Search Results for "severe obesity"
Is There a Role for Gastric Balloons in Severe Obesity?
The idea of endoscopically placing a fluid-filled balloon into the stomach to enhance satiety and reduce food intake is by no means new. Often propagated as an alternative to dieting, the clinical utility of the balloon remains to be defined. In my view the key limitation around the use of this device remains around the fact that it cannot be left in place forever and therefore can never be a definitive treatment for obesity – removal of the balloon, as with any diet, results in weight regain (barring the handful of individuals, who can keep the weight off by continuing on a strict caloric restriction and exercise program). But there may well be clinical uses for the implantable balloon in certain situations – one example would be preparing extremely obese high-risk patients for a more definitive treatment. This concept certainly appears promising based on a recent paper by Stephan Göttig and colleagues from Frankfurt am Main, Germany, published in this month’s issue of Bariatric Surgery. This study retrospectively examined the results in 109 super- and super-super-obese patients (64 m and 45 f), with mean age of 39.1 y and mean BMI of 68.8, who underwent gastric balloon therapy (GBT) for weight loss. Mean duration of balloon therapy was 177 days with a mean weight loss of around 26 Kg or around 9 BMI points. The greatest weight loss was seen in patients with BMI > 80. Not surprisingly, comorbidities improved markedly in around 60% of patients. There were no major complications, but minor complications at balloon placement and removal occurred in a few patients. 69 patients went on to receive bariatric surgery. 10 patients received a second balloon. This study clearly demonstrates the safety and efficacy of GBT in extremely obese patients particularly as a first step before a definitive anti-obesity operation. I can think of similar situations, where weight loss may need to be achieved in severely obese patients before elective diagnostic or therapeutic procedures – not dissimilar to the previously proposed use of protein-sparing low calorie formula diets. Clearly an interesting concept that may deserve further prospective evaluation in severely obese high-risk patients too sick to undergo a primary more definitive intervention. AMS Edmonton, Alberta
Spinal Fusion Surgery in Severe Obesity
Lower back pain is not an uncommon finding in obese and very obese individuals. One surgical treatment option is to create a fusion between two or more vertebrae in an attempt to reduce pain by stopping the motion at the painful vertebral segment(s). In a paper just published in SPINE, Rahul Vaidya and colleagues from the Detroit Receiving Hospital and University Health Center, Detroit, report on their experience in a case series of 63 patients with a BMI of 30 or higher. Despite a higher surgical risk and a 45% greater chance of complications, obese and very obese patients showed significant improvement in visual analog scale for back and leg pain with some improvement in disability scores independent of the BMI of the patient. Thus, despite posing a greater challenge for the surgeon and slightly higher surgical risk, heavier patients stand to benefit as much from surgery as less obese patients. Incidentally, as with other types of orthopedic surgeries that improve mobility, no “spontaneous” weight loss was found to occur after spinal surgery. Important questions that remain to be answered include the role for pre-surgical weight loss and whether or not weight management will be made easier following surgery. AMS Edmonton, Alberta
Three New Genetic Loci for Severe Obesity
Yesterday, Nature Genetics published an early online release of a paper by a large team of European researchers, headed by Philippe Froguel from the Pasteur Institute, Lille, France, that identifies three new genetic loci that account for a substantial amount of childhood-onset and severe adult obesity. The genome-wide association study analysed data from 1,380 Europeans with early-onset and morbid adult obesity and 1,416 age-matched normal-weight controls. Thirty-eight markers showing strong association were further evaluated in 14,186 European subjects. In addition to the previously identified FTO and MC4R genes, the researchers detected significant association of obesity with three new risk loci in NPC1 (endosomal/lysosomal Niemann-Pick C1 gene), near MAF (encoding the transcription factor c-MAF) and near PTER (phosphotriesterase-related gene). Previous studies in mice have suggested that the NPC1 gene has a role in controlling appetite, as mice with a non-functioning NPC1 gene suffer late-onset weight loss and have poor food intake. Based on the present study, the near-NPC1 variant may account for around 10 per cent of all childhood obesity and about 14 per cent of adult morbid obesity cases. The locus located near the PTER gene, the function of which is not known, is estimated to account for up to a third of all childhood obesity, and a fifth of all cases of adult obesity. MAF controls the production of insulin, glucagon and glucagon-like peptides, which play a role both in carbohydrate metabolism as well as food intake. The MAF variant accounts for about 6 per cent of early-onset obesity in children, and 16 per cent of adult morbid obesity. What is surprising is not that these genetic variants exist, but that they have such strong population effects (at least in Europeans). Together with the previously identified FTO and MC4R genes, which were once again confirmed in this study, it appears that the researchers are slowly but steadily circling in on the genetic factors that account for a substantial proportion of early-onset and adult severe obesity. So far, most of these genes appear linked to the regulation of food intake. Even, if it is far from straightforward to use this information for developing new treatments for obesity – we may be one step nearer to better demonstrating that obesity is not a homogeneous entity and that obesity is not simply a matter of “choice”. AMS Edmonton, Alberta
