assigned to receive either acetaminophen iv (group A) or saline placebo iv (group P). Data were collected between Jan 1 and Dec 31, 2016. Group A received acetaminophen every 6 h for a total of four doses. The first dose was administered following the induction of general anesthesia; group P received saline iv on the same schedule. Anesthetic management and prophylactic antiemetic regimen were standardized in all subjects. Postoperative pain management consisted of hydromorphone via patient-controlled infusion pump. Primary outcomes include hospital LoS and associated hospital costs. Secondary outcomes include patient satisfaction and postoperative nausea and pain scores.

RESULTS

Subject demographics (n = 127) and intraoperative management were similar in the two groups. Across all subjects, median hospital LoS in group A (n = 63) was 1.87 vs. 1.97 days in group P (n = 64) (p = 0.03, Wilcoxon rank-sum test). Postoperatively, daily quality-of-recovery (QoR-15) scores, narcotic consumption, and the use of rescue antiemetics were not significantly different between groups. Median hospital costs were as follows: group A, $12,885 vs. group P, $12,977 (n = 64).

CONCLUSIONS

Acetaminophen iv may reduce hospital LoS in subjects undergoing sleeve gastrectomy.

Equity Weights for Socioeconomic Position: Two Methods-Survey of Stated Preferences and Epidemiological Data

BACKGROUND

There is an implicit equity approach in cost-effectiveness analysis that values health gains of socioeconomic position groups equally. An alternative approach is to integrate equity by weighting quality-adjusted life-years according to the socioeconomic position group.

OBJECTIVES

To use two approaches to derive equity weights for use in cost-effectiveness analysis in Australia, in contexts in which the use of the traditional nonweighted quality-adjusted life-years could increase health inequalities between already disadvantaged groups.

METHODS

Equity weights derived using epidemiological data used burden of disease and mortality data by Socio-Economic Indexes for Areas quintiles from the Australian Institute of Health and Welfare. Two ratios were calculated comparing quintile 1 (lowest) to the total Australian population, and comparing quintile 1 to quintile 5 (highest). Preference-based weights were derived using a discrete choice experiment survey (n = 710). Respondents chose between two programs, with varying gains in life expectancy going to a low- or a high-income group. A probit model incorporating nominal values of the difference in life expectancy was estimated to calculate the equity weights.

RESULTS

The epidemiological weights ranged from 1.2 to 1.5, with larger weights when quintile 5 was the denominator. The preference-based weights ranged from 1.3 (95% confidence interval 1.2-1.4) to 1.8 (95% confidence interval 1.6-2.0), with a tendency for increasing weights as the gains to the low-income group increased.

CONCLUSIONS

Both methods derived plausible and consistent weights. Using weights of different magnitudes in sensitivity analysis would allow the appropriate weight to be considered by decision makers and stakeholders to reflect policy objectives.

Use of healthcare services and expenditure in the US in 2025: The effect of obesity and morbid obesity

Objective

This paper explores the contribution of body-mass index (BMI) categories in shaping past trends of use of healthcare services and associated expenditure in the US and projects results to 2025.

Methods

The study uses Medical Expenditure Panel Survey (MEPS) data for 2000–2012, reweighted on National Health and Nutrition Survey (NHANES) data for 1972–2012 and US Census Bureau data, to carry out projections for up to 2025. A combination of logistic regressions and generalized linear models was used to model use and associated expenditure for the following healthcare services: inpatient care (with/without surgery), office-based care, outpatient-care, drug prescription and home health care. Quantile regressions were used to analyse and project BMI levels.

Results

20.5 million individuals will be severely obese in 2025. Normal-weight and overweight individuals have stable trends in use for many healthcare services. Conversely, use of healthcare services in patients in class II and class III obesity will increase substantially. Total healthcare expenditure increases more quickly in the obese population than in normal-weight individuals.

Conclusions

Class III obesity (BMI≥40 kg/m²) significantly affects demand and expenditure for all healthcare services. Careful healthcare service planning and implementing effective policy actions to counteract such trends is crucial to meet future demand.

