Obesity

MAUI, HAWAII – Specialists who study obesity and embrace the increasing number of treatment options are poised to lead the way in stemming the disease, which Andres Acosta, MD, PhD, calls the “epidemic of the century.”

“Gastroenterologists are in the first line of treatment for obesity management,” said Acosta, who runs the precision medicine for obesity lab at the Mayo Clinic in Rochester, Minn.

“Patients with obesity are already in our clinics,” he said in an interview. And too many physicians “are ignoring the problem.”

The vast majority of people with acid reflux have obesity, as do those with nonalcoholic fatty liver disease, he explained. “By targeting those two areas, we’ll be targeting more than 50% of our patients.” Recurring polyps and colon cancer are also often associated with obesity, he said.

Because of their skill as endoscopists, internists, and nutrition experts, gastroenterologists are uniquely positioned to care for obesity, said Acosta, who is first author of a white paper – Practice Guide on Obesity and Weight Management, Education and Resources – developed by the American Gastroenterological Association with input from nine medical societies.
 

More treatment choices

Physicians heard an update on options available in the continuum of obesity care from Christopher Thompson, MD, director of endoscopy at Brigham and Women’s Hospital in Boston, at the Gastroenterology Updates IBD Liver Disease Conference 2020. He discussed the potential weight-loss range and safety profile of each.

Some medications result in a body-weight loss of 5%, whereas gastric bypass surgeries can result in a loss of up to 40%, he said in an interview. And weight loss is typically 10% with intragastric balloon, 15%-20% with aspiration therapies and with endoscopic suturing techniques, and 25%-30% with sleeve gastrectomy.

“It’s nice to be able to offer all of those to patients,” he said, adding that he wants to get the message across to hesitant physicians that obesity management “is not as difficult as they think.”

Physicians can be reluctant to address obesity because of the social stigma associated with excess weight and a discomfort in talking about it.

But “there are ways to open that conversation, and it needs to start happening more,” said Thompson, who pointed out that obesity is the underlying cause of many other illnesses, including diabetes and heart diseases.

And new strategies are in the offing, he explained. His team at Brigham is currently involved in clinical trials to test whether the diversion of food and bile to the lower part of the bowel will generate a metabolic signal that affects insulin resistance and weight, he reported.

They are also testing whether gastric procedures can be combined with small bowel procedures to achieve the weight loss seen with bariatric surgery.

As treatment options for obesity increase, precision medicine will help maximize their potential, said Acosta.
 

Precision medicine will amp up treatments

Acosta outlined the four categories that patients who are obese generally fall into: those with a “hungry brain,” who think they need to eat more than they do; those with a “hungry gut,” whose gut is not sending the proper signal to the brain that it is full; those with “emotional hunger”; and those with abnormal metabolism.

“For each of those, there are genetic circumstances, metabolism, a hormonal profile, as well as pathophysiologic aspects of obesity, that make these groups unique,” he said.

Deciding which patients should get which treatment is the next frontier, he explained. “For example, if you give an intragastric balloon to all comers, patients will lose about 12% of their body weight. But if you separate responders from nonresponders and you select the right intervention, you can achieve an 18% loss of body weight in the right responders.”

At Mayo, they are working on a blood test to break down phenotypes and identify who will respond best to which treatment, he reported. That could lead to a much more efficient use of scarce resources.

“At the same time, I hope that more insurance companies will cover more obesity treatments,” said Acosta.
 

This article first appeared on Medscape.com.

MAUI, HAWAII – Specialists who study obesity and embrace the increasing number of treatment options are poised to lead the way in stemming the disease, which Andres Acosta, MD, PhD, calls the “epidemic of the century.”

“Gastroenterologists are in the first line of treatment for obesity management,” said Acosta, who runs the precision medicine for obesity lab at the Mayo Clinic in Rochester, Minn.

“Patients with obesity are already in our clinics,” he said in an interview. And too many physicians “are ignoring the problem.”

The vast majority of people with acid reflux have obesity, as do those with nonalcoholic fatty liver disease, he explained. “By targeting those two areas, we’ll be targeting more than 50% of our patients.” Recurring polyps and colon cancer are also often associated with obesity, he said.

Because of their skill as endoscopists, internists, and nutrition experts, gastroenterologists are uniquely positioned to care for obesity, said Acosta, who is first author of a white paper – Practice Guide on Obesity and Weight Management, Education and Resources – developed by the American Gastroenterological Association with input from nine medical societies.
 

More treatment choices

Physicians heard an update on options available in the continuum of obesity care from Christopher Thompson, MD, director of endoscopy at Brigham and Women’s Hospital in Boston, at the Gastroenterology Updates IBD Liver Disease Conference 2020. He discussed the potential weight-loss range and safety profile of each.

Some medications result in a body-weight loss of 5%, whereas gastric bypass surgeries can result in a loss of up to 40%, he said in an interview. And weight loss is typically 10% with intragastric balloon, 15%-20% with aspiration therapies and with endoscopic suturing techniques, and 25%-30% with sleeve gastrectomy.

“It’s nice to be able to offer all of those to patients,” he said, adding that he wants to get the message across to hesitant physicians that obesity management “is not as difficult as they think.”

Physicians can be reluctant to address obesity because of the social stigma associated with excess weight and a discomfort in talking about it.

But “there are ways to open that conversation, and it needs to start happening more,” said Thompson, who pointed out that obesity is the underlying cause of many other illnesses, including diabetes and heart diseases.

And new strategies are in the offing, he explained. His team at Brigham is currently involved in clinical trials to test whether the diversion of food and bile to the lower part of the bowel will generate a metabolic signal that affects insulin resistance and weight, he reported.

They are also testing whether gastric procedures can be combined with small bowel procedures to achieve the weight loss seen with bariatric surgery.

As treatment options for obesity increase, precision medicine will help maximize their potential, said Acosta.
 

Precision medicine will amp up treatments

Acosta outlined the four categories that patients who are obese generally fall into: those with a “hungry brain,” who think they need to eat more than they do; those with a “hungry gut,” whose gut is not sending the proper signal to the brain that it is full; those with “emotional hunger”; and those with abnormal metabolism.

“For each of those, there are genetic circumstances, metabolism, a hormonal profile, as well as pathophysiologic aspects of obesity, that make these groups unique,” he said.

Deciding which patients should get which treatment is the next frontier, he explained. “For example, if you give an intragastric balloon to all comers, patients will lose about 12% of their body weight. But if you separate responders from nonresponders and you select the right intervention, you can achieve an 18% loss of body weight in the right responders.”

At Mayo, they are working on a blood test to break down phenotypes and identify who will respond best to which treatment, he reported. That could lead to a much more efficient use of scarce resources.

“At the same time, I hope that more insurance companies will cover more obesity treatments,” said Acosta.
 

This article first appeared on Medscape.com.

MAUI, HAWAII – Specialists who study obesity and embrace the increasing number of treatment options are poised to lead the way in stemming the disease, which Andres Acosta, MD, PhD, calls the “epidemic of the century.”

“Gastroenterologists are in the first line of treatment for obesity management,” said Acosta, who runs the precision medicine for obesity lab at the Mayo Clinic in Rochester, Minn.

“Patients with obesity are already in our clinics,” he said in an interview. And too many physicians “are ignoring the problem.”

The vast majority of people with acid reflux have obesity, as do those with nonalcoholic fatty liver disease, he explained. “By targeting those two areas, we’ll be targeting more than 50% of our patients.” Recurring polyps and colon cancer are also often associated with obesity, he said.

Because of their skill as endoscopists, internists, and nutrition experts, gastroenterologists are uniquely positioned to care for obesity, said Acosta, who is first author of a white paper – Practice Guide on Obesity and Weight Management, Education and Resources – developed by the American Gastroenterological Association with input from nine medical societies.
 

More treatment choices

Physicians heard an update on options available in the continuum of obesity care from Christopher Thompson, MD, director of endoscopy at Brigham and Women’s Hospital in Boston, at the Gastroenterology Updates IBD Liver Disease Conference 2020. He discussed the potential weight-loss range and safety profile of each.

Some medications result in a body-weight loss of 5%, whereas gastric bypass surgeries can result in a loss of up to 40%, he said in an interview. And weight loss is typically 10% with intragastric balloon, 15%-20% with aspiration therapies and with endoscopic suturing techniques, and 25%-30% with sleeve gastrectomy.

“It’s nice to be able to offer all of those to patients,” he said, adding that he wants to get the message across to hesitant physicians that obesity management “is not as difficult as they think.”

Physicians can be reluctant to address obesity because of the social stigma associated with excess weight and a discomfort in talking about it.

But “there are ways to open that conversation, and it needs to start happening more,” said Thompson, who pointed out that obesity is the underlying cause of many other illnesses, including diabetes and heart diseases.

And new strategies are in the offing, he explained. His team at Brigham is currently involved in clinical trials to test whether the diversion of food and bile to the lower part of the bowel will generate a metabolic signal that affects insulin resistance and weight, he reported.

They are also testing whether gastric procedures can be combined with small bowel procedures to achieve the weight loss seen with bariatric surgery.

As treatment options for obesity increase, precision medicine will help maximize their potential, said Acosta.
 

Precision medicine will amp up treatments

Acosta outlined the four categories that patients who are obese generally fall into: those with a “hungry brain,” who think they need to eat more than they do; those with a “hungry gut,” whose gut is not sending the proper signal to the brain that it is full; those with “emotional hunger”; and those with abnormal metabolism.

“For each of those, there are genetic circumstances, metabolism, a hormonal profile, as well as pathophysiologic aspects of obesity, that make these groups unique,” he said.

Deciding which patients should get which treatment is the next frontier, he explained. “For example, if you give an intragastric balloon to all comers, patients will lose about 12% of their body weight. But if you separate responders from nonresponders and you select the right intervention, you can achieve an 18% loss of body weight in the right responders.”

At Mayo, they are working on a blood test to break down phenotypes and identify who will respond best to which treatment, he reported. That could lead to a much more efficient use of scarce resources.

“At the same time, I hope that more insurance companies will cover more obesity treatments,” said Acosta.
 

This article first appeared on Medscape.com.

Obesity during adolescence is associated with increased midlife cancer risk, according to findings from a large population-based cohort of Israeli teens examined between 1967 and 2010.

The association, which was stronger in individuals in the later period of the cohort than in those in the earlier years, suggests that the burden of obesity-related cancers might increase over time, given the increasing prevalence of adolescent obesity, wrote Ariel Furer, MD, of Israel Defense Forces Medical Corps, Ramat Gan, and colleagues. Their report is in The Lancet.

Obesity is a known causal factor for several types of cancer, but most studies have looked at middle-age or older individuals and had relatively short follow-up, and period effects are rarely assessed, the investigators said, noting that “the attributable burden of obesity-related cancer was previously calculated with an unverified assumption that the association remained unchanged over time.

“In contrast to this paucity of knowledge, the prevalence of youth obesity – particularly severe obesity – has increased worldwide, which parallels the rise in youth cancer incidence,” they wrote.

To address this paucity of data, the researchers reviewed medical and sociodemographic data for adolescents who were assessed at age 17 years for medical eligibility for mandatory military service, and linked that information with data from the National Cancer Registry to create a unified file. The primary study outcome was any cancer diagnosis between Jan. 1, 1967, and Dec. 31, 2012, and a secondary endpoint was all-cause mortality through Dec. 31, 2017, among those who developed cancer.

Among nearly 2.3 million participating adolescents who were evaluated for associations between body mass index at age 17 years and later cancer incidence, 1,370,020 were men with more than 29.5 million person-years of follow-up, and 928,110 were women with more than 18 million person-years of follow-up. The numbers of incident cancer cases in the men and women were 26,353 and 29,488, and the mean ages at diagnosis were 43.2 and 40.0 years, respectively, the investigators reported (Lancet. 2020 Feb 3. doi: 10.1016/S2213-8587(20)30019-X).

Adolescent obesity in men was significantly associated with midlife cancer incidence (hazard ratio, 1.26), but in women, no association was seen due to the previously reported inverse associations between obesity and cervical and breast cancers, they said.

However, when those cancers were excluded for women, the adjusted hazard ratio was similar to that for men (HR, 1.27).

Cancer incidence in both men and women increased gradually across BMI percentiles, and for both sexes, overweight BMI was associated with an increased cancer risk after 10 years of follow-up (HR, 1.14 for men, 1.22 for women after exclusion of cervical and breast cancer). Therefore, in some cases the increased cancer risk in those who were overweight as teens was evident before age 30 years, the authors noted.

Further, BMI was positively associated with greater mortality risk. For men, 5-year survival rates were 75.2% in those with adolescent BMI in the 5th-49th percentile, compared with 72.2% in those with BMI in the obesity range (95th percentile or greater), and the corresponding rates in women were 89.3% and 83.1% (HR, 1.33 and 1.89, respectively).

Of note, the investigators identified a period effect. That is, after stratification by enrollment period/cancer recording period (1967-1981/1982-1996 vs. 1982-1996/1997-2011), a stronger association was noted in individuals who entered the study during the later period, compared with those who entered in the early period (HR, 1.36 vs. 1.13; adjusted HR, 1.11 vs. 1.07 per 5 kg/m²). Possible mechanisms for this finding include environmental and nutritional factors, increased use of medical services, and changes in early cancer screening techniques, but further study is needed to verify the trend and “refine the exact nature of carcinogenic elements, compared with earlier periods,” they said.

Also of note, some cancers that were not associated with BMI in the early period, including stomach cancer, non-Hodgkin lymphoma, thyroid cancer, and colorectal and oral cavity cancers, became significantly associated with BMI in the late period.

“The projected population attributable risk percentage, using 2017 prevalence data of high BMI, was 5.1% for any cancer in men and 5.7% for cancers other than breast and cervical in women,” the researchers wrote, noting that this “is probably an underestimation, given the accentuation of the BMI-cancer association and the rapid increase in adolescent obesity prevalence within the past decade in Israel and worldwide.”

In an accompanying editorial, the journal editors noted that the findings by Dr. Furer and colleagues highlight the need to tackle obesity early in life and the need for obesity prevention strategies to reduce cancer incidence and mortality for those cancers that can be prevented by lifestyle modifications. They added, however, that care would be needed to avoid stigmatizing those with obesity, as obesity itself is a “multifactorial condition driven by social injustice and health inequalities” that most often affect those who are least able to implement lifestyle change (Lancet. 2020 Feb 3. doi: 10.106/S2213-8587(20)30031-0).

They also emphasized that the links between obesity and cancer, like those between obesity and other diseases such as diabetes, underscore the fact that noncommunicable diseases do not exist in isolation, and that tackling them requires bold action, a consolidated approach, and elimination of the environmental and social factors driving the epidemic.

The study was limited by a number of factors, including the lack of data on lifestyle factors, underrepresentation of some ethnicities, and lack of data on BMI and medical comorbidities at the time of cancer diagnosis. However, strengths of the study include the systematic data collection, narrow range of age at study entry, strict control of coexisting conditions, and high statistical power, which strengthen the generalizability of the results, the investigators said, concluding, therefore, that “[c]urrent trends of rising BMI among adolescents could constitute an important intervention target for cancer prevention.”

The authors reported having no disclosures.

sworcester@mdedge.com

SOURCE: Furer A et al. Lancet Diabetes Endocrinol. 2020 Feb 3. doi: 10.1016/S2213-8587(20)30019-X.

Obesity during adolescence is associated with increased midlife cancer risk, according to findings from a large population-based cohort of Israeli teens examined between 1967 and 2010.

The association, which was stronger in individuals in the later period of the cohort than in those in the earlier years, suggests that the burden of obesity-related cancers might increase over time, given the increasing prevalence of adolescent obesity, wrote Ariel Furer, MD, of Israel Defense Forces Medical Corps, Ramat Gan, and colleagues. Their report is in The Lancet.

Obesity is a known causal factor for several types of cancer, but most studies have looked at middle-age or older individuals and had relatively short follow-up, and period effects are rarely assessed, the investigators said, noting that “the attributable burden of obesity-related cancer was previously calculated with an unverified assumption that the association remained unchanged over time.

“In contrast to this paucity of knowledge, the prevalence of youth obesity – particularly severe obesity – has increased worldwide, which parallels the rise in youth cancer incidence,” they wrote.

To address this paucity of data, the researchers reviewed medical and sociodemographic data for adolescents who were assessed at age 17 years for medical eligibility for mandatory military service, and linked that information with data from the National Cancer Registry to create a unified file. The primary study outcome was any cancer diagnosis between Jan. 1, 1967, and Dec. 31, 2012, and a secondary endpoint was all-cause mortality through Dec. 31, 2017, among those who developed cancer.

Among nearly 2.3 million participating adolescents who were evaluated for associations between body mass index at age 17 years and later cancer incidence, 1,370,020 were men with more than 29.5 million person-years of follow-up, and 928,110 were women with more than 18 million person-years of follow-up. The numbers of incident cancer cases in the men and women were 26,353 and 29,488, and the mean ages at diagnosis were 43.2 and 40.0 years, respectively, the investigators reported (Lancet. 2020 Feb 3. doi: 10.1016/S2213-8587(20)30019-X).

Adolescent obesity in men was significantly associated with midlife cancer incidence (hazard ratio, 1.26), but in women, no association was seen due to the previously reported inverse associations between obesity and cervical and breast cancers, they said.

However, when those cancers were excluded for women, the adjusted hazard ratio was similar to that for men (HR, 1.27).

Cancer incidence in both men and women increased gradually across BMI percentiles, and for both sexes, overweight BMI was associated with an increased cancer risk after 10 years of follow-up (HR, 1.14 for men, 1.22 for women after exclusion of cervical and breast cancer). Therefore, in some cases the increased cancer risk in those who were overweight as teens was evident before age 30 years, the authors noted.