Pain Catastrophizing in Severe Obesity
BEST HEALTH BLOG FINALIST: The second round of voting is on – please vote AGAIN for your favourite health blog by clicking here Pain is one of the most common and debilitating problems in patients challenged by severe obesity. Not just a consequence of mechanical complications of obesity (osteoarthritis, back pain, plantar fasciitis, fibromyalgia, etc.), pain is often a key barrier to physical activity and thus weight management. In fact, excess pain can promote psychological (e.g. depression, anxiety) and behavioural (e.g. binge eating) factors that may further promote weight gain. This issue is of even more importance in patients who display the now well-described phenomenon of pain catastrophizing, or the maladaptive responses to pain (tendency to focus on and magnify pain sensations with an intense sense of unbearable suffering and helplessness) that plays an extremely important role in how pain is perceived and processed. Pain catastrophizing now accounts for a substantial proportion of pain-related disability. Studies in patients with fibromyalgia show that pain catastrophizing is associated with increased activity in brain areas related to anticipation of pain (medial frontal cortex, cerebellum), attention to pain (dorsal ACC, dorsolateral prefrontal cortex), emotional aspects of pain (claustrum, closely connected to amygdala) and motor control. Thus, catastrophizing influences pain perception through altering attention and anticipation, and heightening emotional responses to pain. In another recent study by Tamara Somers and colleagues from Duke University, morbidly obese patients with osteoarthritis (OA) reported higher levels of pain catastrophizing than OA patients in the overweight and obese category. The severely obese patients who engaged in a high level of pain catastrophizing reported having much more intense and unpleasant pain, higher levels of binge eating, lower self-efficacy for controlling their eating and lower weight-related quality of life. The relationship between pain catastrophizing and eating behaviour is of particular interest, as high-fat and high-sucrose foods have been shown to increase pain tolerance. Thus, binging on highly-palatable foods may be a compensatory response to emotional distress and pain. It is not difficult to see how patients can enter into a vicious cycle of pain, increased eating, weight gain, more pain, more eating, and so on. In routine practice, pain catastrophizing can be easily and reliably assessed with questionnaires like this one, which can be scored like this. Fortunately, pain catastrophizing is responsive to cognitive behavioural therapy, with clinically relevant improvements in upto 50% of individuals. I would have little doubt that failure to recognize and… Read More »
Severe Obesity is Not a Choice!
Last week, the Supreme Court of Canada passed a ruling that would entitle severely handicapped individuals to be accommodated on airlines and specifically extended this ruling to include individuals, who were severely handicapped because of excess weight. This ruling resulted in a flood of raves and rants on why the Supreme Court would promote obesity by accommodating rather than punishing obese people for their laziness and indulgence. The Globe & Mail commentator went as far as to imply that by extending the ruling to obese individuals, the Supreme Court was in fact undermining the case for people with “real disabilities”. In light of this ridiculous and discriminating accusation, I could not help but write the following letter to the Globe & Mail: As Medical Director of one of the largest medical obesity programs in the country, I am appalled at the notion that including obesity in the recent Supreme Court judgement on accommodation of disabled people on airline flights, should be considered by the Globe & Mail commentator as anything but fair. To be clear, this ruling does not provide free rides for anyone with a few pounds excess weight – this ruling is specific in that it addresses the issues of individuals, who suffer from a condition so disabling that they require help with even the most basic functions. The idea that someone with such severe disabling obesity, has gained that amount of weight (often several hundred excess pounds) simply by lack of willpower or sheer laziness rather than some underlying genetic, mental heath or medical issue is not only naïve but also reflects the prevailing negative stereotyping, prejudice and discrimination toward obese individuals, that appears to be perfectly acceptable even to otherwise compassionate and reflective individuals. But that is not even the point. The point is that the Globe & Mail commentator, unlike the Supreme Court, uses causality as a criterium for judging which disability is deserving of special accommodation and which is not. By those standards, it would be fair to ask if the person claiming disability due to a spinal cord or brain injury from a motor vehicle accident was in fact observing the speed limit at the time of the accident or if the person who suffered a disabling stroke always religiously took her blood pressure medications and passed on the salt. Singling out individuals disabled by severe obesity as the only group undeserving of special accommodation… Read More »
