As much as docs (and, well, us) may not want to admit it, our PCP’s can be instrumental in helping with weight loss in the morbidly obese — and I don’t just mean in signing that Letter of Medical Necessity for surgery, either. Let’s face it — not everyone is ready for surgery yet – maybe this is a step in helping some get ready for it.
Primary Care Practice Intervention Can Prompt Weight Loss in Morbidly Obese
February 2, 2010 — Primary care practices can be instrumental in helping patients who are morbidly obese to lose weight and keep it off, according to a study published January 25 in the Archives of Internal Medicine.
“Other therapeutic techniques for treating obesity, besides surgery, including diet, exercise, behavior therapy, and pharmacotherapy, might be applied, but there are few data on applying them in cases of extreme obesity, despite it being commonly encountered,” write Donna H. Ryan, MD, from the Pennington Biomedical Research Center, Baton Rouge, Louisiana, and colleagues. “We developed the Louisiana Obese Subjects Study (LOSS) to test the hypothesis that primary care physicians could effectively implement intensive medical management to treat patients with extreme obesity, with a goal of weight loss at year 2 significantly better than usual care.”
LOSS, a randomized controlled pragmatic clinical trial, took place from July 2005 through January 2008. Volunteers, 83% of whom were women, had body mass indexes of 40 to 60 kg/m2 and a mean age of 47 years. They were divided into 2 groups: intensive medical intervention (IMI; n = 200) and usual care condition (UCC; n = 190). The UCC group was directed to an Internet weight loss program. The IMI faction was counseled by primary care practices to follow these recommendations:
- Maintain a 900-kcal liquid diet for up to 12 weeks.
- Attend group behavioral counseling, follow a standardized diet and exercise program, and take weight-loss medications (choice of sibutramine hydrochloride, orlistat, or diethylpropion hydrochloride) during months 3 through 7.
- Continue medications and adhere to maintenance methods for months 8 through 24.
The retention rate was 51% for the IMI group and 46% for the UCC group (P = .30). Those who attended the final study visit received a $100 gift card.
Physician Support Results in Long-Term Weight Loss
After 2 years, the study authors reported that the IMI group had lost more weight and maintained their weight loss better than the UCC segment:
- In the IMI group, 31% achieved a weight loss of 5% or more, and 7% achieved a 20% or greater weight loss vs 9% and 1%, respectively, in the UCC group.
- A weight loss of −4.9% ± 0.8% in IMI and −0.2 ± 0.3% in UCC was demonstrated by the mean ± SEM baseline observation carried forward.
- A weight loss of −8.3% ± 0.79% for IMI and −0.0% ± 0.4% for UCC was shown by the last-observation-carried-forward analysis.
- The 101 IMI subjects who completed the study lost −9.7% ± 1.3% (−12.7 ± 1.7 kg); the 89 remaining UCC participants lost −0.4% ± 0.7% (−0.5 ± 0.9 kg).
The results were significant (P < .001) at year 2 for all group differences, according to the study authors, given that most of the morbidly obese population will not have weight loss surgery.
“Recently, the SOS [Swedish Obese Subjects] study demonstrated that surgery for obesity is associated with reduction in mortality,” the authors write. “Still, surgery is currently not an option for most patients with extreme obesity because of reimbursement issues and individual preference.”
In an interview with Medscape, John Morton, MD, director of bariatric surgery at Stanford University in Stanford, California, pointed out that, of the 12 million candidates for weight-loss surgery in the United States, fewer than 175,000 undergo such procedures each year. Dr. Morton noted several limitations to the Pennington study, including small sample size, modest weight loss, and high dropout rate. Still, he applauded the results as a forward step in obesity treatment.
“Obesity is a chronic disease and just like any chronic disease it requires a lot of different modalities, including surgery and other medical intervention,” Dr. Morton said. “Even a modest amount of weight loss is going to result in some significant health benefits.”
Physicians See Weight Loss Intervention as “Daunting”
An editorial, published in the same issue of the Archives, said primary care practices are in dire need of a boost to their confidence regarding obesity treatment. In his commentary, Robert F. Kushner, MD, from the Northwestern University Feinberg School of Medicine, Chicago, Illinois, said that obesity intervention is often seen by physicians as a “daunting or even futile task.”
“There are few other examples in medicine where stigmatization of the patient, feelings of being ill equipped, perceived treatment ineffectiveness, and even reluctance to engage in obesity care prevail as major barriers,” Dr. Kushner said.
However, primary care practices can play a valuable role in weight loss and control among morbidly obese patients, the study authors concluded.
“Primary care practices can initiate effective medical management for extreme obesity; future efforts must target improving retention and weight loss maintenance,” the authors write.
