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Clinic goes to bat for bullied kids
NEW ORLEANS – After Massachusetts passed antibullying legislation in 2009, Peter C. Raffalli, MD, saw an opportunity to improve care for the increasing numbers of children presenting to his neurology practice at Boston Children’s Hospital who were victims of bullying – especially those with developmental disabilities.
“I had been thinking of a clinic to help kids with these issues, aside from just helping them deal with the fallout: the depression, anxiety, et cetera, that comes with being bullied,” Dr. Raffalli recalled at the annual meeting of the American Academy of Pediatrics. “I wanted to do something to help present to families the evidence-based strategies regarding bullying prevention, detection, and intervention that might help to stop the bullying.”
This led him to launch the Bullying and Cyberbullying Prevention and Advocacy Collaborative (BACPAC) at Boston Children’s Hospital, which began in 2009 as an educational resource for families, medical colleagues, and schools. Dr. Raffalli also formed an alliance with the Massachusetts Aggression Reduction Center at Bridgewater State University (Ann Neurol. 2016;79[2]:167-8).
Two years later in 2011, BACPAC became a formal clinic at Boston Children’s that serves as a subspecialty consult service for victims of bullying and their families. The clinic team consists of a child neurologist, a social worker, and an education resource specialist who meet with the bullying victim and his/her family in initial consultation for 90 minutes. The goal is to develop an evidence-based plan for bullying prevention, detection, and intervention that is individualized to the patient’s developmental and social needs.
“We tell families that bullying is recognized medically and legally as a form of abuse,” said Dr. Raffalli. “The medical and psychological consequences are similar to other forms of abuse. You’d be surprised how often patients do think the bullying is their fault.”
The extent of the problem
Researchers estimate that 25%-30% of children will experience some form of bullying between kindergarten and grade 12, and about 8% will engage in bullying themselves. When BACPAC began in 2009, Dr. Raffalli conducted an informal search of peer-reviewed literature on bullying in children with special needs; it yielded just four articles. “Since then, there’s been an exponential explosion of literature on various aspects of bullying,” he said. Now there is ample evidence in the peer-reviewed literature to show the increased risk for bullying/cyberbullying in children/teens, not just with neurodevelopmental disorders, but also for kids with other medical disorders such as obesity, asthma, and allergies.
“We’ve had a good number of kids over the years with peanut allergy who were literally threatened physically with peanut butter at school,” he said. “It’s incredible how callous some kids can be. Kids with oppositional defiant disorder, impulse control disorder, and callous/unemotional traits from a psychological standpoint are hardest to reach when it comes to getting them to stop bullying. You’d be surprised how frequently bullies use the phrase [to their victims], ‘You should kill yourself.’ They don’t realize the damage they’re doing to people. Bullying can lead to severe psychological but also long-term medical problems, including suicidal ideation.”
Published studies show that the highest incidences of bullying occur in children with neurodevelopmental conditions such as ADHD, autistic spectrum disorders, Tourette syndrome, and other learning disabilities (Eur J Spec Needs Ed. 2010;25[1]:77-91). This population of children is overrepresented in bullying “because the services they receive at school make their disabilities more visible,” explained Dr. Raffalli, who is also an assistant professor of neurology at Harvard Medical School, Boston. “They stand out, and they have social information–processing deficits or distortions that exacerbate bullying involvement. They also have difficulty interpreting social cues or attributing hostile characteristics to their peer’s behavior.”
The consequences of bullying
The psychological and educational consequences of bullying among children in general include being more likely to develop depression, loneliness, low self-esteem, alcohol and drug abuse, sleeping difficulties, self-harm, and suicidal ideation and attempts. “We’re social creatures, and when we don’t have those social connections, we get very depressed.”
Bullying victims also are more likely to develop school avoidance and absence, decreased school performance, poor concentration, high anxiety, and social withdrawal – all of which limit their opportunities to learn. “The No. 1 thing you can do to help these kids is to believe their story – to explain to them that it’s not their fault, and to explain that you are there for them and that you support them,” he said. “When a kid gets the feeling that someone is willing to listen to them and believe them, it does an enormous good for their emotional state.”
Dr. Raffalli added that a toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity – such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship – without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment well into the adult years.
In the Harvard Review of Psychiatry, researchers set out to investigate what’s known about the long-term health effects of childhood bullying. They found that bullying can induce “aspects of the stress response, via epigenetic, inflammatory, and metabolic mediators [that] have the capacity to compromise mental and physical health, and to increase the risk of disease.” The researchers advised clinicians who care for children to assess the mental and physical health effects of bullying (Harv Rev Psychiatry. 2017;25[2]:89-95).
Additional vulnerabilities for bullying victims include parents and children whose primary language is not English, as well as parents with mental illness or substance abuse and families living in poverty. “We have to keep in mind how much additional stress they may be dealing with. This can make it harder for them to cope. Bullies also are shown to be at higher risk for psychological and legal trouble into adulthood, so we should be trying to help them too. We have to keep in mind that these are all developing kids.”
Cyberbullying
In Dr. Raffalli’s clinical experience, cyberbullying has become the bully’s weapon of choice. “I call it the stealth bomber of bullying,” he said. “Cyberbullying can start as early as the second or third grade. Most parents are not giving phones to second-graders. I’m worried that it’s going to get worse, though, with the excuse that ‘I feel safer if they have a cell phone so they can call me.’ I tell parents that they still make flip phones. You don’t have to get a smartphone for a second- or third-grader, or even for a sixth-grader.”
By the time kids reach fourth and fifth grade, he continued, they begin to form their opinion “about what they believe is cool and not cool, and they begin to get into cliques that have similar beliefs, and support each other, and may break off from old friends.” He added that, while adult predation “makes the news and is certainly something we should all be concerned about, the incidence of being harassed and bullied by someone in your own age group at school is actually much higher and still has serious outcomes, including the possibility of death.”
The Massachusetts antibullying law stipulates that all teachers and all school personnel have to participate in mandatory bullying training. Schools also are required to draft and follow a bullying investigative protocol.
“Apparently the schools have all done this, yet the number of times that schools use interventions that are not advisable, such as mediation, is incredible to me,” Dr. Raffalli said. “Bringing the bully and the victim together for a ‘cup of coffee and a handshake’ is not advisable. Mediation has been shown in a number of studies to be detrimental in bullying situations. Things can easily get worse.”
Often, family members who bring their child to the BACPAC “feel that their child’s school is not helping them,” he said. “We should try to figure out why those schools are having such a hard time and see if we can help them.”
Dr. Raffalli reported having no financial disclosures.
NEW ORLEANS – After Massachusetts passed antibullying legislation in 2009, Peter C. Raffalli, MD, saw an opportunity to improve care for the increasing numbers of children presenting to his neurology practice at Boston Children’s Hospital who were victims of bullying – especially those with developmental disabilities.
“I had been thinking of a clinic to help kids with these issues, aside from just helping them deal with the fallout: the depression, anxiety, et cetera, that comes with being bullied,” Dr. Raffalli recalled at the annual meeting of the American Academy of Pediatrics. “I wanted to do something to help present to families the evidence-based strategies regarding bullying prevention, detection, and intervention that might help to stop the bullying.”
This led him to launch the Bullying and Cyberbullying Prevention and Advocacy Collaborative (BACPAC) at Boston Children’s Hospital, which began in 2009 as an educational resource for families, medical colleagues, and schools. Dr. Raffalli also formed an alliance with the Massachusetts Aggression Reduction Center at Bridgewater State University (Ann Neurol. 2016;79[2]:167-8).
Two years later in 2011, BACPAC became a formal clinic at Boston Children’s that serves as a subspecialty consult service for victims of bullying and their families. The clinic team consists of a child neurologist, a social worker, and an education resource specialist who meet with the bullying victim and his/her family in initial consultation for 90 minutes. The goal is to develop an evidence-based plan for bullying prevention, detection, and intervention that is individualized to the patient’s developmental and social needs.
“We tell families that bullying is recognized medically and legally as a form of abuse,” said Dr. Raffalli. “The medical and psychological consequences are similar to other forms of abuse. You’d be surprised how often patients do think the bullying is their fault.”
The extent of the problem
Researchers estimate that 25%-30% of children will experience some form of bullying between kindergarten and grade 12, and about 8% will engage in bullying themselves. When BACPAC began in 2009, Dr. Raffalli conducted an informal search of peer-reviewed literature on bullying in children with special needs; it yielded just four articles. “Since then, there’s been an exponential explosion of literature on various aspects of bullying,” he said. Now there is ample evidence in the peer-reviewed literature to show the increased risk for bullying/cyberbullying in children/teens, not just with neurodevelopmental disorders, but also for kids with other medical disorders such as obesity, asthma, and allergies.
“We’ve had a good number of kids over the years with peanut allergy who were literally threatened physically with peanut butter at school,” he said. “It’s incredible how callous some kids can be. Kids with oppositional defiant disorder, impulse control disorder, and callous/unemotional traits from a psychological standpoint are hardest to reach when it comes to getting them to stop bullying. You’d be surprised how frequently bullies use the phrase [to their victims], ‘You should kill yourself.’ They don’t realize the damage they’re doing to people. Bullying can lead to severe psychological but also long-term medical problems, including suicidal ideation.”
Published studies show that the highest incidences of bullying occur in children with neurodevelopmental conditions such as ADHD, autistic spectrum disorders, Tourette syndrome, and other learning disabilities (Eur J Spec Needs Ed. 2010;25[1]:77-91). This population of children is overrepresented in bullying “because the services they receive at school make their disabilities more visible,” explained Dr. Raffalli, who is also an assistant professor of neurology at Harvard Medical School, Boston. “They stand out, and they have social information–processing deficits or distortions that exacerbate bullying involvement. They also have difficulty interpreting social cues or attributing hostile characteristics to their peer’s behavior.”
The consequences of bullying
The psychological and educational consequences of bullying among children in general include being more likely to develop depression, loneliness, low self-esteem, alcohol and drug abuse, sleeping difficulties, self-harm, and suicidal ideation and attempts. “We’re social creatures, and when we don’t have those social connections, we get very depressed.”
Bullying victims also are more likely to develop school avoidance and absence, decreased school performance, poor concentration, high anxiety, and social withdrawal – all of which limit their opportunities to learn. “The No. 1 thing you can do to help these kids is to believe their story – to explain to them that it’s not their fault, and to explain that you are there for them and that you support them,” he said. “When a kid gets the feeling that someone is willing to listen to them and believe them, it does an enormous good for their emotional state.”
Dr. Raffalli added that a toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity – such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship – without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment well into the adult years.
In the Harvard Review of Psychiatry, researchers set out to investigate what’s known about the long-term health effects of childhood bullying. They found that bullying can induce “aspects of the stress response, via epigenetic, inflammatory, and metabolic mediators [that] have the capacity to compromise mental and physical health, and to increase the risk of disease.” The researchers advised clinicians who care for children to assess the mental and physical health effects of bullying (Harv Rev Psychiatry. 2017;25[2]:89-95).