Further, BMI was positively associated with greater mortality risk. For men, 5-year survival rates were 75.2% in those with adolescent BMI in the 5th-49th percentile, compared with 72.2% in those with BMI in the obesity range (95th percentile or greater), and the corresponding rates in women were 89.3% and 83.1% (HR, 1.33 and 1.89, respectively).

Of note, the investigators identified a period effect. That is, after stratification by enrollment period/cancer recording period (1967-1981/1982-1996 vs. 1982-1996/1997-2011), a stronger association was noted in individuals who entered the study during the later period, compared with those who entered in the early period (HR, 1.36 vs. 1.13; adjusted HR, 1.11 vs. 1.07 per 5 kg/m²). Possible mechanisms for this finding include environmental and nutritional factors, increased use of medical services, and changes in early cancer screening techniques, but further study is needed to verify the trend and “refine the exact nature of carcinogenic elements, compared with earlier periods,” they said.

Also of note, some cancers that were not associated with BMI in the early period, including stomach cancer, non-Hodgkin lymphoma, thyroid cancer, and colorectal and oral cavity cancers, became significantly associated with BMI in the late period.

“The projected population attributable risk percentage, using 2017 prevalence data of high BMI, was 5.1% for any cancer in men and 5.7% for cancers other than breast and cervical in women,” the researchers wrote, noting that this “is probably an underestimation, given the accentuation of the BMI-cancer association and the rapid increase in adolescent obesity prevalence within the past decade in Israel and worldwide.”

In an accompanying editorial, the journal editors noted that the findings by Dr. Furer and colleagues highlight the need to tackle obesity early in life and the need for obesity prevention strategies to reduce cancer incidence and mortality for those cancers that can be prevented by lifestyle modifications. They added, however, that care would be needed to avoid stigmatizing those with obesity, as obesity itself is a “multifactorial condition driven by social injustice and health inequalities” that most often affect those who are least able to implement lifestyle change (Lancet. 2020 Feb 3. doi: 10.106/S2213-8587(20)30031-0).

They also emphasized that the links between obesity and cancer, like those between obesity and other diseases such as diabetes, underscore the fact that noncommunicable diseases do not exist in isolation, and that tackling them requires bold action, a consolidated approach, and elimination of the environmental and social factors driving the epidemic.

The study was limited by a number of factors, including the lack of data on lifestyle factors, underrepresentation of some ethnicities, and lack of data on BMI and medical comorbidities at the time of cancer diagnosis. However, strengths of the study include the systematic data collection, narrow range of age at study entry, strict control of coexisting conditions, and high statistical power, which strengthen the generalizability of the results, the investigators said, concluding, therefore, that “[c]urrent trends of rising BMI among adolescents could constitute an important intervention target for cancer prevention.”

The authors reported having no disclosures.

sworcester@mdedge.com

SOURCE: Furer A et al. Lancet Diabetes Endocrinol. 2020 Feb 3. doi: 10.1016/S2213-8587(20)30019-X.

Obesity during adolescence is associated with increased midlife cancer risk, according to findings from a large population-based cohort of Israeli teens examined between 1967 and 2010.

The association, which was stronger in individuals in the later period of the cohort than in those in the earlier years, suggests that the burden of obesity-related cancers might increase over time, given the increasing prevalence of adolescent obesity, wrote Ariel Furer, MD, of Israel Defense Forces Medical Corps, Ramat Gan, and colleagues. Their report is in The Lancet.

Obesity is a known causal factor for several types of cancer, but most studies have looked at middle-age or older individuals and had relatively short follow-up, and period effects are rarely assessed, the investigators said, noting that “the attributable burden of obesity-related cancer was previously calculated with an unverified assumption that the association remained unchanged over time.

“In contrast to this paucity of knowledge, the prevalence of youth obesity – particularly severe obesity – has increased worldwide, which parallels the rise in youth cancer incidence,” they wrote.

To address this paucity of data, the researchers reviewed medical and sociodemographic data for adolescents who were assessed at age 17 years for medical eligibility for mandatory military service, and linked that information with data from the National Cancer Registry to create a unified file. The primary study outcome was any cancer diagnosis between Jan. 1, 1967, and Dec. 31, 2012, and a secondary endpoint was all-cause mortality through Dec. 31, 2017, among those who developed cancer.

Among nearly 2.3 million participating adolescents who were evaluated for associations between body mass index at age 17 years and later cancer incidence, 1,370,020 were men with more than 29.5 million person-years of follow-up, and 928,110 were women with more than 18 million person-years of follow-up. The numbers of incident cancer cases in the men and women were 26,353 and 29,488, and the mean ages at diagnosis were 43.2 and 40.0 years, respectively, the investigators reported (Lancet. 2020 Feb 3. doi: 10.1016/S2213-8587(20)30019-X).

Adolescent obesity in men was significantly associated with midlife cancer incidence (hazard ratio, 1.26), but in women, no association was seen due to the previously reported inverse associations between obesity and cervical and breast cancers, they said.

However, when those cancers were excluded for women, the adjusted hazard ratio was similar to that for men (HR, 1.27).

Cancer incidence in both men and women increased gradually across BMI percentiles, and for both sexes, overweight BMI was associated with an increased cancer risk after 10 years of follow-up (HR, 1.14 for men, 1.22 for women after exclusion of cervical and breast cancer). Therefore, in some cases the increased cancer risk in those who were overweight as teens was evident before age 30 years, the authors noted.

Further, BMI was positively associated with greater mortality risk. For men, 5-year survival rates were 75.2% in those with adolescent BMI in the 5th-49th percentile, compared with 72.2% in those with BMI in the obesity range (95th percentile or greater), and the corresponding rates in women were 89.3% and 83.1% (HR, 1.33 and 1.89, respectively).

Of note, the investigators identified a period effect. That is, after stratification by enrollment period/cancer recording period (1967-1981/1982-1996 vs. 1982-1996/1997-2011), a stronger association was noted in individuals who entered the study during the later period, compared with those who entered in the early period (HR, 1.36 vs. 1.13; adjusted HR, 1.11 vs. 1.07 per 5 kg/m²). Possible mechanisms for this finding include environmental and nutritional factors, increased use of medical services, and changes in early cancer screening techniques, but further study is needed to verify the trend and “refine the exact nature of carcinogenic elements, compared with earlier periods,” they said.

Also of note, some cancers that were not associated with BMI in the early period, including stomach cancer, non-Hodgkin lymphoma, thyroid cancer, and colorectal and oral cavity cancers, became significantly associated with BMI in the late period.

“The projected population attributable risk percentage, using 2017 prevalence data of high BMI, was 5.1% for any cancer in men and 5.7% for cancers other than breast and cervical in women,” the researchers wrote, noting that this “is probably an underestimation, given the accentuation of the BMI-cancer association and the rapid increase in adolescent obesity prevalence within the past decade in Israel and worldwide.”

In an accompanying editorial, the journal editors noted that the findings by Dr. Furer and colleagues highlight the need to tackle obesity early in life and the need for obesity prevention strategies to reduce cancer incidence and mortality for those cancers that can be prevented by lifestyle modifications. They added, however, that care would be needed to avoid stigmatizing those with obesity, as obesity itself is a “multifactorial condition driven by social injustice and health inequalities” that most often affect those who are least able to implement lifestyle change (Lancet. 2020 Feb 3. doi: 10.106/S2213-8587(20)30031-0).

They also emphasized that the links between obesity and cancer, like those between obesity and other diseases such as diabetes, underscore the fact that noncommunicable diseases do not exist in isolation, and that tackling them requires bold action, a consolidated approach, and elimination of the environmental and social factors driving the epidemic.

The study was limited by a number of factors, including the lack of data on lifestyle factors, underrepresentation of some ethnicities, and lack of data on BMI and medical comorbidities at the time of cancer diagnosis. However, strengths of the study include the systematic data collection, narrow range of age at study entry, strict control of coexisting conditions, and high statistical power, which strengthen the generalizability of the results, the investigators said, concluding, therefore, that “[c]urrent trends of rising BMI among adolescents could constitute an important intervention target for cancer prevention.”

The authors reported having no disclosures.

sworcester@mdedge.com

SOURCE: Furer A et al. Lancet Diabetes Endocrinol. 2020 Feb 3. doi: 10.1016/S2213-8587(20)30019-X.

The Food and Drug Administration has approved Agile Therapeutics’ levonorgestrel and ethinyl estradiol transdermal system (Twirla) for contraception in women whose body mass index is less than 30 kg/m² and for whom a combined hormonal contraceptive is appropriate.

Applied weekly to the abdomen, buttock, or upper torso (excluding the breasts), Twirla delivers a 30-mcg daily dose of ethinyl estradiol and 120-mcg daily dose of levonorgestrel.

“Twirla is an important addition to available hormonal contraceptive methods, allowing prescribers to now offer appropriate U.S. women a weekly transdermal option that delivers estrogen levels in line with labeled doses of many commonly prescribed oral contraceptives, David Portman, MD, an obstetrician/gynecologist in Columbus, Ohio, and a primary investigator of the SECURE trial, said in a news release issued by the company.

Twirla was evaluated in “a diverse population providing important data to prescribers and to women seeking contraception. It is vital to expand the full range of contraceptive methods and inform the choices that fit an individual’s family planning needs and lifestyle,” Dr. Portman added.

As part of approval, the FDA will require Agile Therapeutics to conduct a long-term, prospective, observational postmarketing study to assess risks for venous thromboembolism and arterial thromboembolism in new users of Twirla, compared with new users of other combined hormonal contraceptives.

Twirla is contraindicated in women at high risk for arterial or venous thrombotic disease, including women with a BMI equal to or greater than 30 kg/m²; women who have headaches with focal neurologic symptoms or migraine with aura; and women older than 35 years who have any migraine headache.

Twirla also should be avoided in women who have liver tumors, acute viral hepatitis, decompensated cirrhosis, liver disease, or undiagnosed abnormal uterine bleeding. It also should be avoided during pregnancy; in women who currently have or who have history of breast cancer or other estrogen- or progestin-sensitive cancer; in women who are hypersensitivity to any components of Twirla; and in women who use hepatitis C drug combinations containing ombitasvir/paraparesis/ritonavir, with or without dasabuvir.

Because cigarette smoking increases the risk for serious cardiovascular events from combined hormonal contraceptive use, Twirla also is contraindicated in women older than 35 who smoke.

Twirla will contain a boxed warning that will include these risks about cigarette smoking and the serious cardiovascular events, and it will stipulate that Twirla is contraindicated in women with a BMI greater than 30 kg/m².

This article first appeared on Medscape.com.

The Food and Drug Administration has approved Agile Therapeutics’ levonorgestrel and ethinyl estradiol transdermal system (Twirla) for contraception in women whose body mass index is less than 30 kg/m² and for whom a combined hormonal contraceptive is appropriate.

Applied weekly to the abdomen, buttock, or upper torso (excluding the breasts), Twirla delivers a 30-mcg daily dose of ethinyl estradiol and 120-mcg daily dose of levonorgestrel.

“Twirla is an important addition to available hormonal contraceptive methods, allowing prescribers to now offer appropriate U.S. women a weekly transdermal option that delivers estrogen levels in line with labeled doses of many commonly prescribed oral contraceptives, David Portman, MD, an obstetrician/gynecologist in Columbus, Ohio, and a primary investigator of the SECURE trial, said in a news release issued by the company.

Twirla was evaluated in “a diverse population providing important data to prescribers and to women seeking contraception. It is vital to expand the full range of contraceptive methods and inform the choices that fit an individual’s family planning needs and lifestyle,” Dr. Portman added.

As part of approval, the FDA will require Agile Therapeutics to conduct a long-term, prospective, observational postmarketing study to assess risks for venous thromboembolism and arterial thromboembolism in new users of Twirla, compared with new users of other combined hormonal contraceptives.

Twirla is contraindicated in women at high risk for arterial or venous thrombotic disease, including women with a BMI equal to or greater than 30 kg/m²; women who have headaches with focal neurologic symptoms or migraine with aura; and women older than 35 years who have any migraine headache.

Twirla also should be avoided in women who have liver tumors, acute viral hepatitis, decompensated cirrhosis, liver disease, or undiagnosed abnormal uterine bleeding. It also should be avoided during pregnancy; in women who currently have or who have history of breast cancer or other estrogen- or progestin-sensitive cancer; in women who are hypersensitivity to any components of Twirla; and in women who use hepatitis C drug combinations containing ombitasvir/paraparesis/ritonavir, with or without dasabuvir.

Because cigarette smoking increases the risk for serious cardiovascular events from combined hormonal contraceptive use, Twirla also is contraindicated in women older than 35 who smoke.

Twirla will contain a boxed warning that will include these risks about cigarette smoking and the serious cardiovascular events, and it will stipulate that Twirla is contraindicated in women with a BMI greater than 30 kg/m².

This article first appeared on Medscape.com.

The Food and Drug Administration has approved Agile Therapeutics’ levonorgestrel and ethinyl estradiol transdermal system (Twirla) for contraception in women whose body mass index is less than 30 kg/m² and for whom a combined hormonal contraceptive is appropriate.

Applied weekly to the abdomen, buttock, or upper torso (excluding the breasts), Twirla delivers a 30-mcg daily dose of ethinyl estradiol and 120-mcg daily dose of levonorgestrel.

“Twirla is an important addition to available hormonal contraceptive methods, allowing prescribers to now offer appropriate U.S. women a weekly transdermal option that delivers estrogen levels in line with labeled doses of many commonly prescribed oral contraceptives, David Portman, MD, an obstetrician/gynecologist in Columbus, Ohio, and a primary investigator of the SECURE trial, said in a news release issued by the company.

Twirla was evaluated in “a diverse population providing important data to prescribers and to women seeking contraception. It is vital to expand the full range of contraceptive methods and inform the choices that fit an individual’s family planning needs and lifestyle,” Dr. Portman added.

As part of approval, the FDA will require Agile Therapeutics to conduct a long-term, prospective, observational postmarketing study to assess risks for venous thromboembolism and arterial thromboembolism in new users of Twirla, compared with new users of other combined hormonal contraceptives.

Twirla is contraindicated in women at high risk for arterial or venous thrombotic disease, including women with a BMI equal to or greater than 30 kg/m²; women who have headaches with focal neurologic symptoms or migraine with aura; and women older than 35 years who have any migraine headache.

Twirla also should be avoided in women who have liver tumors, acute viral hepatitis, decompensated cirrhosis, liver disease, or undiagnosed abnormal uterine bleeding. It also should be avoided during pregnancy; in women who currently have or who have history of breast cancer or other estrogen- or progestin-sensitive cancer; in women who are hypersensitivity to any components of Twirla; and in women who use hepatitis C drug combinations containing ombitasvir/paraparesis/ritonavir, with or without dasabuvir.

Because cigarette smoking increases the risk for serious cardiovascular events from combined hormonal contraceptive use, Twirla also is contraindicated in women older than 35 who smoke.

Twirla will contain a boxed warning that will include these risks about cigarette smoking and the serious cardiovascular events, and it will stipulate that Twirla is contraindicated in women with a BMI greater than 30 kg/m².

This article first appeared on Medscape.com.

The Food and Drug Administration asked Eisai to voluntary withdraw the weight-loss drug lorcaserin (Belviq and Belviq XR) on Feb. 13 after a post-marketing trial with more than 12,000 subjects revealed an increased occurrence of cancer.

In a Drug Safety Communication, the agency said “health care professionals should stop prescribing and dispensing lorcaserin to patients. Contact patients currently taking lorcaserin, inform them of the increased occurrence of cancer seen in the clinical trial, and ask them to stop taking the medicine. Discuss alternative weight-loss medicines or strategies with your patients.”

Eisai is complying with the withdrawal request.

The decision is based on the agency’s review of the 5-year trial, which was designed to evaluate cardiac risk with the drug and ended in June 2018. In total, 7.7% of patients randomized to 10 mg lorcaserin twice daily were diagnosed with 520 primary cancers, compared with 7.1% of placebo subjects diagnosed with 470 cancers, over a median follow-up of 3 years and 3 months. There was one additional cancer observed for every 470 patients treated for 1 year.

“There was no apparent difference in the incidence of cancer over the initial months of treatment, but the imbalance increased with longer duration on lorcaserin,” FDA said. Pancreatic, colorectal, and lung cancers were among those diagnosed.

In short, “we believe that the risks of lorcaserin outweigh its benefits based on our completed review of” the data, the agency said. The FDA is not recommending special cancer screenings for patients who have taken lorcaserin.

The action follows an FDA alert in January about a possible elevated cancer risk based on its preliminary analysis of the study.

Patients were also advised Feb. 13 to stop taking the drug and talk to their providers about alternative weight-loss medications and weight-management programs.

They were also told to dispose of the pills at a drug take-back location if available, but if not, to mix them with an “unappealing substance” such as dirt, cat litter, or used coffee grounds; seal them in plastic bag; and put them in the trash.

aotto@mdedge.com

The Food and Drug Administration asked Eisai to voluntary withdraw the weight-loss drug lorcaserin (Belviq and Belviq XR) on Feb. 13 after a post-marketing trial with more than 12,000 subjects revealed an increased occurrence of cancer.

In a Drug Safety Communication, the agency said “health care professionals should stop prescribing and dispensing lorcaserin to patients. Contact patients currently taking lorcaserin, inform them of the increased occurrence of cancer seen in the clinical trial, and ask them to stop taking the medicine. Discuss alternative weight-loss medicines or strategies with your patients.”

Eisai is complying with the withdrawal request.

The decision is based on the agency’s review of the 5-year trial, which was designed to evaluate cardiac risk with the drug and ended in June 2018. In total, 7.7% of patients randomized to 10 mg lorcaserin twice daily were diagnosed with 520 primary cancers, compared with 7.1% of placebo subjects diagnosed with 470 cancers, over a median follow-up of 3 years and 3 months. There was one additional cancer observed for every 470 patients treated for 1 year.

