Obesity modifies the association between diabetes and iron biomarkers and red cell indices in reproductive-aged women in the United States

Obesity and diabetes are associated with impaired iron metabolism. We aimed to examine the independent relationship between diabetes and iron after controlling for body weight (or obesity) in women aged 20-49 years. The National Health and Nutrition Examination Survey data from 2015 to 2018 were used in this investigation. Body composition data, HbAc1, iron biomarkers (serum ferritin (SF), soluble transferrin receptor (sTfR), and body iron index (BII)), mean corpuscular volume (MCV), mean hemoglobin concentration (MCH), red cell distribution width (RDW), and hemoglobin were used. Linear regression models were used to examine how and to what extent body mass index (BMI) modified the relationship between diabetes and iron status biomarkers. A total of 1834 women aged 20-49 were included in the analysis with a mean (SD) age of 32 .2 ± 6.1 years and BMI of 29.5 ± 6.9 kg/m2. The mean SF (p = 0.014) and BII (p < 0.001) were lower, while sTfR (p < 0.001) was higher in women with diabetes than those with no diabetes. Mean estimates for MCV and MCH were lower, while RDW (p = 0.001) was higher in diabetes patients (all p < 0.001). Women with diabetes were more likely to have iron deficiency, anemia, and iron deficiency anemia than those without diabetes (18.1% vs 8.6%, p < 0.001), (24.4% vs 8.4%, p < 0.001), and (14.8% vs 5.2%, p < 0.001), respectively. Among women with obesity, those with diabetes had lower predicted ferritin (β = -0.19, p = 0.016), BII (β = -0.99, p = 0.016), and hemoglobin (β = -0.27, p = 0.042) than those without diabetes. The study shows that diabetes is linked to lower iron stores; this is exacerbated in those with obesity.

The Need for Patience When Making Operational Changes to Address Quality

PURPOSE/OBJECTIVE(S)

There is increasing recognition in the value of systematically addressing operational issues to improve quality. However, the time necessary for these initiatives has not been well described. Here we report the time necessary to implement meaningful operational changes based on our institutional incident reporting system.

MATERIALS/METHODS

Our department has a robust quality improvement/assurance program where all team members are encouraged to report operational challenges through our "Good Catch Program". A multidisciplinary committee composed of MDs, physicists, dosimetrists, RTTs, RNs, administrators, and industrial engineers meets weekly to review new Good Catches and prior unresolved Good Catches. Each Good Catch was assigned a "Champion" to oversee responses and lead subsequent initiatives. The software tracked when a Good Catch is submitted, each time a note is added (reflecting an individual's comment or summary of group discussion), and when it is "closed". Good Catch closure occurred upon implementation of a change in workflow, development of a new policy, or decision to take no action. In cases where a change in workflow or policy was the consensus decision of the committee, the Good Catch was kept open and re-reviewed at subsequent weekly meetings until a new workflow was in place and relevant teams were onboarded.

RESULTS

From Jan 2015 - Dec 2022, 2748 Good Catches were reported (see Table). Most Good Catches were discussed at only one weekly multidisciplinary committee meeting and closed within 7 days of reporting (69%). For the 854 Good Catches that took >1 week to close, the median time to closure was 16 days (range 7-588 days). In general, the number of notes was higher for Good Catches that took longer to close; however, some Good Catches that closed rapidly had more than 10 notes in a short period of time and other Good Catches with lengthy time to closure had minimal resulting documentation (see Table). Most Good Catches were assigned a Champion who was an MD, Physicist, or RTT, and there was no significant difference in Champion assignments for those good catches that closed quickly (< 8 days) and those that had a longer duration to closure.

CONCLUSION

The majority of operational Good Catches are resolved quickly; speaking to the value of regular weekly multidisciplinary meetings. However, many operational issues require multiple discussion over many weeks and emphasizes that such efforts are challenging and require patience, dedication, and commitment to implement changes in workflow.