Racial disparity in life expectancies and life years lost associated with multiple obesity-related chronic conditions

OBJECTIVE

This study investigated racial disparity in life expectancies (LEs) and life years lost (LYL) associated with multiple obesity-related chronic conditions (OCCs).

METHODS

Data from the Medical Expenditure Panel Survey, 2008-2012, were used. Four OCCs were studied: diabetes, hypertension, coronary heart disease (CHD), and stroke. LE for each subpopulation was simulated by Markov modelling. LYL associated with a disease for a subpopulation was computed by taking the difference between LEs for members of that subpopulation without disease and LEs for members of that subpopulation who had that disease. Racial disparities were measured in the absolute differences in LE and LYL between black women/men and white women/men.

RESULTS

Black individuals had higher risks of developing diabetes, hypertension, and stroke. This disparity in LE between white and black participants was largest in men age 40 to 49 with at least stroke: black men lived 3.12 years shorter than white men. The disparity in LYL between white and black participants was largest in women age 70 to 79 with at least CHD: black women had 1.98 years more LYL than white women.

CONCLUSIONS

Racial disparity exists in incident disease and mortality risks, LEs, and LYL associated with multiple OCCs. Efforts targeting subpopulations with large disparities are required to reduce disparities in the burden of multiple OCCs.

Do acute hospitalised patients in Australia have a different body mass index to the general Australian population: a point prevalence study?

Objective The aim of the present study was to provide a current snapshot of the body mass index (BMI) of the entire patient cohort of an Australian tertiary hospital on one day and compare these data with current published Australian and state (Western Australia) population norms. Methods A single-centre prospective point prevalence study was performed whereby BMI was calculated following actual measurement of patient weight (nurse) and height (physiotherapist) on one day during 2015. Variables were summarised descriptively, and one-way analysis of variance was used to investigate the relationship between continuous BMI and hospital speciality. Multivariate Cox proportional hazards regression was used to analyse the time to leaving hospital, where those who died were censored at their date of death. Results Data were collected from 416 patients (96% of the hospital population on that day). The mean (± s.e.m.) BMI across the whole hospital population was 26.6±2.2kgm-2, with 37% of patients having normal BMI, 8% being underweight, 32% being overweight, 19% being obese and 4% being severely obese. Comparison with both national and state population norms for 2014-15 reflected higher proportions of the hospital population in the underweight and extremely obese categories, and lower proportions in the overweight and obese categories. There was no significant difference in BMI across medical specialties. Conclusions Despite health warnings about the direct relationship between illness and being overweight or obese, the results of the present study reveal fewer hospitalised patients in these BMI categories and more underweight patients than in the non-hospitalised general Australian population. Being overweight or obese may offer some protection against hospitalisation, but there is a point where the deleterious effect of obesity results in more extremely obese individuals being hospitalised than the proportion represented in the general population. What is known about the topic? Although there is significant current published data relating to general Australian population BMI, there is little pertaining specifically to the hospitalised population. Accordingly, although we know that as an affluent Western country we are seeing growing rates of overweight and obese people and relatively few underweight or undernourished people in the general population, we do not know whether these trends are mirrored or magnified in those who are sick in hospital. We also know that although caring for obese patients carries a significant burden, there is the suggestion in some healthcare literature of an 'obesity paradox', whereby in certain disease states being overweight actually decreases mortality and promotes a faster recovery from illness compared with underweight people, who have poorer outcomes. What does this paper add? This paper is the first of its kind to actually measure and calculate the BMI of a whole tertiary Australian hospital population and provide some comparison with published Australian norms. On average, the hospital cohort was overweight, with a mean (± s.e.m.) BMI of 26.6±2.2kgm-2, but less so than the general population, which had a mean BMI of 27.5±0.2kgm-2. The results also indicate that compared with state and national norms, underweight and extremely obese patients were over-represented in the hospitalised cohort, whereas overweight or obese patients were under-represented. What are the implications for practitioners? Although only a single-centre study, the case-mix and socioeconomic catchment area of the hospital evaluated in the present study suggest that it is a typical tertiary urban West Australian facility and, as such, there may be some implications for practitioners. Primarily, administrators need to ensure that we are able to accommodate people of increasing weight in our hospital facilities and have the resources with which to do so, because, on average, hospitalised patients were overweight. In addition, resources need to be available for managing the extremely obese if numbers in this subset of the population increase. Finally, practitioners may also need to consider that although the management of underweight and undernourished patients may be less of a physical burden, there are actually more of these patients in hospital compared with the general population, and they may require a different package of resource utilisation.