The Office of Group Benefits (OGB) for the State of Louisiana funded the study. Abbott Laboratories donated a portion of the sibutramine used in the study. The authors disclosed that OGB’s primary contractee, Pennington Biomedical Research Center, has received research funding from pharmaceutical companies including Abbott Laboratories, Roche, GlaxoSmithKline, Amylin, Johnson & Johnson, Arena, Hollis Eden, Eli Lilly and Co, Merck & Co, Pfizer, Sanofi-Aventis, Shionogi, Takeda Pharmaceutical Co, and Vivus. At the study’s onset, Dr. Kaj Stenlof was an employee of Pennington Management of Clinical Trials, which monitored the research. Fifteen of the 20 study authors receive, have received, or will receive health insurance from the OGB. Several of the study authors have been paid consultation and/or service fees, received grant money from, or hold stock in, Abbott Laboratories, Arena, Johnson & Johnson, Merck & Co, NutriSystem, Sanofi-Aventis, Shionogi, Vivus, Amylin Pharmaceuticals, Orexigen Pharmaceuticals, GlaxoSmithKline, Takeda, Bristol-Myers Squibb, AstraZeneca, Hoffmann-La Roche, Ethicon, Biovitrum, BMS, Global Health Partners, Lenimen, and/or NovoNordisk, all of which manufacture medicines involved in the study. Several of the authors have received salaries from the OGB-sponsored project. A full list of disclosures is available in the original article.
Arch Intern Med. 2010;170:124-125, 146-154.
Well. Maybe. Sorta. Kinda.
Qualified answer is that these are BETTER choices when going out to eat. Given smaller stomachs, and these are even better choices for us.
Thought even those of us with rerouted guts could use this info.
Video from MSNBC.com:
Wow. That’s sobering.
And we know what the number one cause for heart disease is, right?
(Don’t make me slap you silly. Cause I will.)
Heart disease to kill 400,000 in U.S. in 2010
Experts: Progress against cutting cholesterol stalled by rising obesity rates
LONDON – Decades of progress in the United States on cutting cholesterol, blood pressure and smoking are being stalled by rising obesity rates, and heart disease will kill around 400,000 Americans this year, experts said on Monday.
A study by British scientists found that around half of those deaths could be averted if people ate healthier food and quit smoking, and experts warned there was no room for complacency when it came to heart health risks.
Simon Capewell of the University of Liverpool said recent weight trends were “alarming,” with 1.5 billion adults worldwide expected to be overweight by 2015.
“Although (heart disease) death rates have been falling in the United States for four decades, they are now leveling off in young men and women,” he wrote in a study in the World Health Organization’s weekly journal.
“Recent declines in total blood cholesterol have been modest, blood pressure is now rising among women and obesity and diabetes are rising steeply in both sexes.”
The researchers calculated the number of deaths based on lifestyle trends, taking the year 2000 as a base.
They found that almost 200,000 lives could be saved if certain heart risk factors were cut, even modestly, in particular, Capewell said, “if people ate healthier food and stopped smoking.”
Two-thirds of U.S. adults and nearly one in three children are overweight or obese — a condition that increases their risk for diabetes, heart disease and other chronic illnesses.
U.S. health officials last week introduced first lady Michelle Obama as their latest weapon in a fresh campaign against the increasingly-costly weight burden.
But Shanthi Mendis, an expert on chronic disease prevention at the Geneva-based WHO, noted that the United States was not alone in facing an obesity epidemic, and said lifestyle choices now directly affected the health of many of the world’s people.
“Worldwide, nearly one billion adults are overweight and, if no action is taken, this figure will surpass 1.5 billion by 2015,” she said in the study.
“By avoiding tobacco, eating a healthy diet and engaging in regular physical activity, people can dramatically reduce their risk of developing heart disease, stroke or diabetes.”
Not a good day, news-wise.
Obesity on All Measures Linked to Increased Ischemic Stroke Risk
January 22, 2010 — No matter how it is measured, obesity is a significant risk factor for ischemic stroke, not only in men and women but also in both blacks and whites, a new study has found.
The study, which used all 3 measures of obesity — body mass index (BMI), waist circumference, and waist to hip ratio (WHR) — was among the first to look at the association between obesity and stroke risk in blacks and whites.
“This was the first study that shows consistently that obesity increases risk of stroke in both blacks and whites,” said lead author Hiroshi Yatsuya, MD, PhD, visiting associate professor in the Division of Epidemiology & Community Health at the School of Public Health, University of Minnesota, Minneapolis.
The study reinforces the message that controlling obesity, which may help prevent hypertension and diabetes, may reduce the risk for stroke, he said.
The study was published online January 21 and will appear in the March issue of Stroke.