Iron Deficiency and Iron Deficiency Anemia in Women with and without Obesity: NHANES 2001-2006

Obesity has been linked to numerous health and nutritional problems, including impaired iron metabolism, a common cause of anemia. We aimed to determine the prevalence of anemia, iron deficiency (ID), and iron deficiency anemia (IDA) among women aged 20-49 years based on body mass index (BMI) status. We used measures of iron status and body mass index from the 2001-2006 National Health and Nutrition Examination Survey (NHANES). Mean serum ferritin, erythrocyte protoporphyrin, and soluble transferrin receptor were higher, while those of serum iron, percent transferrin saturation, and mean cell volume (MCV) were lower in women with obesity than those with normal weight (all p < 0.016). ID based on the ferritin model was 12.5 ± 1.0% vs. 22.9 ± 1.6% (p < 0.001); 9.0 ± 0.9% vs. 20.0 ± 1.3% (p < 0.001) based on the MCV model; and 8.1 ± 1.0% vs. 10.5 ± 1.2% (p > 0.05) based on the BII model for women with normal weight and women with obesity, respectively. Anemia prevalence was 5.5 ± 0.8% (normal) vs. 9.3 ± 1.0% (obese) (p = 0.005). The IDA estimates based on the ferritin and MCV models were similar but higher than that from the BII model (p < 0.001). Generally, the prevalence rates of ID and anemia (and IDA) were higher for women with obesity, but the method used to define deficiency mattered. The choice of iron indices is important for estimating ID and IDA in populations with obesity.

A-8 Neurocognitive Inhibition Predicts Cortisol Reactivity to a Stressful Speech Task

Objective: Increased stress and cortisol are important risk factors for cardiovascular diseases, including cerebrovascular disease. The present study used an experimental speech task to determine the relationship between inhibitory control and cortisol response to social stress. We hypothesized that poorer inhibitory control would predict larger cortisol response to the stressor.

Method: Participants were 42 women with overweight/obesity recruited for larger project examining the impacts of weight stigma on inflammation. The computerized Stroop Color-Word and Go/No-Go assessed baseline inhibitory control and other neurocognitive factors. Higher scores indicate better performance. After a baseline blood sample, participants were randomized and asked to give a speech (1 = stigma, 0 = neutral). Subsequent blood draws were taken at 30-, 60-, and 90-minutes post-speech. Area under the curve was calculated to represent total cortisol increase.

Results: Analyses, controlling for speech condition and BMI, revealed that cortisol reactivity to the speech task was predicted by both Stroop Color-Word (β = −0.42, p = 0.007) and Interference (β = −0.35, p = 0.022) scores, as well as Go/No-Go Hits (β = −0.33, p = 0.04) and Omissions (β = −0.34, p = 0.03), but not Commissions (β = −0.038; p = 0.81).

Conclusions: The pattern of results suggests that individuals with lower inhibitory control experienced a greater cortisol output after the stressor. In this context, individuals who were better able to ignore irrelevant social aspects of the speech experienced a smaller cortisol reaction than the individuals who could not ignore them. To reduce risk for cerebrovascular disease, clinical interventions should focus on the practice of ignoring irrelevant stressors to promote more adaptive biological responses to stress.

SCOPE 2 - Still Answering the Unanswered Questions in Oesophageal Radiotherapy? SCOPE 2: a Randomised Phase II/III Trial to Study Radiotherapy Dose Escalation in Patients with Oesophageal Cancer Treated with Definitive Chemoradiation with an Embedded Phase II Trial for Patients with a Poor Early Response using Positron Emission Tomography/Computed Tomography

The SCOPE 2 trial of definitive chemoradiotherapy in oesophageal cancer investigates the benefits of radiotherapy dose escalation and systemic therapy optimisation. The trial opened in 2016. The landscape of oesophageal cancer treatment over the lifetime of this trial has changed significantly and the protocol has evolved to reflect this. However, with the recent results of the Dutch phase III ART DECO study showing no improvement in local control or overall survival with radiotherapy dose escalation in a similar patient group, we sought to determine if the SCOPE 2 trial is still answering the key unanswered questions for oesophageal radiotherapy. Here we discuss the rationale behind the SCOPE 2 trial, outline the trial schema and review current data on dose escalation and outline recommendations for future areas of research.