“There was no apparent difference in the incidence of cancer over the initial months of treatment, but the imbalance increased with longer duration on lorcaserin,” FDA said. Pancreatic, colorectal, and lung cancers were among those diagnosed.

In short, “we believe that the risks of lorcaserin outweigh its benefits based on our completed review of” the data, the agency said. The FDA is not recommending special cancer screenings for patients who have taken lorcaserin.

The action follows an FDA alert in January about a possible elevated cancer risk based on its preliminary analysis of the study.

Patients were also advised Feb. 13 to stop taking the drug and talk to their providers about alternative weight-loss medications and weight-management programs.

They were also told to dispose of the pills at a drug take-back location if available, but if not, to mix them with an “unappealing substance” such as dirt, cat litter, or used coffee grounds; seal them in plastic bag; and put them in the trash.

aotto@mdedge.com

The Food and Drug Administration asked Eisai to voluntary withdraw the weight-loss drug lorcaserin (Belviq and Belviq XR) on Feb. 13 after a post-marketing trial with more than 12,000 subjects revealed an increased occurrence of cancer.

In a Drug Safety Communication, the agency said “health care professionals should stop prescribing and dispensing lorcaserin to patients. Contact patients currently taking lorcaserin, inform them of the increased occurrence of cancer seen in the clinical trial, and ask them to stop taking the medicine. Discuss alternative weight-loss medicines or strategies with your patients.”

Eisai is complying with the withdrawal request.

The decision is based on the agency’s review of the 5-year trial, which was designed to evaluate cardiac risk with the drug and ended in June 2018. In total, 7.7% of patients randomized to 10 mg lorcaserin twice daily were diagnosed with 520 primary cancers, compared with 7.1% of placebo subjects diagnosed with 470 cancers, over a median follow-up of 3 years and 3 months. There was one additional cancer observed for every 470 patients treated for 1 year.

“There was no apparent difference in the incidence of cancer over the initial months of treatment, but the imbalance increased with longer duration on lorcaserin,” FDA said. Pancreatic, colorectal, and lung cancers were among those diagnosed.

In short, “we believe that the risks of lorcaserin outweigh its benefits based on our completed review of” the data, the agency said. The FDA is not recommending special cancer screenings for patients who have taken lorcaserin.

The action follows an FDA alert in January about a possible elevated cancer risk based on its preliminary analysis of the study.

Patients were also advised Feb. 13 to stop taking the drug and talk to their providers about alternative weight-loss medications and weight-management programs.

They were also told to dispose of the pills at a drug take-back location if available, but if not, to mix them with an “unappealing substance” such as dirt, cat litter, or used coffee grounds; seal them in plastic bag; and put them in the trash.

aotto@mdedge.com

NEW ORLEANS – Weight-based harassment and bias is extremely prevalent throughout society and in doctors’ own offices, so be aware of ways to address it and support your patients regardless of weight.

Rebecca Puhl, PhD, a deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, said that weight-based discrimination can occur whatever a person’s size or body shape, but it’s most often targeted at youth who are overweight or obese.

These children and teens commonly face teasing, harassment, cyberbullying, physical aggression, and social bullying from peers, coaches, teachers, and even parents, Dr. Puhl told attendees at the annual meeting of the American Academy of Pediatrics.

Common beliefs about overweight people – that they have little self discipline or poor eating and activity habits – only perpetuate stereotypes, she said. Common stereotypes are that people with obesity are noncompliant, lazy, sloppy, unsuccessful, unintelligent, dishonest, and awkward.

And health professionals of every type have been found to harbor these biases. In one study of more than 4,000 first-year medical students, well over half the respondents revealed explicit (74%) and implicit (67%) weight bias (Obesity. 2014 Apr;22[4]:1201-8). The study also found that explicit weight bias was stronger than explicit bias against blacks, Hispanics, LGBTQ people, and poor people.
 

Know the effects of weight stigma

Far from a minor issue, the discrimination that begins in childhood against those who are overweight can have a long-lasting impact on their future prospects and mental health. Being overweight is overwhelmingly cited as the most common reason for bullying (Pediatr Obes. 2016 Aug;11[4]:241-50). Dr. Puhl described to attendees how weight bias shifts throughout a lifetime, beginning as early as preschool. In childhood, the stereotypes about being overweight worsen, and the teasing and bullying increase. By adolescence, this treatment affects teens’ psychological, social, and physical well-being. It then translates in adulthood into reduced opportunities in employment and education, and poorer access and treatment in health care.

The mental distress caused by weight bullying often takes the form of depression, anxiety, and substance use, Dr. Puhl said, and children’s academic success can be hampered by bullying about their weight. One study found a higher risk of poor grades and school avoidance with each additional teasing incident (J Youth Adolesc. 2012 Jan;41[1]:27-40).

Weight stigma also can contribute to more weight gain, obesity, and lower physical activity levels. Maladaptive eating behaviors can result from weight stigmatization as well: binge eating, emotional eating, increased consumption in general, and other eating disorders. Severe binge eating is 80% more likely among teens who are bullied about their weight, Dr. Puhl said, and the risk increases with increased frequency and types of bullying.

Children who are teased about their weight often become less willing to engage in physical activity, she noted. They may skip gym class, feel less competent about physical activity, and end up enjoying sports participation less.

Further, sexual- and gender-minority youth report high rates of weight-related teasing from friends and family regardless of their body mass index (BMI) percentile, Dr. Puhl emphasized. Researchers have found bullying about weight in this population linked to dieting, difficulty sleeping, high stress levels, binge drinking, smoking, and marijuana use.
 

Know how to combat weight bias

Dr. Puhl described strategies for reducing weight bias based on clinical practice recommendations in the American Academy of Pediatrics’ policy statement entitled “Stigma Experienced by Children and Adolescents With Obesity” (Pediatrics. 2017 Dec;140[6]:e20173034).

Be aware. Consider how personal assumptions and attitudes about weight can affect your body language, tone of voice, facial expression, gestures, eye contact (or lack thereof), and spatial distance from the patient.

Recognizing the biological, genetic, and environmental causes of obesity can reduce stigma and improve understanding of the complexity of obesity etiology. It’s also important that you help parents understand this complexity and the negative impact of weight stigma.

Consider language and word choice. “Carefully consider language that might unintentionally communicate bias, blame, or negative judgment,” Dr. Puhl told attendees. “Use language that is supportive and empowering.”

Terms such as “unhealthy weight” and “high BMI” are less stigmatizing than “fat” and “morbidly obese” to parents, she said, and research has found nearly a quarter of parents would avoid future doctor appointments if their child’s doctor used stigmatizing terms to discuss weight (Pediatrics. 2011 Oct;128[4]:e786-93).

Teens themselves may have diverse preferences for the language used. Start by asking: “Could we talk about your weight today?” and then follow up by directly asking, “what words would you feel most comfortable with as we talk about your weight?”

Person-first language – such as “person with obesity” instead of “obese person” also is important to reducing stigma, she said.

It’s normal for you to feel uneasy about bringing up weight with patients, so Dr. Puhl recommended you practice dialogue out loud.

“Acknowledge your strengths,” she said. “You already have the skills and experience of engaging in difficult conversations with patients and families on a range of other health issues,” so apply that in this context as well.

Screen for negative experiences that could indicate weight-based bullying. These could include teasing and bullying, low self-esteem, poor school performance, depression, and anxiety.

“Remember that weight-based victimization can occur at diverse body sizes, not just in youth with obesity,” Dr. Puhl said. If you discover your patient is experiencing weight-related bullying, determine whether they have a support system in place and whether a mental health referral is appropriate. Provide or refer for behavior change counseling with motivational interviewing and patient-centered, empathic approaches. Parents should be aware of the issue and should contact the child’s teachers and school administration to help address it.

But before you do that, keep in mind that it’s not just peers doing the bullying. According to a study of teens with obesity enrolled in a national weight-loss camp, 37% of teen participants in 2012 said that their parents bully them (Pediatrics. 2013 Jan;131[1]:e1-9).

You should assess whether family interactions or the parents’ own history with weight is involved. If parents make disparaging comments about their child’s weight, “use this as an opportunity to model appropriate language and educate parents about weight bias,” Dr. Puhl said.

It’s also important to realize that parents themselves often are frustrated, so critical comments about their language or approach can backfire, she warned. Instead, help parents understand how to create a home setting that encourages healthy food choices, praises children for healthy decision making, and models positive health behaviors. It is key for them to focus on improving their children’s health behaviors rather than focusing on weight.

And before you contact the school, remember teachers also are common perpetrators of weight stigma, Dr. Puhl noted. She gave as an example a study in which investigators assessed 133 teachers’ perceptions of middle or high school students’ abilities based on photos that had been digitally altered to show each girl both as average weight or as overweight. Each photo was associated with an essay specifically chosen because it was neither particularly good nor bad (Brit J Educ Psychol. 2019 Oct 26. doi: 10.1111/bjep.12322). The teachers judged the essays believed to be submitted by overweight girls to be “similar in structural quality,” but they gave the overweight girls lower grades than the average-weight girls. They also indicated that they considered the overweight girls “put forth more effort, needed more remedial assistance, and had lower overall grades in school.” The teachers also rated other teachers’ weight bias to be at a low level, and their own weight bias to be “significantly lower” than the others.

Assess your clinical environment. Be aware of your clinical environment and whether it meets the needs of youth with diverse body sizes. That includes having a range of sturdy armless seating options and adequately sized doorways, hallways, and restrooms. You also should have beds, wheelchairs, and exam tables with adequate weight capacity. Also check that you have supplies, such as robes or blood pressure cuffs, on hand for a variety of body sizes.

NEW ORLEANS – Weight-based harassment and bias is extremely prevalent throughout society and in doctors’ own offices, so be aware of ways to address it and support your patients regardless of weight.

Rebecca Puhl, PhD, a deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, said that weight-based discrimination can occur whatever a person’s size or body shape, but it’s most often targeted at youth who are overweight or obese.

These children and teens commonly face teasing, harassment, cyberbullying, physical aggression, and social bullying from peers, coaches, teachers, and even parents, Dr. Puhl told attendees at the annual meeting of the American Academy of Pediatrics.

Common beliefs about overweight people – that they have little self discipline or poor eating and activity habits – only perpetuate stereotypes, she said. Common stereotypes are that people with obesity are noncompliant, lazy, sloppy, unsuccessful, unintelligent, dishonest, and awkward.

And health professionals of every type have been found to harbor these biases. In one study of more than 4,000 first-year medical students, well over half the respondents revealed explicit (74%) and implicit (67%) weight bias (Obesity. 2014 Apr;22[4]:1201-8). The study also found that explicit weight bias was stronger than explicit bias against blacks, Hispanics, LGBTQ people, and poor people.
 

Know the effects of weight stigma

Far from a minor issue, the discrimination that begins in childhood against those who are overweight can have a long-lasting impact on their future prospects and mental health. Being overweight is overwhelmingly cited as the most common reason for bullying (Pediatr Obes. 2016 Aug;11[4]:241-50). Dr. Puhl described to attendees how weight bias shifts throughout a lifetime, beginning as early as preschool. In childhood, the stereotypes about being overweight worsen, and the teasing and bullying increase. By adolescence, this treatment affects teens’ psychological, social, and physical well-being. It then translates in adulthood into reduced opportunities in employment and education, and poorer access and treatment in health care.

The mental distress caused by weight bullying often takes the form of depression, anxiety, and substance use, Dr. Puhl said, and children’s academic success can be hampered by bullying about their weight. One study found a higher risk of poor grades and school avoidance with each additional teasing incident (J Youth Adolesc. 2012 Jan;41[1]:27-40).

Weight stigma also can contribute to more weight gain, obesity, and lower physical activity levels. Maladaptive eating behaviors can result from weight stigmatization as well: binge eating, emotional eating, increased consumption in general, and other eating disorders. Severe binge eating is 80% more likely among teens who are bullied about their weight, Dr. Puhl said, and the risk increases with increased frequency and types of bullying.

Children who are teased about their weight often become less willing to engage in physical activity, she noted. They may skip gym class, feel less competent about physical activity, and end up enjoying sports participation less.

Further, sexual- and gender-minority youth report high rates of weight-related teasing from friends and family regardless of their body mass index (BMI) percentile, Dr. Puhl emphasized. Researchers have found bullying about weight in this population linked to dieting, difficulty sleeping, high stress levels, binge drinking, smoking, and marijuana use.
 

Know how to combat weight bias

Dr. Puhl described strategies for reducing weight bias based on clinical practice recommendations in the American Academy of Pediatrics’ policy statement entitled “Stigma Experienced by Children and Adolescents With Obesity” (Pediatrics. 2017 Dec;140[6]:e20173034).

Be aware. Consider how personal assumptions and attitudes about weight can affect your body language, tone of voice, facial expression, gestures, eye contact (or lack thereof), and spatial distance from the patient.

Recognizing the biological, genetic, and environmental causes of obesity can reduce stigma and improve understanding of the complexity of obesity etiology. It’s also important that you help parents understand this complexity and the negative impact of weight stigma.

Consider language and word choice. “Carefully consider language that might unintentionally communicate bias, blame, or negative judgment,” Dr. Puhl told attendees. “Use language that is supportive and empowering.”

Terms such as “unhealthy weight” and “high BMI” are less stigmatizing than “fat” and “morbidly obese” to parents, she said, and research has found nearly a quarter of parents would avoid future doctor appointments if their child’s doctor used stigmatizing terms to discuss weight (Pediatrics. 2011 Oct;128[4]:e786-93).

Teens themselves may have diverse preferences for the language used. Start by asking: “Could we talk about your weight today?” and then follow up by directly asking, “what words would you feel most comfortable with as we talk about your weight?”

Person-first language – such as “person with obesity” instead of “obese person” also is important to reducing stigma, she said.

It’s normal for you to feel uneasy about bringing up weight with patients, so Dr. Puhl recommended you practice dialogue out loud.

“Acknowledge your strengths,” she said. “You already have the skills and experience of engaging in difficult conversations with patients and families on a range of other health issues,” so apply that in this context as well.

Screen for negative experiences that could indicate weight-based bullying. These could include teasing and bullying, low self-esteem, poor school performance, depression, and anxiety.

“Remember that weight-based victimization can occur at diverse body sizes, not just in youth with obesity,” Dr. Puhl said. If you discover your patient is experiencing weight-related bullying, determine whether they have a support system in place and whether a mental health referral is appropriate. Provide or refer for behavior change counseling with motivational interviewing and patient-centered, empathic approaches. Parents should be aware of the issue and should contact the child’s teachers and school administration to help address it.

But before you do that, keep in mind that it’s not just peers doing the bullying. According to a study of teens with obesity enrolled in a national weight-loss camp, 37% of teen participants in 2012 said that their parents bully them (Pediatrics. 2013 Jan;131[1]:e1-9).

You should assess whether family interactions or the parents’ own history with weight is involved. If parents make disparaging comments about their child’s weight, “use this as an opportunity to model appropriate language and educate parents about weight bias,” Dr. Puhl said.

It’s also important to realize that parents themselves often are frustrated, so critical comments about their language or approach can backfire, she warned. Instead, help parents understand how to create a home setting that encourages healthy food choices, praises children for healthy decision making, and models positive health behaviors. It is key for them to focus on improving their children’s health behaviors rather than focusing on weight.

And before you contact the school, remember teachers also are common perpetrators of weight stigma, Dr. Puhl noted. She gave as an example a study in which investigators assessed 133 teachers’ perceptions of middle or high school students’ abilities based on photos that had been digitally altered to show each girl both as average weight or as overweight. Each photo was associated with an essay specifically chosen because it was neither particularly good nor bad (Brit J Educ Psychol. 2019 Oct 26. doi: 10.1111/bjep.12322). The teachers judged the essays believed to be submitted by overweight girls to be “similar in structural quality,” but they gave the overweight girls lower grades than the average-weight girls. They also indicated that they considered the overweight girls “put forth more effort, needed more remedial assistance, and had lower overall grades in school.” The teachers also rated other teachers’ weight bias to be at a low level, and their own weight bias to be “significantly lower” than the others.

Assess your clinical environment. Be aware of your clinical environment and whether it meets the needs of youth with diverse body sizes. That includes having a range of sturdy armless seating options and adequately sized doorways, hallways, and restrooms. You also should have beds, wheelchairs, and exam tables with adequate weight capacity. Also check that you have supplies, such as robes or blood pressure cuffs, on hand for a variety of body sizes.

NEW ORLEANS – Weight-based harassment and bias is extremely prevalent throughout society and in doctors’ own offices, so be aware of ways to address it and support your patients regardless of weight.

Rebecca Puhl, PhD, a deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut, Hartford, said that weight-based discrimination can occur whatever a person’s size or body shape, but it’s most often targeted at youth who are overweight or obese.

These children and teens commonly face teasing, harassment, cyberbullying, physical aggression, and social bullying from peers, coaches, teachers, and even parents, Dr. Puhl told attendees at the annual meeting of the American Academy of Pediatrics.

Common beliefs about overweight people – that they have little self discipline or poor eating and activity habits – only perpetuate stereotypes, she said. Common stereotypes are that people with obesity are noncompliant, lazy, sloppy, unsuccessful, unintelligent, dishonest, and awkward.

And health professionals of every type have been found to harbor these biases. In one study of more than 4,000 first-year medical students, well over half the respondents revealed explicit (74%) and implicit (67%) weight bias (Obesity. 2014 Apr;22[4]:1201-8). The study also found that explicit weight bias was stronger than explicit bias against blacks, Hispanics, LGBTQ people, and poor people.
 

Know the effects of weight stigma

Far from a minor issue, the discrimination that begins in childhood against those who are overweight can have a long-lasting impact on their future prospects and mental health. Being overweight is overwhelmingly cited as the most common reason for bullying (Pediatr Obes. 2016 Aug;11[4]:241-50). Dr. Puhl described to attendees how weight bias shifts throughout a lifetime, beginning as early as preschool. In childhood, the stereotypes about being overweight worsen, and the teasing and bullying increase. By adolescence, this treatment affects teens’ psychological, social, and physical well-being. It then translates in adulthood into reduced opportunities in employment and education, and poorer access and treatment in health care.

