Another series of articles in the 2018 JAMA special issue on obesity, deals with the impact of bariatric surgery on health outcomes and overall mortality. The first article by Sayeed Ikramuddin and colleagues is an observational follow-up of a randomized clinical trial at 4 sites in the United States and Taiwan, involving 120 participants who had a hemoglobin A1c(HbA1c) level of 8.0% or higher and a BMI between 30.0 and 39.9. The study compared intensive lifestyle and medical management intervention based on the Diabetes Prevention Program and LookAHEAD trials for 2 years, with and without (60 participants each) Roux-en-Y gastric bypass surgery followed by observation to year 5. At 5 years, 13 participants (23%) in the gastric bypass group and 2 (4%) in the lifestyle-intensive medical management group had achieved the composite triple end point (HbA1c less than 7.0%, LDL cholesterol less than 100 mg/dL, and systolic blood pressure less than 130 mm Hg). In the fifth year, 31 patients (55%) in the gastric bypass group vs 8 (14%) in the lifestyle–medical management group achieved an HbA1c level of less than 7.0%. As is to be expected, surgical treatment resulted in more serious adverse events (66 vs 38 events), most frequently involving gastrointestinal and surgical complications such as strictures, small bowel obstructions, and leaks. A second study by Gunn Signe Jakobsen and colleagues from Norway, reports on changes in obesity related comorbidities in patients with severe obesity (BMI ≥40 or ≥35 and at least 1 comorbidity) undergoing bariatric surgery (n=932, 92 gastric bypass) or specialized medical (“lifestyle”) treatment (n=956) at a tertiary care outpatient center. Based on drugs dispensed according to the Norwegian Prescription Database and data from the Norwegian Patient Registry and a local laboratory database, surgically treated patients had a greater likelihood of remission (RR, 2.1) and lesser likelihood for new onset of hypertension (RR, 0.4), a greater likelihood of diabetes remission (RR, 3.9) but also a greater risk of new-onset depression (RR, 1.5) and treatment with opioids (RR, 1.3. Again, as expected, surgical patients had a greater risk for undergoing at least 1 additional gastrointestinal surgical procedure (RR, 2.0). From these findings the researchers conclude that adding gastric bypass to lifestyle and intensive medical management alone in patients with severe obesity and type 2 diabetes, there remained a significantly better composite triple end point in the surgical group at 5 years. The third study by Orna Reges and colleagues from… Read More »
This week, JAMA revisits obesity with a dedicated theme issue, which includes a range of articles on obesity prevention and management (including several on the impact of taxing sugar-sweetened beverages and five original long-term studies on bariatric surgery). In an accompanying editorial, Edward Livingston notes that, “The approach to the prevention and treatment of obesity needs to be reimagined. The relentless increase in the rate of obesity suggests that the strategies used to date for prevention are simply not working.” Also, “From a population perspective, the increase in obesity over the past 4 decades has coincided with reductions in home cooking, greater reliance on preparing meals from packaged foods, the rise of fast foods and eating in restaurants, and a reduction in physical activity. There are excess calories in almost everything people eat in the modern era. Because of this, selecting one particular food type, like SSBs, for targeted reductions is not likely to influence obesity at the population level. Rather, there is a need to consider the entire food supply and gradually encourage people to be more aware of how many calories they ingest from all sources and encourage them to select foods resulting in fewer calories eaten on a daily basis. Perhaps tax policy could be used to encourage these behaviors, with taxes based on the calorie content of foods. Revenue generated from these taxes could be used to subsidize healthy foods to make them more affordable.” Over the next few days, I will be reviewing about the individual articles and viewpoints included in this special issue. In the meantime, the entire issue is available here. @DrSharma Edmonton, AB
In follow up to yesterday’s guest post by Christy Turer on her challenges in getting timely diagnostics and treatment for a patient with severe obstructive sleep apnea (OSA), it appears timely that this week’s issue of the Canadian Medical Association Journal (CMAJ) features a full-length update on the diagnosis and treatment of OSA in adults. As Cheryl Laratta form the University of British Columbia and colleagues point out, OSA) is likely underdiagnosed in Canada with lack of appropriate treatment putting many at risk of poor quality of life, comorbidity, motor vehicle crashes and increased health care utilization. Clinical features include daytime sleepiness, unrefreshing sleep or fatigue, frequent nocturnal waking due to choking or gasping, nocturia, morning headaches, poor concentration, irritability and erectile dysfunction. Bed partners may report snoring or witnessed apneas. Atypical symptoms, more frequently reported by women, include insomnia, impaired memory, mood disturbance, reflux and nocturnal enuresis. However, as the authors point out, the correlation of symptoms with disease severity is poor, which is why it