Additional vulnerabilities for bullying victims include parents and children whose primary language is not English, as well as parents with mental illness or substance abuse and families living in poverty. “We have to keep in mind how much additional stress they may be dealing with. This can make it harder for them to cope. Bullies also are shown to be at higher risk for psychological and legal trouble into adulthood, so we should be trying to help them too. We have to keep in mind that these are all developing kids.”
Cyberbullying
In Dr. Raffalli’s clinical experience, cyberbullying has become the bully’s weapon of choice. “I call it the stealth bomber of bullying,” he said. “Cyberbullying can start as early as the second or third grade. Most parents are not giving phones to second-graders. I’m worried that it’s going to get worse, though, with the excuse that ‘I feel safer if they have a cell phone so they can call me.’ I tell parents that they still make flip phones. You don’t have to get a smartphone for a second- or third-grader, or even for a sixth-grader.”
By the time kids reach fourth and fifth grade, he continued, they begin to form their opinion “about what they believe is cool and not cool, and they begin to get into cliques that have similar beliefs, and support each other, and may break off from old friends.” He added that, while adult predation “makes the news and is certainly something we should all be concerned about, the incidence of being harassed and bullied by someone in your own age group at school is actually much higher and still has serious outcomes, including the possibility of death.”
The Massachusetts antibullying law stipulates that all teachers and all school personnel have to participate in mandatory bullying training. Schools also are required to draft and follow a bullying investigative protocol.
“Apparently the schools have all done this, yet the number of times that schools use interventions that are not advisable, such as mediation, is incredible to me,” Dr. Raffalli said. “Bringing the bully and the victim together for a ‘cup of coffee and a handshake’ is not advisable. Mediation has been shown in a number of studies to be detrimental in bullying situations. Things can easily get worse.”
Often, family members who bring their child to the BACPAC “feel that their child’s school is not helping them,” he said. “We should try to figure out why those schools are having such a hard time and see if we can help them.”
Dr. Raffalli reported having no financial disclosures.
NEW ORLEANS – After Massachusetts passed antibullying legislation in 2009, Peter C. Raffalli, MD, saw an opportunity to improve care for the increasing numbers of children presenting to his neurology practice at Boston Children’s Hospital who were victims of bullying – especially those with developmental disabilities.
“I had been thinking of a clinic to help kids with these issues, aside from just helping them deal with the fallout: the depression, anxiety, et cetera, that comes with being bullied,” Dr. Raffalli recalled at the annual meeting of the American Academy of Pediatrics. “I wanted to do something to help present to families the evidence-based strategies regarding bullying prevention, detection, and intervention that might help to stop the bullying.”
This led him to launch the Bullying and Cyberbullying Prevention and Advocacy Collaborative (BACPAC) at Boston Children’s Hospital, which began in 2009 as an educational resource for families, medical colleagues, and schools. Dr. Raffalli also formed an alliance with the Massachusetts Aggression Reduction Center at Bridgewater State University (Ann Neurol. 2016;79[2]:167-8).
Two years later in 2011, BACPAC became a formal clinic at Boston Children’s that serves as a subspecialty consult service for victims of bullying and their families. The clinic team consists of a child neurologist, a social worker, and an education resource specialist who meet with the bullying victim and his/her family in initial consultation for 90 minutes. The goal is to develop an evidence-based plan for bullying prevention, detection, and intervention that is individualized to the patient’s developmental and social needs.
“We tell families that bullying is recognized medically and legally as a form of abuse,” said Dr. Raffalli. “The medical and psychological consequences are similar to other forms of abuse. You’d be surprised how often patients do think the bullying is their fault.”
The extent of the problem
Researchers estimate that 25%-30% of children will experience some form of bullying between kindergarten and grade 12, and about 8% will engage in bullying themselves. When BACPAC began in 2009, Dr. Raffalli conducted an informal search of peer-reviewed literature on bullying in children with special needs; it yielded just four articles. “Since then, there’s been an exponential explosion of literature on various aspects of bullying,” he said. Now there is ample evidence in the peer-reviewed literature to show the increased risk for bullying/cyberbullying in children/teens, not just with neurodevelopmental disorders, but also for kids with other medical disorders such as obesity, asthma, and allergies.
“We’ve had a good number of kids over the years with peanut allergy who were literally threatened physically with peanut butter at school,” he said. “It’s incredible how callous some kids can be. Kids with oppositional defiant disorder, impulse control disorder, and callous/unemotional traits from a psychological standpoint are hardest to reach when it comes to getting them to stop bullying. You’d be surprised how frequently bullies use the phrase [to their victims], ‘You should kill yourself.’ They don’t realize the damage they’re doing to people. Bullying can lead to severe psychological but also long-term medical problems, including suicidal ideation.”
Published studies show that the highest incidences of bullying occur in children with neurodevelopmental conditions such as ADHD, autistic spectrum disorders, Tourette syndrome, and other learning disabilities (Eur J Spec Needs Ed. 2010;25[1]:77-91). This population of children is overrepresented in bullying “because the services they receive at school make their disabilities more visible,” explained Dr. Raffalli, who is also an assistant professor of neurology at Harvard Medical School, Boston. “They stand out, and they have social information–processing deficits or distortions that exacerbate bullying involvement. They also have difficulty interpreting social cues or attributing hostile characteristics to their peer’s behavior.”
The consequences of bullying
The psychological and educational consequences of bullying among children in general include being more likely to develop depression, loneliness, low self-esteem, alcohol and drug abuse, sleeping difficulties, self-harm, and suicidal ideation and attempts. “We’re social creatures, and when we don’t have those social connections, we get very depressed.”
Bullying victims also are more likely to develop school avoidance and absence, decreased school performance, poor concentration, high anxiety, and social withdrawal – all of which limit their opportunities to learn. “The No. 1 thing you can do to help these kids is to believe their story – to explain to them that it’s not their fault, and to explain that you are there for them and that you support them,” he said. “When a kid gets the feeling that someone is willing to listen to them and believe them, it does an enormous good for their emotional state.”
Dr. Raffalli added that a toxic stress response can occur when a child experiences strong, frequent, and/or prolonged adversity – such as physical or emotional abuse, chronic neglect, caregiver substance abuse or mental illness, exposure to violence, and/or the accumulated burdens of family economic hardship – without adequate adult support. This kind of prolonged activation of the stress response systems can disrupt the development of brain architecture and other organ systems, and increase the risk for stress-related disease and cognitive impairment well into the adult years.
In the Harvard Review of Psychiatry, researchers set out to investigate what’s known about the long-term health effects of childhood bullying. They found that bullying can induce “aspects of the stress response, via epigenetic, inflammatory, and metabolic mediators [that] have the capacity to compromise mental and physical health, and to increase the risk of disease.” The researchers advised clinicians who care for children to assess the mental and physical health effects of bullying (Harv Rev Psychiatry. 2017;25[2]:89-95).
Additional vulnerabilities for bullying victims include parents and children whose primary language is not English, as well as parents with mental illness or substance abuse and families living in poverty. “We have to keep in mind how much additional stress they may be dealing with. This can make it harder for them to cope. Bullies also are shown to be at higher risk for psychological and legal trouble into adulthood, so we should be trying to help them too. We have to keep in mind that these are all developing kids.”
Cyberbullying
In Dr. Raffalli’s clinical experience, cyberbullying has become the bully’s weapon of choice. “I call it the stealth bomber of bullying,” he said. “Cyberbullying can start as early as the second or third grade. Most parents are not giving phones to second-graders. I’m worried that it’s going to get worse, though, with the excuse that ‘I feel safer if they have a cell phone so they can call me.’ I tell parents that they still make flip phones. You don’t have to get a smartphone for a second- or third-grader, or even for a sixth-grader.”
By the time kids reach fourth and fifth grade, he continued, they begin to form their opinion “about what they believe is cool and not cool, and they begin to get into cliques that have similar beliefs, and support each other, and may break off from old friends.” He added that, while adult predation “makes the news and is certainly something we should all be concerned about, the incidence of being harassed and bullied by someone in your own age group at school is actually much higher and still has serious outcomes, including the possibility of death.”
The Massachusetts antibullying law stipulates that all teachers and all school personnel have to participate in mandatory bullying training. Schools also are required to draft and follow a bullying investigative protocol.
“Apparently the schools have all done this, yet the number of times that schools use interventions that are not advisable, such as mediation, is incredible to me,” Dr. Raffalli said. “Bringing the bully and the victim together for a ‘cup of coffee and a handshake’ is not advisable. Mediation has been shown in a number of studies to be detrimental in bullying situations. Things can easily get worse.”
Often, family members who bring their child to the BACPAC “feel that their child’s school is not helping them,” he said. “We should try to figure out why those schools are having such a hard time and see if we can help them.”
Dr. Raffalli reported having no financial disclosures.
EXPERT ANALYSIS FROM AAP 2019
Evidence builds for effects of obesity, low physical activity on development of psoriatic arthritis
A new Norwegian study has identified a high body mass index and lower levels of physical activity as modifiable risk factors for developing psoriatic arthritis (PsA).
“Our study adds to the growing evidence that the risk of PsA is modifiable and highlights the importance of preventive work against obesity as well as encouraging physical activity in order to reduce the incidence of PsA,” wrote Ruth S. Thomsen, MD, of the Norwegian University of Science and Technology, and coauthors. The study was published in Arthritis Care & Research.
To determine the impact that adiposity and body fat distribution have on developing PsA, the researchers analyzed data from 36,626 women and men who participated in two surveys from the longitudinal, population-based Norwegian HUNT Study. All participants did not have diagnosed PsA at baseline in 1995-1997. Variables used in statistical analysis included calculated baseline BMI, waist circumference, waist-hip ratio, and level of physical activity.
Between baseline and follow-up in 2012, 185 new cases of PsA were reported. One standard deviation increase in BMI (4.2 kg/m2 for women, 3.5 kg/m2 for men) and waist circumstance (10.8 cm for women, 8.6 cm for men) was associated with adjusted hazard ratios of 1.40 (95% confidence interval, 1.24-1.58) and 1.48 (95% CI, 1.31-1.68), accordingly. Obese individuals – defined as BMI of 30 kg/m2 or higher – had an adjusted HR of 2.46 (95% CI, 1.65-3.68) when compared with individuals at normal weight.
Compared to individuals with BMI less than 25 kg/m2 and a high level of physical activity, individuals with BMI at 25 kg/m2 or higher and any lower level of physical activity had an adjusted HR of 2.06 (95% CI, 1.18-3.58). In addition, individuals with a high waist circumference – defined as 81 cm or more in women and 95 cm or more in men – and low physical activity had an adjusted HR of 2.22 (95% CI, 1.37-3.58) in comparison to those with a high waist circumference and high physical activity (adjusted HR, 1.84; 95% CI, 0.97-3.47). Physical activity level was considered low with less than 3 hours of light physical activity and no hard physical activity per week and high with any amount of light activity plus 1 or more hours of hard physical activity.
The authors acknowledged the study’s potential limitations, including the requirement for participants to complete the final two HUNT study surveys and the use of stricter criteria than usual in validating PsA diagnoses.
