primary care counseling for obesity, nutrition, and physical activity 2013 eileen l. seeholzer,...
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Primary Care Counseling for Obesity, Nutrition,
and Physical Activity2013
Eileen L. Seeholzer, M.D., MS Associate Prof. - Case Western University School of Medicine
Dir. Weight Management and MetroHealthy Wellness Programs
Dept. of Medicine and Center for Healthcare Research and Policy
MetroHealth Medical Center
Objectives
To describe the evidence for and tools to provide effective office counseling for: Obesity Nutrition Physical Activity
Scope of the problem in the U.S.1999-2010 data
Prevalence of adult obesity is 36% Overweight and obesity prevalence is 69% Overweight + obesity prevalence is 77-80% for non-
Hispanic blacks, Hispanics, and Mexican-Americans Obesity rates highest in lowest socioeconomic levels
and in women who self-identify a part of an ethnic minority -rates of obesity 50% in some groups
Obesity prevalence in children and adolescents is 16.9%
1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307(5):491-497. 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA 2012;307(5):483-490.
Obesity Risk Higher if:
Female, black (women), Hispanic or and native American Maternal smoking or diabetes Lower socioeconomic status Sedentary lifestyle Higher fast-food intake Increased time-spent watching TV Pregnancy (2-3kg if age 18-30) – ? more in black women Sleep deprivation (<7 hours nightly, shift work, untreated
sleep apnea) Smoking cessation – average 4-5kg Medications Injury/condition impairing ambulation/use of lower
extremities
Obesity is a chronic disease
There are many definitions of "chronic condition", some more expansive than others. We characterize it as any condition that requires ongoing adjustments by the affected person and interactions with the health care system. © 2006-2011 Improving Chronic Illness Care
Obesity is often not reversible: Adipose tissue hyperplasia
At normal BMI ranges usually very little visceral fat is present– largely subcutaneous
With weight gain the adipocytes increase in size and then in number – both hypertrophy and hyperplasia.
Hyperplasia may not be reversible
Fat cell hyperplasia can be different depending on individual characteristics and the degree of weight gain. With more weight gain at least some hyperplasia occurs
Bray, George. Medications for Obesity: Mechanisms and Applications. Clin Chest Med 30 (2009) 525–538
Obesity Treatment Pyramid
DietDiet Physical ActivityPhysical Activity
Lifestyle ModificationLifestyle Modification
PharmacotherapyPharmacotherapy
SurgerySurgery
NAASO Slide Library
Impact of Weight Loss on Risk Factors
~5%Weight Loss
5%-10%Weight Loss
HbA1c
Blood Pressure
Total Cholesterol
HDL Cholesterol
Triglycerides
1. Wing RR et al. Arch Intern Med. 1987;147:1749-1753; 2. Mertens IL, Van Gaal LF. Obes Res. 2000;8:270-
278; 3. Blackburn G. Obes Res. 1995;3 (Suppl 2):211S-216S; 4. Ditschunheit HH et al. Eur J Clin Nutr.
2002;56:264-270.NAASO Slide Library
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Defining Lifestyle Treatment Non-drug treatment in which an individual opts
to engage and persist in regular activities to prevent, improve, or control a medical condition.
