Search Results for "severe obesity"
Will Severe Obesity go the Way of Malignant Hypertension?
Back in the mid-eighties, when I was still training in nephrology, it seemed not a week would go by without being called upon to attend to a patient with malignant hypertension. These patients, with blood pressures well over 200/120 mmHg, would often show up with no prior anti-hypertensive medication or, in some cases, not even a known diagnosis of hypertension. Without immediate attention, these patients were in acute danger of progressing to kidney or heart failure or experiencing strokes. Today, 40 years later, malignant hypertension is a comparatively rare occurrence and can generally be well managed thanks to major advances in and widespread early use of anti-hypertensive medications. Given the current splurge and momentum we are witnessing in ever more effective anti-obesity medications, I wonder if we will be looking back in a couple of decades remembering the days when we used to routinely see patients with BMIs of 50, 60, 70, 80, or even higher, with all of the accompanying complications. Indeed, the only reason why so many patients with severe obesity exist today, is that this progressive chronic disease has largely gone untreated (with the exception of the tiny brave minority that may have undergone bariatric surgery). After all, everyone living with severe obesity today, must at some point have had less severe obesity. That should have been the time where they should have been appropriately diagnosed and managed to halt progression and to avoid complications. Thus far, that has not been the case. Even today, despite advances in obesity treatments, people living with early stages (or even later stages) of obesity receive virtually no obesity care, which is why we continue to see such large numbers of untreated individuals progressing to severe obesity with all its complications. Now, with the recent developments in anti-obesity medications, I can foresee a future where severe obesity eventually goes the way of malignant hypertension – it goes back to being the rare disorder it once was. How long will this take? It all depends on just how soon we can take obesity seriously, implement early detection and clinical care, and make effective obesity treatments available to everyone who needs them. We have done it for hypertension – we can do it for obesity. @DrSharmaBerlin, D
Fit-Fat Paradox Holds For People With Severe Obesity
Regular readers will be quite familiar with the findings that cardiometabolic health appears to be far more related to “fitness” than to “fatness” – in other words, it is quite possible to mitigate the metabolic risks commonly associated with excess body fat by improving cardiorespiratory fitness. Now, a study by Kathy Do and colleagues from York University, Toronto, published in BMC Obesity, shows that this relationship also holds for people with quite severe obesity. The researcher studied 853 patients from the Wharton Medical Clinics in the Greater Toronto Area, who completed a clinical examination and maximal treadmill test. Patients were then categorized into fit and unfit based on age- and sex-categories and in terms of fatness based on BMI class. Within the sample, 41% of participants with mild obesity (BMI<35) had high fitness whereas only 25% and 11% of the participants with moderate (BMI 35-40) and severe obesity (BMI>40), respectively, had high fitness. Individuals with higher fitness tended to be younger and more likely to be female. While overall fitness did not appear to be independently associated with most of the metabolic risk factors (except systolic blood pressure and triglycerides), the effect of fitness in patients with severe obesity was more pronounced. Thus, the prevalent relative risk for pre-clinical hypertension, hypertriglyceridemia and hypoalphalipoproteinemia and pre-diabetes was only elevated in the unfit moderate and severe obesity groups, and fitness groups were only significantly different in their relative risk for prevalent pre-clinical hypertension within the severe obesity group. Similarly, high fitness was associated with smaller waist circumferences, with differences between high and low fitness being larger in those with severe obesity than with mild obesity. Based on these findings, the researchers conclude that the favourable associations of having high fitness on health may be similar if not augmented in individuals with severe compared to mild obesity. However, it is also apparent based on the rather low number of “fit” individuals in the severe obesity category (only about 1 in 10), that maintaining a high level of fitness proves to be more challenging the higher the BMI. @DrSharma Edmonton, AB
Gastric Bypass Vs. Sleeve Gastrectomy For Severe Obesity
In the 2018 special issue of JAMA on obesity, two research articles compare long-term outcomes (5 years) after laparoscopic roux-en-Y gastric bypass (RYG) to sleeve gastrectomy (SG). In the first study by Ralph Peterli and colleagues from Switzerland, the authors report on the findings from the Swiss Multicenter Bypass or Sleeve Study (SM-BOSS), a 2-group randomized trial, that included 217 patients at 4 bariatric centres, who were enrolled and randomly assigned to SG or RYG. At 5 years, weight loss was slightly greater in the RYG group but this difference was not statistically significantly. Gastric reflux improved more after RYG and was more likely to worsen with SG. Reoperation rates were marginally higher in the RYG group (seven reoperations after sleeve gastrectomy were for severe GERD, and 17 reoperations after bypass were for internal hernias) . In the second study Paulina Salminen and colleagues from Finland report on the Sleeve vs Bypass (SLEEVEPASS) multicenter, multisurgeon, open-label, randomized clinical equivalence trial which randomly assigned patients with severe obesity to SG (n=121) or RYG (n=119) with a 5-year follow-up period. At 5 years, weight loss, remission