The study was partially funded by a grant Dr. Thomsen received from the Norwegian Extra Foundation for Health and Rehabilitation. The authors reported no conflicts of interest.
SOURCE: Thomsen RS et al. Arthritis Care Res. 2019 Dec 7. doi: 10.1002/acr.24121.
A new Norwegian study has identified a high body mass index and lower levels of physical activity as modifiable risk factors for developing psoriatic arthritis (PsA).
“Our study adds to the growing evidence that the risk of PsA is modifiable and highlights the importance of preventive work against obesity as well as encouraging physical activity in order to reduce the incidence of PsA,” wrote Ruth S. Thomsen, MD, of the Norwegian University of Science and Technology, and coauthors. The study was published in Arthritis Care & Research.
To determine the impact that adiposity and body fat distribution have on developing PsA, the researchers analyzed data from 36,626 women and men who participated in two surveys from the longitudinal, population-based Norwegian HUNT Study. All participants did not have diagnosed PsA at baseline in 1995-1997. Variables used in statistical analysis included calculated baseline BMI, waist circumference, waist-hip ratio, and level of physical activity.
Between baseline and follow-up in 2012, 185 new cases of PsA were reported. One standard deviation increase in BMI (4.2 kg/m2 for women, 3.5 kg/m2 for men) and waist circumstance (10.8 cm for women, 8.6 cm for men) was associated with adjusted hazard ratios of 1.40 (95% confidence interval, 1.24-1.58) and 1.48 (95% CI, 1.31-1.68), accordingly. Obese individuals – defined as BMI of 30 kg/m2 or higher – had an adjusted HR of 2.46 (95% CI, 1.65-3.68) when compared with individuals at normal weight.
Compared to individuals with BMI less than 25 kg/m2 and a high level of physical activity, individuals with BMI at 25 kg/m2 or higher and any lower level of physical activity had an adjusted HR of 2.06 (95% CI, 1.18-3.58). In addition, individuals with a high waist circumference – defined as 81 cm or more in women and 95 cm or more in men – and low physical activity had an adjusted HR of 2.22 (95% CI, 1.37-3.58) in comparison to those with a high waist circumference and high physical activity (adjusted HR, 1.84; 95% CI, 0.97-3.47). Physical activity level was considered low with less than 3 hours of light physical activity and no hard physical activity per week and high with any amount of light activity plus 1 or more hours of hard physical activity.
The authors acknowledged the study’s potential limitations, including the requirement for participants to complete the final two HUNT study surveys and the use of stricter criteria than usual in validating PsA diagnoses.
The study was partially funded by a grant Dr. Thomsen received from the Norwegian Extra Foundation for Health and Rehabilitation. The authors reported no conflicts of interest.
SOURCE: Thomsen RS et al. Arthritis Care Res. 2019 Dec 7. doi: 10.1002/acr.24121.
A new Norwegian study has identified a high body mass index and lower levels of physical activity as modifiable risk factors for developing psoriatic arthritis (PsA).
“Our study adds to the growing evidence that the risk of PsA is modifiable and highlights the importance of preventive work against obesity as well as encouraging physical activity in order to reduce the incidence of PsA,” wrote Ruth S. Thomsen, MD, of the Norwegian University of Science and Technology, and coauthors. The study was published in Arthritis Care & Research.
To determine the impact that adiposity and body fat distribution have on developing PsA, the researchers analyzed data from 36,626 women and men who participated in two surveys from the longitudinal, population-based Norwegian HUNT Study. All participants did not have diagnosed PsA at baseline in 1995-1997. Variables used in statistical analysis included calculated baseline BMI, waist circumference, waist-hip ratio, and level of physical activity.
Between baseline and follow-up in 2012, 185 new cases of PsA were reported. One standard deviation increase in BMI (4.2 kg/m2 for women, 3.5 kg/m2 for men) and waist circumstance (10.8 cm for women, 8.6 cm for men) was associated with adjusted hazard ratios of 1.40 (95% confidence interval, 1.24-1.58) and 1.48 (95% CI, 1.31-1.68), accordingly. Obese individuals – defined as BMI of 30 kg/m2 or higher – had an adjusted HR of 2.46 (95% CI, 1.65-3.68) when compared with individuals at normal weight.
Compared to individuals with BMI less than 25 kg/m2 and a high level of physical activity, individuals with BMI at 25 kg/m2 or higher and any lower level of physical activity had an adjusted HR of 2.06 (95% CI, 1.18-3.58). In addition, individuals with a high waist circumference – defined as 81 cm or more in women and 95 cm or more in men – and low physical activity had an adjusted HR of 2.22 (95% CI, 1.37-3.58) in comparison to those with a high waist circumference and high physical activity (adjusted HR, 1.84; 95% CI, 0.97-3.47). Physical activity level was considered low with less than 3 hours of light physical activity and no hard physical activity per week and high with any amount of light activity plus 1 or more hours of hard physical activity.
The authors acknowledged the study’s potential limitations, including the requirement for participants to complete the final two HUNT study surveys and the use of stricter criteria than usual in validating PsA diagnoses.
The study was partially funded by a grant Dr. Thomsen received from the Norwegian Extra Foundation for Health and Rehabilitation. The authors reported no conflicts of interest.
SOURCE: Thomsen RS et al. Arthritis Care Res. 2019 Dec 7. doi: 10.1002/acr.24121.
FROM ARTHRITIS CARE & RESEARCH
Bariatric surgery tied to fewer cerebrovascular events
PHILADELPHIA – Obese people living in the United Kingdom who underwent bariatric surgery had a two-thirds lower rate of major cerebrovascular events than that of a matched group of obese residents who did not undergo bariatric surgery, in a retrospective study of 8,424 people followed for a mean of just over 11 years.
Although the cut in cerebrovascular events that linked with bariatric surgery shown by the analysis was mostly driven by a reduced rate of transient ischemic attacks, a potentially unreliable diagnosis, the results showed consistent reductions in the rates of acute ischemic strokes as well as in acute, nontraumatic intracranial hemorrhages, two other components of the combined primary endpoint, Maddalena Ardissino, MBBS, said at the American Heart Association scientific sessions.
This finding of an apparent benefit from bariatric surgery in obese patients in a large U.K. database confirms other findings from a “fast-growing” evidence base showing benefits from bariatric surgery for reducing other types of cardiovascular disease events, said Dr. Ardissino, a researcher at Imperial College, London. However, the impact of bariatric surgery specifically on cerebrovascular events had not received much attention in published studies, she noted.
Her study used data collected by the Clinical Practice Research Datalink, which has primary and secondary care health records for about 42 million U.K. residents. The researchers focused on more than 251,000 obese U.K. adults (body mass index of 30 kg/m2 or greater) without a history of a cerebrovascular event who had at least 1 year of follow-up, a data file that included 4,212 adults who had undergone bariatric surgery. Their analysis matched these surgical patients with an equal number of obese adults who did not have surgery, pairing the cases and controls based on age, sex, and BMI. The resulting matched cohorts each averaged 50 years old, with a mean BMI of 40.5 kg/m2.
During just over 11 years of average follow-up, the incidence of acute ischemic stroke, acute intracranial hemorrhage, subarachnoid hemorrhage, or transient ischemic attack was about 1.3% in those without bariatric surgery and about 0.4% in those who had surgery, an absolute risk reduction of 0.9 linked with surgery and a relative risk reduction of 65% that was statistically significant, Dr. Ardissino reported. All-cause mortality was about 70% lower in the group that underwent bariatric surgery compared with those who did not have surgery, a finding that confirmed prior reports. She cautioned that the analysis was limited by a relatively low number of total events, and by the small number of criteria used for cohort matching that might have left unadjusted certain potential confounders such as the level of engagement people had with their medical care.
SOURCE: Ardissino M. AHA 2019, Abstract 335.
PHILADELPHIA – Obese people living in the United Kingdom who underwent bariatric surgery had a two-thirds lower rate of major cerebrovascular events than that of a matched group of obese residents who did not undergo bariatric surgery, in a retrospective study of 8,424 people followed for a mean of just over 11 years.
Although the cut in cerebrovascular events that linked with bariatric surgery shown by the analysis was mostly driven by a reduced rate of transient ischemic attacks, a potentially unreliable diagnosis, the results showed consistent reductions in the rates of acute ischemic strokes as well as in acute, nontraumatic intracranial hemorrhages, two other components of the combined primary endpoint, Maddalena Ardissino, MBBS, said at the American Heart Association scientific sessions.
This finding of an apparent benefit from bariatric surgery in obese patients in a large U.K. database confirms other findings from a “fast-growing” evidence base showing benefits from bariatric surgery for reducing other types of cardiovascular disease events, said Dr. Ardissino, a researcher at Imperial College, London. However, the impact of bariatric surgery specifically on cerebrovascular events had not received much attention in published studies, she noted.
Her study used data collected by the Clinical Practice Research Datalink, which has primary and secondary care health records for about 42 million U.K. residents. The researchers focused on more than 251,000 obese U.K. adults (body mass index of 30 kg/m2 or greater) without a history of a cerebrovascular event who had at least 1 year of follow-up, a data file that included 4,212 adults who had undergone bariatric surgery. Their analysis matched these surgical patients with an equal number of obese adults who did not have surgery, pairing the cases and controls based on age, sex, and BMI. The resulting matched cohorts each averaged 50 years old, with a mean BMI of 40.5 kg/m2.
During just over 11 years of average follow-up, the incidence of acute ischemic stroke, acute intracranial hemorrhage, subarachnoid hemorrhage, or transient ischemic attack was about 1.3% in those without bariatric surgery and about 0.4% in those who had surgery, an absolute risk reduction of 0.9 linked with surgery and a relative risk reduction of 65% that was statistically significant, Dr. Ardissino reported. All-cause mortality was about 70% lower in the group that underwent bariatric surgery compared with those who did not have surgery, a finding that confirmed prior reports. She cautioned that the analysis was limited by a relatively low number of total events, and by the small number of criteria used for cohort matching that might have left unadjusted certain potential confounders such as the level of engagement people had with their medical care.
SOURCE: Ardissino M. AHA 2019, Abstract 335.
PHILADELPHIA – Obese people living in the United Kingdom who underwent bariatric surgery had a two-thirds lower rate of major cerebrovascular events than that of a matched group of obese residents who did not undergo bariatric surgery, in a retrospective study of 8,424 people followed for a mean of just over 11 years.
Although the cut in cerebrovascular events that linked with bariatric surgery shown by the analysis was mostly driven by a reduced rate of transient ischemic attacks, a potentially unreliable diagnosis, the results showed consistent reductions in the rates of acute ischemic strokes as well as in acute, nontraumatic intracranial hemorrhages, two other components of the combined primary endpoint, Maddalena Ardissino, MBBS, said at the American Heart Association scientific sessions.
This finding of an apparent benefit from bariatric surgery in obese patients in a large U.K. database confirms other findings from a “fast-growing” evidence base showing benefits from bariatric surgery for reducing other types of cardiovascular disease events, said Dr. Ardissino, a researcher at Imperial College, London. However, the impact of bariatric surgery specifically on cerebrovascular events had not received much attention in published studies, she noted.