is important for physicians to be alert to milder symptoms and screen individuals who present with known risk factors like overweight/obesity, increased neck circumference and nasopharangeal crowding. Importantly, while the presence of these features increases pre-test probability, neither history nor physical examination are enough to rule out OSA. A number of questionnaires (e.g. Berlin Questionnaire, STOP-Bang, etc.) are available to assist in screening patients. As for diagnosis, “The gold standard for diagnosis of OSA is attended polysomnography (level I study), which involves collection of seven or more data channels, including electroencephalogram and electrooculogram for sleep staging, electromyogram, electrocardiogram and respiratory channels.” Less reliably, “Level III sleep studies record a minimum of three channels of data while the patient sleeps at home. Level III studies usually monitor airflow, snoring, respiratory excursion, body position, heart rate and oxygen saturation, but some validated devices use surrogate measurements for these variables, such as tonometry or actigraphy, and the technology is constantly evolving.51 Level III studies do not record sleep; therefore, severity of OSA is estimated using the respiratory event index, which is the number of desaturation events per hour of total recording time.” Treatment options include nightly use of a continuous positive airway pressure (CPAP) device or the use of oral devices (for less severe cases). The latter should be custom fitted by a dentist with extensive experience or additional training in dental sleep medicine. Oddly enough, there is no mention of obesity… Read More »
Today’s guest post comes from Christy Turer, MD, Assistant Professor of Pediatrics, Internal Medicine, and Clinical Sciences at University of Texas Southwestern (UTSW) Medical Center, Dallas, Texas, USA. This week, I saw a 50 year-old female patient with obesity (BMI 44) who desperately needs screening and treatment for obstructive sleep apnea (OSA). Over the past four years, her heart function (ejection fraction) has declined from >60% to now ~20% with significant pulmonary hypertension, almost certainly related to undiagnosed, untreated OSA based on multiple nightly witnessed apneas. Although she now sleeps with oxygen, this does nothing for her hypopnea-related, sympathetic overdrive-mediated, cardiac dysfunction. Without CPAP treatment, her life expectancy is two years or less. Unfortunately, within the public health system for which I work (county system that offers free or discounted healthcare to poor residents in a metropolitan city, USA), the average wait time for a sleep study is 1-2 years. To be fair, this patient has had a previous attempt at a sleep study in a sleep lab a couple of years ago. At that time, however, the study was inconclusive, because she could not fall asleep in the sleep lab’s unfamiliar environment. It is frustrating not being able to help my patients with suspected sleep apnea, especially, when I know that help could be available. It is high time we had a technological disruption that enables cheap, reliable, in-home OSA assessment for patients. Christy Turer, MD Dallas, TX Dr Turer is a standing member of the US Food and Drug Administration’s Pediatric Advisory Committee, a consultant to the FDA’s Endocrinologic/Metabolic Drugs Advisory Committee, and Past-Chair of the Obesity Society’s Clinical Management of Obesity Section. She has authored numerous scientific articles and lectured widely on primary-care evaluation and management of overweight/obesity and related metabolic comorbidities across the lifespan. Her comments do not reflect the views of UTSW, FDA, or any of her funding sources.
As readers will be well aware, n terms of health risks, fat is not fat is not fat is not fat. Rather, whether or not body fat affects health depends very much on the type of body fat and its location. While there have been ample attempts at trying to describe body fat distribution with simple anthropometric tools like measuring tapes and callipers, these rather crude and antiquated approaches have never established themselves in clinical practice simply because they are cumbersome, inaccurate, and fail to reliably capture the exact anatomical location of body fat. Furthermore, they provide no insights into ectopic fat deposition – i.e. the amount of fat in organs like liver or muscle, a key determinant of metabolic disease. Recent advances in imaging technology together with sophisticated image recognition now offers a much more compelling insight into fat phenotype. In this regard, readers may be interested in a live webinar that will be hosted by the Canadian Obesity Network at 12.00 pm Eastern Standard Time on Thu, Nov 23, 2017. The webinar provides an overview of a new technology developed by the Swedish company AMRA, that may have both important research and clinical applications. The talk features Olof Dahlqvist Leinhard, PhD, Chief Scientific Officer & Co-Founder at AMRA and Ian Neeland, MD, a general cardiologist with special expertise in obesity and cardiovascular disease, as well as noninvasive imaging at the UT Southwestern Medical Center in Dallas, US. Registration for this seminar is free but seats are limited. To join the live event register here. I have recently heard this talk and can only recommend it to anyone interested in obesity research or management. @DrSharma Edmonton, AB