For obesity treatments may include activities affecting: Dietary patterns and content Activity level Sleep quantity and quality Other behavioral habits
Eating and Activity Assessment and counseling are necessary medical care
Physicians are required to let a patient know the most effective preventive and treatment tools for chronic disease
A person’s activity and diet are two of their most important medications
Patients want our help to discern where their efforts are best spent
Obesity prevention/treatment, healthy diet and physical activity reduce the risk of or prevent many conditions:
Hypertension Diabetes mellitus type 2 Dyslipidemia Obstructive sleep apnea GERD Asthma Degenerative disease of weight-bearing joints Cardiovascular, cerebral, and peripheral vascular disease Breast, colorectal, and endometrial cancer Depression and anxiety Infertility and sexual dysfunction
and several cancers
Increased Risks in Pregnancy associated with Obesity Gestational Diabetes Hypertension Disordered breathing/Obstructive Sleep Apnea Cesarean section rate (RR1.5-1.8) Congenital heart defects (OR 1.4-2.0) Spina Bifida (OR 3.5) Omphalocele (OR 3.3) Increased levels of leptin, crp and tnf-alpha
Obesity treatment: Healthier eating and active living for life
The goal is to reduce fat mass and preserve or increase lean mass and fitness Diet changes drive weight loss Exercise preserves weight loss and lean
mass Pregnancy, menopause, injury, aging, and
sedentary life are particular times adipose tissue increase is likely
Rationale for Providers to Guide Lifestyle Treatment for Obesity
Patients who improve dietary, activity, and other behavioral recommendations have: better health outcomes, better social outcomes, and reduced mortality
Non-Pharmacologic Treatments
Weight loss goals of 5-15% considered achievable and sustainable,
and improve health
Components of Basic Program Diet Recommendations Exercise Recommendations Behavior Therapy Monitoring and/or follow-up life-long
All 4 components needed!
Results from Non-pharmacologic Programs Patients overwhelmingly regain the
weight if there is no long-term plan
Behavior therapy and exercise key to weight loss maintenance
High intensity interventions most effective
-18-16-14-12-10
-8-6-4-20
Long-term Weight Loss is Improved with Long-term Maintenance Therapy
Wei
ght L
oss
(%)
Perri et al. J Consult Clin Psychol 1988;56:529. NAASO Slide Library
0 1 2 3 4 5 6 7 8 9 10 11 12
Time (mo)
13 14 15 16 17
PP <0.05 <0.05
No maintenance txNo maintenance tx
Maintenance txMaintenance tx
Diet andDiet andbehaviorbehaviormodificationmodificationtherapytherapy
Look AHEAD
Unick JL, Beavers D, Bond DS et al. The Long-term Effectiveness of a Lifestyle Intervention in Severely Obese Individuals. Am J Med 2013;126(3):236-242.
Commercial Programs
Limited studies show: They can work, are often expensive, none
proven superior. More improvements in lipid profile and
fasting sugar results known in low carbohydrate diets, the new Weight Watchers, and Mediterranean diets
1. Rock CL, Flatt SW, Sherwood NE, Karanja N, Pakiz B, Thomson CA. Effect of a free prepared meal and incentivized weight loss program on weight loss and weight loss maintenance in obese and overweight women: a randomized controlled trial. JAMA 2010;304(16):1803-1810
2. Jolly K, Daley A, Adab P et al. A randomised controlled trial to compare a range of commercial or primary care led weight reduction programmes with a minimal intervention control for weight loss in obesity: the Lighten Up trial. BMC Public Health 2010;10:439.
3. Cobiac L, Vos T, Veerman L. Cost-effectiveness of Weight Watchers and the Lighten Up to a Healthy Lifestyle program. Aust N Z J Public Health 2010;34(3):240-247.
4. Brown T, Avenell A, Edmunds LD et al. Systematic review of long-term lifestyle interventions to prevent weight gain and morbidity in adults. Obes Rev 2009;10(6):627-638.
5. Morgan LM, Griffin BA, Millward DJ et al. Comparison of the effects of four commercially available weight-loss programmes on lipid-based cardiovascular risk factors. Public Health Nutr 2009;12(6):799-807.
Panel B shows the change in weight for each of the dietary Groups during the weight-maintenance intervention, adjusted for body-mass index at randomization, Weight loss during the low- calorie-diet phase, sex, family Type (single-parent family, two-parent family with one parentas participant, or two-parent family with both parentsas participants), center, and age at screening, on the basis of an intention-to-treat mixed-model analysis.
The changes in body weight from randomization to week 26 among participants who completed the interventionare also shown (boxes). HGI denotes high glycemic index, HP high protein, LGI
low glycemic index, and LP low protein.
