Thursday, December 11, 2014

How Effective Is Obesity Management In Primary Care?

sharma-obesity-doctor-kidLosing weight with behavioural interventions in the context of a clinical trial, where you are often dealing with volunteers who are generally provided interventions that are far better structured and standardised than we can ever hope to deliver in a primary care settings, tells us little about the effectiveness of such interventions in real life.

Now a paper by Tom Wadden and colleagues from the University of Pennsylvania, published in JAMA, presents a systematic review of the behavioral treatment of obesity in patients encountered in primary care settings as delivered by primary care practitioners working alone or with trained interventionists (eg, medical assistants, registered dietitians), or by trained interventionists working independently..

A search of the literature yielded 12 trials, involving 3893 participants, that met inclusion-exclusion criteria and prespecified quality ratings.

At 6-months weight changes in the intervention groups ranged from a loss of 0.3 kg to 6.6 kg compared to a gain of 0.9 kg to a loss of 2.0 kg in the control group.

As one may expect, interventions that prescribed both reduced energy intake (eg, ≥ 500 kcal/d) and increased physical activity (eg, ≥150 minutes a week of walking), with traditional behavioral therapy, generally produced larger weight loss than interventions without all three specific components.

Also, more treatment sessions (in person or by telephone) were associated with greater mean weight loss and likelihood of patients losing 5% or more of baseline weight.

Unfortunately, overtime, weight loss in both groups declined with longer follow-up (12-24 months).

Thus, the authors conclude that,

“Intensive behavioral counseling can induce clinically meaningful weight loss, but there is little research on primary care practitioners providing such care. The present findings suggest that a range of trained interventionists, who deliver counseling in person or by telephone, could be considered for treating overweight or obesity in patients encountered in primary care settings.”

Whether any of this is worth the cost and effort was not discussed. My guess is that to see greater success in primary care we need better treatments that move well beyond the rather simplistic ‘eat-less move-more’ paradigm.

@DrSharma
Edmonton, AB

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Monday, December 8, 2014

Effectiveness Of Obesity Management For Osteoarthritis

sharma-obesity-knee-osteoarthritis1Osteoarthritis is one of the most common and disabling complications of obesity. Irrespective of whether or not the osteoarthritis is directly caused by excess weight, there is little doubt that the sheer mechanical forces acting on the affected joints will significantly impact mobility and quality of life.

Now the Canadian Agency for Drugs and Technologies in Health (CADTH) has released a report on the Clinical Effectiveness of Obesity Management Interventions Delivered in Primary Care for Patients with Osteoarthritis.

This systematic review of the literature leads to the following findings:

1) Dietary weight loss interventions, either alone or in combination with exercise produce greater reductions in the peak knee compressive force and plasma levels of interleukin-6 (IL-6) in knee OA patients compared with exercise-induced weight loss.

2) There is a significantly greater reduction in pain and improvements in functions in patients who received diet plus exercise interventions compared with either diet–only or exercise–only interventions.

3) Regardless of the type of weight-loss interventions, participants who lost 10% or more of baseline body weight had greater reductions in knee compressive force, systemic IL-6 concentrations, and pain, as well as gained greater improvement in function than those who lost less of their baseline weight.

4) Participants who lost the most weight also experienced greater loss of bone mass density at the femoral neck and hip, but not the spine, without a significant change of their baseline clinical classification with regards to osteoporosis or osteopenia.

Thus, in summary, weight loss, particularly when achieved through a combination of both diet and exercise can result in significant improvement in physical function, mobility, and pain scores in individuals with osteoarthritis.

Unfortunately, this is by no means easy to achieve and even harder to sustain.

Although I may sound like a broken record – we desperately need better treatments for obesity.

@DrSharma
Edmonton, AB

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Thursday, December 4, 2014

Can Gut Bugs Cause Depression?

sharma-obesity-gut-buts1Regular readers will by now be well aware of the rapidly growing body of researcher supporting the idea that your gut bugs (of which you have more than you have cells in your body) may well play a key role in determining your risk for obesity and other metabolic disorders.

Now, a paper by Ruth Ann Luna and Jane Foster from Baylor College of Medicine and McMaster University, respectively, published in Current Opinion in Biotechnology, review the evidence that gut bugs may well also have significant effects on your stress response as well as other aspects of mental healthy, including depression.

As one example, they cite a study that shows,

“…a general underrepresentation of the Bacteroidetes phylum in depressed patients and an association of the Lachnospiraceae family with the depression group, and interestingly, even with a decrease in Bacteroidetes, specific operational taxonomic units (OTUs) identified as members of the Bacteroidetes phylum correlated with depression.”

They also cite a number of studies showing that stress can affect gut bug populations and that certain gut bacteriomes are associated with a greater stress response, suggesting that the relationship between gut bugs and stressors may well be a two-way street.