The mental distress caused by weight bullying often takes the form of depression, anxiety, and substance use, Dr. Puhl said, and children’s academic success can be hampered by bullying about their weight. One study found a higher risk of poor grades and school avoidance with each additional teasing incident (J Youth Adolesc. 2012 Jan;41[1]:27-40).

Weight stigma also can contribute to more weight gain, obesity, and lower physical activity levels. Maladaptive eating behaviors can result from weight stigmatization as well: binge eating, emotional eating, increased consumption in general, and other eating disorders. Severe binge eating is 80% more likely among teens who are bullied about their weight, Dr. Puhl said, and the risk increases with increased frequency and types of bullying.

Children who are teased about their weight often become less willing to engage in physical activity, she noted. They may skip gym class, feel less competent about physical activity, and end up enjoying sports participation less.

Further, sexual- and gender-minority youth report high rates of weight-related teasing from friends and family regardless of their body mass index (BMI) percentile, Dr. Puhl emphasized. Researchers have found bullying about weight in this population linked to dieting, difficulty sleeping, high stress levels, binge drinking, smoking, and marijuana use.
 

Know how to combat weight bias

Dr. Puhl described strategies for reducing weight bias based on clinical practice recommendations in the American Academy of Pediatrics’ policy statement entitled “Stigma Experienced by Children and Adolescents With Obesity” (Pediatrics. 2017 Dec;140[6]:e20173034).

Be aware. Consider how personal assumptions and attitudes about weight can affect your body language, tone of voice, facial expression, gestures, eye contact (or lack thereof), and spatial distance from the patient.

Recognizing the biological, genetic, and environmental causes of obesity can reduce stigma and improve understanding of the complexity of obesity etiology. It’s also important that you help parents understand this complexity and the negative impact of weight stigma.

Consider language and word choice. “Carefully consider language that might unintentionally communicate bias, blame, or negative judgment,” Dr. Puhl told attendees. “Use language that is supportive and empowering.”

Terms such as “unhealthy weight” and “high BMI” are less stigmatizing than “fat” and “morbidly obese” to parents, she said, and research has found nearly a quarter of parents would avoid future doctor appointments if their child’s doctor used stigmatizing terms to discuss weight (Pediatrics. 2011 Oct;128[4]:e786-93).

Teens themselves may have diverse preferences for the language used. Start by asking: “Could we talk about your weight today?” and then follow up by directly asking, “what words would you feel most comfortable with as we talk about your weight?”

Person-first language – such as “person with obesity” instead of “obese person” also is important to reducing stigma, she said.

It’s normal for you to feel uneasy about bringing up weight with patients, so Dr. Puhl recommended you practice dialogue out loud.

“Acknowledge your strengths,” she said. “You already have the skills and experience of engaging in difficult conversations with patients and families on a range of other health issues,” so apply that in this context as well.

Screen for negative experiences that could indicate weight-based bullying. These could include teasing and bullying, low self-esteem, poor school performance, depression, and anxiety.

“Remember that weight-based victimization can occur at diverse body sizes, not just in youth with obesity,” Dr. Puhl said. If you discover your patient is experiencing weight-related bullying, determine whether they have a support system in place and whether a mental health referral is appropriate. Provide or refer for behavior change counseling with motivational interviewing and patient-centered, empathic approaches. Parents should be aware of the issue and should contact the child’s teachers and school administration to help address it.

But before you do that, keep in mind that it’s not just peers doing the bullying. According to a study of teens with obesity enrolled in a national weight-loss camp, 37% of teen participants in 2012 said that their parents bully them (Pediatrics. 2013 Jan;131[1]:e1-9).

You should assess whether family interactions or the parents’ own history with weight is involved. If parents make disparaging comments about their child’s weight, “use this as an opportunity to model appropriate language and educate parents about weight bias,” Dr. Puhl said.

It’s also important to realize that parents themselves often are frustrated, so critical comments about their language or approach can backfire, she warned. Instead, help parents understand how to create a home setting that encourages healthy food choices, praises children for healthy decision making, and models positive health behaviors. It is key for them to focus on improving their children’s health behaviors rather than focusing on weight.

And before you contact the school, remember teachers also are common perpetrators of weight stigma, Dr. Puhl noted. She gave as an example a study in which investigators assessed 133 teachers’ perceptions of middle or high school students’ abilities based on photos that had been digitally altered to show each girl both as average weight or as overweight. Each photo was associated with an essay specifically chosen because it was neither particularly good nor bad (Brit J Educ Psychol. 2019 Oct 26. doi: 10.1111/bjep.12322). The teachers judged the essays believed to be submitted by overweight girls to be “similar in structural quality,” but they gave the overweight girls lower grades than the average-weight girls. They also indicated that they considered the overweight girls “put forth more effort, needed more remedial assistance, and had lower overall grades in school.” The teachers also rated other teachers’ weight bias to be at a low level, and their own weight bias to be “significantly lower” than the others.

Assess your clinical environment. Be aware of your clinical environment and whether it meets the needs of youth with diverse body sizes. That includes having a range of sturdy armless seating options and adequately sized doorways, hallways, and restrooms. You also should have beds, wheelchairs, and exam tables with adequate weight capacity. Also check that you have supplies, such as robes or blood pressure cuffs, on hand for a variety of body sizes.

GRAPEVINE, TEX.* – Pregnant women with type 2 diabetes or prediabetes had significantly less gestational weight gain if they had metformin exposure at any point in their pregnancies, with no differences in infant birth weight or postnatal infant hypoglycemia, according to research presented at the meeting sponsored by the Society for Maternal-Fetal Medicine.

Kari Oakes/MDedge News

In a retrospective single-center review of 284 women without metformin exposure and 227 with metformin exposure in pregnancy, metformin exposure at any point in pregnancy was associated with a significantly greater chance of appropriate – rather than excessive – weight gain.

The relationship held true for the 169 women who had metformin in their first trimester of pregnancy. Here, 69% of women had appropriate weight gain using Institute of Medicine and American College of Obstetricians and Gynecologists standards, compared with 54% of the 282 women who had no metformin exposure (adjusted odds ratio 1.92, P = .003). A further 22% of women receiving metformin in their first trimester of pregnancy lost weight, compared with 9% of women without metformin exposure (aOR 2.11, P = .019). There was no significant difference between the two groups in infant birth weight.

Separately, study author Jacquelyn Adams, MD, and her colleagues analyzed outcomes for the full cohort of 227 women who received metformin at any point in their pregnancy, comparing them again to the 282 women who had not received metformin. Most women (85%) were on 2 g of metformin at the time of delivery. These results again showed a greater likelihood of appropriate weight gain in the metformin group (69%; aOR 1.85; P = .002). Maternal weight loss was seen in 20% of this group (aOR 1.98, P = .018). Infant birth weights were not significantly different between these two groups.

“We found that women who had been on metformin at any point in their pregnancy had more appropriate weight gain and less excessive weight gain,” said Dr. Adams, a maternal-fetal medicine fellow at the University of Wisconsin–Madison. “Actually, some women on metformin had even had a little bit of weight loss, with no difference in their baby’s birth weight. So that’s really exciting, because our starting prepregnancy body mass index was 33-36 [kg/m²], which is considered obese,” she said in an interview.

This is an important finding, said Dr. Adams, because previous work has shown that less weight gain in pregnancy is associated with lower risk for hypertension and preeclampsia, and lower rates of fetal macrosomia.

What about infant outcomes? Dr. Adams said that there were many concerns about metformin: “Would it affect baby outcome? Were those babies more likely to be hypoglycemic? Were they more likely to be growth restricted? Were they more likely to have issues in the NICU? And the answer was really, ‘No.’ ”

“So we can both help these women have appropriate weight gain and not have any negative effects on these babies,” she added.

Specifically, Dr. Adams and her coinvestigators found no significant differences between the groups in gestational age at birth, likelihood of neonatal ICU admission, Apgar scores, neonatal hypoglycemia, respiratory distress syndrome, or fetal death. Fetal growth restriction and anomalies occurred at a low and similar rate between the groups.

Dr. Adams said that she was not surprised to see that metformin was associated with less weight gain in pregnancy, but she was surprised at how highly significant the differences were with metformin use. “Metformin is first-line for diabetes in nonpregnant individuals because it’s associated with things like weight loss, and because of ease of use and lack of hypoglycemia – so I was really hoping to see this kind of result.”

Women receiving metformin were a mean 34 years old, while those who didn’t get metformin were 32 years old, a significant difference. Prepregnancy body mass index also was higher in those receiving metformin, and they were more likely to have a type 2 diabetes diagnosis. A similar proportion of both groups – about two-thirds – were white, and about 20% were Hispanic.

The lower weight gain seen in metformin-takers also might smooth the way post partum, said Dr. Adams. “My perception is that, when these women leave us, they might not have any primary care follow-up; they might not have anybody following their diabetes; and metformin is a very viable way to help them in their life outside of pregnancy.

“Not to mention that all the weight you gain in pregnancy, you do eventually have to lose post partum,” she added, “so having less pregnancy weight gain kind of sets them up for success in their postpregnancy life as well.”

Asked whether these results inform the ongoing question of whether insulin or metformin is the most appropriate first-line treatment for gestational diabetes, Dr. Adams first noted that “there’s a lot of crossover,” pointing out that over 60% of the participants in her study eventually also required insulin.

“It’s a question I would love to address in a head-to-head trial,” she said, adding that questions about metformin’s effects on the placenta and the potential for later deleterious effects require more study.

In her practice, Dr. Adams said that patients generally are discharged with a metformin prescription, and then meet with a diabetes educator 1 week after delivery to assess blood glucose levels and adjust medical management. Following that, a warm hand-off to a primary care practice who can continue management and education is optimal, she said.

In terms of next steps, “We would really love to look at metformin in the postpartum period,” said Dr. Adams. Ideally, future work could look for outcomes that extend beyond the 6- to 8-week postpartum follow-up visit. For example, she said, there are indications that women with insulin insensitivity might benefit from metformin while breastfeeding; it’s also possible that metformin might reduce the risk of postpartum preeclampsia.

Dr. Adams reported that she had no conflicts of interest and no outside sources of funding.

koakes@mdedge.com

SOURCE: Adams J et al. SMFM 2020, Abstract 335.

*This story was updated 2/10/2020.

GRAPEVINE, TEX.* – Pregnant women with type 2 diabetes or prediabetes had significantly less gestational weight gain if they had metformin exposure at any point in their pregnancies, with no differences in infant birth weight or postnatal infant hypoglycemia, according to research presented at the meeting sponsored by the Society for Maternal-Fetal Medicine.

Kari Oakes/MDedge News

In a retrospective single-center review of 284 women without metformin exposure and 227 with metformin exposure in pregnancy, metformin exposure at any point in pregnancy was associated with a significantly greater chance of appropriate – rather than excessive – weight gain.

The relationship held true for the 169 women who had metformin in their first trimester of pregnancy. Here, 69% of women had appropriate weight gain using Institute of Medicine and American College of Obstetricians and Gynecologists standards, compared with 54% of the 282 women who had no metformin exposure (adjusted odds ratio 1.92, P = .003). A further 22% of women receiving metformin in their first trimester of pregnancy lost weight, compared with 9% of women without metformin exposure (aOR 2.11, P = .019). There was no significant difference between the two groups in infant birth weight.

Separately, study author Jacquelyn Adams, MD, and her colleagues analyzed outcomes for the full cohort of 227 women who received metformin at any point in their pregnancy, comparing them again to the 282 women who had not received metformin. Most women (85%) were on 2 g of metformin at the time of delivery. These results again showed a greater likelihood of appropriate weight gain in the metformin group (69%; aOR 1.85; P = .002). Maternal weight loss was seen in 20% of this group (aOR 1.98, P = .018). Infant birth weights were not significantly different between these two groups.

“We found that women who had been on metformin at any point in their pregnancy had more appropriate weight gain and less excessive weight gain,” said Dr. Adams, a maternal-fetal medicine fellow at the University of Wisconsin–Madison. “Actually, some women on metformin had even had a little bit of weight loss, with no difference in their baby’s birth weight. So that’s really exciting, because our starting prepregnancy body mass index was 33-36 [kg/m²], which is considered obese,” she said in an interview.

This is an important finding, said Dr. Adams, because previous work has shown that less weight gain in pregnancy is associated with lower risk for hypertension and preeclampsia, and lower rates of fetal macrosomia.

What about infant outcomes? Dr. Adams said that there were many concerns about metformin: “Would it affect baby outcome? Were those babies more likely to be hypoglycemic? Were they more likely to be growth restricted? Were they more likely to have issues in the NICU? And the answer was really, ‘No.’ ”

“So we can both help these women have appropriate weight gain and not have any negative effects on these babies,” she added.

Specifically, Dr. Adams and her coinvestigators found no significant differences between the groups in gestational age at birth, likelihood of neonatal ICU admission, Apgar scores, neonatal hypoglycemia, respiratory distress syndrome, or fetal death. Fetal growth restriction and anomalies occurred at a low and similar rate between the groups.

Dr. Adams said that she was not surprised to see that metformin was associated with less weight gain in pregnancy, but she was surprised at how highly significant the differences were with metformin use. “Metformin is first-line for diabetes in nonpregnant individuals because it’s associated with things like weight loss, and because of ease of use and lack of hypoglycemia – so I was really hoping to see this kind of result.”

Women receiving metformin were a mean 34 years old, while those who didn’t get metformin were 32 years old, a significant difference. Prepregnancy body mass index also was higher in those receiving metformin, and they were more likely to have a type 2 diabetes diagnosis. A similar proportion of both groups – about two-thirds – were white, and about 20% were Hispanic.

The lower weight gain seen in metformin-takers also might smooth the way post partum, said Dr. Adams. “My perception is that, when these women leave us, they might not have any primary care follow-up; they might not have anybody following their diabetes; and metformin is a very viable way to help them in their life outside of pregnancy.

“Not to mention that all the weight you gain in pregnancy, you do eventually have to lose post partum,” she added, “so having less pregnancy weight gain kind of sets them up for success in their postpregnancy life as well.”

Asked whether these results inform the ongoing question of whether insulin or metformin is the most appropriate first-line treatment for gestational diabetes, Dr. Adams first noted that “there’s a lot of crossover,” pointing out that over 60% of the participants in her study eventually also required insulin.

“It’s a question I would love to address in a head-to-head trial,” she said, adding that questions about metformin’s effects on the placenta and the potential for later deleterious effects require more study.

In her practice, Dr. Adams said that patients generally are discharged with a metformin prescription, and then meet with a diabetes educator 1 week after delivery to assess blood glucose levels and adjust medical management. Following that, a warm hand-off to a primary care practice who can continue management and education is optimal, she said.

In terms of next steps, “We would really love to look at metformin in the postpartum period,” said Dr. Adams. Ideally, future work could look for outcomes that extend beyond the 6- to 8-week postpartum follow-up visit. For example, she said, there are indications that women with insulin insensitivity might benefit from metformin while breastfeeding; it’s also possible that metformin might reduce the risk of postpartum preeclampsia.

Dr. Adams reported that she had no conflicts of interest and no outside sources of funding.

koakes@mdedge.com

SOURCE: Adams J et al. SMFM 2020, Abstract 335.

*This story was updated 2/10/2020.

GRAPEVINE, TEX.* – Pregnant women with type 2 diabetes or prediabetes had significantly less gestational weight gain if they had metformin exposure at any point in their pregnancies, with no differences in infant birth weight or postnatal infant hypoglycemia, according to research presented at the meeting sponsored by the Society for Maternal-Fetal Medicine.

Kari Oakes/MDedge News

In a retrospective single-center review of 284 women without metformin exposure and 227 with metformin exposure in pregnancy, metformin exposure at any point in pregnancy was associated with a significantly greater chance of appropriate – rather than excessive – weight gain.

The relationship held true for the 169 women who had metformin in their first trimester of pregnancy. Here, 69% of women had appropriate weight gain using Institute of Medicine and American College of Obstetricians and Gynecologists standards, compared with 54% of the 282 women who had no metformin exposure (adjusted odds ratio 1.92, P = .003). A further 22% of women receiving metformin in their first trimester of pregnancy lost weight, compared with 9% of women without metformin exposure (aOR 2.11, P = .019). There was no significant difference between the two groups in infant birth weight.

Separately, study author Jacquelyn Adams, MD, and her colleagues analyzed outcomes for the full cohort of 227 women who received metformin at any point in their pregnancy, comparing them again to the 282 women who had not received metformin. Most women (85%) were on 2 g of metformin at the time of delivery. These results again showed a greater likelihood of appropriate weight gain in the metformin group (69%; aOR 1.85; P = .002). Maternal weight loss was seen in 20% of this group (aOR 1.98, P = .018). Infant birth weights were not significantly different between these two groups.

“We found that women who had been on metformin at any point in their pregnancy had more appropriate weight gain and less excessive weight gain,” said Dr. Adams, a maternal-fetal medicine fellow at the University of Wisconsin–Madison. “Actually, some women on metformin had even had a little bit of weight loss, with no difference in their baby’s birth weight. So that’s really exciting, because our starting prepregnancy body mass index was 33-36 [kg/m²], which is considered obese,” she said in an interview.

This is an important finding, said Dr. Adams, because previous work has shown that less weight gain in pregnancy is associated with lower risk for hypertension and preeclampsia, and lower rates of fetal macrosomia.

What about infant outcomes? Dr. Adams said that there were many concerns about metformin: “Would it affect baby outcome? Were those babies more likely to be hypoglycemic? Were they more likely to be growth restricted? Were they more likely to have issues in the NICU? And the answer was really, ‘No.’ ”

“So we can both help these women have appropriate weight gain and not have any negative effects on these babies,” she added.