Larsen TM, Dalskov SM, van BM, et al. Diets with high or low protein content and glycemic index for weight-loss maintenance. N.Engl.J.Med. 2010 Nov 25;363(22):2102-13
Eat a lower-calorie diet
Women Calorie guide (Kcal)
Shorter, post-menopausal, less active 1000-1200
Average height, moderately active 1200-1400
Younger, taller, moderately to very active women
1400-1800
Men Men
Shorter, less active 1400-1600
Average height, moderately active 1800-2000
Younger, taller, moderately to very active 2000-2200
Prudent Dietary Recommendations for addressing obesity and cardiovascular risk factors
• Low SFA (<7%), TFA (<1%), dietary cholesterol (<200mg)• Rich in PUFA• ample fiber 30g/day – soluble fiber emphasis• nuts as able 1 oz a day and other soy and legumes• lean dairy• 5-7 servings of fruits and vegetables daily• limit sugary beverages• limit refined foods• rich in whole grains• Energy balanced to prevent weight gain• Avoid high salt food – over 450mg/serving and <2000mg/day• For many, a low calorie diet that is low in fat and refined
carbohydrates is best for long-term adherence
Van HL, McCoin M, Kris-Etherton PM et al. The evidence for dietary prevention and treatment of cardiovascular disease. J Am Diet Assoc 2008;108(2):287-33
Dietary Recommendations
Low-calorie diet better than very-low calorie diet for maintaining weight loss
Meal replacements (e.g. South Beach, Atkins, Slimfast or Glucerna) often helpful in improving success with dietary caloric adherence – best if >12g-14g protein, >5gm fiber, <7grams sugar
Portion-controlled servings also useful for weight loss adherence
Diet Recommendations
Can be achieved with plans – do not need to count- few people can count accurately
Planning, routinizing, and tracking support success
Encourage use of low or no-cost supports for both ideas and tracking like: myfitnesspal.com and sparkpeople.com
Bray, George. Medications for Obesity: Mechanisms and Applications. Clin Chest Med 30 (2009) 525–538
What modifies the REE over time?
Aerobic exercise from 40-60 minutes can raise REE the following day for 19-24 hours
Caffeine mildly raises REE Resistance work over time will increase
lean mass and raise REE for that weight Calorie restriction lowers REE Weight loss of 10-20% reduces REE –
(lasts at least 3-5 years)
Effect of exercise on body composition and energy expenditure
Moderate to vigorous aerobic activity of 35 minutes or more increases RMR the following day
Regular resistance exercise slows or prevents the loss of lean mass, preserving a higher RMR and insulin sensitivity
All activity has calorie output
Activity as a single intervention
Buchner DM. Physical activity and prevention of cardiovascular disease in older adults. Clin Geriatr Med 2009;25(4):661-75, viii.
What exercise is Recommended?
CDC/ACSM -1993: 30 min. of moderate activity most/all days of the week (also endorsed by ACOG 2012 for pregnant women with no contraindications)
AHA – 2003: 30-60 min. of activity 4-6x weekly and resistance training 2-3 x weekly
IOM - 2003: 60 minutes of physical activity daily
USPSTF – 2012: avoid inactivity; be physically active > 150 minutes/week; include muscle-strengthening activities twice weekly or more (endorsed by AAFP)
General Exercise Goal Recommendations
Aerobic Activity: 30-60 minutes of moderate to vigorous activity most days of the week (e.g. brisk walking, stationary bike, swimming)
Strengthening/Resistance 3 days a week
When do I prescribe Exercise? Research shows effective counseling
can be done in about 5 minutes Research shows patients who are
counseled to exercise by physicians have higher activity levels in the year following the counseling
Calfas, K. J.; Long, B. J.et.al. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med. 1996 May-1996 Jun 30; 25(3):225-33.