The authors go on to describe a number of pathways that may link gut bugs to humoral, neural, and cellular signaling pathways to brain function.

Clearly, this appears a rich area of research that may well reveal pathways common to both neurological and metabolic issues, both of which may turn out to be amenable to dietary and probiotic interventions.

@DrSharma
London, UK

ResearchBlogging.orgLuna RA, & Foster JA (2014). Gut brain axis: diet microbiota interactions and implications for modulation of anxiety and depression. Current opinion in biotechnology, 32C, 35-41 PMID: 25448230

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Wednesday, December 3, 2014

Does Your Liver Control Your Appetite?

Fatty Liver

Fatty Liver

The answer may well be “yes”, at least if you happen to be a mouse.

In a rather exciting study by Iliana López-Soldado and colleagues from the Institute for Research in Biomedicine, Barcelona, published in DIABETES, the researchers show that increased liver glycogen content may affect appetite (measured as food intake) and otherwise have beneficial effects on metabolism.

In their experiments, the researchers used genetically modified mice, which overexpress an enzyme (PTG) resulting in increased liver glycogen.

Not only did these animals reduce their food intake when fed a high fat diet, they also did not develop the typical glucose intolerance, elevated insulin levels and fatty liver seen in normal mice on this diet.

Apart from losing weight (associated with lower leptin levels), these animals also had lower expression of neuropeptide Y (NPY) and higher expression of propiomelanocortin (POMC) in the hypothalamus.

Thus, the authors summarize their findings as follows:

:…liver glycogen accumulation caused a reduced food intake, protected against the deleterious effects of a HFD and diminished the metabolic impact of fasting. Therefore, we propose that hepatic glycogen content be considered a potential target for the pharmacological manipulation of diabetes and obesity.”

As a number of compounds exist that may do exactly that, these studies may point to a novel pathway for the pharmacological treatment of obesity – but let’s keep in mind that the road from finding in mice to effective treatments in humans is a long and thorny road.

@DrSharma
Edmonton, AB

ResearchBlogging.orgLópez-Soldado I, Zafra D, Duran J, Adrover A, Calbó J, & Guinovart JJ (2014). Liver glycogen reduces food intake and attenuates obesity in a high-fat diet-fed mouse model. Diabetes PMID: 25277398

 

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Tuesday, December 2, 2014

Does Maternal Obesity Affect the Gut Microbiome of the Offspring?

sharma-obesity-gut-buts1Yesterday, I blogged about the Maternal Resource Hypothesis, proposed by Edward Archer, as a driver of childhood obesity.

Today’s post is about another interesting finding by Jeffrey Galley and colleagues from Ohio State University, published in PLOS one, suggesting that maternal obesity may be associated with differences in the gut microbiome in children in early life.

The researchers compared the gut bugs from fecal samples from children 18–27 months of age (n = 77) born to obese or non-obese mothers.

At least in women of higher socioeconomic status, offspring of obese mothers showed significant differences in their gut bacteriome from those of non-obese mothers in a manner that has been previously linked to differences in weight and diet (differences were noted in the abundances of Faecalibacterium spp., Eubacterium spp., Oscillibacter spp., and Blautia spp).

While these findings were limited to women of higher socioeconomic status, the authors do not have a ready explanation for these findings.

Their best guess is that perhaps the etiology of obesity may differ between women of higher and lower socioeconomic status and it may well be that the extent to which maternal obesity confers measureable changes to the gut microbiome of offspring may differ based on the etiology of maternal obesity.

It is unlikely that dietary differences explain these findings:

“In our sample, we found no differences in the children from obese and non-obese mothers in terms of breastfeeding behavior, age at which solid foods were introduced, or the current frequency of consumption of meat, vegetables, and cereals/grains regardless of maternal SES. This suggests that diet did not explain the observed differences in the children’s gut microbiome related to maternal obesity and SES.”

Indeed, the authors are quick to point out that further research is needed to better understand the relevance of the observed differences in gut microbiome composition for weight trajectory over the life course of the offspring:

The potential role of the gut microbiome in this intergenerational transmission of obesity risk warrants further attention. In particular, the stability of such effects into later childhood and adolescence, the clinical relevance of abundances of specific bacteria in conferring risk for obesity, and the ultimate impact of early life microbial profiles on long-term weight trajectory remains to be explicated.”

Nevertheless, these findings are intriguing in that they suggest a link between maternal obesity and the possible transmission of obesogenic microbes to their offspring.

@DrSharma
Vancouver, BC

ResearchBlogging.orgGalley JD, Bailey M, Kamp Dush C, Schoppe-Sullivan S, & Christian LM (2014). Maternal obesity is associated with alterations in the gut microbiome in toddlers. PloS one, 9 (11) PMID: 25409177

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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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