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What Happens To Patients With Severe Obesity In Hospitals?

With the increasing number of Canadians living with severe obesity (BMIs 50+), it is not unexpected that more of them will be seen in healthcare settings. However, whether or not Canadian hospitals are ready to look after these patients with in the right setting with the right equipment and whether healthcare providers are aware of and sensitive to the special needs of these patients is not clear. This is why, Mary Forhan and her team at the University of Alberta is currently conducting a qualitative and quantitative assessment of exactly what problems patients with severe obesity face in healthcare settings. The study, funded by Alberta Innovates Health Solution (AIHS) will look at the special challenges that these patients present in a range for settings – acute care, cancer, cardiology and rehabilitation. A substudy will also examine the issues faced by kids and adolescent with severe obesity in healthcare settings. Together, this project should lead to a better understanding on how healthcare systems better prepare themselves to deliver compassionate and professional care to adults and children living with severe obesity in Alberta. The learnings will likely also inform healthcare systems elsewhere. For more on this study visit the AIHS website. If you are someone living with severe obesity, who has experienced issues in your healthcare that could have been prevented or addressed with appropriate equipment and/or training, I’d love to hear your story. @DrSharma Edmonton, AB Conflict: I am a co-investigator on this project.

Accuracy of Forearm Blood Pressure Measurements in Severe Obesity

Getting reliable blood pressure readings in patients with obesity can pose a problem, even when extra-large cuffs are available. An often discussed alternative is the use of forearm readings using a regular cuff, but the reliability of these readings remains unknown. Now a study by Marie-Eve Leblanc and colleagues from the University of Laval, Quebec, Canada, published in Blood Pressure Monitoring, shows that forearm measurements with an oscillometric device can be reliably measured and are highly predictive of intra-arterial blood pressure measurements in patients with sever obesity. The study involved 25 participants with an average BMI of 50.9kg/m2. Overall, sensitivity (0.98) and predictive values (0.93) for the presence of systemic hypertension were excellent, indicating that the forearm approach is a promising alternative to systemic hypertension diagnosis in severe obesity. This may well simplify blood pressure measurements in patients presenting with severe obesity, where upper arm measurements may be difficult. @DrSharma Calgary, AB

Even Modest Weight Loss Is Associated With Improved Health Status in Patients With Severe Obesity

The title of this post may sound like a “no-brainer”, but the research literature on the long-term health benefits of weight loss from longitudinal intervention studies in people with severe obesity is much thinner than most people would expect. Thus, a new study from our group, that looks at the relationship between changes in body weight and changes in health status over two years in patients with severe obesity enrolled in the Alberta Population-based Prospective Evaluation of the Quality of Life Outcomes and Economic Impact of Bariatric Surgery (APPLES) study, published in OBESITY, may well be of considerable interest. As described previously, APPLES is a 500-patient cohort study in which consecutive, consenting adults with BMI levels > 35 kg/m2 were recruited from the Edmonton Adult Bariatric Specialty Clinic. The 500 patients enrolled were between 18 and 60 years old and were either wait-listed (n=150), beginning intensive medical treatment (n=200) or had just been approved for bariatric surgery (n=150). Complete follow-up data at 24 months was available for over 80% of participants. At study enrollment, the proportion of patients who reported >2 and >3 chronic conditions was 95.4% and 85.8%, respectively. The most common single chronic conditions at baseline were joint pain (72.2%), anxiety or depression (65.4%), hypertension (63.4%), dyslipidemia (60.4%), diabetes mellitus (44.6%), gastrointestinal reflux disease (35.4%), and sleep apnea (33.5%). After 2 years, just over 50% of participants had maintained a weight loss > 5%, with a mean weight change for the entire cohort of about 13 kg. Losing > 5% weight was associated with an almost 2-fold increased likelihood of reporting a reduction in multimorbidity at 2-year follow-up, whereby outcomes varied between treatment groups: in the surgery group, the top three chronic conditions that decreased in prevalence over follow-up were sleep apnea (43% at baseline vs. 25% at 2 years,), dyslipidemia (60% vs. 47%), and anxiety or depression (59% vs. 47%); in the medically treated group anxiety or depression (69% vs. 57%) and joint pain (77% vs. 67%); and none in the wait-listed group. As expected, any reduction in multimorbidity was associated with a clinically important improvement in overall health status. In summary, this paper not only documents the considerable multimorbidity associated with severe obesity, it also documents the clinically important improvement in health status associated even with a rather modest 5% weight loss over 2 years in these individuals. @DrSharma Edmonton, AB