Long, B. J.; Calfas, K. J, et.al. A multisite field test of the acceptability of physical activity counseling in primary care: project PACE. Am J Prev Med. 1996 Mar-1996 Apr 30; 12(2):73-81.
Lewis, B. S. and Lynch, W. D. The effect of physician advice on exercise behavior. Prev Med. 1993 Jan; 22(1):110-21.
Where does a patient begin Reducing TV time is a free way for a patient to reduce
sedentary activity and possibly reduce calories
Activities should include safe, weather independent, and cost neutral options
Activities should be chosen in part on patients personal preference
Scheduling time or making daily weekly goals help patients maintain routines (step/day or minute/week goals)
Small bouts at work / home
Assessing Weight Loss Readiness MotivationMotivation:: Patient is ready to make long-term Patient is ready to make long-term
changes in activity AND diet to lead to a lower weightchanges in activity AND diet to lead to a lower weight
Stress level:Stress level: Patient is f Patient is free of major life crisesree of major life crises
Psychiatric issues:Patient does not have untreated or under treated depression, substance abuse, bulimia nervosa
Medical issuesMedical issues:: Patient medical problems are stable Patient medical problems are stable
Time availability:Time availability: Patient can devote 15-30 min/d to Patient can devote 15-30 min/d to weight control for next 26 weeksweight control for next 26 weeks
Patient Ready?Patient Ready?Patient Ready?Patient Ready?
Prevent weight gain and Prevent weight gain and explore barriers to weight explore barriers to weight
reductionreduction
Initiate weight loss Initiate weight loss therapytherapy
YESYES NONO
Clinical Guidelines on the Identification, Evaluation and Treatment of overweight and Obesity in Adults, NIH – NHLBI 1998
Assess values and motivators
The effort of lifestyle change is great Motivations vary Persistence is linked to how connected a
person is to his or her motivator Values like responsibility, self-concern,
and honesty may be key to making and adapting plans
Four Components of Successful Weight Loss
Weight loss goal
Monitoring weight loss
Regular physical activity
Low calorie diet
Build in Monitoring - Success and persistence linked to keeping records or high structure
Journal Reflect on data Daily to weekly weights Goal setting
Lifestyle management: Processes to be tended and amended
Sustainable Choices fit Values Plans to reduce barriers Preferences – convenience, type Resources – time, money, place Finances Ability
Lifestyle management: Connect patients to local resources
Refer to programs – nutritionists, Weight management clinic, behaviorists, appropriate commercial diets, self-help groups, local recreation centers, local produce programs
Encourage investigation and experimentation
Encourage persistence, flexibility, and hope
Document the plan
Type of goal: dietary, activity, other Tools to achieve: stuff, time, people,
places, skills, knowledge Date for start Resources needed: people, places
things Anticipated barriers Strategies Assess and redesign
How do I follow-up with clients/patients?
Research shows that appointments 1-2 times a month for at least 16 weeks are most effective in establishing behavior changes. Long-term frequent follow-up needed for maintenance.