Specifically, Dr. Adams and her coinvestigators found no significant differences between the groups in gestational age at birth, likelihood of neonatal ICU admission, Apgar scores, neonatal hypoglycemia, respiratory distress syndrome, or fetal death. Fetal growth restriction and anomalies occurred at a low and similar rate between the groups.

Dr. Adams said that she was not surprised to see that metformin was associated with less weight gain in pregnancy, but she was surprised at how highly significant the differences were with metformin use. “Metformin is first-line for diabetes in nonpregnant individuals because it’s associated with things like weight loss, and because of ease of use and lack of hypoglycemia – so I was really hoping to see this kind of result.”

Women receiving metformin were a mean 34 years old, while those who didn’t get metformin were 32 years old, a significant difference. Prepregnancy body mass index also was higher in those receiving metformin, and they were more likely to have a type 2 diabetes diagnosis. A similar proportion of both groups – about two-thirds – were white, and about 20% were Hispanic.

The lower weight gain seen in metformin-takers also might smooth the way post partum, said Dr. Adams. “My perception is that, when these women leave us, they might not have any primary care follow-up; they might not have anybody following their diabetes; and metformin is a very viable way to help them in their life outside of pregnancy.

“Not to mention that all the weight you gain in pregnancy, you do eventually have to lose post partum,” she added, “so having less pregnancy weight gain kind of sets them up for success in their postpregnancy life as well.”

Asked whether these results inform the ongoing question of whether insulin or metformin is the most appropriate first-line treatment for gestational diabetes, Dr. Adams first noted that “there’s a lot of crossover,” pointing out that over 60% of the participants in her study eventually also required insulin.

“It’s a question I would love to address in a head-to-head trial,” she said, adding that questions about metformin’s effects on the placenta and the potential for later deleterious effects require more study.

In her practice, Dr. Adams said that patients generally are discharged with a metformin prescription, and then meet with a diabetes educator 1 week after delivery to assess blood glucose levels and adjust medical management. Following that, a warm hand-off to a primary care practice who can continue management and education is optimal, she said.

In terms of next steps, “We would really love to look at metformin in the postpartum period,” said Dr. Adams. Ideally, future work could look for outcomes that extend beyond the 6- to 8-week postpartum follow-up visit. For example, she said, there are indications that women with insulin insensitivity might benefit from metformin while breastfeeding; it’s also possible that metformin might reduce the risk of postpartum preeclampsia.

Dr. Adams reported that she had no conflicts of interest and no outside sources of funding.

koakes@mdedge.com

SOURCE: Adams J et al. SMFM 2020, Abstract 335.

*This story was updated 2/10/2020.

New studies show that many people who lose weight can maintain that loss for longer than a few months by utilizing strategies that can be undertaken upon your recommendation and with your ongoing support. In this article, I review the evidence that supports the effectiveness of those interventions and activities for helping patients keep off the weight they’ve lost.

Prolonging the duration of weight maintenance

Until recently, most studies that focused on weight maintenance after weight loss followed subjects for only a few months or a year after the goal was achieved. With that limited window of follow-up, the belief arose in weight-loss medicine that most people gain back lost weight within 2 years. Findings that are emerging from recent studies with longer follow-up, however, suggest that weight loss can be maintained for as long as 8 years.¹

The National Health and Nutrition Examination Survey² and the Action in Health for Diabetes (Look AHEAD) trial^3,4 reported that, among adults who lost 10% or more of body weight, approximately 60% maintained that weight loss at 1 year. Look AHEAD had a much longer duration: 42% of participants who lost at least 10% of body weight by the end of Year 1 maintained at least that 10% loss by the end of Year 4.⁵ In addition, Look AHEAD demonstrated that extended provision of maintenance interventions after weight loss can facilitate clinically meaningful weight loss for as long as 8 years—2 or 3 times longer than what was reported in earlier randomized trials.⁴

We have evidence-based guidance for achieving long-term weight maintenance and good reason to believe that success is achievable for patients. The 10 strategies that follow can help you to guide patients to become successful “maintainers.”

IMAGE: @JOE GORMAN

1. Emphasize more weight loss in the first 3 months of a program

Losing more weight initially seems to point to more success in relation to maintenance. This suggests that more intensive help, such as more frequent visits with a physician and a dietitian during the first 3 months might be an important step to help patients lose and maintain weight.

These 10 strategies can help guide patients to become successful "maintainers."

Much of our information on successful maintainers comes from the National Weight Control Registry (NWCR) at the Warren Alpert Medical School at Brown University.¹ This research study has gathered information from more than 10,000 people who successfully lost ≥ 30 lb (average, 60 lb) and kept it off for at least 1 year. To challenge the widespread belief that only a few people who attempt weight loss succeed long term, the NWCR identifies and investigates the characteristics of individuals who have succeeded.

A new and encouraging finding is from a small study that showed that people can maintain weight loss brought about by either medical or surgical means: Those who lost > 15% of their starting weight and were followed closely by health care professionals maintained their weight loss at 1 year.⁵

Continue to: 2. Advise patients to consume fewer calories and eat more nonglycemic fruits and vegetables

2. Advise patients to consume fewer calories and eat more nonglycemic fruits and vegetables

When a person loses weight, their basal metabolic rate drops; to maintain their new weight, they need to consume fewer calories. That person must continue to have a calorie deficit, which varies individually but is often about 500 kcal/d. There is no formula for this; at our clinic, when a patient achieves goal weight, we have them increase intake by 100 kcal/d/wk in nutritious food until they start to gain weight. When they start to gain weight, we have them decrease intake by 100 kcal/d until they do not gain any longer.

Many patients complain of hunger after they lose weight because of an increase in the body’s level of ghrelin, the hunger hormone, and a decrease in the level of leptin, which is associated with satiety. Many achieve a lower calorie count and fight hunger by increasing fiber intake.

In a 24-year study that looked at weight change, researchers noted a strong inverse association between increased intake of higher-fiber, lower-glycemic fruits and vegetables and weight change.⁶ Lower-glycemic vegetables include most vegetables (exceptions are corn, potatoes, and peas, which are associated with weight gain). Benefit was strongest with berries, apples, pears, tofu or soy, cauliflower, and cruciferous and green leafy vegetables.⁶ Adding 1 serving a day of nonstarchy fruits and vegetables was associated with less weight gain over time.

The order in which food is eaten might be important, as evidenced by a small study⁷ that ­focused on patients with diabetes. ­Investigators found that subjects who ate vegetables first, protein second, and grain third had fewer fluctuations in blood glucose level than those who ate carbohydrates first—­suggesting that this order might be a good way for patients to eat at least some of their meals. The reduced insulin excursions observed in this experimental setting suggest that the vegetable–protein–grain meal pattern can improve insulin sensitivity and help with blood glucose control.

3. Encourage patients to eat at home and to avoid processed foods

In a small, randomized controlled study⁸ in 2019 at the National Institutes of Health, 20 inpatients were fed an ultraprocessed diet that was matched, in calories and macronutrients, in an unprocessed diet fed to controls. Subjects in the ultraprocessed food group ate, on average, 500 kcal/d more and gained 2 lbs in 2 weeks. An ultraprocessed breakfast might consist of a bagel with cream cheese and turkey bacon; the unprocessed breakfast was oatmeal with bananas, walnuts, and skim milk. Notably, the ultraprocessed diet was cheaper; nonprocessed foods cost 50% more.

Continue to: A retrospective review...

Losing the most weight and making frequent office visits to a physician and dietitian early in weight loss can determine the success of maintenance later.

A retrospective review of a sample of US adults’ caloric and nutritional intake determined that eating at a full-service restaurant is not associated with consumption of fewer calories than eating at a fast food restaurant: Eating at either type of restaurant was associated with excess (approximately 200 kcal/meal) caloric intake.⁹

4. Emphasize the importance of eating breakfast and increasing protein intake

Increased protein throughout the day, particularly at breakfast, has been suggested to help with weight maintenance. In a large European study,¹⁰ even slightly increased protein intake (approximately 1.2 g/kg of body weight and of low glycemic index food) was associated with weight maintenance. In another review,¹¹ researchers concluded that 25 to 30 g of protein at each meal can provide improvement in appetite and weight management, although they cautioned that further research is needed. A study that looked at increasing intake of protein at breakfast to 35 g in adolescent females resulted in less snacking later in the day.¹²

In the NWCR, successful maintainers had breakfast daily, a lower fat diet, and fewer calories (approximately 1500 kcal/d)— routines that were all associated with greater success.¹ Therefore, eating protein at approximately 1.2 g/kg of body weight (possibly, even more [35 g] at breakfast) and ingesting less fat and fewer calories all contributed to successful maintenance. Eating nuts and legume-based proteins, such as beans and tofu, should be encouraged.

Only a few studies have looked at dairy protein intake and weight maintenance. In one study, consumption of dairy proteins was not associated with a change in body weight or other metabolic risk markers during weight maintenance.¹³ Yogurt, because of its probiotic content, might be good for weight maintenance, but this has not been studied well, and studies that have been conducted are inconclusive.¹⁴

Another study looked at consumption of protein supplements. It found no improvement in body composition over a 24-week period when protein intake was increased to 1.45 g/kg when compared to 1.16 g/kg in controls. Although subjects felt less hungry, this was not reflected in a reduction in caloric intake.¹⁵

Continue to: Most patients do need counseling...

Most patients do need counseling on whole grain intake: Explaining that a bagel is the same as 4 servings of toast and that a cup (ie, a fistful) of cooked pasta is 3 servings of grains is helpful. Patients should aim for 1 serving of grain at each meal; when shopping for grains, they should choose those that have the “whole” first on the list of ingredients because whole grain, rather than refined grain, intake is associated with less diabetes and colon cancer.¹⁶

5. Underscore the importance of self-monitoring

Self-monitoring is key to weight maintenance. This can mean weighing oneself or tracking one’s food intake (or both). Daily weighing is important: A study showed that patients who decrease how often they weigh themselves were likely to eat more and thus gain weight.¹⁷

Monitoring intake is also important. Recommended online calorie counters (eg, ­myfitnesspal.com, loseit.com), tools such as a Fitbit, or even keeping a food diary to help patients track intake. In a review of technology-based interventions to maintain weight loss, the use of apps was variable and effectiveness of devices was mixed. The authors recommended that physicians complement Web-based applications with personal contact.¹⁸

6. Encourage patients to spend more time exercising

After weight loss is achieved, maintaining a high level of activity is important. Recommendations focus on moving about 1 hr/d or 200 to 300 min/wk.¹⁹ A program of several daily “bouts,” or episodes of moderate-to-vigorous physical activity, is recommended in the new Centers for Disease Control and Prevention guidelines¹⁹ and might be preferable, or equivalent, to a concentrated expenditure of energy. Patients might consider, for example, a 10-minute session, 4 times a day, 5 days a week, instead of a ­single, 40-minute session, 5 days a week.¹⁹ Furthermore, to sustain weight loss, moderate exercise might be more effective than exercise of vigorous intensity or extended duration.¹⁹ Most patients in the NWCR report that walking is their principal form of activity.¹

Resistance training, which improves muscle strength and endurance, with or without diet restriction, has not been shown to be effective for weight loss but might help with weight maintenance and might improve a patient’s lipid profile, insulin resistance, and blood pressure. In obese adolescents, resistance weight training led to positive changes in body composition, such as decreased waist circumference.²⁰ Resistance training likely enhances weight maintenance and should be encouraged because of its effect on increasing lean muscle mass, the most important factor in determining basal metabolic rate.

Continue to: 7. Work with patients to ensure sound sleep hygiene

7. Work with patients to ensure sound sleep hygiene

Short sleep duration (< 6 hours a night) is associated with obesity. There are few studies on weight maintenance and sleep; a study that was reviewed by the NWCR found that people who are highly successful at both weight loss and long-term maintenance are more likely to (1) be categorized as a “morning-type” chronotype (ie, getting up early), and (2) report longer sleep duration and better sleep quality, compared to treatment-seeking overweight and obese subjects. Furthermore, these NWCR subjects were more likely to report shorter sleep latency (time required to fall asleep) and were less likely to report short sleep, defined as < 6 to 7 hours a night.²¹

Counsel patients to eat fewer calories, avoid highly processed foods, and increase protein intake—preferably by preparing food at home.

Patients should strive for 7 to 8 hours of sleep a night; sleep apnea should be addressed as necessary.¹⁷ It is important for doctors to encourage patients to go to bed and get up at the same times every day (eg, 10 pm to 6 am daily).

8. Start a trial of medical therapy

Weight-loss medicines are beyond the scope of this article but worth discussing. In accordance with obesity guidelines, if a patient responds well to a weight-loss medication and loses ≥ 5% of body weight after 3 months, continue prescribing the medication. If the medication is ineffective or the patient experiences adverse effects, stop the prescription and consider an alternative medication or approach to maintenance.

The US Food and Drug Administration has approved 5 medications for long-term use in weight maintenance: the 2 combination formulations bupropion–naltrexone and phentermine–topiramate, as well as liraglutide, lorcaserin, and orlistat. A review of the use of these drugs over 1 year showed that they provide a modest favorable effect on cardiometabolic outcomes that vary by drug class.²² In particular, liraglutide has been shown to reduce the risk of cardiovascular disease outcomes in patients with diabetes who have a history of atherosclerotic disease or heart attack and stroke.²³ Further research is needed to evaluate the long-term impact of these drugs on cardiovascular risk.

9. Address mental health challenges

Certain personal traits and behaviors appear to help people lose weight: In a study, maintainers were more likely to be characterized as being good problem-solvers, having hope, and having a more positive mood.^24,25

Continue to: Addressing mental health issues...

Addressing mental health issues, especially depression, is paramount in patients with obesity. Treating patients with depression and hopelessness, as well as helping them with problem-solving, should be the focus of weight-management care.

A retrospective review determined that eating at a full-service restaurant is not associated with consumption of fewer calories than eating at a fast food restaurant.

Choosing an antidepressant not associated with the adverse effect of weight gain is important. Almost all selective serotonin reuptake inhibitors and tricyclic antidepressants are associated with weight gain; bupropion is weight neutral and should be first-line treatment for patients who are overweight and obese.²⁶ If using an antidepressant associated with weight gain, initiate weight monitoring if the patient gains 3% of body weight in the first month of therapy. When caring for a patient who takes an antipsychotic, consider consulting with their mental health professional to determine the value of prescribing metformin, which has been shown to decrease weight gain associated with antipsychotics.²⁷

Because depression, anxiety, and attention deficit-hyperactivity disorder are all associated with obesity, it is important to work with obese patients’ mental health care providers to design ways to improve their care.

10. Encourage patients to modify old habits and adopt new ones

Focusing on establishing good habits can be helpful. In Great Britain, a program focused on forming new healthy habits and breaking old unhealthy habits by restructuring daily routines and increasing mindfulness was successful in keeping weight off in 65% of participants—an impressive degree of success.²⁴ Successful maintainers were sent daily text messages requesting that they interrupt their routines, which shifted their attention away from eating. Some of these distracting tasks included driving to work by a different route or volunteering for a charity. Such small changes helped improve weight maintenance.

Intuitive eating and mindfulness can help. New concepts that focus on healthy eating without caloric restriction are also emerging; one such approach is intuitive eating, which promotes eating that is based not only on cues connected to hunger and fullness, but also on enjoyment of food, such as eating slowly and savoring every bite.²⁸ Techniques such as sipping water or resting the fork between bites of food has been helpful with some patients. More research in the area of intuitive eating is needed.

Continue to: Recognizing true physiologic hunger...

Recognizing true physiologic hunger distinct from emotional hunger can improve with mindfulness training. This practice might provide a better way to help the so-called yo-yo dieter and binge eater to reach metabolic health. Interestingly, successful weight maintainers who allow themselves less restriction on weekends maintain weight better than those who try to restrict diet every day, according to a recent study.²⁹

Recommend a support group. Accountability is important: Group therapy in obesity treatment may be more effective than individual treatment.³⁰

The support of a group and the regular attendance at group meetings are connected to further significant weight loss in the weight-loss period and, later, during maintenance. Monthly meetings seem to help patients with weight maintenance but more research is needed to determine what interval of support-group meeting attendance is most effective.

CORRESPONDENCE
Marijane Hynes, MD, The George Washington University Medical Faculty Associates, Fifth Floor/Internal Medicine, 2150 Pennsylvania Avenue NW, Washington, DC 20037; mhynes@mfa.gwu.edu.

New studies show that many people who lose weight can maintain that loss for longer than a few months by utilizing strategies that can be undertaken upon your recommendation and with your ongoing support. In this article, I review the evidence that supports the effectiveness of those interventions and activities for helping patients keep off the weight they’ve lost.

Prolonging the duration of weight maintenance

Until recently, most studies that focused on weight maintenance after weight loss followed subjects for only a few months or a year after the goal was achieved. With that limited window of follow-up, the belief arose in weight-loss medicine that most people gain back lost weight within 2 years. Findings that are emerging from recent studies with longer follow-up, however, suggest that weight loss can be maintained for as long as 8 years.¹

The National Health and Nutrition Examination Survey² and the Action in Health for Diabetes (Look AHEAD) trial^3,4 reported that, among adults who lost 10% or more of body weight, approximately 60% maintained that weight loss at 1 year. Look AHEAD had a much longer duration: 42% of participants who lost at least 10% of body weight by the end of Year 1 maintained at least that 10% loss by the end of Year 4.⁵ In addition, Look AHEAD demonstrated that extended provision of maintenance interventions after weight loss can facilitate clinically meaningful weight loss for as long as 8 years—2 or 3 times longer than what was reported in earlier randomized trials.⁴

We have evidence-based guidance for achieving long-term weight maintenance and good reason to believe that success is achievable for patients. The 10 strategies that follow can help you to guide patients to become successful “maintainers.”