Adverse Childhood Experiences and Obesity Linked to Indicators of Gut Permeability and Inflammation

Objectives

Gut permeability appears to increase cardiovascular disease risk by allowing bacterial components to enter the bloodstream, leading to low-grade inflammation. Emerging evidence suggests that psychosocial stress promotes gut permeability, but the effect of chronic stress induced by adverse childhood experiences (ACEs) on the gut barrier remains unclear. Moreover, the existence of an additive effect of psychological stressors and nutritional factors that increase gut permeability – such as obesity – is unknown. We aimed to: 1) investigate the effect of ACEs on gut permeability indices, and 2) examine whether high ACE status and obesity in combination have a greater, negative effect on indicators of gut permeability and inflammation than either alone.

Methods

Women (N = 79, aged 18–84 y) free of cardiometabolic diseases (other than obesity) and inflammatory conditions and not regularly taking anti-inflammatory medications were included in a 2 × 2 factorial design with ACE status (either 0 ACEs or 3 + ACEs) and body mass index (BMI) (either normal-weight [18.5–24.9 kg/m²; NW] or obesity [>30 kg/m²; OB]) as factors (n = 15–27/group). Fasting serum was obtained and markers of gut permeability (i.e., lipopolysaccharide [LPS] binding protein; fatty-acid binding protein-2 [FABP2]; anti-LPS core IgM; soluble CD14 (sCD14) and inflammation (i.e., C-reactive protein [CRP]; tumor necrosis factor [TNF]-α; interleukin [IL]-6) measured. Data were analyzed using 2-way ANCOVA (age-adjusted) with SPSS 26.

Results

LPS binding protein and FABP2 were higher in OB versus NW, regardless of ACE status (P_BMI ≤ 0.04). Higher ACE status was associated with increased circulating anti-LPS core IgM (P_ACE = 0.04), but BMI had no effect. sCD14 was unaffected by BMI or ACEs. CRP was elevated in OB vs. NW (P_BMI < 0.001) and tended to be higher with 3 + ACEs compared to 0 ACEs (P_ACE = 0.06). Moreover, TNF-α was greater in 3 + ACEs relative to 0 ACEs (P_ACE = 0.03). IL-6 was unaltered by BMI or ACE status. No interaction effects were observed for any marker of gut permeability or inflammation.

Conclusions

High ACE status and obesity were independently associated with evidence of gut permeability and inflammation, but no combination of BMI and ACE status affected these measures.

Funding Sources

NIA R36, NIGMS P20, NHLBI F31.

Associations of Adverse Childhood Experiences with Executive Function and Brain-Derived Neurotrophic Factor

Adverse childhood experiences (ACEs) may predict markers of neurocognitive performance (i.e., executive function; EF) and brain health/plasticity (i.e., brain-derived neurotropic factor; BDNF). This pilot examined the magnitude of effects between: 1) ACES and EF performance, 2) ACEs and BDNF levels, and 3) EF performance and BDNF levels. We hypothesize that higher ACEs will be associated with poorer EF scores and lower BNDF levels and that lower EF scores will be associated with lower BDNF levels. Given the pilot nature of the study, an emphasis is placed on effect size vs. significance. Participants were 36 middle-aged women enrolled in the NICE SPACES trial (age=31.4 years, BMI=34.2, racially minoritized=37.9%). ACES were quantified using the 10-item Adverse Childhood Experiences Scale. EF was measured using the fluid cognition composite from the NIH Toolbox – Cognition Battery. BDNF was estimated using proBDNF levels estimated from serum collected via venipuncture. Higher ACEs levels were not directly associated with EF scores (b = 0.03, p = .854); but did show a meaningful negative beta coefficient with BDNF levels (b = -0.34, p = .053). EF scores and BDNF showed a positive coefficient that did not reach significance (b = .26, p = .122). In a modest pilot of middle-age women, higher ACEs were associated with lower BDNF, indicating greater adversity in childhood is linked to lower neurotrophins levels in adulthood. The lower BDNF levels may help explain poorer performance on cognitive tasks. Larger follow-up studies in more powered samples are warranted given the size of detected coefficients.

