Wednesday, April 2, 2014

Trotting Out STAMPEDE

sharma-obesity-blood-sugar-testing2In the obesity world, this week’s big news is the publication of the three year results of the STAMPEDE trial in the New England Journal of Medicine.

As a regular reader, you may recall my previous post on this randomised controlled trial of bariatric surgery for the treatment of type 2 diabetes.

STAMPEDE involved the randomisation of 150 obese patients with uncontrolled type 2 diabetes to either intensive medical therapy alone or intensive medical therapy plus Roux-en-Y gastric bypass or sleeve gastrectomy.

Rather than weight loss, the primary end point of STAMPEDE was a glycated hemoglobin (HbA1C) level of 6.0% or less (from a mean baseline of 9.3%).

For the 91% of the patients who completed 36 months of follow-up at three years, 5% of the patients in the medical-therapy group achieved an HbA1c of 6.0% compared to 38% of those in the gastric-bypass group and 24% of those in the sleeve-gastrectomy group.

In addition, surgically treated subjects overall had far lesser need for glucose-lowering medications, including insulin than those receiving medical treatment.

Weight was reduced by 20-25% in the surgical groups compared to a 4% weight loss in the medical arm of the study.

Quality-of-life was also significantly better in the two surgical groups than in the medical-therapy group.

There were no major late surgical complications.

By any reasonable standard, there cannot be any remaining doubt in anyone’s mind that surgical treatment for type 2 diabetes is vastly superior to anything that medical treatment has to offer.

Diabetologists and, in fact, all physicians, diabetes educators, dietitians and other health professionals, who fail to inform and counsel their type 2 patients with regard to surgical treatment options for their condition, risk being accused of malpractice.

Whether patients want surgery for diabetes or not is ultimately their choice – being informed of the potential benefits of surgery should not be a matter of choice – it should be good clinical practice.

@DrSharma
Edmonton, AB

Disclaimer: I am NOT a surgeon!

ResearchBlogging.orgSchauer PR, Bhatt DL, Kirwan JP, Wolski K, Brethauer SA, Navaneethan SD, Aminian A, Pothier CE, Kim ES, Nissen SE, Kashyap SR, & the STAMPEDE Investigators (2014). Bariatric Surgery versus Intensive Medical Therapy for Diabetes – 3-Year Outcomes. The New England journal of medicine PMID: 24679060

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Tuesday, April 1, 2014

Dr. Oz’s Next Miracle Obesity Cure: Ginger?

ginger-health-benefits-usesA recent article in Forbes Magazine noted at least 16 nonsensical “weight-loss miracles” discovered by Dr. Oz.

Well, allow me to be the first to predict another weight-loss miacle that may soon make the airwaves (or rather your cable): ginger.

And this would by no means be a surprise given that Saravanan and colleagues from Tamil Nadu, India, in a paper published in the Journal of the Science of Food and Agriculture, note the anti-obesity effects of ginger, especially in the face of a high-fat diet.

Unfortunately (not that Dr. Oz would care), this finding was in rats, who were given varying amounts of gingerol for 30 days.

And indeed, at the highest dose (75 mg/Kg), animals did have lower glucose level, body weight, leptin, insulin, amylase, lipase plasma and tissue lipids when compared to controls.

As the authors show, this was about as much of an effect as seen in animals treated with lorcaserin, an anti-obesity drug recently approved by the FDA.

While, to their credit, the authors make only generically optimistic claims as to the use of these findings rather than proclaim  another “weight-loss miracle”, they also fail to tell us exactly how many kilograms of fresh ginger (or even ginger extract) one would have to eat every day to come anywhere close to reaching an effective dose of gingerol.

Never mind that we also have no idea how such a dose would be tolerated in humans (yes, natural products have side effects!), or even whether or not ginger would in fact have any similar effects on body weight or metabolism in humans.

Surely, there is nothing wrong with this line of research. Many medical discoveries (e.g. aspirin) were made through the isolation of pharmacologically active moieties from plants.

What is wrong, however, is when such basic findings are overhyped and presented as “miracles” with claims of curing everything from obesity and heart disease to cancer and Alzheimer’s (surprisingly such claims often fail to include world peace).

Will Dr. Oz pick up on ginger? I don’t know. But if he does, remember you heard it here first.

@DrSharma
Edmonton, AB

ResearchBlogging.orgSaravanan G, Ponmurugan P, Deepa MA, & Senthilkumar B (2014). Antiobesity action of gingerol: Effect on lipid profile, insulin, leptin, amylase and lipase on male obese rats induced by a high-fat diet. Journal of the science of food and agriculture PMID: 24615565

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Thursday, March 20, 2014

Sleep Duration Strongest Predictor of Health Risk in Obese Teens?

sharma-obesity-kid-sleep-book

If you had to guess the strongest predictor of cardiometabolic health risks in  obese teenagers, most of us would probably suspect their diet, sedentariness, or even mental health issues around mood, body image, or self-esteem.

Few of us would have guessed sleep duration.

But this is exactly what was found by Paul Gordon and colleagues from the University of Michigan, in a study published in the Journal of Pediatrics.

Although relatively small (the study included just 37 participants aged 11-17), the researchers went to great lengths to objectively measure habitual physical activity and sleep patterns as well as a wide range of cardiometabolic risk factors.