of diabetes, as well as improvements in dyslipidemia and hypertension were slightly higher in the RYG group than in the SG group. Overall, there was no difference in improvement in quality of life or in morbidity rates between the two groups. There was no treatment-related mortality in either group. In an accompanying editorial, David Arterburn and Arniban Gupta from the University of Washington, Seattle, note that, “Collectively, these studies provide reassuring data to suggest that the rapid switch from Roux-en-Y gastric bypass to sleeve gastrectomy in the last decade has not been a therapeutic misadventure similar to the rise and fall of the adjustable gastric band,5 which has been all but abandoned.” They also point to five important learnings from these studies: Patients should be informed that deciding between sleeve gastrectomy and bypass is complex and requires patients to simultaneously consider information about many factors, including weight loss, control of different comorbidities, and short- and long-term risks. Weight loss between the two procedures are more or less on par. GS may be a reasonable choice even for patients with diabetes. Patients with GERD deserve careful consideration, because their outcomes are differentially affected by sleeve gastrectomy and gastric bypass. Given the relative parity between these procedures in weight loss and comorbidity resolution, shared decision making conversations should prioritize… Read More »
Guest Post: Complications of Cardiac Surgery in Severe Obesity
Today’s guest post comes from Tasuku Terada, a postdoctoral research fellow with the Bariatric Care and Rehabilitation Research Group (BCRRG), a multidisciplinary research collaboration, focused on improving the care and rehabilitation outcomes of patients with obesity. Dr. Terada is an Exercise Physiologist and 2015 Canadian Obesity Network, Obesity Research Bootcamp alumni. His research interests include the role of exercise in counteracting chronic health conditions associated with obesity. Obesity is a risk factor for cardiovascular disease, and referrals for coronary artery bypass graft surgery (CABG) have increased in patients with severe obesity (body mass index: BMI ≥40 kg/m2). In our recent study published in the Journal of American Heart Association, using data from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, we show that patients with severe obesity were 53% more likely to have complications within 30 days of surgery and had threefold higher risk of infection compared to patients without obesity. In addition, the median hospital stay was one day longer in patients with severe obesity compared to patients without obesity. In patients with severe obesity, those who had diabetes and experienced infection stayed 3.2 times longer days in hospital compared to patients without either condition. Taken together, these results highlight a need for attentive care in bypass patients with severe obesity. Strategies to minimize the risks of infection and efforts to ensure good glucose control for patients with diabetes may also be important for better patient care quality and to reduce the length of hospital stay. This type of information should be useful to caregivers and lead to prevention or preparation for possible adverse outcomes. This study was supported by a Partnerships for Research and Innovation in the Health System (PRIHS) award from Alberta Innovates – Health Solutions (AIHS). Tasuku Terada Edmonton, AB
Risks Of Severe Obesity In Children And Young Adults
Yes, body fat is not a measure of health and it is possible to be healthy across a wide range of body weights. However, this may become harder and harder, the more weight you gain. Thus, a study by Asheley Skinner and colleagues, published in the New England Journal of Medicine, shows that increased cardiometabolic risk is tightly linked with severe obesity both in children and young adults. The study looks at cross-sectional data from overweight or obese children and young adults (3-19 yrs) who were included in the US National Health and Nutrition Examination Survey (NHANES) from 1999 through 2012. Among 8579 children and young adults with a body-mass index at the 85th percentile or higher (according to the Centers for Disease Control and Prevention growth charts), 46.9% were overweight, 36.4% had class I obesity, 11.9% had class II obesity, and 4.8% had class III obesity. Overall, for a given weight, males tended to have higher cardiometabolic risk than females. Even after controlling for age, race or ethnic group, more severe obesity maps more likely to be associated with low HDL cholesterol level, high systolic and diastolic blood pressures, and high triglyceride and glycated hemoglobin levels. Importantly, while this relationship was constantly present in males, the there were fewer significant differences in these variables according to weight category among female participants, suggesting that for a given body weight, girls were less likely to be at cardiometabolic risk compared to boys. Thus, while body weight (or body fat) may not be a precise measure of individual health, the risk for having one or more cardiometabolic risk factor increases substantially with increasing severity of obesity. However, it is also important to note that even in kids and youth with class III obesity, 70% of participants had normal lipids and about 90% of participants did not have elevated blood pressure or glycated hemoglobin. This points to the fact that for a given body weight there is indeed wide variability in whether or not someone actually has cardiometabolic risk factors. Thus, whether or not it makes sense to target every kid that presents with an elevated BMI for intervention, remains to be shown – most likely such an approach would probably not be cost-effective. As in adults, it seems that interventions in kids are probably best targeted by global risk rather than simply by numbers on a scale. @DrSharma Edmonton, AB