Her study used data collected by the Clinical Practice Research Datalink, which has primary and secondary care health records for about 42 million U.K. residents. The researchers focused on more than 251,000 obese U.K. adults (body mass index of 30 kg/m2 or greater) without a history of a cerebrovascular event who had at least 1 year of follow-up, a data file that included 4,212 adults who had undergone bariatric surgery. Their analysis matched these surgical patients with an equal number of obese adults who did not have surgery, pairing the cases and controls based on age, sex, and BMI. The resulting matched cohorts each averaged 50 years old, with a mean BMI of 40.5 kg/m2.
During just over 11 years of average follow-up, the incidence of acute ischemic stroke, acute intracranial hemorrhage, subarachnoid hemorrhage, or transient ischemic attack was about 1.3% in those without bariatric surgery and about 0.4% in those who had surgery, an absolute risk reduction of 0.9 linked with surgery and a relative risk reduction of 65% that was statistically significant, Dr. Ardissino reported. All-cause mortality was about 70% lower in the group that underwent bariatric surgery compared with those who did not have surgery, a finding that confirmed prior reports. She cautioned that the analysis was limited by a relatively low number of total events, and by the small number of criteria used for cohort matching that might have left unadjusted certain potential confounders such as the level of engagement people had with their medical care.
SOURCE: Ardissino M. AHA 2019, Abstract 335.
REPORTING FROM AHA 2019
Reward, decision-making brain regions altered in teens with obesity
CHICAGO – according to a Brazilian study that used MRI to detect these changes.
Brain changes were significantly correlated with increased levels of insulin, leptin, and other appetite- and diet-related hormones and neurohormones, as well as with inflammatory markers.
In an interview at the annual meeting of the Radiological Society of North America, Pamela Bertolazzi, a PhD student at the University of São Paulo, explained that childhood obesity in Brazil is estimated to have climbed by up to 40% in recent years, with almost one-third of Brazilian children and adolescents experiencing obesity. Epidemiologists estimate that there’s the potential for 2.6 million premature deaths from this level of overweight and obesity, she said. Brazil has over 211 million residents.
Previous studies have established diffusion tensor imaging as an MRI technique to assess white-matter integrity and architecture. Fractional anisotropy (FA) is a measure of brain tract integrity, and decreased FA can indicate demyelination or axonal degeneration.
Ms. Bertolazzi and colleagues compared 60 healthy weight adolescents with 57 adolescents with obesity to see how cerebral connectivity differed, and further correlated MRI findings with a serum assay of 57 analytes including inflammatory markers, neuropeptides, and hormones.
Adolescents aged 12-16 years were included if they met World Health Organization criteria for obesity or for healthy weight. The z score for the participants with obesity was 2.74, and 0.25 for the healthy-weight participants (P less than .001). Individuals who were underweight or overweight (but not obese) were excluded. Those with known significant psychiatric diagnoses or prior traumatic brain injury or neurosurgery also were excluded.
The mean age of participants was 14 years, and 29 of the 57 (51%) participants with obesity were female, as were 33 of 60 (55%) healthy weight participants. There was no significant difference in socioeconomic status between the two groups.
When participants’ brain MRI results were reviewed, Ms. Bertolazzi and associates saw several regions that had decreased FA only in the adolescents with obesity. In general terms, these brain areas are known to be concerned with appetite and reward.
Decreased FA – indicating demyelination or axonal degeneration – was seen particularly on the left-hand side of the corpus callosum, “the largest association pathway in the human brain,” said Ms. Bertolazzi. Looking at the interaction between decreased FA in this area and levels of various analytes, leptin, insulin, C-peptide, and total glucagonlike peptide–1 levels all were negatively associated with FA levels. A ratio of leptin to the anti-inflammatory cytokine interleukin-10 also had a negative correlation with FA levels. All of these associations were statistically significant.
Decreased FA also was seen in the orbitofrontal gyrus, an area of the prefrontal cortex that links decision making with emotions and reward. Here, significant negative associations were seen with C-peptide, amylin, and the ratios of several other inflammatory markers to IL-10.
“Obesity was associated with a reduction of cerebral integrity in obese adolescents,” said Ms. Bertolazzi. The clinical significance of these findings is not yet known. However, she said that the disruption in regulation of reward and appetite circuitry her study found may set up adolescents with excess body mass for a maladaptive positive feedback loop: elevated insulin, leptin, and inflammatory cytokine levels may be contributing to disrupted appetite, which in turn contributes to ongoing increases in body mass index.
She and her colleagues are planning to enroll adolescents with obesity and their families in nutritional education and exercise programs, hoping to interrupt the cycle. They plan to obtain a baseline serum assay and MRI scan with diffusion tensor imaging and FA, and to repeat the studies about 3 months into an intensive intervention, to test the hypothesis that increased exercise and improved diet will result in reversal of the brain changes they found in this exploratory study. In particular, said Ms. Bertolazzi, they hope that encouraging physical activity will boost levels of HDL cholesterol, which may have a neuroprotective effect.
Ms. Bertolazzi reported no outside sources of funding and no conflicts of interest.
CHICAGO – according to a Brazilian study that used MRI to detect these changes.
Brain changes were significantly correlated with increased levels of insulin, leptin, and other appetite- and diet-related hormones and neurohormones, as well as with inflammatory markers.
In an interview at the annual meeting of the Radiological Society of North America, Pamela Bertolazzi, a PhD student at the University of São Paulo, explained that childhood obesity in Brazil is estimated to have climbed by up to 40% in recent years, with almost one-third of Brazilian children and adolescents experiencing obesity. Epidemiologists estimate that there’s the potential for 2.6 million premature deaths from this level of overweight and obesity, she said. Brazil has over 211 million residents.
Previous studies have established diffusion tensor imaging as an MRI technique to assess white-matter integrity and architecture. Fractional anisotropy (FA) is a measure of brain tract integrity, and decreased FA can indicate demyelination or axonal degeneration.
Ms. Bertolazzi and colleagues compared 60 healthy weight adolescents with 57 adolescents with obesity to see how cerebral connectivity differed, and further correlated MRI findings with a serum assay of 57 analytes including inflammatory markers, neuropeptides, and hormones.
Adolescents aged 12-16 years were included if they met World Health Organization criteria for obesity or for healthy weight. The z score for the participants with obesity was 2.74, and 0.25 for the healthy-weight participants (P less than .001). Individuals who were underweight or overweight (but not obese) were excluded. Those with known significant psychiatric diagnoses or prior traumatic brain injury or neurosurgery also were excluded.
The mean age of participants was 14 years, and 29 of the 57 (51%) participants with obesity were female, as were 33 of 60 (55%) healthy weight participants. There was no significant difference in socioeconomic status between the two groups.
When participants’ brain MRI results were reviewed, Ms. Bertolazzi and associates saw several regions that had decreased FA only in the adolescents with obesity. In general terms, these brain areas are known to be concerned with appetite and reward.
Decreased FA – indicating demyelination or axonal degeneration – was seen particularly on the left-hand side of the corpus callosum, “the largest association pathway in the human brain,” said Ms. Bertolazzi. Looking at the interaction between decreased FA in this area and levels of various analytes, leptin, insulin, C-peptide, and total glucagonlike peptide–1 levels all were negatively associated with FA levels. A ratio of leptin to the anti-inflammatory cytokine interleukin-10 also had a negative correlation with FA levels. All of these associations were statistically significant.
Decreased FA also was seen in the orbitofrontal gyrus, an area of the prefrontal cortex that links decision making with emotions and reward. Here, significant negative associations were seen with C-peptide, amylin, and the ratios of several other inflammatory markers to IL-10.
“Obesity was associated with a reduction of cerebral integrity in obese adolescents,” said Ms. Bertolazzi. The clinical significance of these findings is not yet known. However, she said that the disruption in regulation of reward and appetite circuitry her study found may set up adolescents with excess body mass for a maladaptive positive feedback loop: elevated insulin, leptin, and inflammatory cytokine levels may be contributing to disrupted appetite, which in turn contributes to ongoing increases in body mass index.
She and her colleagues are planning to enroll adolescents with obesity and their families in nutritional education and exercise programs, hoping to interrupt the cycle. They plan to obtain a baseline serum assay and MRI scan with diffusion tensor imaging and FA, and to repeat the studies about 3 months into an intensive intervention, to test the hypothesis that increased exercise and improved diet will result in reversal of the brain changes they found in this exploratory study. In particular, said Ms. Bertolazzi, they hope that encouraging physical activity will boost levels of HDL cholesterol, which may have a neuroprotective effect.
Ms. Bertolazzi reported no outside sources of funding and no conflicts of interest.
CHICAGO – according to a Brazilian study that used MRI to detect these changes.
Brain changes were significantly correlated with increased levels of insulin, leptin, and other appetite- and diet-related hormones and neurohormones, as well as with inflammatory markers.
In an interview at the annual meeting of the Radiological Society of North America, Pamela Bertolazzi, a PhD student at the University of São Paulo, explained that childhood obesity in Brazil is estimated to have climbed by up to 40% in recent years, with almost one-third of Brazilian children and adolescents experiencing obesity. Epidemiologists estimate that there’s the potential for 2.6 million premature deaths from this level of overweight and obesity, she said. Brazil has over 211 million residents.
Previous studies have established diffusion tensor imaging as an MRI technique to assess white-matter integrity and architecture. Fractional anisotropy (FA) is a measure of brain tract integrity, and decreased FA can indicate demyelination or axonal degeneration.
Ms. Bertolazzi and colleagues compared 60 healthy weight adolescents with 57 adolescents with obesity to see how cerebral connectivity differed, and further correlated MRI findings with a serum assay of 57 analytes including inflammatory markers, neuropeptides, and hormones.
Adolescents aged 12-16 years were included if they met World Health Organization criteria for obesity or for healthy weight. The z score for the participants with obesity was 2.74, and 0.25 for the healthy-weight participants (P less than .001). Individuals who were underweight or overweight (but not obese) were excluded. Those with known significant psychiatric diagnoses or prior traumatic brain injury or neurosurgery also were excluded.
The mean age of participants was 14 years, and 29 of the 57 (51%) participants with obesity were female, as were 33 of 60 (55%) healthy weight participants. There was no significant difference in socioeconomic status between the two groups.
When participants’ brain MRI results were reviewed, Ms. Bertolazzi and associates saw several regions that had decreased FA only in the adolescents with obesity. In general terms, these brain areas are known to be concerned with appetite and reward.
Decreased FA – indicating demyelination or axonal degeneration – was seen particularly on the left-hand side of the corpus callosum, “the largest association pathway in the human brain,” said Ms. Bertolazzi. Looking at the interaction between decreased FA in this area and levels of various analytes, leptin, insulin, C-peptide, and total glucagonlike peptide–1 levels all were negatively associated with FA levels. A ratio of leptin to the anti-inflammatory cytokine interleukin-10 also had a negative correlation with FA levels. All of these associations were statistically significant.
Decreased FA also was seen in the orbitofrontal gyrus, an area of the prefrontal cortex that links decision making with emotions and reward. Here, significant negative associations were seen with C-peptide, amylin, and the ratios of several other inflammatory markers to IL-10.