Severe Obesity Is Easier To Manage in Kids Than in Teens

To anyone who has raised adolescents, the findings of this study should not come as a surprise. According to a study by Thomas Reinehr from the University of Witten/Herdecke, Germany, published in Pediatric Obesity, extremely obese children respond better than extremely obese adolescents to behavioural interventions. The researchers looked at data from a one-year intensive behavioural intervention 1291 children (mean age 11.0years, mean BMI 27.5, 55.8% female, 37.6% extremely obese (defined by BMI-SDS >2.3) at end of intervention and 1 year later. While the overall mean BMI-SDS wqs indeed reduced (−0.20 ± 0.32 at end of intervention and −0.14 ± 0.37 1 year later), and there were no significant differences in the outcomes of overweight and obese kids vs. overweight and obese adolescents, this was not the case for the severely obese group. Here, the group of extremely obese kids (>10 years), showed only a rather modest treatment effect compared to younger extremely obese kids (<10 years). Thus the authors conclude that, “Our study demonstrated an encouraging effect of lifestyle intervention in extremely obese children ≤10 years at the end of intervention and 1 year later, but only a limited effect in extremely obese adolescents >10 years.” This is not unlike the situation for other chronic diseases, where management in adolescents tends to be more challenging than managing younger kids or adults. I guess this is simply another fact that obesity management shares with the management of other chronic diseases. If you have experience with managing adolescent obesity, I’d certainly like to hear from you. @DrSharma Edmonton, AB

Is Severe Obesity Associated With Increased Risk For Fractures?

According to conventional wisdom, one (of the few) health benefits of obesity is stronger bones. However, according to a study by Sarah Cawsey and colleagues (me included) from the University of Alberta, published in Osteoporosis International, these “stronger” bones may not be quite strong enough to prevent spontaneous and traumatic fractures. Our study examined the relationship between fracture history and bone mineral density (BMD measured by DEXA) in 400 women with a mean age of 44 yrs and a mean BMI of 46. Twenty two percent of women (n=87) reported a total of 178 fractures. Of particular note, fragility-type fractures (hip, vertebra, proximal humerus, distal forearm, and ankle/lower leg) were present in 58 (14.5%) of the women. There was a markedly higher proportion of fractures in women in the lowest femoral neck BMD quintile who had any fracture history (41.3 vs. 17.2%), any fragility-type fractures (26.7 vs. 11.7%), hand and foot fractures (16.0 vs. 5.5%), other fracture types (5.3 vs. 1.2 %), and osteoporotic fractures (8.0 vs. 1.2%) compared to the remaining population. No clinical or biochemical predictors of fracture risk were identified apart from BMD. Our finding show that severely obese women with the lowest BMD values, despite these being close to what would be considered “normal” in a non-obese woman, are at a significantly elevated risk of all types of fractures compared to severely obese women with elevated BMD. Given the substantial fracture risk seen in our study, it may well be worth considering evaluating the potential benefits of routine BMD assessments in pre-menopausal women with severe obesity. @DrSharma Gambach, Germany Cawsey S, Padwal R, Sharma AM, Wang X, Li S, & Siminoski K (2014). Women with severe obesity and relatively low bone mineral density have increased fracture risk. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA PMID: 25182230.