Amongst all of the measured variables, total sleep time and sleep fragmentation were inversely and independently associated with metabolic risk – the shorter the sleep time, the greater the risk.

This relationship remained robust even when the data were adjusted for various measures of physical activity, anthropometry, and adiposity.

Most subjects slept about seven hours a night, typically waking up at least once, with only five subjects getting the minimum recommended 8.5 hours of sleep each night.

Given what we now know about the profound impact of sleep deprivation on metabolism, physical activity and eating behaviours, it is astonishing that so little attention is being paid to the issue of sleep both in the public discourse of obesity as well as in clinical management of excess weight.

As I have said before, the three key drivers of obesity in my view are lack of time, lack of sleep and increased stress – everything else is either a consequence of or compounded by these factors.

Is it time for doctors to begin handing out sleep prescriptions?

@DrSharma
Edmonton, AB

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Wednesday, March 19, 2014

Can Testosterone Lead to Weight Loss in Hypogonadal Men?

sharma-obesity-impotenceLoss of male gonadal function has been associated with weight gain (particularly visceral adiposity) as well as metabolic disturbances including dyslipidemia and insulin resistance.

However, wether or not hormonal substitution with testosterone (T) ameliorates these metabolic abnormalities or even leads to weight loss remains controversial.

Now a 6-year observational study by Ahmad Haider and colleagues from Germany, published in the International Journal of Endocrinology, strongly suggests that this may well be the case.

The authors analysed data from two prospective longitudinal studies that included 156 obese hypogonadal men, aged between 41 and 73 years (mean 61.17 ± 6.18) with previously diagnosed type 2 diabetes, who were seeking urological consultation for various conditions such as erectile dysfunction, decreased libido, questions about their T status, or a variety of urological complaints.

All subjects  had subnormal plasma total T levels and at least mild symptoms of hypogonadism assessed by the Aging Males’ Symptoms scale (AMS).

Treatment was started with parenteral T undecanoate 1000 mg (Nebido, Bayer Pharma, Berlin, Germany), administered at baseline and 6 weeks and thereafter every 12 weeks for up to 72 months. Subjects were also given general advice on healthy eating and physical activity.

This treatment resulted in an increase in total T levels from 8.9 ± 1.99 nmol/L to above 16 nmol/L within the first year of therapy, and remained at this physiological level throughout the course of treatment.

This change in T levels was associated with a progressive 12 cm decrease in waist circumference and weight loss of about 17.5 Kg (15% of initial weight) with BMI dropping from 36.5 to 31.2 at year 6.

Concomitantly, fasting glucose declined from 7.06 to 5.59 mmol/L and HbA1c decreased from 8.08 to 6.14%.

There were also favourable changes in systolic and diastolic blood pressure, lipid profiles including triglycerides and total cholesterol:HDL ratio, as well as CRP and liver enzymes.

While general caution is in order given that there was no control group, these finding certainly strongly suggest a possible role for T-replacement therapy in hypogonadal males presenting with symptoms of hypogonadism and weight gain.

Clearly, the 15% weight loss is impressive and well-exceeds what is generally seen with pharmacological obesity treatments.

If nothing else, these observations should prompt the conduct of a well-designed randomised controlled trial to confirm the effect and safety of T replacement therapy for obesity in hypogonadal men.

@DrSharma
Edmonton, AB

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Monday, March 17, 2014

Why There Is HOPE For The NFL

sharma-obesity-footballA sad consequence of professional athleticism are the many health hazards associated with competitive sports.

This also applies to US National Football League (NFL) players, particularly to linesmen, who have a markedly increased risk for excessive weight gain with all the metabolic and physical health consequences commonly seen in obese individuals.

This is now of so great a concern, that the US Living Heart Foundation has created the Heart, Obesity, Education, Prevention (HOPE) program dedicated to screening former National Football League (NFL) players for health, in particular cardiovascular health, problems.

As described by George Buchwald, in an article published in SOARD, the mission of HOPE is two fold:

(1) Screening of former NFL players focused on obesity and the obesity comorbidities with referral of selected players on a voluntary basis to a regional center of excellence for further assessment and therapy.

(2) Recruiting successfully managed players as emissaries to the general public to discuss the diagnosis, prevention, and treatment of obesity and the obesity comorbidities.

Buchwald is particularly enthusiastic about the latter, as professional athletes have hero status and command the attention of the public – this could be a natural conduit for health messages.

The LIFE HOPE program also offers treatments to NFL players for their obesity, including diet, exercise, behavior modification, pharmaceuticals, and metabolic/bariatric surgery.

Of note, the program is a partnership between the NFL, the Living Heart Foundation and Covidien, a leading maker of devices for bariatric surgery.

Whether or not this approach to recruiting (former) elite athletes with obesity to promote health messages (including promoting bariatric surgery) bears fruit remains to be seen.

I wonder what you think about this initiative.

@DrSharma
Edmonton, AB

 

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In The News

Diabetics in most need of bariatric surgery, university study finds

Oct. 18, 2013 – Ottawa Citizen: "Encouraging more men to consider bariatric surgery is also important, since it's the best treatment and can stop diabetic patients from needing insulin, said Dr. Arya Sharma, chair in obesity research and management at the University of Alberta." Read article

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