“Obesity was associated with a reduction of cerebral integrity in obese adolescents,” said Ms. Bertolazzi. The clinical significance of these findings is not yet known. However, she said that the disruption in regulation of reward and appetite circuitry her study found may set up adolescents with excess body mass for a maladaptive positive feedback loop: elevated insulin, leptin, and inflammatory cytokine levels may be contributing to disrupted appetite, which in turn contributes to ongoing increases in body mass index.
She and her colleagues are planning to enroll adolescents with obesity and their families in nutritional education and exercise programs, hoping to interrupt the cycle. They plan to obtain a baseline serum assay and MRI scan with diffusion tensor imaging and FA, and to repeat the studies about 3 months into an intensive intervention, to test the hypothesis that increased exercise and improved diet will result in reversal of the brain changes they found in this exploratory study. In particular, said Ms. Bertolazzi, they hope that encouraging physical activity will boost levels of HDL cholesterol, which may have a neuroprotective effect.
Ms. Bertolazzi reported no outside sources of funding and no conflicts of interest.
REPORTING FROM RSNA 2019
Bariatric surgery should be considered in individuals with class 1 obesity
Mitchel L. Zoler’s article on Abstract A105, presented at Obesity Week 2019, addresses an important health concern and is timely.
Over the past 4 decades we have seen a rise in the prevalence of obesity and associated health complications, not just in the United States but across the world. The incidence of obesity (having a BMI greater than 30) was 35% for women and 31% for men in the United States, and associated deaths and disability were primarily attributed to diabetes and cardiovascular disease resulting from obesity.
This article references the benefits of bariatric/metabolic surgery in individuals with class 1 obesity. In the United States, more than half of those who meet the criteria for obesity come under the class 1 category (BMI, 30-34.9). Those in this class of obesity are at increased risk of developing diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular disease, obstructive sleep apnea, polycystic ovarian syndrome, and bone and joint disorders.
There are several studies that document the significant reduction in incidence of the above cardiometabolic risks with sustained weight loss. Nonsurgical interventions in individuals with class 1 obesity through lifestyle modifications and pharmacotherapy have not demonstrated success in providing persistent weight loss or metabolic benefits. The data presented in this article are of great significance to patients and physicians alike as they highlight the long-term benefits and reversal of metabolic disorders.
Current guidelines for bariatric surgery for individuals with a BMI greater than 35 were published in 1991. Since then several safe surgical options including laparoscopic procedures, sleeve gastrectomy, and adjustable gastric banding have been developed with decreased surgical risks, morbidity, and mortality.
The International Federation for the Surgery of Obesity and Metabolic Disorders, the International Diabetes Federation, and the National Institute for Health and Care Excellence of the United Kingdom, have supported the option of bariatric surgery in class 1 obese individuals with metabolic disorders.
While lifestyle modifications with medications should be the first-line treatment for class 1 obesity, as a primary care physician I believe that, given the major changes in the surgical options, the proven long-term benefits, and the rising incidences of obesity and metabolic syndrome, it is time for the health care community, insurers, patients, and all other stakeholders to consider bariatric surgery in class 1 obese individuals as a potential and viable option.
Noel N. Deep, MD, is a general internist in a multispecialty group practice with Aspirus Antigo (Wis.) Clinic and the chief medical officer and a staff physician at Aspirus Langlade Hospital in Antigo. He is also assistant clinical professor at the Medical College of Wisconsin, Central Wisconsin Campus, Wausau, and the governor of the Wisconsin chapter of the American College of Physicians. Dr. Deep serves on the editorial advisory board of Internal Medicine News.
He made these comments in response to questions from MDedge and had no relevant disclosures.
Mitchel L. Zoler’s article on Abstract A105, presented at Obesity Week 2019, addresses an important health concern and is timely.
Over the past 4 decades we have seen a rise in the prevalence of obesity and associated health complications, not just in the United States but across the world. The incidence of obesity (having a BMI greater than 30) was 35% for women and 31% for men in the United States, and associated deaths and disability were primarily attributed to diabetes and cardiovascular disease resulting from obesity.
This article references the benefits of bariatric/metabolic surgery in individuals with class 1 obesity. In the United States, more than half of those who meet the criteria for obesity come under the class 1 category (BMI, 30-34.9). Those in this class of obesity are at increased risk of developing diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular disease, obstructive sleep apnea, polycystic ovarian syndrome, and bone and joint disorders.
There are several studies that document the significant reduction in incidence of the above cardiometabolic risks with sustained weight loss. Nonsurgical interventions in individuals with class 1 obesity through lifestyle modifications and pharmacotherapy have not demonstrated success in providing persistent weight loss or metabolic benefits. The data presented in this article are of great significance to patients and physicians alike as they highlight the long-term benefits and reversal of metabolic disorders.
Current guidelines for bariatric surgery for individuals with a BMI greater than 35 were published in 1991. Since then several safe surgical options including laparoscopic procedures, sleeve gastrectomy, and adjustable gastric banding have been developed with decreased surgical risks, morbidity, and mortality.
The International Federation for the Surgery of Obesity and Metabolic Disorders, the International Diabetes Federation, and the National Institute for Health and Care Excellence of the United Kingdom, have supported the option of bariatric surgery in class 1 obese individuals with metabolic disorders.
While lifestyle modifications with medications should be the first-line treatment for class 1 obesity, as a primary care physician I believe that, given the major changes in the surgical options, the proven long-term benefits, and the rising incidences of obesity and metabolic syndrome, it is time for the health care community, insurers, patients, and all other stakeholders to consider bariatric surgery in class 1 obese individuals as a potential and viable option.
Noel N. Deep, MD, is a general internist in a multispecialty group practice with Aspirus Antigo (Wis.) Clinic and the chief medical officer and a staff physician at Aspirus Langlade Hospital in Antigo. He is also assistant clinical professor at the Medical College of Wisconsin, Central Wisconsin Campus, Wausau, and the governor of the Wisconsin chapter of the American College of Physicians. Dr. Deep serves on the editorial advisory board of Internal Medicine News.
He made these comments in response to questions from MDedge and had no relevant disclosures.
Mitchel L. Zoler’s article on Abstract A105, presented at Obesity Week 2019, addresses an important health concern and is timely.
Over the past 4 decades we have seen a rise in the prevalence of obesity and associated health complications, not just in the United States but across the world. The incidence of obesity (having a BMI greater than 30) was 35% for women and 31% for men in the United States, and associated deaths and disability were primarily attributed to diabetes and cardiovascular disease resulting from obesity.
This article references the benefits of bariatric/metabolic surgery in individuals with class 1 obesity. In the United States, more than half of those who meet the criteria for obesity come under the class 1 category (BMI, 30-34.9). Those in this class of obesity are at increased risk of developing diabetes, hypertension, hyperlipidemia, coronary artery disease, cerebrovascular disease, obstructive sleep apnea, polycystic ovarian syndrome, and bone and joint disorders.
There are several studies that document the significant reduction in incidence of the above cardiometabolic risks with sustained weight loss. Nonsurgical interventions in individuals with class 1 obesity through lifestyle modifications and pharmacotherapy have not demonstrated success in providing persistent weight loss or metabolic benefits. The data presented in this article are of great significance to patients and physicians alike as they highlight the long-term benefits and reversal of metabolic disorders.
Current guidelines for bariatric surgery for individuals with a BMI greater than 35 were published in 1991. Since then several safe surgical options including laparoscopic procedures, sleeve gastrectomy, and adjustable gastric banding have been developed with decreased surgical risks, morbidity, and mortality.
The International Federation for the Surgery of Obesity and Metabolic Disorders, the International Diabetes Federation, and the National Institute for Health and Care Excellence of the United Kingdom, have supported the option of bariatric surgery in class 1 obese individuals with metabolic disorders.
While lifestyle modifications with medications should be the first-line treatment for class 1 obesity, as a primary care physician I believe that, given the major changes in the surgical options, the proven long-term benefits, and the rising incidences of obesity and metabolic syndrome, it is time for the health care community, insurers, patients, and all other stakeholders to consider bariatric surgery in class 1 obese individuals as a potential and viable option.
Noel N. Deep, MD, is a general internist in a multispecialty group practice with Aspirus Antigo (Wis.) Clinic and the chief medical officer and a staff physician at Aspirus Langlade Hospital in Antigo. He is also assistant clinical professor at the Medical College of Wisconsin, Central Wisconsin Campus, Wausau, and the governor of the Wisconsin chapter of the American College of Physicians. Dr. Deep serves on the editorial advisory board of Internal Medicine News.
He made these comments in response to questions from MDedge and had no relevant disclosures.
Effective NASH medications are coming ‘sooner than you think’
SAN ANTONIO – The therapeutic Dark Ages of nonalcoholic steatohepatitis (NASH) are finally drawing to a close.
“NASH-specific therapies are coming soon – sooner than you think,” Naim Alkhouri, MD, predicted at the annual meeting of the American College of Gastroenterology.
And that, he added, has important implications for clinical practice. Physicians are going to need to step up their game with regard to screening and staging patients with nonalcoholic fatty liver disease to identify the right candidates for the coming effective treatments.
The new treatment era in NASH could dawn as soon as the spring of 2020, by which time the Food and Drug Administration is expected to issue a decision on obeticholic acid, an oral FXR agonist for which the agency has granted breakthrough therapy status. Intercept Pharmaceuticals has filed for marketing approval of obeticholic acid for NASH on the strength of the positive 18-month histologic results of the pivotal phase 3 REGENERATE trial, the first-ever successful phase 3 study of a medication for NASH, noted Dr. Alkhouri, a gastroenterologist at the University of Texas, San Antonio, and director of the Metabolic Health Center at the Texas Liver Institute.
At present there are no FDA-approved pharmacotherapies for NASH. The unmet medical need is huge, since NASH is now recognized to be a full-blown, burgeoning epidemic. NASH will soon become the No. 1 indication for liver transplantation in the United States. A full-throttle race is on to find effective therapies targeting the various dimensions of NASH, with more than 70 drugs now in phase 2 studies. These drugs collectively address all four mechanisms of the disease’s development and progression: the metabolic targets, perturbations in the gut-liver axis, liver inflammation, and fibrosis.
Moreover, even as the FDA considers the application for approval of obeticholic acid in NASH, at least four other investigational drugs are in pivotal phase 3 clinical trials. These include elafibranor, aramchol, resmetirom, and cenicriviroc.
Cenicriviroc is a dual CCR 2/5 receptor antagonist that targets the hepatic inflammation and fibrosis dimensions of NASH. It is now being evaluated in the phase 3 AURORA trial on the strength of the earlier positive phase 2b Centaur study, in which patients randomized to cenicriviroc were twice as likely to experience significant improvement in fibrosis as were placebo-treated controls.
Elafibranor, aramchol, and resmetirom employ different mechanisms of action to address the metabolic derangements of NASH. What they share in common is their aim to reduce the influx of free fatty acids from adipose tissue to the liver, and/or to inhibit lipogenesis from carbohydrate building blocks. In so doing, these medications should result in reduced hepatocyte injury and liver inflammation.