The impact of EndoBarrier gastrointestinal liner in obese patients with normal glucose tolerance and in patients with type 2 diabetes

AIMS

The duodenal-jejunal bypass sleeve ((DJBS) or EndoBarrier Gastrointestinal Liner) induces weight loss in obese subjects and may improve glucose homeostasis in patients with type 2 diabetes (T2D). To explore the underlying mechanisms, we evaluated postprandial physiology including glucose metabolism, gut hormone secretion, gallbladder emptying, appetite and food intake in patients undergoing DJBS treatment.

MATERIAL AND METHODS

A total of 10 normal glucose-tolerant (NGT) obese subjects and 9 age-, body weight- and body mass index-matched metformin-treated T2D patients underwent a liquid mixed meal test and a subsequent ad libitum meal test before implantation with DJBS and 1 week (1w) and 26 weeks (26w) after implantation.

RESULTS

At 26w, both groups had achieved a weight loss of 6 to 7 kg. Postprandial glucagon-like peptide-1 (GLP-1) and peptide YY responses increased at 1w and 26w, but only in T2D subjects. In contrast, glucose-dependent insulinotropic polypeptide responses were reduced only by DJBS in the NGT group. Postprandial glucose, insulin, C-peptide, glucagon, cholecystokinin and gastrin responses were unaffected by DJBS in both groups. Satiety and fullness sensations were stronger and food intake was reduced at 1w in NGT subjects; no changes in appetite measures or food intake were observed in the T2D group. No effect of DJBS on postprandial gallbladder emptying was observed, and gastric emptying was not delayed.

CONCLUSIONS

DJBS-induced weight loss was associated with only marginal changes in postprandial physiology, which may explain the absence of effect on postprandial glucose metabolism.

The Burden of Obesity on Diabetes in the United States: Medical Expenditure Panel Survey, 2008 to 2012

BACKGROUND

Diabetes is one of the most prevalent and costly chronic diseases in the United States.

OBJECTIVES

To analyze the risk of developing diabetes and the annual cost of diabetes for a US general population.

METHODS

Data from the Medical Expenditure Panel Survey, 2008 to 2012, were used to analyze 1) probabilities of developing diabetes and 2) annual total health care expenditures for diabetics. The age-, sex-, race-, and body mass index (BMI)-specific risks of developing diabetes were estimated by fitting an exponential survival function to age at first diabetes diagnosis. Annual health care expenditures were estimated using a generalized linear model with log-link and gamma variance function. Complex sampling designs in the Medical Expenditure Panel Survey were adjusted for. All dollar values are presented in 2012 US dollars.

RESULTS

We observed a more than 6 times increase in diabetes risks for class III obese (BMI ≥ 40 kg/m²) individuals compared with normal-weight individuals. Using age 50 years as an example, we found a more than 3 times increase in annual health care expenditures for those with diabetes ($13,581) compared with those without diabetes ($3,954). Compared with normal-weight (18.5 ≤ BMI < 25 kg/m²) individuals, class II obese (35 ≤ BMI < 40 kg/m²) and class III obese (BMI ≥ 40 kg/m²) individuals incurred an annual marginal cost of $628 and $756, respectively. The annual health care expenditure differentials between those with and without diabetes of age 50 years were the highest for individuals with class II ($12,907) and class III ($9,703) obesity.

CONCLUSIONS

This article highlights the importance of obesity on diabetes burden. Our results suggested that obesity, in particular, class II and class III (i.e., BMI ≥ 35 kg/m²) obesity, is associated with a substantial increase in the risk of developing diabetes and imposes a large economic burden.