IMAGE: @JOE GORMAN

1. Emphasize more weight loss in the first 3 months of a program

Losing more weight initially seems to point to more success in relation to maintenance. This suggests that more intensive help, such as more frequent visits with a physician and a dietitian during the first 3 months might be an important step to help patients lose and maintain weight.

These 10 strategies can help guide patients to become successful "maintainers."

Much of our information on successful maintainers comes from the National Weight Control Registry (NWCR) at the Warren Alpert Medical School at Brown University.¹ This research study has gathered information from more than 10,000 people who successfully lost ≥ 30 lb (average, 60 lb) and kept it off for at least 1 year. To challenge the widespread belief that only a few people who attempt weight loss succeed long term, the NWCR identifies and investigates the characteristics of individuals who have succeeded.

A new and encouraging finding is from a small study that showed that people can maintain weight loss brought about by either medical or surgical means: Those who lost > 15% of their starting weight and were followed closely by health care professionals maintained their weight loss at 1 year.⁵

Continue to: 2. Advise patients to consume fewer calories and eat more nonglycemic fruits and vegetables

2. Advise patients to consume fewer calories and eat more nonglycemic fruits and vegetables

When a person loses weight, their basal metabolic rate drops; to maintain their new weight, they need to consume fewer calories. That person must continue to have a calorie deficit, which varies individually but is often about 500 kcal/d. There is no formula for this; at our clinic, when a patient achieves goal weight, we have them increase intake by 100 kcal/d/wk in nutritious food until they start to gain weight. When they start to gain weight, we have them decrease intake by 100 kcal/d until they do not gain any longer.

Many patients complain of hunger after they lose weight because of an increase in the body’s level of ghrelin, the hunger hormone, and a decrease in the level of leptin, which is associated with satiety. Many achieve a lower calorie count and fight hunger by increasing fiber intake.

In a 24-year study that looked at weight change, researchers noted a strong inverse association between increased intake of higher-fiber, lower-glycemic fruits and vegetables and weight change.⁶ Lower-glycemic vegetables include most vegetables (exceptions are corn, potatoes, and peas, which are associated with weight gain). Benefit was strongest with berries, apples, pears, tofu or soy, cauliflower, and cruciferous and green leafy vegetables.⁶ Adding 1 serving a day of nonstarchy fruits and vegetables was associated with less weight gain over time.

The order in which food is eaten might be important, as evidenced by a small study⁷ that ­focused on patients with diabetes. ­Investigators found that subjects who ate vegetables first, protein second, and grain third had fewer fluctuations in blood glucose level than those who ate carbohydrates first—­suggesting that this order might be a good way for patients to eat at least some of their meals. The reduced insulin excursions observed in this experimental setting suggest that the vegetable–protein–grain meal pattern can improve insulin sensitivity and help with blood glucose control.

3. Encourage patients to eat at home and to avoid processed foods

In a small, randomized controlled study⁸ in 2019 at the National Institutes of Health, 20 inpatients were fed an ultraprocessed diet that was matched, in calories and macronutrients, in an unprocessed diet fed to controls. Subjects in the ultraprocessed food group ate, on average, 500 kcal/d more and gained 2 lbs in 2 weeks. An ultraprocessed breakfast might consist of a bagel with cream cheese and turkey bacon; the unprocessed breakfast was oatmeal with bananas, walnuts, and skim milk. Notably, the ultraprocessed diet was cheaper; nonprocessed foods cost 50% more.

Continue to: A retrospective review...

Losing the most weight and making frequent office visits to a physician and dietitian early in weight loss can determine the success of maintenance later.

A retrospective review of a sample of US adults’ caloric and nutritional intake determined that eating at a full-service restaurant is not associated with consumption of fewer calories than eating at a fast food restaurant: Eating at either type of restaurant was associated with excess (approximately 200 kcal/meal) caloric intake.⁹

4. Emphasize the importance of eating breakfast and increasing protein intake

Increased protein throughout the day, particularly at breakfast, has been suggested to help with weight maintenance. In a large European study,¹⁰ even slightly increased protein intake (approximately 1.2 g/kg of body weight and of low glycemic index food) was associated with weight maintenance. In another review,¹¹ researchers concluded that 25 to 30 g of protein at each meal can provide improvement in appetite and weight management, although they cautioned that further research is needed. A study that looked at increasing intake of protein at breakfast to 35 g in adolescent females resulted in less snacking later in the day.¹²

In the NWCR, successful maintainers had breakfast daily, a lower fat diet, and fewer calories (approximately 1500 kcal/d)— routines that were all associated with greater success.¹ Therefore, eating protein at approximately 1.2 g/kg of body weight (possibly, even more [35 g] at breakfast) and ingesting less fat and fewer calories all contributed to successful maintenance. Eating nuts and legume-based proteins, such as beans and tofu, should be encouraged.

Only a few studies have looked at dairy protein intake and weight maintenance. In one study, consumption of dairy proteins was not associated with a change in body weight or other metabolic risk markers during weight maintenance.¹³ Yogurt, because of its probiotic content, might be good for weight maintenance, but this has not been studied well, and studies that have been conducted are inconclusive.¹⁴

Another study looked at consumption of protein supplements. It found no improvement in body composition over a 24-week period when protein intake was increased to 1.45 g/kg when compared to 1.16 g/kg in controls. Although subjects felt less hungry, this was not reflected in a reduction in caloric intake.¹⁵

Continue to: Most patients do need counseling...

Most patients do need counseling on whole grain intake: Explaining that a bagel is the same as 4 servings of toast and that a cup (ie, a fistful) of cooked pasta is 3 servings of grains is helpful. Patients should aim for 1 serving of grain at each meal; when shopping for grains, they should choose those that have the “whole” first on the list of ingredients because whole grain, rather than refined grain, intake is associated with less diabetes and colon cancer.¹⁶

5. Underscore the importance of self-monitoring

Self-monitoring is key to weight maintenance. This can mean weighing oneself or tracking one’s food intake (or both). Daily weighing is important: A study showed that patients who decrease how often they weigh themselves were likely to eat more and thus gain weight.¹⁷

Monitoring intake is also important. Recommended online calorie counters (eg, ­myfitnesspal.com, loseit.com), tools such as a Fitbit, or even keeping a food diary to help patients track intake. In a review of technology-based interventions to maintain weight loss, the use of apps was variable and effectiveness of devices was mixed. The authors recommended that physicians complement Web-based applications with personal contact.¹⁸

6. Encourage patients to spend more time exercising

After weight loss is achieved, maintaining a high level of activity is important. Recommendations focus on moving about 1 hr/d or 200 to 300 min/wk.¹⁹ A program of several daily “bouts,” or episodes of moderate-to-vigorous physical activity, is recommended in the new Centers for Disease Control and Prevention guidelines¹⁹ and might be preferable, or equivalent, to a concentrated expenditure of energy. Patients might consider, for example, a 10-minute session, 4 times a day, 5 days a week, instead of a ­single, 40-minute session, 5 days a week.¹⁹ Furthermore, to sustain weight loss, moderate exercise might be more effective than exercise of vigorous intensity or extended duration.¹⁹ Most patients in the NWCR report that walking is their principal form of activity.¹

Resistance training, which improves muscle strength and endurance, with or without diet restriction, has not been shown to be effective for weight loss but might help with weight maintenance and might improve a patient’s lipid profile, insulin resistance, and blood pressure. In obese adolescents, resistance weight training led to positive changes in body composition, such as decreased waist circumference.²⁰ Resistance training likely enhances weight maintenance and should be encouraged because of its effect on increasing lean muscle mass, the most important factor in determining basal metabolic rate.

Continue to: 7. Work with patients to ensure sound sleep hygiene

7. Work with patients to ensure sound sleep hygiene

Short sleep duration (< 6 hours a night) is associated with obesity. There are few studies on weight maintenance and sleep; a study that was reviewed by the NWCR found that people who are highly successful at both weight loss and long-term maintenance are more likely to (1) be categorized as a “morning-type” chronotype (ie, getting up early), and (2) report longer sleep duration and better sleep quality, compared to treatment-seeking overweight and obese subjects. Furthermore, these NWCR subjects were more likely to report shorter sleep latency (time required to fall asleep) and were less likely to report short sleep, defined as < 6 to 7 hours a night.²¹

Counsel patients to eat fewer calories, avoid highly processed foods, and increase protein intake—preferably by preparing food at home.

Patients should strive for 7 to 8 hours of sleep a night; sleep apnea should be addressed as necessary.¹⁷ It is important for doctors to encourage patients to go to bed and get up at the same times every day (eg, 10 pm to 6 am daily).

8. Start a trial of medical therapy

Weight-loss medicines are beyond the scope of this article but worth discussing. In accordance with obesity guidelines, if a patient responds well to a weight-loss medication and loses ≥ 5% of body weight after 3 months, continue prescribing the medication. If the medication is ineffective or the patient experiences adverse effects, stop the prescription and consider an alternative medication or approach to maintenance.

The US Food and Drug Administration has approved 5 medications for long-term use in weight maintenance: the 2 combination formulations bupropion–naltrexone and phentermine–topiramate, as well as liraglutide, lorcaserin, and orlistat. A review of the use of these drugs over 1 year showed that they provide a modest favorable effect on cardiometabolic outcomes that vary by drug class.²² In particular, liraglutide has been shown to reduce the risk of cardiovascular disease outcomes in patients with diabetes who have a history of atherosclerotic disease or heart attack and stroke.²³ Further research is needed to evaluate the long-term impact of these drugs on cardiovascular risk.

9. Address mental health challenges

Certain personal traits and behaviors appear to help people lose weight: In a study, maintainers were more likely to be characterized as being good problem-solvers, having hope, and having a more positive mood.^24,25

Continue to: Addressing mental health issues...

Addressing mental health issues, especially depression, is paramount in patients with obesity. Treating patients with depression and hopelessness, as well as helping them with problem-solving, should be the focus of weight-management care.

A retrospective review determined that eating at a full-service restaurant is not associated with consumption of fewer calories than eating at a fast food restaurant.

Choosing an antidepressant not associated with the adverse effect of weight gain is important. Almost all selective serotonin reuptake inhibitors and tricyclic antidepressants are associated with weight gain; bupropion is weight neutral and should be first-line treatment for patients who are overweight and obese.²⁶ If using an antidepressant associated with weight gain, initiate weight monitoring if the patient gains 3% of body weight in the first month of therapy. When caring for a patient who takes an antipsychotic, consider consulting with their mental health professional to determine the value of prescribing metformin, which has been shown to decrease weight gain associated with antipsychotics.²⁷

Because depression, anxiety, and attention deficit-hyperactivity disorder are all associated with obesity, it is important to work with obese patients’ mental health care providers to design ways to improve their care.

10. Encourage patients to modify old habits and adopt new ones

Focusing on establishing good habits can be helpful. In Great Britain, a program focused on forming new healthy habits and breaking old unhealthy habits by restructuring daily routines and increasing mindfulness was successful in keeping weight off in 65% of participants—an impressive degree of success.²⁴ Successful maintainers were sent daily text messages requesting that they interrupt their routines, which shifted their attention away from eating. Some of these distracting tasks included driving to work by a different route or volunteering for a charity. Such small changes helped improve weight maintenance.

Intuitive eating and mindfulness can help. New concepts that focus on healthy eating without caloric restriction are also emerging; one such approach is intuitive eating, which promotes eating that is based not only on cues connected to hunger and fullness, but also on enjoyment of food, such as eating slowly and savoring every bite.²⁸ Techniques such as sipping water or resting the fork between bites of food has been helpful with some patients. More research in the area of intuitive eating is needed.

Continue to: Recognizing true physiologic hunger...

Recognizing true physiologic hunger distinct from emotional hunger can improve with mindfulness training. This practice might provide a better way to help the so-called yo-yo dieter and binge eater to reach metabolic health. Interestingly, successful weight maintainers who allow themselves less restriction on weekends maintain weight better than those who try to restrict diet every day, according to a recent study.²⁹

Recommend a support group. Accountability is important: Group therapy in obesity treatment may be more effective than individual treatment.³⁰

The support of a group and the regular attendance at group meetings are connected to further significant weight loss in the weight-loss period and, later, during maintenance. Monthly meetings seem to help patients with weight maintenance but more research is needed to determine what interval of support-group meeting attendance is most effective.

CORRESPONDENCE
Marijane Hynes, MD, The George Washington University Medical Faculty Associates, Fifth Floor/Internal Medicine, 2150 Pennsylvania Avenue NW, Washington, DC 20037; mhynes@mfa.gwu.edu.

New studies show that many people who lose weight can maintain that loss for longer than a few months by utilizing strategies that can be undertaken upon your recommendation and with your ongoing support. In this article, I review the evidence that supports the effectiveness of those interventions and activities for helping patients keep off the weight they’ve lost.

Prolonging the duration of weight maintenance

Until recently, most studies that focused on weight maintenance after weight loss followed subjects for only a few months or a year after the goal was achieved. With that limited window of follow-up, the belief arose in weight-loss medicine that most people gain back lost weight within 2 years. Findings that are emerging from recent studies with longer follow-up, however, suggest that weight loss can be maintained for as long as 8 years.¹

The National Health and Nutrition Examination Survey² and the Action in Health for Diabetes (Look AHEAD) trial^3,4 reported that, among adults who lost 10% or more of body weight, approximately 60% maintained that weight loss at 1 year. Look AHEAD had a much longer duration: 42% of participants who lost at least 10% of body weight by the end of Year 1 maintained at least that 10% loss by the end of Year 4.⁵ In addition, Look AHEAD demonstrated that extended provision of maintenance interventions after weight loss can facilitate clinically meaningful weight loss for as long as 8 years—2 or 3 times longer than what was reported in earlier randomized trials.⁴

We have evidence-based guidance for achieving long-term weight maintenance and good reason to believe that success is achievable for patients. The 10 strategies that follow can help you to guide patients to become successful “maintainers.”

IMAGE: @JOE GORMAN

1. Emphasize more weight loss in the first 3 months of a program

Losing more weight initially seems to point to more success in relation to maintenance. This suggests that more intensive help, such as more frequent visits with a physician and a dietitian during the first 3 months might be an important step to help patients lose and maintain weight.

These 10 strategies can help guide patients to become successful "maintainers."

Much of our information on successful maintainers comes from the National Weight Control Registry (NWCR) at the Warren Alpert Medical School at Brown University.¹ This research study has gathered information from more than 10,000 people who successfully lost ≥ 30 lb (average, 60 lb) and kept it off for at least 1 year. To challenge the widespread belief that only a few people who attempt weight loss succeed long term, the NWCR identifies and investigates the characteristics of individuals who have succeeded.

A new and encouraging finding is from a small study that showed that people can maintain weight loss brought about by either medical or surgical means: Those who lost > 15% of their starting weight and were followed closely by health care professionals maintained their weight loss at 1 year.⁵

Continue to: 2. Advise patients to consume fewer calories and eat more nonglycemic fruits and vegetables

2. Advise patients to consume fewer calories and eat more nonglycemic fruits and vegetables

When a person loses weight, their basal metabolic rate drops; to maintain their new weight, they need to consume fewer calories. That person must continue to have a calorie deficit, which varies individually but is often about 500 kcal/d. There is no formula for this; at our clinic, when a patient achieves goal weight, we have them increase intake by 100 kcal/d/wk in nutritious food until they start to gain weight. When they start to gain weight, we have them decrease intake by 100 kcal/d until they do not gain any longer.

Many patients complain of hunger after they lose weight because of an increase in the body’s level of ghrelin, the hunger hormone, and a decrease in the level of leptin, which is associated with satiety. Many achieve a lower calorie count and fight hunger by increasing fiber intake.

In a 24-year study that looked at weight change, researchers noted a strong inverse association between increased intake of higher-fiber, lower-glycemic fruits and vegetables and weight change.⁶ Lower-glycemic vegetables include most vegetables (exceptions are corn, potatoes, and peas, which are associated with weight gain). Benefit was strongest with berries, apples, pears, tofu or soy, cauliflower, and cruciferous and green leafy vegetables.⁶ Adding 1 serving a day of nonstarchy fruits and vegetables was associated with less weight gain over time.

The order in which food is eaten might be important, as evidenced by a small study⁷ that ­focused on patients with diabetes. ­Investigators found that subjects who ate vegetables first, protein second, and grain third had fewer fluctuations in blood glucose level than those who ate carbohydrates first—­suggesting that this order might be a good way for patients to eat at least some of their meals. The reduced insulin excursions observed in this experimental setting suggest that the vegetable–protein–grain meal pattern can improve insulin sensitivity and help with blood glucose control.

3. Encourage patients to eat at home and to avoid processed foods

In a small, randomized controlled study⁸ in 2019 at the National Institutes of Health, 20 inpatients were fed an ultraprocessed diet that was matched, in calories and macronutrients, in an unprocessed diet fed to controls. Subjects in the ultraprocessed food group ate, on average, 500 kcal/d more and gained 2 lbs in 2 weeks. An ultraprocessed breakfast might consist of a bagel with cream cheese and turkey bacon; the unprocessed breakfast was oatmeal with bananas, walnuts, and skim milk. Notably, the ultraprocessed diet was cheaper; nonprocessed foods cost 50% more.

Continue to: A retrospective review...

Losing the most weight and making frequent office visits to a physician and dietitian early in weight loss can determine the success of maintenance later.