The analysis included 13,549 participants (5930 men and 7619 women and 3694 blacks and 9855 whites) aged 46 to 64 years from the Atherosclerosis Risk in Communities (ARIC) Study who were recruited from 4 US communities and followed up from 1987 to 2005.
Participants were interviewed over the telephone and completed several clinic visits.
To determine obesity, researchers used BMI, that is, weight in kilograms divided by height in meters squared, waist circumference alone, and WHR, the ratio of waist circumference taken at umbilical level to hip measurement taken at maximum buttock circumference.
Table. Mean Obesity Measures at Baseline by Race and Sex
Group BMI Waist Circumference Waist to Hip Ratio Black women 30.8 100.3 0.90 Black men 27.6 96.7 0.94 White women 26.6 93.0 0.89 White men 27.4 99.5 0.97
BMI = body mass index
During follow-up, there were 598 ischemic strokes. Researchers confirmed the incidence of stroke through hospital discharge records and imaging information. Blacks had a 2 to 3 times higher incidence of ischemic stroke compared with whites in each obesity group.
The researchers calculated stroke incidence according to different quintiles of obesity, using all 3 obesity measures. For BMI, they found that the stroke incidence per 1000 person-years ranged from 1.2 for white women in the lowest category to 8.0 for black men in the highest category.
Linear Relationship Between Stroke and Obesity
For other obesity measurements, the stroke incidence rate had a similar range. Using waist circumference, the rates ranged from a low of 1.1 per 1000 person-years for white women in the lowest quintile to 8.2 in black men in the highest quintile. Using WHR, the lowest rate was 1.1 for white women in the lowest category, and the highest was 8.2 for black women in the top category.
No matter what obesity measure was used, the results showed about twice the stroke risk among patients in the highest category compared with those in the lowest. For example, for BMI, the risk for patients in the highest category was 1.4 to 2.1 times higher than those in the lowest BMI category (varying modestly by race and sex).
Dr. Yatsuya noted that the correlation between increasing stroke incidence and increasing degree of obesity was apparent in both races and sexes.
However, said Dr. Yatsuya, much of the association between stroke and obesity in this study could be explained by diabetes and hypertension, both of which are well-established risk factors for stroke.
“Either blood pressure or diabetes mellitus alone could have eliminated significant associations between obesity measure quintiles and ischemic stroke incidence,” the study authors point out.
Given the strong association between obesity and hypertension and other risk factors, including diabetes, they conclude that “obesity would be an important target for prevention of ischemic stroke.”
There is still a debate in the scientific community about which measure of obesity is most accurate. According to Dr. Yatsuya, BMI might be the easiest to obtain because a clinician just needs to know height and weight. Getting an accurate waist circumference and WHR may be challenging in obese patients, he said.
Using proportion attributable fraction values — the proportion that might be prevented by eliminating a risk factor — the researchers estimated that 18% to 20% of ischemic stroke may be accounted for by a BMI of 28 or more.
Stroke is the third leading cause of death and the leading cause of serious long-term disability in the United States.
Reinforces Obesity Importance
Reached for a comment, Ralph L. Sacco, MS, MD, professor and chair of neurology at the University of Miami in Florida and a member of the American Academy of Neurology, said the study is a “well-done, large, prospective study” that reinforces the importance of obesity as a risk factor not just for heart attack but also for stroke.
One of Dr. Sacco’s own studies, using data from the Northern Manhattan Stroke Study and published in 2003, showed an elevated stroke risk for both blacks and whites using WHR but not BMI (Suk SH, et al. Stroke 2003;34:1586-1592).
“This [new] study is much larger and has much more statistical power and was able to show BMI, as well as waist circumference and waist-to-hip ratio, all great markers for obesity, increased risk in both blacks and whites,” he notes.
Another report from the Northern Manhattan Cohort Study by Dr. Sacco and colleagues, published last year in the Journal of the American College of Cardiology, showed that an elevated waist circumference in both men and women and across whites, blacks, and Hispanics increased the risk not only for stroke but also for myocardial infarction and vascular death (Sacco RL, et al. J Am Coll Cardiol. 2009;54:2303-2311).
All this research is important because obesity is becoming “an alarming trend,” with Americans being less physically active and following unhealthy diets, said Dr. Sacco. “We’re concerned about a higher proportion of the US population that will be obese and at higher risk for high blood pressure, diabetes, and now definitely stroke.”
Dr. Sacco also noted that in this new study, the stroke risk drops after controlling for other factors. “To us, this just means that some of the effect that obesity has is through high blood pressure, diabetes, and other vascular risk factors.”
The ARIC Study was funded by the National Heart, Lung, and Blood Institute. The authors have disclosed no relevant financial relationships.
Stroke. Published online January 21, 2010.