Association of waist and hip circumference and waist-hip ratio with type 2 diabetes risk in first-degree relatives

AIMS

To evaluate the association of type 2 diabetes risk in first-degree relatives of diabetics with waist and hip circumference (WC and HC) and waist-hip ratio (WHR).

METHODS

We retrieved the data of 1319 subjects who had at least two visits during 2003-2010 and had been examined for diabetes status, WC and HC. Joint survival-longitudinal analysis and Cox regression were performed and the results were compared.

RESULTS

There was a significant direct relationship between diabetes risk and WC and WHR. The risk increased by 23% (95% CI: 5%-38%) and by 28% (95% CI: 9%-58%) respectively, for every 10cm increase in WC and 10% increase in WHR. Post-hoc subgroup analysis showed that these findings were present in females, but not in males. No significant association was seen for HC. Simple Cox regression showed direct association with WC and HC and no association with WHR.

CONCLUSIONS

In addition to dependence on measurement time, results from Cox model were inconclusive. The joint model showed a direct effect of WC and WHR albeit weaker than those in the general population, suggesting the possibility that factors other than the obesity indices are playing a stronger role in the elevated risk in this population. Multivariate models are needed for shedding light on the association.

Duration of Adulthood Overweight, Obesity, and Cancer Risk in the Women's Health Initiative: A Longitudinal Study from the United States

BACKGROUND

High body mass index (BMI) has become the leading risk factor of disease burden in high-income countries. While recent studies have suggested that the risk of cancer related to obesity is mediated by time, insights into the dose-response relationship and the cumulative impact of overweight and obesity during the life course on cancer risk remain scarce. To our knowledge, this study is the first to assess the impact of adulthood overweight and obesity duration on the risk of cancer in a large cohort of postmenopausal women.

METHODS AND FINDINGS

Participants from the observational study of the Women's Health Initiative (WHI) with BMI information from at least three occasions during follow-up, free of cancer at baseline, and with complete covariate information were included (n = 73,913). Trajectories of BMI across ages were estimated using a quadratic growth model; overweight duration (BMI ≥ 25 kg/m2), obesity duration (BMI ≥ 30 kg/m2), and weighted cumulative overweight and obese years, which take into account the degree of overweight and obesity over time (a measure similar to pack-years of cigarette smoking), were calculated using predicted BMIs. Cox proportional hazard models were applied to determine the cancer risk associated with overweight and obesity duration. In secondary analyses, the influence of important effect modifiers and confounders, such as smoking status, postmenopausal hormone use, and ethnicity, was assessed. A longer duration of overweight was significantly associated with the incidence of all obesity-related cancers (hazard ratio [HR] per 10-y increment: 1.07, 95% CI 1.06-1.09). For postmenopausal breast and endometrial cancer, every 10-y increase in adulthood overweight duration was associated with a 5% and 17% increase in risk, respectively. On adjusting for intensity of overweight, these figures rose to 8% and 37%, respectively. Risks of postmenopausal breast and endometrial cancer related to overweight duration were much more pronounced in women who never used postmenopausal hormones. This study has limitations because some of the anthropometric information was obtained from retrospective self-reports. Furthermore, data from longitudinal studies with long-term follow-up and repeated anthropometric measures are typically subject to missing data at various time points, which was also the case in this study. Yet, this limitation was partially overcome by using growth curve models, which enabled us to impute data at missing time points for each participant.

CONCLUSIONS

In summary, this study showed that a longer duration of overweight and obesity is associated with an increased risk of developing several forms of cancer. Furthermore, the degree of overweight experienced during adulthood seemed to play an important role in the risk of developing cancer, especially for endometrial cancer. Although the observational nature of our study precludes inferring causality or making clinical recommendations, our findings suggest that reducing overweight duration in adulthood could reduce cancer risk and that obesity prevention is important from early onset. If this is true, health care teams should recognize the potential of obesity management in cancer prevention and that excess body weight in women is important to manage regardless of the age of the patient.

All-Cause and Cause-Specific Mortality Associated with Bariatric Surgery: A Review

The question of whether or not nonsurgical intentional or voluntary weight loss results in reduced mortality has been equivocal, with long-term mortality following weight loss being reported as increased, decreased, and not changed. In part, inconsistent results have been attributed to the uncertainty of whether the intentionality of weight loss is accurately reported in large population studies and also that achieving significant and sustained voluntary weight loss in large intervention trials is extremely difficult. Bariatric surgery has generally been free of these conflicts. Patients voluntarily undergo surgery and the resulting weight is typically significant and sustained. These elements, combined with possible non-weight loss-related mechanisms, have resulted in improved comorbidities, which likely contribute to a reduction in long-term mortality. This paper reviews the association between bariatric surgery and long-term mortality. From these studies, the general consensus is that bariatric surgical patients have: 1) significantly reduced long-term all-cause mortality when compared to severely obese non-bariatric surgical control groups; 2) greater mortality when compared to the general population, with the exception of one study; 3) reduced cardiovascular-, stroke-, and cancer-caused mortality when compared to severely obese non-operated controls; and 4) increased risk for externally caused death such as suicide.

What Does Self-rated Health Mean? Changes and Variations in the Association of Obesity with Objective and Subjective Components Of Self-rated Health

There are concerns about the meaning of self-rated health (SRH) and the factors individuals consider. To illustrate how SRH is contextualized, we examine how the obesity-SRH association varies across age, periods, and cohorts. We decompose SRH into subjective and objective components and use a mechanism-based age-period-cohort model approach with four decades (1970s to 2000s) and five birth cohorts of National Health and Nutrition Examination Survey data (N = 26,184). Obese adults rate their health more negatively than non-obese when using overall SRH with little variation by age, period, or cohort. However, when we decomposed SRH into objective and subjective components, the obesity gap widened with increasing age in objective SRH but narrowed in subjective SRH. Additionally, the gap narrowed for more recently born cohorts for objective SRH but widened for subjective SRH. The results provide indirect evidence that the relationship between obesity and SRH is socially patterned according to exposure to information about obesity and the availability of resources to manage it.

Inequity to the utilization of bariatric surgery: a systematic review and meta-analysis

This systematic review explores the sociodemographic factors associated with the utilization of bariatric surgery among eligible patients. Electronic databases were searched for population-based studies that explored the relationship between sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Twelve retrospective cohort studies were retrieved, of which the results of 9 studies were pooled using a random effects model. Patients who received bariatric surgery were significantly more likely to be white versus non-white (OR 1.54; 95% CI 1.08, 2.19), female versus male (OR 2.80; 95% CI 2.46, 3.22), and have private versus government or public insurance (OR 2.51; 95% CI 1.04, 6.05). Prospective cohort studies are warranted to further determine the relative effect of these factors, adjusting for confounding factors.

Influence of urban neighbourhood environment on physical activity and obesity-related diseases

OBJECTIVES

The impact of characteristics of neighbourhood environment on physical activity and obesity-related diseases is still the subject of debate. This study aimed to explore the impact of urban neighbourhood environment on physical activity and obesity-related diseases.

STUDY DESIGN

Cross-sectional study.

METHODS

Individuals who participated in the 2009 national health-screening programme, submitted all necessary information, and had lived in Community 1 (Haengdang) or Community 2 (Ilsan) for at least 2 years (n = 16,178) were selected for inclusion in this study. Anthropometric measures were taken and physical activity was assessed using a short questionnaire.

RESULTS

No significant difference in the trigger factors for walking, including the amount of neighbourhood park space, number of shopping malls, and distance between the community and shopping malls, was found between the two communities. However, Community 2 had a better street environment than Community 1. Participants who lived in Community 2 were more physically active [adjusted odds ratio (OR) 1.31, 95% confidence interval (CI) 1.16-1.48] and walked more regularly (adjusted OR 1.09, 95% CI 1.02-1.17) than participants who lived in Community 1, and were less likely to have abdominal obesity (adjusted OR 0.83, 95% CI 0.77-0.91), hypertension (adjusted OR 0.88, 95% CI 0.80-0.97) and diabetes (adjusted OR 0.86, 95% CI 0.75-0.99). However, the risk of dyslipidaemia, especially in terms of low-density lipoprotein cholesterol, was higher in Community 2.

CONCLUSIONS

These results suggest that a walkable environment has a positive influence on hypertension and diabetes, and physical activity is the possible mechanism for this association. A walkable environment may function as an important tool for health promotion in urban areas.

Life years lost and lifetime health care expenditures associated with diabetes in the U.S., National Health Interview Survey, 1997-2000

OBJECTIVE

This study analyzed the lifetime health care expenditures and life years lost associated with diabetes in the U.S.

RESEARCH DESIGN AND METHODS

Data from the National Health Interview Survey (NHIS), the Medical Expenditure Panel Survey from 1997 to 2000, and the NHIS Linked Mortality Public-use Files with a mortality follow-up to 2006 were used to estimate age-, race-, sex-, and BMI-specific risk of diabetes, mortality, and annual health care expenditures for both patients with diabetes and those without diabetes. A Markov model populated by the risk and cost estimates was used to compute life years and total lifetime health care expenditures by age, race, sex, and BMI classifications for patients with diabetes and without diabetes.

RESULTS

Predicted life expectancy for patients with diabetes and without diabetes demonstrated an inverted U shape across most BMI classifications, with highest life expectancy being for the overweight. Lifetime health care expenditures were higher for whites than blacks and for females than males. Using U.S. adults aged 50 years as an example, we found that diabetic white females with a BMI >40 kg/m(2) had 17.9 remaining life years and lifetime health expenditures of $185,609, whereas diabetic white females with normal weight had 22.2 remaining life years and lifetime health expenditures of $183,704.

CONCLUSIONS

Our results show that diabetes is associated with large decreases in life expectancy and large increases in lifetime health care expenditures. In addition to decreasing life expectancy by 3.3 to 18.7 years, diabetes increased lifetime health care expenditures by $8,946 to $159,380 depending on age-race-sex-BMI classification groups.

Leptin gene tetranucleotide repeat polymorphism in obese individuals in Egypt

BACKGROUND

Leptin is a peptide hormone secreted by the adipose tissue. Genetic mutations of the leptin gene were reported to cause severe obesity.

OBJECTIVES

This study was undertaken to investigate the association of the polymorphic tetranucleotide repeat locus 3' UTR of leptin gene with obesity in Egyptian cases.

SUBJECTS AND METHODS

This study has included 120 subjects affected with obesity 57 of them were consistent with the diagnosis of metabolic syndrome (MS) while the rest (63) had simple obesity. These cases were compared to 83 normal weight healthy controls. All participants were subjected to an estimation of their body mass index (BMI), waist hip ratio (WHR), serum as well as characterization of leptin gene tetranucleotide repeat (TTTC)n polymorphism by PCR technique.

RESULTS

Thirteen different alleles were identified in all cases of obesity versus only 5 alleles in normal controls. The most frequent allele was the 154 bp allele (57.5% in all cases of obesity vs. 92.2% in controls). Total cases with obesity showed a significantly higher carriage rate of class II alleles (I/II + II/II genotypes) compared to healthy controls (48.3% vs. 6.0%, OR=14.6, 95% CI=5.5-38.6, p=<0.0001). This was more apparent in the group with simple obesity (52.3% vs. 6.0%, OR=17.2, 95% CI=6.1-48.1, p=<0.0001) than in MS cases (43.9 % vs. 6.0 %, OR =12.19, 95% CI=4.9-30.4, p=< 0.0001). Interestingly, cases with MS did not differ from those with simple obesity regarding their class I or II allele frequencies (p> 0.05). Although serum lipids were significantly higher in obese cases compared to controls, no difference was found among obese cases with different leptin gene class genotypes (p> 0.05).

CONCLUSIONS

Tetranucleotide repeat (TTTC)n polymorphism in the 3' UTR of the human leptin gene was associated with obesity in Egyptian obese cases showing higher class II allele carriage rate. However, the lipoprotein levels were not affected by this polymorphism.

Incidence and outcomes of chemotherapy and radiation in morbidly obese patients with locally advanced lung and esophageal cancers: a single-institution experience

BACKGROUND

In 2012, the American Society of Clinical Oncology issued a guideline urging health care professionals to "routinely use an obese patient's actual body weight, rather than an ideal body weight or other estimate, to calculate the appropriate dose of nearly all chemotherapy drugs. " This guideline does not address dosages for patients who are morbidly obese (body mass index ≥ 40) and receiving concomitant chemotherapy and radiation.

METHODS

This report describes a single-institution experience intended to address the issue of appropriate dosages for this patient population.

RESULTS

Among 1,886 cancer patients who received curative thoracic radiation at the Mayo Clinic, 16 (0.8%) were morbidly obese and received concomitant chemotherapy and radiation. Charlson morbidity scores for the cohort ranged from 2 to 9, and 10 patients had esophageal cancer. Ten of 16 patients received an initial chemotherapy dose reduction, and 4 of these patients experienced major adverse events, including 1 death. Similarly, among the 6 patients who received full-dose chemotherapy at the beginning of treatment, 2 had major adverse events. Nine patients went on to have their cancers resected, but no differences in survival were apparent among patients who received initial dose reductions and those who did not.

CONCLUSIONS

This single-institution experience remains limited. However, in view of the severe toxicity observed in this cohort, chemotherapy dose reductions seem appropriate in specific instances. Clinicians should also consider prescribing newer chemotherapy regimens that may be better tolerated in morbidly obese patients with cancer.

Racial differences in adipose tissue distribution and risk of aggressive prostate cancer among men undergoing radiotherapy

BACKGROUND

Although elevated body mass index (BMI) has been associated with increased risk of aggressive prostate cancer, the importance of adipose tissue distribution is not well understood. We examined associations between overall and visceral obesity and aggressive prostate cancer risk. Moreover, given racial differences in adipose tissue distribution, we examined whether race modified these associations.

METHODS

We conducted a cross-sectional analysis of 308 radiotherapy-treated patients with prostate cancer within the Durham VA from 2005 to 2011. Multivariable logistic regression examined the association between BMI categories and tertiles of waist circumference (WC), visceral fat area (VFA), and periprostatic adipose tissue area (PPAT) with high-grade prostate cancer risk (Gleason score ≥7 vs. ≤6). Models stratified by race examined whether these associations differed between black and nonblack men.

RESULTS

Both elevated BMI (Ptrend = 0.054) and WC (Ptrend = 0.040) were associated with increased high-grade prostate cancer risk, with similar results between races, although the association with BMI was not statistically significant. In contrast, elevated VFA was associated with increased aggressive prostate cancer risk in black men (Ptrend = 0.002) but not nonblack men (Ptrend = 0.831), with a significant interaction between race and VFA (Pinteraction = 0.035). Though similar patterns were observed for PPAT, none was statistically significant.

CONCLUSIONS

Among men undergoing radiotherapy for prostate cancer, visceral obesity is associated with increased aggressive prostate cancer risk, particularly among black men. If confirmed in future studies, these results suggest that adipose tissue distribution differences may contribute to prostate cancer racial disparity.

IMPACT

These findings highlight the need to elucidate mechanisms contributing to racial differences in the association between visceral obesity and aggressive prostate cancer.

Veno-venous extracorporeal membrane oxygenation in obese surgical patients with hypercapnic lung failure

BACKGROUND

In patients with a body mass index (BMI) > 35 kg/m(2) , or in extreme cases weighting > 250 kg, we are faced with special challenges in therapy and logistics. The aim was to analyze the feasibility of the extracorporeal membrane oxygenation (ECMO) in these patients.