A retrospective review of a sample of US adults’ caloric and nutritional intake determined that eating at a full-service restaurant is not associated with consumption of fewer calories than eating at a fast food restaurant: Eating at either type of restaurant was associated with excess (approximately 200 kcal/meal) caloric intake.⁹

4. Emphasize the importance of eating breakfast and increasing protein intake

Increased protein throughout the day, particularly at breakfast, has been suggested to help with weight maintenance. In a large European study,¹⁰ even slightly increased protein intake (approximately 1.2 g/kg of body weight and of low glycemic index food) was associated with weight maintenance. In another review,¹¹ researchers concluded that 25 to 30 g of protein at each meal can provide improvement in appetite and weight management, although they cautioned that further research is needed. A study that looked at increasing intake of protein at breakfast to 35 g in adolescent females resulted in less snacking later in the day.¹²

In the NWCR, successful maintainers had breakfast daily, a lower fat diet, and fewer calories (approximately 1500 kcal/d)— routines that were all associated with greater success.¹ Therefore, eating protein at approximately 1.2 g/kg of body weight (possibly, even more [35 g] at breakfast) and ingesting less fat and fewer calories all contributed to successful maintenance. Eating nuts and legume-based proteins, such as beans and tofu, should be encouraged.

Only a few studies have looked at dairy protein intake and weight maintenance. In one study, consumption of dairy proteins was not associated with a change in body weight or other metabolic risk markers during weight maintenance.¹³ Yogurt, because of its probiotic content, might be good for weight maintenance, but this has not been studied well, and studies that have been conducted are inconclusive.¹⁴

Another study looked at consumption of protein supplements. It found no improvement in body composition over a 24-week period when protein intake was increased to 1.45 g/kg when compared to 1.16 g/kg in controls. Although subjects felt less hungry, this was not reflected in a reduction in caloric intake.¹⁵

Continue to: Most patients do need counseling...

Most patients do need counseling on whole grain intake: Explaining that a bagel is the same as 4 servings of toast and that a cup (ie, a fistful) of cooked pasta is 3 servings of grains is helpful. Patients should aim for 1 serving of grain at each meal; when shopping for grains, they should choose those that have the “whole” first on the list of ingredients because whole grain, rather than refined grain, intake is associated with less diabetes and colon cancer.¹⁶

5. Underscore the importance of self-monitoring

Self-monitoring is key to weight maintenance. This can mean weighing oneself or tracking one’s food intake (or both). Daily weighing is important: A study showed that patients who decrease how often they weigh themselves were likely to eat more and thus gain weight.¹⁷

Monitoring intake is also important. Recommended online calorie counters (eg, ­myfitnesspal.com, loseit.com), tools such as a Fitbit, or even keeping a food diary to help patients track intake. In a review of technology-based interventions to maintain weight loss, the use of apps was variable and effectiveness of devices was mixed. The authors recommended that physicians complement Web-based applications with personal contact.¹⁸

6. Encourage patients to spend more time exercising

After weight loss is achieved, maintaining a high level of activity is important. Recommendations focus on moving about 1 hr/d or 200 to 300 min/wk.¹⁹ A program of several daily “bouts,” or episodes of moderate-to-vigorous physical activity, is recommended in the new Centers for Disease Control and Prevention guidelines¹⁹ and might be preferable, or equivalent, to a concentrated expenditure of energy. Patients might consider, for example, a 10-minute session, 4 times a day, 5 days a week, instead of a ­single, 40-minute session, 5 days a week.¹⁹ Furthermore, to sustain weight loss, moderate exercise might be more effective than exercise of vigorous intensity or extended duration.¹⁹ Most patients in the NWCR report that walking is their principal form of activity.¹

Resistance training, which improves muscle strength and endurance, with or without diet restriction, has not been shown to be effective for weight loss but might help with weight maintenance and might improve a patient’s lipid profile, insulin resistance, and blood pressure. In obese adolescents, resistance weight training led to positive changes in body composition, such as decreased waist circumference.²⁰ Resistance training likely enhances weight maintenance and should be encouraged because of its effect on increasing lean muscle mass, the most important factor in determining basal metabolic rate.

Continue to: 7. Work with patients to ensure sound sleep hygiene

7. Work with patients to ensure sound sleep hygiene

Short sleep duration (< 6 hours a night) is associated with obesity. There are few studies on weight maintenance and sleep; a study that was reviewed by the NWCR found that people who are highly successful at both weight loss and long-term maintenance are more likely to (1) be categorized as a “morning-type” chronotype (ie, getting up early), and (2) report longer sleep duration and better sleep quality, compared to treatment-seeking overweight and obese subjects. Furthermore, these NWCR subjects were more likely to report shorter sleep latency (time required to fall asleep) and were less likely to report short sleep, defined as < 6 to 7 hours a night.²¹

Counsel patients to eat fewer calories, avoid highly processed foods, and increase protein intake—preferably by preparing food at home.

Patients should strive for 7 to 8 hours of sleep a night; sleep apnea should be addressed as necessary.¹⁷ It is important for doctors to encourage patients to go to bed and get up at the same times every day (eg, 10 pm to 6 am daily).

8. Start a trial of medical therapy

Weight-loss medicines are beyond the scope of this article but worth discussing. In accordance with obesity guidelines, if a patient responds well to a weight-loss medication and loses ≥ 5% of body weight after 3 months, continue prescribing the medication. If the medication is ineffective or the patient experiences adverse effects, stop the prescription and consider an alternative medication or approach to maintenance.

The US Food and Drug Administration has approved 5 medications for long-term use in weight maintenance: the 2 combination formulations bupropion–naltrexone and phentermine–topiramate, as well as liraglutide, lorcaserin, and orlistat. A review of the use of these drugs over 1 year showed that they provide a modest favorable effect on cardiometabolic outcomes that vary by drug class.²² In particular, liraglutide has been shown to reduce the risk of cardiovascular disease outcomes in patients with diabetes who have a history of atherosclerotic disease or heart attack and stroke.²³ Further research is needed to evaluate the long-term impact of these drugs on cardiovascular risk.

9. Address mental health challenges

Certain personal traits and behaviors appear to help people lose weight: In a study, maintainers were more likely to be characterized as being good problem-solvers, having hope, and having a more positive mood.^24,25

Continue to: Addressing mental health issues...

Addressing mental health issues, especially depression, is paramount in patients with obesity. Treating patients with depression and hopelessness, as well as helping them with problem-solving, should be the focus of weight-management care.

A retrospective review determined that eating at a full-service restaurant is not associated with consumption of fewer calories than eating at a fast food restaurant.

Choosing an antidepressant not associated with the adverse effect of weight gain is important. Almost all selective serotonin reuptake inhibitors and tricyclic antidepressants are associated with weight gain; bupropion is weight neutral and should be first-line treatment for patients who are overweight and obese.²⁶ If using an antidepressant associated with weight gain, initiate weight monitoring if the patient gains 3% of body weight in the first month of therapy. When caring for a patient who takes an antipsychotic, consider consulting with their mental health professional to determine the value of prescribing metformin, which has been shown to decrease weight gain associated with antipsychotics.²⁷

Because depression, anxiety, and attention deficit-hyperactivity disorder are all associated with obesity, it is important to work with obese patients’ mental health care providers to design ways to improve their care.

10. Encourage patients to modify old habits and adopt new ones

Focusing on establishing good habits can be helpful. In Great Britain, a program focused on forming new healthy habits and breaking old unhealthy habits by restructuring daily routines and increasing mindfulness was successful in keeping weight off in 65% of participants—an impressive degree of success.²⁴ Successful maintainers were sent daily text messages requesting that they interrupt their routines, which shifted their attention away from eating. Some of these distracting tasks included driving to work by a different route or volunteering for a charity. Such small changes helped improve weight maintenance.

Intuitive eating and mindfulness can help. New concepts that focus on healthy eating without caloric restriction are also emerging; one such approach is intuitive eating, which promotes eating that is based not only on cues connected to hunger and fullness, but also on enjoyment of food, such as eating slowly and savoring every bite.²⁸ Techniques such as sipping water or resting the fork between bites of food has been helpful with some patients. More research in the area of intuitive eating is needed.

Continue to: Recognizing true physiologic hunger...

Recognizing true physiologic hunger distinct from emotional hunger can improve with mindfulness training. This practice might provide a better way to help the so-called yo-yo dieter and binge eater to reach metabolic health. Interestingly, successful weight maintainers who allow themselves less restriction on weekends maintain weight better than those who try to restrict diet every day, according to a recent study.²⁹

Recommend a support group. Accountability is important: Group therapy in obesity treatment may be more effective than individual treatment.³⁰

The support of a group and the regular attendance at group meetings are connected to further significant weight loss in the weight-loss period and, later, during maintenance. Monthly meetings seem to help patients with weight maintenance but more research is needed to determine what interval of support-group meeting attendance is most effective.

CORRESPONDENCE
Marijane Hynes, MD, The George Washington University Medical Faculty Associates, Fifth Floor/Internal Medicine, 2150 Pennsylvania Avenue NW, Washington, DC 20037; mhynes@mfa.gwu.edu.

LAS VEGAS – Researchers have devised a risk calculator for patients with obesity and type 2 diabetes that can estimate their 10-year risk for death and cardiovascular disease events if their clinical status continues relatively unchanged, or if they opt to undergo bariatric surgery.

Mitchel L. Zoler/MDedge News

The Individualized Diabetes Complications risk score “can provide personalized, evidence-based risk information for patients with type 2 diabetes and obesity about their future cardiovascular disease outcomes and mortality with and without metabolic surgery,” Ali Aminian, MD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

Although the calculator needs validation in a prospective, randomized study to document its impact on practice, it is now available on two separate websites and as a downloadable app, said Dr. Aminian, a surgeon at the Cleveland Clinic.

The calculator inputs data for 26 distinct, “readily available” demographic and clinical entries, and based on that, estimates the patient’s 10-year risk for all-cause death, diabetic kidney disease, cerebrovascular disease, heart failure, and coronary artery disease if no surgery occurs or after some type of metabolic or bariatric surgery. The calculator does not currently have the ability to individualize predicted risks based on the specific type of metabolic surgery performed, but that is planned as a future refinement of the score.

“We validated the model in the nonsurgical patients, which showed it was very accurate. The next step is to run a randomized trial to see how useful the calculator is” for assisting in patients’ decision making, Dr. Aminian said.

The data for deriving the risk calculator, and for a preliminary validation of it, came from 13,722 patients with obesity (body mass index, 30 kg/m² or greater) and type 2 diabetes, who were managed at the Cleveland Clinic during 1998-2017, drawn from more than 287,000 such patients in the clinic’s database. The study focused on 2,287 patients who underwent metabolic (bariatric) surgery and 11,435 patients from the same database who did not have surgery and matched by propensity scoring on a 5:1 basis with those who had surgery. The two cohorts this created matched well for age (about 54 years), sex (about two-thirds women), BMI (about 44 kg/m²), and the prevalence of various comorbidities at baseline.

Dr. Aminian and associates then analyzed the incidence of all-cause mortality and various cardiovascular disease endpoints, as well as nephropathy during follow-up, through December 2018. Patients who had undergone metabolic surgery showed statistically significant reductions in the incidence of each of those events, compared with patients who did not have surgery (JAMA. 2019;322[13]:1271-82).The investigators used these findings to create their model for calculating a patient’s risk score. For example, to calculate an estimate for the 10-year risk from all-cause mortality, the results showed that the most powerful risk factors were age, baseline body mass index, heart failure, need for insulin, and smoking status. For the endpoint of nephropathy, the most important factors were estimated glomerular filtration rate at baseline and age. Identified risk factors could account for about 80% of the 10-year risk for all-cause death and for about 75% of the risk for developing nephropathy during 10 years, based on the area-under-the-curve values the model produced.

The calculator is available at a website maintained by the Cleveland Clinic, at a site of the American Society for Metabolic and Bariatric Surgery, and in app stores, he said.

The work was partially funded by Medtronic. Dr. Aminian has received grants from Medtronic.

The AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper provides physicians with a comprehensive, multidisciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at www.gastro.org/obesity.

mzoler@mdedge.com

SOURCE: Aminian A et al. Obesity Week 2019, Abstract A101.

LAS VEGAS – Researchers have devised a risk calculator for patients with obesity and type 2 diabetes that can estimate their 10-year risk for death and cardiovascular disease events if their clinical status continues relatively unchanged, or if they opt to undergo bariatric surgery.

Mitchel L. Zoler/MDedge News

The Individualized Diabetes Complications risk score “can provide personalized, evidence-based risk information for patients with type 2 diabetes and obesity about their future cardiovascular disease outcomes and mortality with and without metabolic surgery,” Ali Aminian, MD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

Although the calculator needs validation in a prospective, randomized study to document its impact on practice, it is now available on two separate websites and as a downloadable app, said Dr. Aminian, a surgeon at the Cleveland Clinic.

The calculator inputs data for 26 distinct, “readily available” demographic and clinical entries, and based on that, estimates the patient’s 10-year risk for all-cause death, diabetic kidney disease, cerebrovascular disease, heart failure, and coronary artery disease if no surgery occurs or after some type of metabolic or bariatric surgery. The calculator does not currently have the ability to individualize predicted risks based on the specific type of metabolic surgery performed, but that is planned as a future refinement of the score.

“We validated the model in the nonsurgical patients, which showed it was very accurate. The next step is to run a randomized trial to see how useful the calculator is” for assisting in patients’ decision making, Dr. Aminian said.

The data for deriving the risk calculator, and for a preliminary validation of it, came from 13,722 patients with obesity (body mass index, 30 kg/m² or greater) and type 2 diabetes, who were managed at the Cleveland Clinic during 1998-2017, drawn from more than 287,000 such patients in the clinic’s database. The study focused on 2,287 patients who underwent metabolic (bariatric) surgery and 11,435 patients from the same database who did not have surgery and matched by propensity scoring on a 5:1 basis with those who had surgery. The two cohorts this created matched well for age (about 54 years), sex (about two-thirds women), BMI (about 44 kg/m²), and the prevalence of various comorbidities at baseline.

Dr. Aminian and associates then analyzed the incidence of all-cause mortality and various cardiovascular disease endpoints, as well as nephropathy during follow-up, through December 2018. Patients who had undergone metabolic surgery showed statistically significant reductions in the incidence of each of those events, compared with patients who did not have surgery (JAMA. 2019;322[13]:1271-82).The investigators used these findings to create their model for calculating a patient’s risk score. For example, to calculate an estimate for the 10-year risk from all-cause mortality, the results showed that the most powerful risk factors were age, baseline body mass index, heart failure, need for insulin, and smoking status. For the endpoint of nephropathy, the most important factors were estimated glomerular filtration rate at baseline and age. Identified risk factors could account for about 80% of the 10-year risk for all-cause death and for about 75% of the risk for developing nephropathy during 10 years, based on the area-under-the-curve values the model produced.

The calculator is available at a website maintained by the Cleveland Clinic, at a site of the American Society for Metabolic and Bariatric Surgery, and in app stores, he said.

The work was partially funded by Medtronic. Dr. Aminian has received grants from Medtronic.

The AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper provides physicians with a comprehensive, multidisciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at www.gastro.org/obesity.

mzoler@mdedge.com

SOURCE: Aminian A et al. Obesity Week 2019, Abstract A101.

LAS VEGAS – Researchers have devised a risk calculator for patients with obesity and type 2 diabetes that can estimate their 10-year risk for death and cardiovascular disease events if their clinical status continues relatively unchanged, or if they opt to undergo bariatric surgery.

Mitchel L. Zoler/MDedge News

The Individualized Diabetes Complications risk score “can provide personalized, evidence-based risk information for patients with type 2 diabetes and obesity about their future cardiovascular disease outcomes and mortality with and without metabolic surgery,” Ali Aminian, MD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.

Although the calculator needs validation in a prospective, randomized study to document its impact on practice, it is now available on two separate websites and as a downloadable app, said Dr. Aminian, a surgeon at the Cleveland Clinic.

The calculator inputs data for 26 distinct, “readily available” demographic and clinical entries, and based on that, estimates the patient’s 10-year risk for all-cause death, diabetic kidney disease, cerebrovascular disease, heart failure, and coronary artery disease if no surgery occurs or after some type of metabolic or bariatric surgery. The calculator does not currently have the ability to individualize predicted risks based on the specific type of metabolic surgery performed, but that is planned as a future refinement of the score.

“We validated the model in the nonsurgical patients, which showed it was very accurate. The next step is to run a randomized trial to see how useful the calculator is” for assisting in patients’ decision making, Dr. Aminian said.

The data for deriving the risk calculator, and for a preliminary validation of it, came from 13,722 patients with obesity (body mass index, 30 kg/m² or greater) and type 2 diabetes, who were managed at the Cleveland Clinic during 1998-2017, drawn from more than 287,000 such patients in the clinic’s database. The study focused on 2,287 patients who underwent metabolic (bariatric) surgery and 11,435 patients from the same database who did not have surgery and matched by propensity scoring on a 5:1 basis with those who had surgery. The two cohorts this created matched well for age (about 54 years), sex (about two-thirds women), BMI (about 44 kg/m²), and the prevalence of various comorbidities at baseline.

Dr. Aminian and associates then analyzed the incidence of all-cause mortality and various cardiovascular disease endpoints, as well as nephropathy during follow-up, through December 2018. Patients who had undergone metabolic surgery showed statistically significant reductions in the incidence of each of those events, compared with patients who did not have surgery (JAMA. 2019;322[13]:1271-82).The investigators used these findings to create their model for calculating a patient’s risk score. For example, to calculate an estimate for the 10-year risk from all-cause mortality, the results showed that the most powerful risk factors were age, baseline body mass index, heart failure, need for insulin, and smoking status. For the endpoint of nephropathy, the most important factors were estimated glomerular filtration rate at baseline and age. Identified risk factors could account for about 80% of the 10-year risk for all-cause death and for about 75% of the risk for developing nephropathy during 10 years, based on the area-under-the-curve values the model produced.

The calculator is available at a website maintained by the Cleveland Clinic, at a site of the American Society for Metabolic and Bariatric Surgery, and in app stores, he said.

The work was partially funded by Medtronic. Dr. Aminian has received grants from Medtronic.

The AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper provides physicians with a comprehensive, multidisciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at www.gastro.org/obesity.

mzoler@mdedge.com

SOURCE: Aminian A et al. Obesity Week 2019, Abstract A101.