MUTYH-associated polyposis - colorectal phenotype and management

AIM

The aim was to determine the presentation, management and outcomes of MUTYH-associated polyposis (MAP).

METHOD

A prospectively maintained database was used to identify patients with MAP. Demographic data and data on germline mutation, surgical management, histopathology of tumours and endoscopic surveillance were collected.

RESULTS

In all, 134 patients with MAP were identified. The majority presented symptomatically (n = 83). Sixty-eight patients developed cancer (seven synchronous, 12 metachronous). The median age at diagnosis of first colorectal cancer was 47 years (range 33-74 years). Cancers occurred in the context of a few adenomas (< 10). The majority of patients (n = 108) had surgery as the first line management. One patient received palliative care. Twenty-five patients had endoscopic surveillance as first line management; no cancers occurred in this group. Patients who had segmental resection and postoperative surveillance still appeared to be at risk of metachronous cancer (5/30, 17%).

CONCLUSIONS

MUTYH testing should be considered even in the context of cancers occurring with fewer than 10 adenomas. In cases of primary colorectal cancers, extended surgery should be considered if patients do not have access to high quality endoscopic surveillance postoperatively. For some patients, endoscopic therapy is an appropriate and safe option in expert hands.

Cost-Effectiveness Analysis of Stereotactic Ablative Body Radiation Therapy Compared With Surgery and Radiofrequency Ablation in Two Patient Cohorts: Metastatic Liver Cancer and Hepatocellular Carcinoma

AIMS

To compare the cost-effectiveness of stereotactic ablative body radiation therapy (SABR) with radiofrequency ablation and surgery in adult patients with metastatic liver cancer and hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Two patient cohorts were assessed: liver oligometastases and HCC. For each patient cohort, a decision analytic model was constructed to assess the cost-effectiveness of interventions over a 5-year horizon. A Markov process was embedded in the decision model to simulate the possible prognosis of cancer. Data on transition probabilities, survival, side-effects, quality of life and costs were obtained from published sources and the SABR Commissioning through Evaluation (CtE) scheme. The primary outcome was the incremental cost-effectiveness ratio with respect to quality-adjusted life-years. The robustness of the results was examined in a sensitivity analysis. Analyses were conducted from a National Health Service and Personal Social Services perspective.

RESULTS

In the base case analysis, which assumed that all three interventions were associated with the same cancer progression rates and mortality rates, SABR was the most cost-effective intervention for both patient cohorts. This conclusion was sensitive to the cancer progression rate, mortality rate and cost of interventions. Assuming a willingness-to-pay threshold of £20 000 per quality-adjusted life-year, the probability that SABR is cost-effective was 57% and 50% in liver oligometastases and HCC, respectively.

CONCLUSIONS

Our results indicate a potential for SABR to be cost-effective for patients with liver oligometastases and HCC. This finding supports further investigation in clinical trials directly comparing SABR with surgery and radiofrequency ablation.

Cognitive and Behavioral Factors Differentially Related to Intuitive Eating

Objectives

Inhibitory control measured by the Go/No-Go Task measures automatic inhibition. Difficulty with inhibition can extend into eating behavior, leading to unhealthy patterns such as emotional eating. Individuals who eat emotionally may also be less likely to engage in adaptive patterns of eating, such as intuitive eating (IE). IE is based on internal regulation of eating behaviors rather than eating for non-physiological reasons (e.g., emotions). This study sought to investigate the relationship between inhibitory control, emotional eating, and IE.