Follow-up can be in person, group visit, on-line or by phone
Pick your counseling tool
Solution-focused brief therapy 5 As Motivational interviewing Personal improvement (systems approach) Diet and activity prescriptions
Make your approach: Non-judgmental Patient-centered Focused Documentation friendly
Regulation of Food Intake
BrainBrain
NPYAGRPgalanin
Orexin-Adynorphin
StimulateStimulateα-MSHCRH/UCNGLP-I
CARTNE5-HT
InhibitInhibit
Central SignalsCentral Signals
Glucose
CCK, GLP-1,Apo-A-IVVagal afferents
Insulin
Ghrelin
Leptin
Cortisol
Peripheral signalsPeripheral signals PeripheralPeripheral organsorgans
+
+
Gastrointestinaltract
Adiposetissue
FoodIntake
Adrenal glands
External factorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues
NAASO Slide Library
Drugs Approved by FDA for Treating Obesity
• Orlistat (Xenical)• Lorcaserin (Belviq) • Phentermine-topiramate (Qsymia)• Phentermine (Adipex-P,
Suprenza). (short-term only)
Obesity is not fair Other diseases promote obesity and impede its treatment How much and how well we sleep matters It really is unfair for women – pregnancy, motherhood,
and menopause provide additional challenges and opportunities
Obesity is not always reversible, and its control with treatment is variable
Average activity levels currently lead to decreased lean mass quantity and quality. This decrease has profound implications for obesity and chronic disease prevention and treatment
Exercise cannot over-come high calorie-dense foods for many people
Key Knowledge about obesity that change treatment approach
It is not just calories – protein, fiber, fat composition, sugar, and other factors affect: satiety and satiation, blood pressure, lipids, insulin sensitivity
Some foods make you hungry When we eat matters The goal is to teach people basic concepts to assess,
adjust and adapt as change is relentless Healthcare providers have more impact when they are
engaged, not perfect, in making healthy lifestyle choices The environment matters- While everyone does not get “sick” in high risk
environments, fewer can stay well, get better, improve optimally
We all work harder to make good choices in less healthy environments – do we really want to work that hard?
Key Knowledge about obesity that changes treatment approach
Conclusion
Obesity is a chronic disease influenced by multiple endocrine pathways that influence eating behaviors and activity levels
Neuroendocrine substances that are made in the brain, the gastrointestinal system, and the adipose tissue are just being elucidated.
Obesity treatment requires behavioral treatment and may require pharmacologic and sometimes invasive treatment to produce optimal disease control
Obesity Treatment Guidelines
The Practical GuideThe Practical Guidecan be found at:can be found at:
NHLBI web site:www.nhlbi.nih.gov
The Obesity Society web site:www.obesity.org
Obesity-Related ResourcesProfessional Associations
The Obesity Society
American Academy of Family Physicians (AAFP)
American College of Sports Medicine (ACSM)
American Diabetes Association (ADA)
American Dietetic Association (ADA)
American Gastroenterological Association (AGA)
American Heart Association (AOA)
American Obesity Association (AOA)
American Society for Bariatric Surgery (ASBS)
www.obesity.org
www.aafp.org
www.acsm.org
www.diabetes.org
www.eatright.org
www.gastro.org
www.americanheart.org
www.obesity.org
www.asbs.org
Centers for Disease Control (CDC): Obesity and Overweight
Centers for Disease Control (CDC): Prevalence data and growth charts
National Institutes of Health (NIH)
National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK) Weight-Control Information Network (WIN)
National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK) Weight Loss and Control
National Library of Medicine, MEDLINE Plus
Obesity-Related ResourcesGovernment Organizations
www.cdc.gov/nccdphp/dnpa/obesity/ index.htm
www.cdc.gov/nchs/nhanes.htm
www.nih.gov
www.niddk.nih.gov/health/nutrit/win.htm
www.niddk.nih.gov/health/nutrit/nutrit. htm
www.nlm.nih.gov/medlineplus/obesity.html
Weight friendly medications NOT approved for Obesity treatment
Anti-epileptics Topiramate Zonisamide
Incretins Exenatide Liraglutide Pramlintide and other amylin analogues
-32
-28
-24
-20
-16
-12
-8
-4
0
Effect of Continuous and Intermittent Phentermine Therapy on Body Weight(Short-term only approved)
0
Time (weeks)
8 24 28
Munro JF et al. Brit Med J 1:352, 1968 NAASO Slide Library
Wei
ght L
oss
(lbs)
364 12 16 20 32
Alternate Phentermine and Dummy
ContinuousPhentermine
Continuous Dummy
Allison DB, Gadde KM, Garvey WT et al. Controlled-Release Phentermine/Topiramate in Severely Obese Adults: A Randomized Controlled Trial (EQUIP). Obesity (Silver Spring) 2012;20(2):330-342.