Young people treated with bariatric surgery for severe obesity did not experience better mental health in the 5 years following their procedures, Swedish researchers said, and indeed fared worse than their nontreated peers on certain measures.

The results of this study do not necessarily argue “that metabolic and bariatric surgery during adolescence causes mental health problems,” the investigators wrote in the Lancet Child and Adolescent Health, but “it is reasonable to conclude that metabolic and bariatric surgery does not result in a substantial alleviation of mental health problems in adolescents with severe obesity,” and that “long-term mental health support should be required in programs providing adolescent metabolic and bariatric surgery.”

Kajsa Järvholm, PhD, of Skåne University Hospital, in Malmö, Sweden, and colleagues reported results from a prospective nonrandomized study that recruited 81 adolescents in Sweden aged 13-18 years (mean age, 16.5) who had a body mass index of 40 or higher, or BMI of 35 with obesity-related comorbidities and who underwent Roux-en-Y gastric bypass for weight loss. Subjects were matched by age, sex, and BMI to 80 controls (mean age, 15.8 years) who were assigned to conventional nonsurgical treatment. All patients were assessed at 1, 2, and 5 years.

Although mental health treatment, including use of psychiatric drugs, did not differ between the groups at baseline, during the follow-up period the subjects who underwent surgery saw 15% more impatient and outpatient mental health treatment, compared with controls, a significant difference. About a quarter of patients in the surgically treated group required specialized mental health treatment for the first time after their surgeries.

Though the surgical group lost much more weight – mean BMI was 32.3 at 5 years, compared with 41.7 for controls – none of the mental health changes from baseline were significantly associated with percentage change of BMI at 5 years.

The findings from the study are consistent with results from studies in adults in which bariatric surgery improves many health outcomes but does not alter the need for mental health treatment. Although 5 years is a longer follow-up than in previous studies in young patients – a key strength of the study – Dr. Järvholm and colleagues acknowledged some weaknesses, including a nonrandomized design, lack of a comparison group of nonobese youths for mental health measures, a small sample size, and a surgical procedure that is now out of favor in adolescents.

The study was funded by Swedish government and health foundations. Dr. Järvholm disclosed pharmaceutical industry funding not related to the study, and three coauthors also disclosed industry relationships.

SOURCE: Järvholm K et al. Lancet Child Adolesc Health. 2020. doi: 10.1016/s2352-4642(20)30024-9.

Young people treated with bariatric surgery for severe obesity did not experience better mental health in the 5 years following their procedures, Swedish researchers said, and indeed fared worse than their nontreated peers on certain measures.

The results of this study do not necessarily argue “that metabolic and bariatric surgery during adolescence causes mental health problems,” the investigators wrote in the Lancet Child and Adolescent Health, but “it is reasonable to conclude that metabolic and bariatric surgery does not result in a substantial alleviation of mental health problems in adolescents with severe obesity,” and that “long-term mental health support should be required in programs providing adolescent metabolic and bariatric surgery.”

Kajsa Järvholm, PhD, of Skåne University Hospital, in Malmö, Sweden, and colleagues reported results from a prospective nonrandomized study that recruited 81 adolescents in Sweden aged 13-18 years (mean age, 16.5) who had a body mass index of 40 or higher, or BMI of 35 with obesity-related comorbidities and who underwent Roux-en-Y gastric bypass for weight loss. Subjects were matched by age, sex, and BMI to 80 controls (mean age, 15.8 years) who were assigned to conventional nonsurgical treatment. All patients were assessed at 1, 2, and 5 years.

Although mental health treatment, including use of psychiatric drugs, did not differ between the groups at baseline, during the follow-up period the subjects who underwent surgery saw 15% more impatient and outpatient mental health treatment, compared with controls, a significant difference. About a quarter of patients in the surgically treated group required specialized mental health treatment for the first time after their surgeries.

Though the surgical group lost much more weight – mean BMI was 32.3 at 5 years, compared with 41.7 for controls – none of the mental health changes from baseline were significantly associated with percentage change of BMI at 5 years.

The findings from the study are consistent with results from studies in adults in which bariatric surgery improves many health outcomes but does not alter the need for mental health treatment. Although 5 years is a longer follow-up than in previous studies in young patients – a key strength of the study – Dr. Järvholm and colleagues acknowledged some weaknesses, including a nonrandomized design, lack of a comparison group of nonobese youths for mental health measures, a small sample size, and a surgical procedure that is now out of favor in adolescents.

The study was funded by Swedish government and health foundations. Dr. Järvholm disclosed pharmaceutical industry funding not related to the study, and three coauthors also disclosed industry relationships.

SOURCE: Järvholm K et al. Lancet Child Adolesc Health. 2020. doi: 10.1016/s2352-4642(20)30024-9.

Young people treated with bariatric surgery for severe obesity did not experience better mental health in the 5 years following their procedures, Swedish researchers said, and indeed fared worse than their nontreated peers on certain measures.

The results of this study do not necessarily argue “that metabolic and bariatric surgery during adolescence causes mental health problems,” the investigators wrote in the Lancet Child and Adolescent Health, but “it is reasonable to conclude that metabolic and bariatric surgery does not result in a substantial alleviation of mental health problems in adolescents with severe obesity,” and that “long-term mental health support should be required in programs providing adolescent metabolic and bariatric surgery.”

Kajsa Järvholm, PhD, of Skåne University Hospital, in Malmö, Sweden, and colleagues reported results from a prospective nonrandomized study that recruited 81 adolescents in Sweden aged 13-18 years (mean age, 16.5) who had a body mass index of 40 or higher, or BMI of 35 with obesity-related comorbidities and who underwent Roux-en-Y gastric bypass for weight loss. Subjects were matched by age, sex, and BMI to 80 controls (mean age, 15.8 years) who were assigned to conventional nonsurgical treatment. All patients were assessed at 1, 2, and 5 years.

Although mental health treatment, including use of psychiatric drugs, did not differ between the groups at baseline, during the follow-up period the subjects who underwent surgery saw 15% more impatient and outpatient mental health treatment, compared with controls, a significant difference. About a quarter of patients in the surgically treated group required specialized mental health treatment for the first time after their surgeries.

Though the surgical group lost much more weight – mean BMI was 32.3 at 5 years, compared with 41.7 for controls – none of the mental health changes from baseline were significantly associated with percentage change of BMI at 5 years.

The findings from the study are consistent with results from studies in adults in which bariatric surgery improves many health outcomes but does not alter the need for mental health treatment. Although 5 years is a longer follow-up than in previous studies in young patients – a key strength of the study – Dr. Järvholm and colleagues acknowledged some weaknesses, including a nonrandomized design, lack of a comparison group of nonobese youths for mental health measures, a small sample size, and a surgical procedure that is now out of favor in adolescents.

The study was funded by Swedish government and health foundations. Dr. Järvholm disclosed pharmaceutical industry funding not related to the study, and three coauthors also disclosed industry relationships.

SOURCE: Järvholm K et al. Lancet Child Adolesc Health. 2020. doi: 10.1016/s2352-4642(20)30024-9.

Risk for preterm birth in women with prepregancy obesity differs significantly by the mother’s age and race/ethnicity, according to new findings from an analysis that used a large, ethnically diverse population sample.

Previous study findings have demonstrated that pregnant women with obesity have a higher risk of giving birth to preterm babies, but the effect of age and race on that risk was not clear until now.

In this latest study, Wei Bao, MD, and colleagues at the University of Iowa, Iowa City, looked at records from 7.14 million live births registered in the U.S. National Vital Statistics System for 2016 and 2017, of which about 7.4% were preterm. The researchers excluded from their sample women with preexisting diabetes or hypertension.

For the cohort overall, there was a significant association between prepregnancy body mass index and preterm birth, with mothers who were overweight (adjusted odds ratio, 1.02; 95% confidence interval, 1.01–1.03) or obese (aOR, 1.18; 95%CI, 1.18–1.19), having a significantly higher risk of preterm birth, compared with healthy weight mothers. Underweight women also had a greater risk of preterm birth, compared with the healthy weight references (aOR, 1.33; 95% CI, 1.31–1.35), the researchers reported, adding that the association between maternal underweight and preterm birth was consistent across the maternal age and race/ethnicity groups.

Dr. Bao and colleagues found that, among non-Hispanic white women (who made up about half the cohort), maternal obesity was inversely associated with preterm birth when mothers were younger than 20 years (aOR, 0.92; 95% CI, 0.88-0.97), but there was a crossover effect at age 20, when maternal obesity became positively associated with preterm birth until age 39 (aOR, 1.04 at ages 20-24, to 1.40 at ages 35-39). A similar pattern was seen in Hispanic women, for whom maternal obesity was not associated with preterm birth when they were younger than 20 (aOR, 0.98; 95% CI, 0.93-1.04), but was positively associated with preterm birth after age 20 until age 39 (aOR, 1.06 at ages 20-24, to 1.38 at ages 35-39).

However, the crossover effect occurred considerably later in black women with obesity, for whom maternal obesity remained inversely associated with preterm birth until age 30 (aOR, 0.76 before age 20; 0.83 at ages 20-24; 0.98 at ages 25-29), at which point the crossover effect kicked in, and maternal obesity became positively associated with preterm birth, increasing steadily with advancing age (aOR, 1.15 at ages 30-34; 1.26 at ages 35-39; 1.29 from age 40). “Our results, which are based on a large and diverse U.S. population, provide, for the first time, a comprehensive review of the association between maternal obesity and preterm birth for women [at a] range of ages,” Dr. Bao and colleagues wrote in their analysis, which was published in Lancet Diabetes & Endocrinology.

The researchers hypothesized that the inverse association between prepregnancy obesity and preterm birth in teenagers and younger women could be explained by the fact that “[healthy weight] teenagers, who are still growing and developing, might compete with the fetus for nutrients, which could subsequently affect physiological and metabolic systems involved with parturition,” whereas pregnant teenagers with obesity “might not need to compete (or compete to a lesser extent) for nutrients with their babies for their own growth.” The researchers stressed that more research was needed to understand the underlying mechanisms of the associations. The findings of a protective effect until age 30 in black women also require further study, Dr. Bao and colleagues said.

They stressed that the findings do not argue for weight gain as a preventive measure against preterm birth for normal weight young women, as “younger women, whether obese or not, have a higher risk of preterm birth than women aged 25-29 years do in Hispanic and in non-Hispanic white populations. Additionally, the adverse effects that maternal obesity has on other perinatal and neonatal outcomes should not be overlooked.”

The National Institutes of Health funded the study. The authors declared no conflicts of interest.

SOURCE: Bao et al. Lancet Diabetes Endocrinol. 2019;7:707-14.

Risk for preterm birth in women with prepregancy obesity differs significantly by the mother’s age and race/ethnicity, according to new findings from an analysis that used a large, ethnically diverse population sample.

Previous study findings have demonstrated that pregnant women with obesity have a higher risk of giving birth to preterm babies, but the effect of age and race on that risk was not clear until now.

In this latest study, Wei Bao, MD, and colleagues at the University of Iowa, Iowa City, looked at records from 7.14 million live births registered in the U.S. National Vital Statistics System for 2016 and 2017, of which about 7.4% were preterm. The researchers excluded from their sample women with preexisting diabetes or hypertension.

For the cohort overall, there was a significant association between prepregnancy body mass index and preterm birth, with mothers who were overweight (adjusted odds ratio, 1.02; 95% confidence interval, 1.01–1.03) or obese (aOR, 1.18; 95%CI, 1.18–1.19), having a significantly higher risk of preterm birth, compared with healthy weight mothers. Underweight women also had a greater risk of preterm birth, compared with the healthy weight references (aOR, 1.33; 95% CI, 1.31–1.35), the researchers reported, adding that the association between maternal underweight and preterm birth was consistent across the maternal age and race/ethnicity groups.

Dr. Bao and colleagues found that, among non-Hispanic white women (who made up about half the cohort), maternal obesity was inversely associated with preterm birth when mothers were younger than 20 years (aOR, 0.92; 95% CI, 0.88-0.97), but there was a crossover effect at age 20, when maternal obesity became positively associated with preterm birth until age 39 (aOR, 1.04 at ages 20-24, to 1.40 at ages 35-39). A similar pattern was seen in Hispanic women, for whom maternal obesity was not associated with preterm birth when they were younger than 20 (aOR, 0.98; 95% CI, 0.93-1.04), but was positively associated with preterm birth after age 20 until age 39 (aOR, 1.06 at ages 20-24, to 1.38 at ages 35-39).

However, the crossover effect occurred considerably later in black women with obesity, for whom maternal obesity remained inversely associated with preterm birth until age 30 (aOR, 0.76 before age 20; 0.83 at ages 20-24; 0.98 at ages 25-29), at which point the crossover effect kicked in, and maternal obesity became positively associated with preterm birth, increasing steadily with advancing age (aOR, 1.15 at ages 30-34; 1.26 at ages 35-39; 1.29 from age 40). “Our results, which are based on a large and diverse U.S. population, provide, for the first time, a comprehensive review of the association between maternal obesity and preterm birth for women [at a] range of ages,” Dr. Bao and colleagues wrote in their analysis, which was published in Lancet Diabetes & Endocrinology.

The researchers hypothesized that the inverse association between prepregnancy obesity and preterm birth in teenagers and younger women could be explained by the fact that “[healthy weight] teenagers, who are still growing and developing, might compete with the fetus for nutrients, which could subsequently affect physiological and metabolic systems involved with parturition,” whereas pregnant teenagers with obesity “might not need to compete (or compete to a lesser extent) for nutrients with their babies for their own growth.” The researchers stressed that more research was needed to understand the underlying mechanisms of the associations. The findings of a protective effect until age 30 in black women also require further study, Dr. Bao and colleagues said.

They stressed that the findings do not argue for weight gain as a preventive measure against preterm birth for normal weight young women, as “younger women, whether obese or not, have a higher risk of preterm birth than women aged 25-29 years do in Hispanic and in non-Hispanic white populations. Additionally, the adverse effects that maternal obesity has on other perinatal and neonatal outcomes should not be overlooked.”

The National Institutes of Health funded the study. The authors declared no conflicts of interest.

SOURCE: Bao et al. Lancet Diabetes Endocrinol. 2019;7:707-14.

Risk for preterm birth in women with prepregancy obesity differs significantly by the mother’s age and race/ethnicity, according to new findings from an analysis that used a large, ethnically diverse population sample.

Previous study findings have demonstrated that pregnant women with obesity have a higher risk of giving birth to preterm babies, but the effect of age and race on that risk was not clear until now.

In this latest study, Wei Bao, MD, and colleagues at the University of Iowa, Iowa City, looked at records from 7.14 million live births registered in the U.S. National Vital Statistics System for 2016 and 2017, of which about 7.4% were preterm. The researchers excluded from their sample women with preexisting diabetes or hypertension.

For the cohort overall, there was a significant association between prepregnancy body mass index and preterm birth, with mothers who were overweight (adjusted odds ratio, 1.02; 95% confidence interval, 1.01–1.03) or obese (aOR, 1.18; 95%CI, 1.18–1.19), having a significantly higher risk of preterm birth, compared with healthy weight mothers. Underweight women also had a greater risk of preterm birth, compared with the healthy weight references (aOR, 1.33; 95% CI, 1.31–1.35), the researchers reported, adding that the association between maternal underweight and preterm birth was consistent across the maternal age and race/ethnicity groups.

Dr. Bao and colleagues found that, among non-Hispanic white women (who made up about half the cohort), maternal obesity was inversely associated with preterm birth when mothers were younger than 20 years (aOR, 0.92; 95% CI, 0.88-0.97), but there was a crossover effect at age 20, when maternal obesity became positively associated with preterm birth until age 39 (aOR, 1.04 at ages 20-24, to 1.40 at ages 35-39). A similar pattern was seen in Hispanic women, for whom maternal obesity was not associated with preterm birth when they were younger than 20 (aOR, 0.98; 95% CI, 0.93-1.04), but was positively associated with preterm birth after age 20 until age 39 (aOR, 1.06 at ages 20-24, to 1.38 at ages 35-39).

However, the crossover effect occurred considerably later in black women with obesity, for whom maternal obesity remained inversely associated with preterm birth until age 30 (aOR, 0.76 before age 20; 0.83 at ages 20-24; 0.98 at ages 25-29), at which point the crossover effect kicked in, and maternal obesity became positively associated with preterm birth, increasing steadily with advancing age (aOR, 1.15 at ages 30-34; 1.26 at ages 35-39; 1.29 from age 40). “Our results, which are based on a large and diverse U.S. population, provide, for the first time, a comprehensive review of the association between maternal obesity and preterm birth for women [at a] range of ages,” Dr. Bao and colleagues wrote in their analysis, which was published in Lancet Diabetes & Endocrinology.

The researchers hypothesized that the inverse association between prepregnancy obesity and preterm birth in teenagers and younger women could be explained by the fact that “[healthy weight] teenagers, who are still growing and developing, might compete with the fetus for nutrients, which could subsequently affect physiological and metabolic systems involved with parturition,” whereas pregnant teenagers with obesity “might not need to compete (or compete to a lesser extent) for nutrients with their babies for their own growth.” The researchers stressed that more research was needed to understand the underlying mechanisms of the associations. The findings of a protective effect until age 30 in black women also require further study, Dr. Bao and colleagues said.

They stressed that the findings do not argue for weight gain as a preventive measure against preterm birth for normal weight young women, as “younger women, whether obese or not, have a higher risk of preterm birth than women aged 25-29 years do in Hispanic and in non-Hispanic white populations. Additionally, the adverse effects that maternal obesity has on other perinatal and neonatal outcomes should not be overlooked.”

The National Institutes of Health funded the study. The authors declared no conflicts of interest.

SOURCE: Bao et al. Lancet Diabetes Endocrinol. 2019;7:707-14.