Methods

108 adults with overweight/obesity enrolled in a weight loss trial participated in the study. The sample was 46 ± 11 years old, 72% female, 76% White, and had a mean BMI of 35.7 ± 5.9 kg/m2. All data were collected at the baseline assessment visit. Emotional eating and IE were measured via self-report with the Emotional Eating Scale (EES) and Intuitive Eating Scale-2 (IES-2), respectively. The EES provides a total score and the IES-2 provides a total score and four subscale scores: Unconditional Permission to Eat (PERM), Eating for Physical Rather than Emotional Reasons (PHYS), Reliance on Hunger and Satiety Cues (REL), and Body-Food Choice Congruence (CON). Inhibitory control was measured via behavioral tests with the Automated Neuropsychological Assessments Metrics-4 (ANAM-4) Go/No-Go subtest.

Results

A theoretically-driven path analysis model was calculated using AMOS, using the Go/No-Go subtest and EES as determinates of the four IE subscales. Overall, the path model was effective at capturing variability in two (PHYS & REL) of the four outcome variables. Substantial differences were observed in terms of the magnitude of the path coefficients (PERM ß = .04; PHYS ß = –.74) and the amount of variance captured across the IES-2 subscales criterion measure (R2 ranged from .00—.54). The overall fit indices for the model were above threshold: χ2(7) = 2.19, P = .95, χ2/DF = 0.31, CFI = 1.00, TLI = 1.20, and RMSEA = .000 (.000; .011).

Conclusions

These findings help shed light on how inhibitory control, emotional eating, and IE are associated with one another. Surprisingly, inhibitory control was unrelated to IE. Further, emotional eating may only contribute to certain facets of IE — eating for physical rather than emotional reasons and reliance on hunger and satiety cues.

Funding Sources

K23DK103941.

Differences in Food Susceptibility Between High and Low Intuitive Eaters

Objectives

Intuitive eating (IE) is a pattern of adaptive eating behaviors that consists of four facets: Unconditional Permission to Eat (PERM), Eating for Physical Rather than Emotional Reasons (PHYS), Reliance on Hunger and Satiety Cues (REL), and Body-Food Choice Congruence (CON). The objective of this study was to observe differences in self-reported susceptibility to highly palatable foods between individuals high and low in intuitive eating.

Methods

66 adults (70% female; 77% white; age 46 ± 12; BMI 36.3 ± 6.5 kg/m2) with overweight/obesity enrolled in a behavioral weight loss trial participated in the study. Measures were collected at baseline assessments or at the initial treatment session via self-report scales. Intuitive eating was measured with the Intuitive Eating Scale-2, which includes a total score and four subscale scores: PERM, CON, REL, and PHYS. Food susceptibility was measured with the Power of Food Scale. BMI was objectively measured and calculated as kg/m2. Covariates included age, sex, race, education, and BMI. Individuals were grouped as high IE (≥75th percentile) and low IE (≤25th percentile) for total and subscale scores. Data were analyzed with Analyses of Covariance.

Results

Overall, high IE individuals displayed less food susceptibility (M = 40.1 ± 12.3) – as observed by lower PFS scores – than low IE individuals (M = 66.1 ± 13.7, F(1,31) = 30.56, P &lt; .001). This pattern was true for three of the four IE subscales: PHYS; Eating for Physical vs. Emotional Reasons (F(1,31) = 7.878, P = .009), REL; Reliance on Hunger and Satiety Cues (F(1,39) = 22.99, P &lt; .001), and CON; Body-Food Choice Congruence (F(1,23) = 6.001, P = .022). However, there were no differences in PFS scores between individuals high (M = 55.82 ± 18.64) and low (M = 51.87 ± 18.90) in Unconditional Permission to Eat (PERM; F(1,21) = .269, P = .610).

Conclusions

In adults with overweight/obesity, individuals who displayed higher levels of IE generally reported less susceptibility to hyper-palatable foods, which may be congruent with improved health. Upon observation of the IE subscales, this was not true for Unconditional Permission to Eat. Surprisingly, there were no differences in food susceptibility between those who report giving themselves more or less permission to eat freely.