Allison DB, Gadde KM, Garvey WT et al. Controlled-Release Phentermine/Topiramate in Severely Obese Adults: A Randomized Controlled Trial (EQUIP). Obesity (Silver Spring) 2012;20(2):330-342.
Controlled-Release Phentermine/Topiramate in Severely Obese Adults
Allison DB, Gadde KM, Garvey WT et al. Controlled-Release Phentermine/Topiramate in Severely Obese Adults: A Randomized Controlled Trial (EQUIP). Obesity (Silver Spring) 2012;20(2):330-342.
Controlled-Release Phentermine/Topiramate in Severely Obese Adults
Orlistat Prevents Fat Digestion and Absorption by Binding to Gastrointestinal Lipases
TG=triglyceride; MG=monoglyceride; FA=fatty acid. NAASO Slide Libary
Mucosal CellMucosal CellIntestinal LumenIntestinal Lumen
OrlistatOrlistat TGTG
LIPASELIPASE
LIPASELIPASE
LIPASELIPASE
Bile AcidsBile AcidsMicelleMicelle
MGMGFAFA
-12
-9
-6
-3
0
Effect of Long-term Orlistat Therapy on Body Weight
0Weeks
52
Torgenson et al. Diabetes Care 2004;27:155 NAASO Slide Library
Cha
nge
in W
eigh
t (kg
)
104 156 208
P<0.001 vs placebo
-4.1 kg
-6.9 kg
Placebo
Orlistat
Meta-analysis of RCTs Evaluating Effect of Orlistat Therapy on Weight Loss at 1-Year
Study or Sub-category
WMD (random)95% CI
Hollander 1998*
Sjostrom 1998
Davidson 1999
Finer 2000
Heuptman 2000
Lindgarde 2000
Rossner 2000
Bakris 2002
Broom 2002
Kelley 2002*
Miles 2002*
Total (95% CI)
Padwal et al. Int J Obes 2003;27:1437
*All subjects had type 2 diabetesWMD=weighted mean difference
FavoursTreatment
FavoursControl
-10 -5 0 105
Food and the Incretins:Glucagon-like-peptide (GLP-1)
Site of Synthesis: secreted of the L- cells distal small intestine, Also made in the NTS, hypothalamus and amygdala
Site(s) of action: Inhibits NPY neurons and stimulates the POMC system, PYY decreases ghrelin levels, activates neurons in the area postrema of the PVN
Factors affecting production: secreted in response to rapid passage of food to hindgut with contact with chyme
Major known effects: increases insulin secretion and increases insulin sensitivity. It leads to decreased food ingestion and weight.
GLP-1 receptor agonists (i.e. exenatide, liraglutide) Mechanism: long-acting synthetic peptide that
is a GLP-1 receptor agonist Currently twice daily or daily subcutaneous dosing Weekly dosing in release
Side effects: Most common is nausea Hypoglycemia as discussed prior Weight loss ?increase in INR in patients on coumadin Local reaction/allergy ?rare pancreatitis
TABLE 1 -- Potential targets for new obesity treatments
Agonists/stimulatorsAdiponectin 2αMSH/MC4R Apolipoprotein A-IVBrain-derived neurotrophic factor/TrkB receptor CCK/CCK-A receptor CNTF/axokine Cocaine- and amphetaimine-regulated transcript GLP-1/exendin-4 Human GH fragment (AOD9604) Insulin mimeticsLeptin; leptin receptor OxyntomodulinPYYPhosphatidylinositol 3-kinase Somatostatin β3, serotonin, norepinephrine, dopamine receptors
Antagonists/inhibitorsAcetyl CoA carboxylase Agouti-related protein 11βHSD1Central CPT1CRH receptorDP-IVEndocannabinoid receptor (rimonabant/SR141716A)Fatty acid synthase (cerulenin; C75) Galanin GIPGhrelinHistamine receptorMCHNPYOrexin A and BSuppressor of cytokine signaling-3Tyrosine phosphatase IB
Korner J - J Clin Endocrinol Metab - 01-JUN-2004; 89(6): 2616-21
Brethauer, Stacy A. Sleeve Gastrectomy. Surgical Clinics of North America; Volume 91, Issue 6 (December 2011).
Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.
Mackey RH, Belle SH, Courcoulas AP et al. Distribution of 10-year and lifetime predicted risk for cardiovascular disease prior to surgery in the longitudinal assessment of bariatric surgery-2 study. Am J Cardiol 2012;110(8):1130-1137.
Bariatric Outcomes from SOS The Swedish Obese Subjects (SOS) study is an ongoing, nonrandomized, prospective,
controlled study in Sweden of 2010 obese participants who underwent bariatric surgery and 2037 contemporaneously matched obese controls between Surgery patients underwent gastric bypass (13.2%), banding (18.7%), or vertical banded gastroplasty (68.1%), and controls
MAIN OUTCOME : The primary end point of the SOS study (total mortality) There were 129 deaths in the control group and 101 deaths in the surgery group. The unadjusted overall hazard ratio was 0.76 in the surgery group (P=0.04), as compared with the control group, and the hazard ratio adjusted for sex, age, and risk factors was 0.71 (P=0.01). The most common causes of death were myocardial infarction (control group, 25 subjects; surgery group, 13 subjects) and cancer (control group, 47; surgery group, 29).
Bariatric surgery was associated with a reduced number of cardiovascular deaths (28 events among 2010 patients in the surgery group vs 49 events among 2037 patients in the control group; adjusted hazard ratio [HR], 0.47; 95% CI, 0.29-0.76; P = .002). The number of total first time (fatal or nonfatal) cardiovascular events was lower in the surgery group (199 events among 2010 patients) than in the control group (234 events among 2037 patients; adjusted HR, 0.67; 95% CI, 0.54-0.83; P < .001). average of 10.9 years of follow-up.
1.Sjostrom L, Peltonen M, Jacobson P et al. Bariatric surgery and long-term cardiovascular events. JAMA 2012;307(1):56-65. 2.Sjostrom L, Narbro K, Sjostrom CD et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357(8):741-752
Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.
Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.
Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.
Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.
Brethauer, Stacy A. Sleeve Gastrectomy. Surgical Clinics of North America; Volume 91, Issue 6 (December 2011).
Comparison of surgical and lifestyle intervention for obesity on DM and cardiovascular risk factors
Hofso D, Nordstrand N, Johnson LK et al. Obesity-related cardiovascular risk factors after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention. Eur J Endocrinol 2010;163(5):735-745.
DESIGN: One-year controlled clinical trial
METHODS: Morbidly obese subjects (19-66 years, mean (s.d.) body mass index 45.1 kg/m(2) (5.6), 103 women) were treated with either Roux-en-Y gastric bypass surgery (n=80) or intensive lifestyle intervention at a rehabilitation centre (n=66). The dropout rate within both groups was 5%.
RESULTS: Among the 76 completers in the surgery group and the 63 completers in the lifestyle group, mean (s.d.) 1-year weight loss was 30% (8) and 8% (9) respectively. Beneficial effects on glucose metabolism, blood pressure, lipids and low-grade inflammation were observed in both groups. Remission rates of type 2 diabetes and hypertension were significantly higher in the surgery group than the lifestyle intervention group; 70 vs 33%, P=0.027, and 49 vs 23%, P=0.016. The improvements in glycaemic control and blood pressure were mediated by weight reduction. The surgery group experienced a significantly greater reduction in the prevalence of metabolic syndrome, albuminuria and electrocardiographic left ventricular hypertrophy than the lifestyle group. Gastrointestinal symptoms and symptomatic postprandial hypoglycaemia developed more frequently after gastric bypass surgery than after lifestyle intervention. There were no deaths.
CONCLUSIONS: Type 2 diabetes and obesity-related cardiovascular risk factors were improved after both treatment strategies. However, the improvements were greatest in those patients treated with gastric bypass surgery.Citation: