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

VN:F [1.9.22_1171]
Rating: 10.0/10 (1 vote cast)
VN:F [1.9.22_1171]
Rating: 0 (from 0 votes)


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

VN:F [1.9.22_1171]
Rating: 0.0/10 (0 votes cast)
VN:F [1.9.22_1171]
Rating: 0 (from 0 votes)


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

 

VN:F [1.9.22_1171]
Rating: 10.0/10 (1 vote cast)
VN:F [1.9.22_1171]
Rating: +1 (from 1 vote)


Tuesday, January 21, 2014

Quality of Life in Obesity is Determined by Health, Not Size

weight scale helpOver the past few days, I have been posting on the results of the APPLES study – a prospective 24-month assessment of patients wait-listed for or undergoing treatment at a publicly funded bariatric centre in Alberta, Canada.

In a separate analysis, just released in OBESITY, Lindsey Warkentin and colleagues present the baseline quality of life (QoL) data for the 500 patients enrolled in this study.

As noted previously, the average BMI of participants in this study was 47.9, 90% were female with an average age of 43.

Quality of life was assessed at the time of enrolment in the study using several standardized and validated instruments (Short-Form (SF)-12 [Physical (PCS) and Mental (MCS) component summary scores], EuroQol (EQ)-5D [Index and Visual Analog Scale (VAS)], and Impact of Weight on Quality of Life (IWQOL)-Lite).

As may be expected, the overall QoL of these patients was substantially lower than the general population in Alberta.

Thus, the mean physical and mental component summary scores in the SF-12, were both substantially lower (by about 10 points) than general population scores in Albertan adults. Similar reductions in QoL were found with the other instruments.

Key predictors of poor QoL included fibromyalgia, pain, depression, sleep apnea, coronary artery disease and stroke (among others).

Interestingly, however, despite a wide range of body weights in this study, BMI itself had almost no predictive value in terms of health status or quality of life.

This is perhaps not surprising, as we have previously shown that BMI alone is not a reliable or even sensitive measure of health (which is why we developed the Edmonton Obesity Staging System to better characterize the health status of individuals with obesity).

Thus, it is the actual presence of related illnesses that determine the quality of life – not simply the amount of excess body fat.

This finding has important implications for treatment and prioritization.

For one, as noted previously, BMI or other measures of size alone are a poor guide as to how sick your patient is – determining the health impact of excess weight actually requires assessing the presence of physical and mental comorbidities (of which there are many).

Conversely, as QoL is largely dependent on the presence of related illnesses – it may well be that treating and controlling these illnesses may have a great impact (and perhaps be far more effective and practical) than simply focussing on weight loss.

Thus, for example, it may be far more cost effective and practical to treat the symptoms of severe osteoarthritis (by replacing a knee or hip) or the symptoms of sleep apnea (with CPAP) than simply focussing all attention on dropping the numbers on the scale.

As much as losing weight may be the preferred option (if we had better treatments), better management of relevant comorbidities could perhaps result in substantial greater improvements in health-related quality of life than struggling to lose a few pounds.

Thus, an important tenet of bariatric care has to focus on better managing the health problems that obese patients present with even if significant and persistent weight loss remains elusive in most patients.

Bariatric care is so more than just running a weight-loss clinic.

@DrSharma
Edmonton, AB

ResearchBlogging.orgWarkentin LM, Majumdar SR, Johnson JA, Agborsangaya CB, Rueda-Clausen C, Sharma AM, Klarenbach SW, Birch DW, Karmali S, McCargar L, Fassbender K, & Padwal RS (2014). Predictors of health-related quality of life in 500 severely obese patients: An assessment using three validated instruments. Obesity (Silver Spring, Md.) PMID: 24415405

.

VN:F [1.9.22_1171]
Rating: 10.0/10 (5 votes cast)
VN:F [1.9.22_1171]
Rating: +2 (from 2 votes)


Friday, January 17, 2014

Bariatric Care: What Surgery Delivers

sharma-obesity-bariatric-surgery21Continuing in my discussion of the weight and health outcomes of the APPLES study, reported by Padwal and colleagues in Medical Care, we now turn our attention to the 150 participants who underwent bariatric surgery in a publicly funded bariatric program.

As noted in yesterday’s post, all surgical patients underwent intensive medical assessment and behavioural interventions prior to undergoing surgery. Thus, the outcomes reported in this group of participants is on top of any weight loss or benefits that patients may have experienced as a result of this intervention prior to surgery. It is thus, not surprising that at the time of enrolment to the APPLES study, surgical participants were approximately 4 Kg lighter than the “medical” participants (this being the average weight loss seen in the “medically” managed group).

Of the 150 surgical participants, 129 (86%) completed their 24 month visit. Data for the “drop-outs” was analysed as “last-observation-carried-forward”.

Overall weight loss at 24 months for the surgical group was 22 Kg (16.3%) with 75% achieving more than 5% weight loss, and 63% achieving more than 10% weight loss.

There were distinct differences in weight-loss outcomes between the different surgical procedures (all of which were performed in approximately equal proportions).

While the average weight-loss at 24 months for patients undergoing adjustable gastric banding was a paltry 7 Kg (5.8%), sleeve gastrectomy patients lost 21 Kg (16%), whereas bypass patients lost 37 Kg (26%) of their initial body weight.

All of these weight-losses were associated with marked improvements in cardiovascular risk factors.

There are several important learnings from this data.

1) Surgical treatments were markedly more effective than behavioural intervention (no surprise here).

2) There are significant differences in the amount of weight lost with the different surgical procedures, with bypass patients losing almost five times more weight that those undergoing gastric banding (rather unexpected).

3) Even with the greater weight loss achieved through surgical treatment, the average weight loss is still well under 30% of initial weight – again speaking to the refractoriness of severe obesity even with surgery.

Thus, despite its greater efficacy, even bariatric surgery will still leave many patients obese (based on BMI).

For clinicians (and patients) this means that many patients undergoing bariatric surgery, despite significant weight loss and considerable improvements in health and quality of life, may still be disappointed to not achieve their “ideal” or “dream” weight.

In the next post, I will summarize the overall learnings from this study and what they mean for the current status of bariatric care.

@DrSharma
Banff, AB

ResearchBlogging.orgPadwal RS, Rueda-Clausen CF, Sharma AM, Agborsangaya CB, Klarenbach S, Birch DW, Karmali S, McCargar L, & Majumdar SR (2013). Weight Loss and Outcomes in Wait-listed, Medically Managed, and Surgically Treated Patients Enrolled in a Population-based Bariatric Program: Prospective Cohort Study. Medical care PMID: 24374423

.

VN:F [1.9.22_1171]
Rating: 10.0/10 (1 vote cast)
VN:F [1.9.22_1171]
Rating: +2 (from 2 votes)

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

» More news articles...

Publications

"Metabolically healthy overweight and obesity."

» Browse and download more journal publications...

Watch Dr. Sharma in the News!

Dr. Sharma - NEWS Videos

Listen to Dr. Sharma!

Dr. Sharma - on CBC.ca

Watch Dr. Sharma on Listen Up


  • Subscribe via Email

    Enter your email address:

    Delivered by FeedBurner




  • Arya Mitra Sharma
  • Disclaimer

    Postings on this blog represent the personal views of Dr. Arya M. Sharma. They are not representative of or endorsed by Alberta Health Services or the Weight Wise Program.
  • Archives

     

  • RSS Weighty Matters

  • Click for related posts

  • Disclaimer

    Medical information and privacy
    Any medical discussion on this page is intended to be of a general nature only. This page is not designed to give specific medical advice. If you have a medical problem you should consult your own physician for advice specific to your own situation.


  • Meta

  • Obesity Links

  • If you have benefitted from the information on this site, please take a minute to donate to its maintenance.

  • Home | News | KOL | Media | Publications | Trainees | About
    Copyright 2008–2014 Dr. Arya Sharma, All rights reserved.
    Blog Widget by LinkWithin