Elafibranor is a peroxisome proliferator-activated receptor alpha/delta agonist that achieved significant biopsy-proven reversal of NASH in moderate- or severely affected patients in the phase 2 GOLDEN study. The phase 3 RESOLVE IT trial is underway.
Aramchol is a first-in-class synthetic fatty acid/bile acid conjugate that inhibits stearoyl-CoA desaturate activity. It’s designed to improve insulin resistance and curb accumulation of triglycerides in hepatocytes. In the 52-week, phase 2 ARREST trial, oral aramchol at 600 mg/day was 4.7-fold more likely than was placebo to achieve NASH resolution without worsening of fibrosis. The drug is now in phase 3 in the ARMOR study.
Resmetirom is a selective thyroid hormone receptor–beta agonist. Activation of the beta receptor lowers LDL cholesterol, triglycerides, and liver fat, whereas activation of the alpha receptor has the unwanted effects of promoting bone loss, thyrotoxicosis, and arrhythmias. In phase 2, 75% of patients on high-dose resmetirom achieved at least a 30% reduction in hepatic fat by MRI at week 12, compared with 18% of placebo-treated controls. And 39% of the high-dose resmetirom group showed histologic resolution of NASH on a week-36 liver biopsy, as did a mere 6% of controls. The phase 3 MAESTRO randomized trial is underway.
Obeticholic acid addresses the gut-liver axis abnormalities present in NASH, especially the exuberant bile acid circulation.
Clinical implications of the coming wave of medications
In Dr. Alkhouri’s view, .
“These are the patients with a high chance of progressing to cirrhosis and end-stage liver disease,” the gastroenterologist said.
Patients with earlier-stage nonalcoholic fatty liver disease are best managed via lifestyle changes, with particular emphasis upon 10% weight loss accompanied by exercise. And patients with more advanced disease – NASH with cirrhosis – appear thus far to be beyond the reach of the next-generation therapies.
None of the coming drugs is a cure-all. In the landmark phase 3 REGENERATE trial, for example, the rate of the primary outcome – fibrosis improvement of at least one stage plus no worsening of NASH at 18 months – was 23% in patients randomized to obeticholic acid at 25 mg/day, compared to 12% with placebo.
“These are not like hepatitis C medications, with 97% efficacy, so combination therapy targeting upstream and downstream for NASH is rational,” Dr. Alkhouri observed.
He reported serving on advisory boards for Allergan, Gilead, and Intercept, and receiving research grants from those companies as well as from Galmed, Genfit, and Madrigal.
*This story was updated on 12/5/2019.
SAN ANTONIO – The therapeutic Dark Ages of nonalcoholic steatohepatitis (NASH) are finally drawing to a close.
“NASH-specific therapies are coming soon – sooner than you think,” Naim Alkhouri, MD, predicted at the annual meeting of the American College of Gastroenterology.
And that, he added, has important implications for clinical practice. Physicians are going to need to step up their game with regard to screening and staging patients with nonalcoholic fatty liver disease to identify the right candidates for the coming effective treatments.
The new treatment era in NASH could dawn as soon as the spring of 2020, by which time the Food and Drug Administration is expected to issue a decision on obeticholic acid, an oral FXR agonist for which the agency has granted breakthrough therapy status. Intercept Pharmaceuticals has filed for marketing approval of obeticholic acid for NASH on the strength of the positive 18-month histologic results of the pivotal phase 3 REGENERATE trial, the first-ever successful phase 3 study of a medication for NASH, noted Dr. Alkhouri, a gastroenterologist at the University of Texas, San Antonio, and director of the Metabolic Health Center at the Texas Liver Institute.
At present there are no FDA-approved pharmacotherapies for NASH. The unmet medical need is huge, since NASH is now recognized to be a full-blown, burgeoning epidemic. NASH will soon become the No. 1 indication for liver transplantation in the United States. A full-throttle race is on to find effective therapies targeting the various dimensions of NASH, with more than 70 drugs now in phase 2 studies. These drugs collectively address all four mechanisms of the disease’s development and progression: the metabolic targets, perturbations in the gut-liver axis, liver inflammation, and fibrosis.
Moreover, even as the FDA considers the application for approval of obeticholic acid in NASH, at least four other investigational drugs are in pivotal phase 3 clinical trials. These include elafibranor, aramchol, resmetirom, and cenicriviroc.
Cenicriviroc is a dual CCR 2/5 receptor antagonist that targets the hepatic inflammation and fibrosis dimensions of NASH. It is now being evaluated in the phase 3 AURORA trial on the strength of the earlier positive phase 2b Centaur study, in which patients randomized to cenicriviroc were twice as likely to experience significant improvement in fibrosis as were placebo-treated controls.
Elafibranor, aramchol, and resmetirom employ different mechanisms of action to address the metabolic derangements of NASH. What they share in common is their aim to reduce the influx of free fatty acids from adipose tissue to the liver, and/or to inhibit lipogenesis from carbohydrate building blocks. In so doing, these medications should result in reduced hepatocyte injury and liver inflammation.
Elafibranor is a peroxisome proliferator-activated receptor alpha/delta agonist that achieved significant biopsy-proven reversal of NASH in moderate- or severely affected patients in the phase 2 GOLDEN study. The phase 3 RESOLVE IT trial is underway.
Aramchol is a first-in-class synthetic fatty acid/bile acid conjugate that inhibits stearoyl-CoA desaturate activity. It’s designed to improve insulin resistance and curb accumulation of triglycerides in hepatocytes. In the 52-week, phase 2 ARREST trial, oral aramchol at 600 mg/day was 4.7-fold more likely than was placebo to achieve NASH resolution without worsening of fibrosis. The drug is now in phase 3 in the ARMOR study.
Resmetirom is a selective thyroid hormone receptor–beta agonist. Activation of the beta receptor lowers LDL cholesterol, triglycerides, and liver fat, whereas activation of the alpha receptor has the unwanted effects of promoting bone loss, thyrotoxicosis, and arrhythmias. In phase 2, 75% of patients on high-dose resmetirom achieved at least a 30% reduction in hepatic fat by MRI at week 12, compared with 18% of placebo-treated controls. And 39% of the high-dose resmetirom group showed histologic resolution of NASH on a week-36 liver biopsy, as did a mere 6% of controls. The phase 3 MAESTRO randomized trial is underway.
Obeticholic acid addresses the gut-liver axis abnormalities present in NASH, especially the exuberant bile acid circulation.
Clinical implications of the coming wave of medications
In Dr. Alkhouri’s view, .
“These are the patients with a high chance of progressing to cirrhosis and end-stage liver disease,” the gastroenterologist said.
Patients with earlier-stage nonalcoholic fatty liver disease are best managed via lifestyle changes, with particular emphasis upon 10% weight loss accompanied by exercise. And patients with more advanced disease – NASH with cirrhosis – appear thus far to be beyond the reach of the next-generation therapies.
None of the coming drugs is a cure-all. In the landmark phase 3 REGENERATE trial, for example, the rate of the primary outcome – fibrosis improvement of at least one stage plus no worsening of NASH at 18 months – was 23% in patients randomized to obeticholic acid at 25 mg/day, compared to 12% with placebo.
“These are not like hepatitis C medications, with 97% efficacy, so combination therapy targeting upstream and downstream for NASH is rational,” Dr. Alkhouri observed.
He reported serving on advisory boards for Allergan, Gilead, and Intercept, and receiving research grants from those companies as well as from Galmed, Genfit, and Madrigal.
*This story was updated on 12/5/2019.
SAN ANTONIO – The therapeutic Dark Ages of nonalcoholic steatohepatitis (NASH) are finally drawing to a close.
“NASH-specific therapies are coming soon – sooner than you think,” Naim Alkhouri, MD, predicted at the annual meeting of the American College of Gastroenterology.
And that, he added, has important implications for clinical practice. Physicians are going to need to step up their game with regard to screening and staging patients with nonalcoholic fatty liver disease to identify the right candidates for the coming effective treatments.
The new treatment era in NASH could dawn as soon as the spring of 2020, by which time the Food and Drug Administration is expected to issue a decision on obeticholic acid, an oral FXR agonist for which the agency has granted breakthrough therapy status. Intercept Pharmaceuticals has filed for marketing approval of obeticholic acid for NASH on the strength of the positive 18-month histologic results of the pivotal phase 3 REGENERATE trial, the first-ever successful phase 3 study of a medication for NASH, noted Dr. Alkhouri, a gastroenterologist at the University of Texas, San Antonio, and director of the Metabolic Health Center at the Texas Liver Institute.
At present there are no FDA-approved pharmacotherapies for NASH. The unmet medical need is huge, since NASH is now recognized to be a full-blown, burgeoning epidemic. NASH will soon become the No. 1 indication for liver transplantation in the United States. A full-throttle race is on to find effective therapies targeting the various dimensions of NASH, with more than 70 drugs now in phase 2 studies. These drugs collectively address all four mechanisms of the disease’s development and progression: the metabolic targets, perturbations in the gut-liver axis, liver inflammation, and fibrosis.
Moreover, even as the FDA considers the application for approval of obeticholic acid in NASH, at least four other investigational drugs are in pivotal phase 3 clinical trials. These include elafibranor, aramchol, resmetirom, and cenicriviroc.
Cenicriviroc is a dual CCR 2/5 receptor antagonist that targets the hepatic inflammation and fibrosis dimensions of NASH. It is now being evaluated in the phase 3 AURORA trial on the strength of the earlier positive phase 2b Centaur study, in which patients randomized to cenicriviroc were twice as likely to experience significant improvement in fibrosis as were placebo-treated controls.
Elafibranor, aramchol, and resmetirom employ different mechanisms of action to address the metabolic derangements of NASH. What they share in common is their aim to reduce the influx of free fatty acids from adipose tissue to the liver, and/or to inhibit lipogenesis from carbohydrate building blocks. In so doing, these medications should result in reduced hepatocyte injury and liver inflammation.
Elafibranor is a peroxisome proliferator-activated receptor alpha/delta agonist that achieved significant biopsy-proven reversal of NASH in moderate- or severely affected patients in the phase 2 GOLDEN study. The phase 3 RESOLVE IT trial is underway.
Aramchol is a first-in-class synthetic fatty acid/bile acid conjugate that inhibits stearoyl-CoA desaturate activity. It’s designed to improve insulin resistance and curb accumulation of triglycerides in hepatocytes. In the 52-week, phase 2 ARREST trial, oral aramchol at 600 mg/day was 4.7-fold more likely than was placebo to achieve NASH resolution without worsening of fibrosis. The drug is now in phase 3 in the ARMOR study.
Resmetirom is a selective thyroid hormone receptor–beta agonist. Activation of the beta receptor lowers LDL cholesterol, triglycerides, and liver fat, whereas activation of the alpha receptor has the unwanted effects of promoting bone loss, thyrotoxicosis, and arrhythmias. In phase 2, 75% of patients on high-dose resmetirom achieved at least a 30% reduction in hepatic fat by MRI at week 12, compared with 18% of placebo-treated controls. And 39% of the high-dose resmetirom group showed histologic resolution of NASH on a week-36 liver biopsy, as did a mere 6% of controls. The phase 3 MAESTRO randomized trial is underway.