Funding Sources

K23DK103941.

Adverse childhood experiences and cognitive function among adults with excess adiposity

BACKGROUND

Adverse childhood experiences (ACEs) and obesity are independently associated with brain/neurocognitive health. Despite a growing emphasis on the importance of early life adversity on health, the relationship between ACEs and neurocognition in adults with overweight/obesity is unclear. The objective was to examine associations between self-reported ACEs and measured neurocognitive domains in a sample of adults with overweight/obesity.

METHODS

Participants were 95 predominantly white, highly educated adult women (76% female, 81% Caucasian, and 75% ≥ bachelor's degree) with excess adiposity enrolled in the Cognitive and Self-regulatory Mechanisms of Obesity Study. ACEs and fluid/crystallized neurocognitive domains were measured at baseline using the Adverse Childhood Experiences Scale and the NIH Toolbox Cognition Battery and Automated Neuropsychological Assessment Metric, respectively.

RESULTS

Higher ACEs scores were negatively correlated with fluid cognition (r = -.34, P < .001) but not crystallized cognition (r = .01, ns). Individuals with 3 and 4+ ACEs displayed significantly lower fluid cognition scores than those with fewer ACEs F 4,89 = 3.24, P < .05. After accounting for body mass index (BMI), age, sex, race, and education, higher ACEs scores were still associated with poorer performance on overall fluid cognition (β = -.36, P < .01), along with the following subtests: Stroop Colour/Word test (β = -.23, P < .05), Go/No-Go omissions (β = .29, P < .01), and Picture Sequence Memory task (β = -.30, P < .01).

CONCLUSIONS

The role of ACEs in health may be related to their associations with executive function and episodic neurocognitive domains essential to cognitive processing and self-regulation. Obesity science should further examine the role of ACEs and neurocognition in obesity prevention, prognosis, and treatment using more rigorous, prospective designs and more diverse samples.

Platelet Behaviour in Non-Insulin-Dependent Diabetes -Influence of Vascular Complications, Treatment and Metabolic Control

Platelet-rich plasma was prepared from 47 patients with noninsulin-dependent diabetes treated with glibenclamide and metformin, and 21 controls. The release of radio-labelled 5-hydroxy-tryptamine in response to aggregating agents (adenosine diphosphate, adrenaline and sodium arachidonate), and the effects on release of a selective thromboxane inhibitor (UK-34787) were investigated. Subsequently, 20 of the diabetic subjects were chosen at random for treatment with insulin; the remainder continued to take tablets. Platelet studies were then repeated, in all patients, after 4 and 6 months.

The results showed an association between platelet behaviour and the presence of vascular complications, and were consistent with previous observations of reduced platelet reactivity in patients taking sulphonylureas. There was no correlation of platelet reactivity with blood glucose, glycosylated haemoglobin or lipid levels.

Session 3: Intra-operative radiotherapy - creating new surgical boundaries

In patients with advanced and recurrent colorectal cancer, surgical resection with clear margins is the greatest challenge and is limited by known anatomical constraints. Preoperative or intra-operative assessment of the limits of surgical dissection may help to explore the possibility of improving resectability through either targeted external beam radiotherapy or intra-operative radiotherapy. Professor Chang reviews the evidence base and potential advantages and disadvantages of this approach, whilst the expert panel agree a consensus on the evidence for assessment and therapy of such patients.

Session 3: Beyond the boundaries of Total Mesorectal Excision - where surgeons fear to tread

Approximately 10-15% of patients present with an advanced rectal cancer that extends beyond the conventional total mesorectal excision (TME) planes. In such cases extending the surgery to ensure resection with clear margins (R0 resection) is essential in order to achieve long-term cure. Professor Holm describes the techniques of beyond-TME exenterative surgery, the methods of patient selection and outcomes.