METHODS

We report 12 adult patients [10 male, 2 female; mean age 56.7 (34-74) years; mean BMI 47.9 (35-88.6) kg/m(2) ] with acute lung failure treated with veno-venous ECMO from 1 January 2009 to 30 June 2013. All patients were cannulated percutaneously into the right internal jugular vein and one of the femoral veins at the bedside.

RESULTS

The mean time to ECMO after admission to the intensive care unit (ICU) was 2 days (0-10), and the mean ECMO run time was 9 days (4 h-20 days). Lung failure occurred in the contexts of wound infection (two patients), anaphylactic shock (one patient), major trauma (one patients) and pneumonia after surgery (four patients), and respiratory failure in abdominal sepsis (four patients). The mean time in the ICU was 31 days (0-89), and the mean time at the hospital was 38 days (0-101). Three patients died on the system because of multiorgan failure; nine patients were weaned from ECMO (75%); and six were patients discharged from the ICU and from the hospital (survival rate 50%).

CONCLUSIONS

ECMO in obese patients is feasible and life saving. Therefore, a percutaneous cannulation remains feasible. The goals of the ECMO therapy include early spontaneous breathing, tracheotomy, rapid reduction of sedation and adequate analgesia. Rehabilitation includes nutritional therapy, as well as psychiatric therapy and bariatric surgery, as perspectives for the future.

Health inequity in access to bariatric surgery: a protocol for a systematic review

BACKGROUND

Bariatric surgery is the only weight-loss treatment available that results in both sustained weight loss and improvements of obesity-related comorbidities. Individuals who meet the eligibility criteria for bariatric surgery are generally older, come from racial or ethnic minorities, are economically disadvantaged, and have low levels of education. However, the population who actually receives bariatric surgery does not reflect the individuals who need it the most. The objective is to conduct a systematic review of the literature exploring the inequities to the access of bariatric surgery.

METHODS/DESIGN

EMBASE and Medline databases will be searched for observational studies that compared at least one of the PROGRESS-PLUS sociodemographic characteristics of patients eligible for bariatric surgery to those who actually received the procedure. Articles published in the year 1980 to present with no language restrictions will be included. For inclusion, studies must only include adults (≥18 years old) who meet National Institutes of Health (NIH) eligibility criteria for bariatric surgery defined as having either (1) a body mass index (BMI) of 40 kg/m² or greater; or (2) BMI of 35 kg/m² or greater with significant weight-related comorbidities. Eligible interventions will include malabsorptive, restrictive, and mixed bariatric procedures.

DISCUSSION

There appears to be inequities in access to bariatric surgery. In order to resolve the health inequity in the treatment of obesity, a synthesis of the literature is needed to explore and identify barriers to accessing bariatric surgery. It is anticipated that the results from this systematic review will have important implications for advancing solutions to minimize inequities in the utilization of bariatric surgery. http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42013004920.

Obesity, mortality, and life years lost associated with breast cancer in nonsmoking US Women, National Health Interview Survey, 1997-2000

INTRODUCTION

The relationship between obesity and breast cancer has been extensively investigated. However, how obesity and breast cancer interplay to affect mortality and life expectancy of women in the United States has not been well studied.

METHODS

We used data from the National Health Interview Survey, 1997-2000. Our sample included nonsmoking, nonpregnant women who reported a body mass index of at least 18.5 kg/m(2) and no cancer other than breast cancer at the time of the survey. A survival model with Gamma frailty and Gompertz baseline was used to estimate relative risks of total mortality and project life years lost associated with breast cancer by obesity status and age.

RESULTS

Breast cancer increased risk of mortality depending on degree of obesity and decreased life years by 1 to 12 years depending on race, age, and obesity status. Relative risks for death increased with degree of obesity. Obese women under age 50 across all racial groups were predicted to lose the most life years; racial groups other than whites and blacks lost the most life years (11.9 y), followed by whites (9.8 y) and blacks (9.2 y).

CONCLUSION

The number of life years lost associated with breast cancer was more marked for more obese than for less obese women and for women under age 50 and women aged 70 or older than for women aged 50 through 69. Public health initiatives should put more emphasis on the prevention and control of obesity for these target populations.