Obeticholic acid addresses the gut-liver axis abnormalities present in NASH, especially the exuberant bile acid circulation.
Clinical implications of the coming wave of medications
In Dr. Alkhouri’s view, .
“These are the patients with a high chance of progressing to cirrhosis and end-stage liver disease,” the gastroenterologist said.
Patients with earlier-stage nonalcoholic fatty liver disease are best managed via lifestyle changes, with particular emphasis upon 10% weight loss accompanied by exercise. And patients with more advanced disease – NASH with cirrhosis – appear thus far to be beyond the reach of the next-generation therapies.
None of the coming drugs is a cure-all. In the landmark phase 3 REGENERATE trial, for example, the rate of the primary outcome – fibrosis improvement of at least one stage plus no worsening of NASH at 18 months – was 23% in patients randomized to obeticholic acid at 25 mg/day, compared to 12% with placebo.
“These are not like hepatitis C medications, with 97% efficacy, so combination therapy targeting upstream and downstream for NASH is rational,” Dr. Alkhouri observed.
He reported serving on advisory boards for Allergan, Gilead, and Intercept, and receiving research grants from those companies as well as from Galmed, Genfit, and Madrigal.
*This story was updated on 12/5/2019.
REPORTING FROM ACG 2019
Click for Credit: PPI use & dementia; Weight loss after gastroplasty; more
Here are 5 articles from the December issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Sustainable weight loss seen 5 years after endoscopic sleeve gastroplasty
To take the posttest, go to: https://bit.ly/37lteRX
Expires May 16, 2020
2. PT beats steroid injections for knee OA
To take the posttest, go to: https://bit.ly/2KIWKY6
Expires May 17, 2020
3. Better screening needed to reduce pregnancy-related overdose, death
To take the posttest, go to: https://bit.ly/2XEZyuG
Expires May 17, 2020
4. Meta-analysis finds no link between PPI use and risk of dementia
To take the posttest, go to: https://bit.ly/2Xzs7JM
Expires June 3, 2020
5. Study: Cardiac biomarkers predicted CV events in CAP
To take the posttest, go to: https://bit.ly/33bAH2u
Expires August 13, 2020
Here are 5 articles from the December issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Sustainable weight loss seen 5 years after endoscopic sleeve gastroplasty
To take the posttest, go to: https://bit.ly/37lteRX
Expires May 16, 2020
2. PT beats steroid injections for knee OA
To take the posttest, go to: https://bit.ly/2KIWKY6
Expires May 17, 2020
3. Better screening needed to reduce pregnancy-related overdose, death
To take the posttest, go to: https://bit.ly/2XEZyuG
Expires May 17, 2020
4. Meta-analysis finds no link between PPI use and risk of dementia
To take the posttest, go to: https://bit.ly/2Xzs7JM
Expires June 3, 2020
5. Study: Cardiac biomarkers predicted CV events in CAP
To take the posttest, go to: https://bit.ly/33bAH2u
Expires August 13, 2020
Here are 5 articles from the December issue of Clinician Reviews (individual articles are valid for one year from date of publication—expiration dates below):
1. Sustainable weight loss seen 5 years after endoscopic sleeve gastroplasty
To take the posttest, go to: https://bit.ly/37lteRX
Expires May 16, 2020
2. PT beats steroid injections for knee OA
To take the posttest, go to: https://bit.ly/2KIWKY6
Expires May 17, 2020
3. Better screening needed to reduce pregnancy-related overdose, death
To take the posttest, go to: https://bit.ly/2XEZyuG
Expires May 17, 2020
4. Meta-analysis finds no link between PPI use and risk of dementia
To take the posttest, go to: https://bit.ly/2Xzs7JM
Expires June 3, 2020
5. Study: Cardiac biomarkers predicted CV events in CAP
To take the posttest, go to: https://bit.ly/33bAH2u
Expires August 13, 2020
Obesity dropping in kids aged 2-4 years in WIC program
During 2010-2016, the prevalence of obesity among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program significantly decreased in 73% of 56 states and territories, Liping Pan, MD, and colleagues reported in the Morbidity and Mortality Weekly Report.
The obesity prevalence decreases varied, but exceeded 3% in Guam, New Jersey, New Mexico, Northern Mariana Islands, Puerto Rico, Utah, and Virginia. Puerto Rico experienced the greatest benefit, with an 8% decrease in obesity among children aged 2-4 years enrolled in the WIC program, wrote Dr. Pan, an epidemiologist at the Centers for Disease Control and Prevention and coauthors.
Although the changes were small, the positive trend gains more import when viewed in light of the country’s long-term obesity trends, Dr. Pan and his team wrote. After a short-lived dip during 2007-2012, obesity has been on the rise among these children, jumping from 8% in 2012 to 14% in 2016. “Thus, even these small decreases indicate progress for this vulnerable WIC population,” the team said.
WIC extends nutritional assistance to families whose income is 185% or less of the federal poverty guideline or are eligible for other programs, as well as being deemed at nutritional risk.
The current study looked at obesity trends during 2010-2016 among 12,403,629 WIC recipients aged 2-4 years in all 50 U.S. states and five territories.
In 2010, obesity prevalence ranged from a low of 10% in Colorado to a high of 22% in Virginia. In Alaska, Puerto Rico, and Virginia, it was 20% or higher. Only in Colorado and Hawaii was obesity prevalence 10% or less among these children.
By 2016, obesity prevalence among children aged 2-4 years ranged from 8% in the Northern Mariana Islands to 19.8% in Alaska. It was less than 20% in all the states and territories, and less than 10% in Colorado, Guam, Hawaii, Northern Mariana Islands, Utah, and Wyoming.
It increased during 2010-2016, however, in Alabama (0.5%), North Carolina (0.6%), and West Virginia (2.2%).
The changes reflect the 2009 program revisions made to adhere to the 2005 Dietary Guidelines for Americans and the infant food and feeding practice guidelines of the American Academy of Pediatrics, Dr. Pan and associates wrote.
“The revised food packages include a broader range of healthy food options; promote fruit, vegetable, and whole wheat product purchases; support breastfeeding; and give WIC state and territory agencies more flexibility to accommodate cultural food preferences,” the authors noted.
In response to the changes, Dr. Pan and associates noted, authorized WIC stores began carrying healthier offerings. Tracking showed that children in the program consumed more fruits, vegetables, and whole grain products and less juice, white bread, and whole milk after the revisions than they did previously.
Despite the good news, childhood obesity rates still are too high and much remains to be done, they noted.
“Multiple approaches are needed to address and eliminate childhood obesity. The National Academy of Medicine and other groups have recommended a comprehensive and integrated approach that calls for positive changes in physical activity and food and beverage environments in multiple settings including home, early care and education [such as nutrition standards for food served], and community [such as neighborhood designs that encourage walking and biking] to promote healthy eating and physical activity for young children. Further implementation of these positive changes across the United States could further the decreases in child-hood obesity,” Dr. Pan and coauthors concluded.
Dr. Pan and coauthors had no financial disclosures.
SOURCE: Pan L et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68(46):1057-61.
During 2010-2016, the prevalence of obesity among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program significantly decreased in 73% of 56 states and territories, Liping Pan, MD, and colleagues reported in the Morbidity and Mortality Weekly Report.
The obesity prevalence decreases varied, but exceeded 3% in Guam, New Jersey, New Mexico, Northern Mariana Islands, Puerto Rico, Utah, and Virginia. Puerto Rico experienced the greatest benefit, with an 8% decrease in obesity among children aged 2-4 years enrolled in the WIC program, wrote Dr. Pan, an epidemiologist at the Centers for Disease Control and Prevention and coauthors.
Although the changes were small, the positive trend gains more import when viewed in light of the country’s long-term obesity trends, Dr. Pan and his team wrote. After a short-lived dip during 2007-2012, obesity has been on the rise among these children, jumping from 8% in 2012 to 14% in 2016. “Thus, even these small decreases indicate progress for this vulnerable WIC population,” the team said.
WIC extends nutritional assistance to families whose income is 185% or less of the federal poverty guideline or are eligible for other programs, as well as being deemed at nutritional risk.
The current study looked at obesity trends during 2010-2016 among 12,403,629 WIC recipients aged 2-4 years in all 50 U.S. states and five territories.
In 2010, obesity prevalence ranged from a low of 10% in Colorado to a high of 22% in Virginia. In Alaska, Puerto Rico, and Virginia, it was 20% or higher. Only in Colorado and Hawaii was obesity prevalence 10% or less among these children.
By 2016, obesity prevalence among children aged 2-4 years ranged from 8% in the Northern Mariana Islands to 19.8% in Alaska. It was less than 20% in all the states and territories, and less than 10% in Colorado, Guam, Hawaii, Northern Mariana Islands, Utah, and Wyoming.
It increased during 2010-2016, however, in Alabama (0.5%), North Carolina (0.6%), and West Virginia (2.2%).
The changes reflect the 2009 program revisions made to adhere to the 2005 Dietary Guidelines for Americans and the infant food and feeding practice guidelines of the American Academy of Pediatrics, Dr. Pan and associates wrote.
“The revised food packages include a broader range of healthy food options; promote fruit, vegetable, and whole wheat product purchases; support breastfeeding; and give WIC state and territory agencies more flexibility to accommodate cultural food preferences,” the authors noted.
In response to the changes, Dr. Pan and associates noted, authorized WIC stores began carrying healthier offerings. Tracking showed that children in the program consumed more fruits, vegetables, and whole grain products and less juice, white bread, and whole milk after the revisions than they did previously.
Despite the good news, childhood obesity rates still are too high and much remains to be done, they noted.
“Multiple approaches are needed to address and eliminate childhood obesity. The National Academy of Medicine and other groups have recommended a comprehensive and integrated approach that calls for positive changes in physical activity and food and beverage environments in multiple settings including home, early care and education [such as nutrition standards for food served], and community [such as neighborhood designs that encourage walking and biking] to promote healthy eating and physical activity for young children. Further implementation of these positive changes across the United States could further the decreases in child-hood obesity,” Dr. Pan and coauthors concluded.
Dr. Pan and coauthors had no financial disclosures.
SOURCE: Pan L et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68(46):1057-61.
During 2010-2016, the prevalence of obesity among children in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program significantly decreased in 73% of 56 states and territories, Liping Pan, MD, and colleagues reported in the Morbidity and Mortality Weekly Report.
The obesity prevalence decreases varied, but exceeded 3% in Guam, New Jersey, New Mexico, Northern Mariana Islands, Puerto Rico, Utah, and Virginia. Puerto Rico experienced the greatest benefit, with an 8% decrease in obesity among children aged 2-4 years enrolled in the WIC program, wrote Dr. Pan, an epidemiologist at the Centers for Disease Control and Prevention and coauthors.
Although the changes were small, the positive trend gains more import when viewed in light of the country’s long-term obesity trends, Dr. Pan and his team wrote. After a short-lived dip during 2007-2012, obesity has been on the rise among these children, jumping from 8% in 2012 to 14% in 2016. “Thus, even these small decreases indicate progress for this vulnerable WIC population,” the team said.
WIC extends nutritional assistance to families whose income is 185% or less of the federal poverty guideline or are eligible for other programs, as well as being deemed at nutritional risk.
The current study looked at obesity trends during 2010-2016 among 12,403,629 WIC recipients aged 2-4 years in all 50 U.S. states and five territories.
In 2010, obesity prevalence ranged from a low of 10% in Colorado to a high of 22% in Virginia. In Alaska, Puerto Rico, and Virginia, it was 20% or higher. Only in Colorado and Hawaii was obesity prevalence 10% or less among these children.
By 2016, obesity prevalence among children aged 2-4 years ranged from 8% in the Northern Mariana Islands to 19.8% in Alaska. It was less than 20% in all the states and territories, and less than 10% in Colorado, Guam, Hawaii, Northern Mariana Islands, Utah, and Wyoming.
It increased during 2010-2016, however, in Alabama (0.5%), North Carolina (0.6%), and West Virginia (2.2%).
The changes reflect the 2009 program revisions made to adhere to the 2005 Dietary Guidelines for Americans and the infant food and feeding practice guidelines of the American Academy of Pediatrics, Dr. Pan and associates wrote.
“The revised food packages include a broader range of healthy food options; promote fruit, vegetable, and whole wheat product purchases; support breastfeeding; and give WIC state and territory agencies more flexibility to accommodate cultural food preferences,” the authors noted.
In response to the changes, Dr. Pan and associates noted, authorized WIC stores began carrying healthier offerings. Tracking showed that children in the program consumed more fruits, vegetables, and whole grain products and less juice, white bread, and whole milk after the revisions than they did previously.
Despite the good news, childhood obesity rates still are too high and much remains to be done, they noted.
“Multiple approaches are needed to address and eliminate childhood obesity. The National Academy of Medicine and other groups have recommended a comprehensive and integrated approach that calls for positive changes in physical activity and food and beverage environments in multiple settings including home, early care and education [such as nutrition standards for food served], and community [such as neighborhood designs that encourage walking and biking] to promote healthy eating and physical activity for young children. Further implementation of these positive changes across the United States could further the decreases in child-hood obesity,” Dr. Pan and coauthors concluded.
Dr. Pan and coauthors had no financial disclosures.
SOURCE: Pan L et al. MMWR Morb Mortal Wkly Rep. 2019 Nov 22;68(46):1057-61.
FROM THE MORBIDITY AND MORTALITY WEEKLY REPORT
Women with obesity need not boost calories during pregnancy
LAS VEGAS – Contrary to current U.S. dietary recommendations for pregnancy, women with obesity should not increase their energy intake during pregnancy to achieve the current recommended level of gestational weight gain, based on findings from an intensive assessment of 54 women with obesity during weeks 13-37 of pregnancy.
To achieve the gestational weight gain of 11-20 pounds (5-9.1 kg) recommended by the Institute of Medicine, women with obesity ‒ those with a body mass index of 30 kg/m2 or greater ‒ had an average energy intake during the second and third trimesters of 125 kcal/day less than their energy expenditure, Leanne M. Redman, PhD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, women in the study who had inadequate gestational weight gain had a daily calorie deficit that was only slightly larger, an average of 262 kcal/day below their energy expenditure. As a consequence, Dr. Redman believes the take-home message from her findings is that pregnant women with obesity should maintain their prepregnancy energy intake, though she also strongly recommended improvements in diet quality.
“Chasing a 100-kcal/day deficit in intake is extremely problematic,” Dr. Redman admitted, so she suggested that women with obesity be advised simply to not increase their calorie intake during pregnancy.
“The message is: Focus on improving diet quality rather than increasing calories,” she said in an interview. Pregnant women with obesity “do not need to increase calorie intake. They need to improve their diet quality,” with increased consumption of fruits and vegetables, said Dr. Redman, a professor and director of the Reproductive Endocrinology and Women’s Health Laboratory at Louisiana State University’s Pennington Biomedical Research Center in Baton Rouge.
The results she reported represent “the first time” researchers have examined energy expenditure and weight-gain trajectories in women with obesity throughout the second and third trimesters. Until now, dietary energy recommendations for women with obesity during pregnancy were based on observations made in women without obesity.
Those observations led the Institute of Medicine to call for a recommended pregnancy weight gain of 11-20 pounds in women with obesity, as well as gains of 25-35 pounds in women with a normal body mass index of 18.5-24.9 kg/m2 (Weight Gain During Pregnancy: Reexamining the Guidelines; May 2009). In that 2009 document, the IOM committee said that, in general, pregnant women should add 340 kcal/day to their prepregnancy intake during the second trimester and add 452 kcal/day during the third trimester without regard to their prepregnancy body mass index, a recommendation that clinicians continued to promote in subsequent years (Med Clin North Amer. 2016;100[6]:1199-215), and that was generally affirmed by the American College of Obstetricians and Gynecologists in 2013 and reaffirmed in 2018.*
The new evidence collected by Dr. Redman and associates “challenges current practice and argues that women with obesity should not be advised to consume additional energy during pregnancy as currently recommended,” they wrote in an article with their findings published a few days before Dr. Redman gave her talk (J Clin Invest. 2019;129[11]:4682-90).
The MomEE (Determinants of Gestational Weight Gain in Obese Pregnant Women) study enrolled 72 women with obesity during the first trimester of pregnancy and collected complete data through the end of the third trimester from 54 women. The researchers collected data on weight, body fat mass, and energy expenditure at multiple times during the second and third trimesters and calculated energy intake.
Based on body weights at the end of the third trimester, the researchers divided the 54 women into three subgroups: 10 women (19%) with inadequate weight gain by the IOM recommendations, 8 (15%) who had the IOM’s recommended weight gain of 11-20 pounds, and 36 women (67%; total is greater than 100% because of rounding) with excess weight gain, and within each group, they calculated the average level of energy intake relative to energy expenditure.
In addition to the daily calorie deficits associated with women who maintained recommended or inadequate weight, the researchers also found that women with excess weight gain averaged 186 more kcal/day than required to meet their daily energy expenditure.
The analyses showed that the increased energy demand of pregnancy and the fetus is compensated for by mobilization of the maternal fat mass in women with obesity, and that an imbalance between energy intake and expenditure is the main driver of weight gain during pregnancy. The results also highlighted how often pregnant women with obesity fail to follow a diet that results in the recommended weight gain of 11-20 pounds. In the MomEE cohort, two-thirds of enrolled women had excess weight gain.
The finding that women had the recommended weight gain on a diet that cut their daily calorie intake by about 100 kcal/day during the last two trimesters highlighted the nutritional challenge faced by women with obesity who are pregnant. “About three-quarters of women in the study had poor diet quality. There is an opportunity to improve diet with more fruits and vegetables to increase fullness, and [to reduce] energy-dense foods,” Dr. Redman said.
She is planning to collaborate on a study that will test the efficacy and safety of providing pregnant women with extreme obesity (class II-III) with defined meals to provide better control of energy intake and nutritional quality. Dr. Redman said she also hoped that the new findings she reported would be taken into account by the advisory committee assembled by the Department of Health & Human Services and the Department of Agriculture, which are currently preparing a revision of U.S. dietary guidelines for release in 2020.
The National Institutes of Health and the Clinical Research Cores at Pennington Biomedical Research Center funded the study. Dr. Redman had no disclosures.
SOURCE: Redman LM et al. Obesity Week 2019, Abstract T-OR-2079.
*This article was updated 2/7/2020.
The results reported by Dr. Redman from the MomEE study showed that women with obesity need not ingest surplus calories to gain weight during pregnancy. The findings indicate that pregnant women efficiently convert a portion of their accumulated fat mass to fat-free mass in the form of the fetus, uterus, blood volume, and other tissue. A deficit of about approximately 100 kcal/day effectively kept weight gain within the 11- to 20-pound target recommended by the Institute of Medicine in 2009.
But the weight gains recommended for women with obesity may be too high. The desire of the writers of the IOM recommendation to avoid negative perinatal outcomes for infants may instead lead to negative maternal outcomes, such as preeclampsia, gestational hypertension, and need for cesarean birth. Gestational weight gains below what the IOM recommended for women with obesity may be able to serve present-day standards and work better for these pregnant women by reducing their morbidity risk. Future studies should take into careful account overall nutrient values rather than just calorie intake, as well as physical activity.
The MomEE results showed that a striking two-thirds of women with obesity gained an excess of weight during pregnancy, beyond the 2009 recommendations. This finding highlights the need to identify strategies that can prevent excessive weight gain. Furthermore, results from several studies and systematic reviews suggest that the IOM recommendation for weight gain during pregnancy is too high for women with obesity, especially those with class II-III obesity, with a body mass index of 35 kg/m2 or greater. In my opinion, an appropriate weight-gain target to replace the current, blanket recommendation of 11-20 pounds gained for all women with obesity is a target of 5-15 pounds gained for women with class I obesity, less than 10 pounds for class II obesity, and no change in prepregnancy weight for women with class III obesity.
Sarah S. Comstock, PhD, is a nutrition researcher at Michigan State University, East Lansing. She is an inventor named on three patents that involve nutrition. She made these comments in an editorial that accompanied the MomEE report (J Clin Invest. 2019;129[11]:4567-9).
The results reported by Dr. Redman from the MomEE study showed that women with obesity need not ingest surplus calories to gain weight during pregnancy. The findings indicate that pregnant women efficiently convert a portion of their accumulated fat mass to fat-free mass in the form of the fetus, uterus, blood volume, and other tissue. A deficit of about approximately 100 kcal/day effectively kept weight gain within the 11- to 20-pound target recommended by the Institute of Medicine in 2009.
But the weight gains recommended for women with obesity may be too high. The desire of the writers of the IOM recommendation to avoid negative perinatal outcomes for infants may instead lead to negative maternal outcomes, such as preeclampsia, gestational hypertension, and need for cesarean birth. Gestational weight gains below what the IOM recommended for women with obesity may be able to serve present-day standards and work better for these pregnant women by reducing their morbidity risk. Future studies should take into careful account overall nutrient values rather than just calorie intake, as well as physical activity.
The MomEE results showed that a striking two-thirds of women with obesity gained an excess of weight during pregnancy, beyond the 2009 recommendations. This finding highlights the need to identify strategies that can prevent excessive weight gain. Furthermore, results from several studies and systematic reviews suggest that the IOM recommendation for weight gain during pregnancy is too high for women with obesity, especially those with class II-III obesity, with a body mass index of 35 kg/m2 or greater. In my opinion, an appropriate weight-gain target to replace the current, blanket recommendation of 11-20 pounds gained for all women with obesity is a target of 5-15 pounds gained for women with class I obesity, less than 10 pounds for class II obesity, and no change in prepregnancy weight for women with class III obesity.
Sarah S. Comstock, PhD, is a nutrition researcher at Michigan State University, East Lansing. She is an inventor named on three patents that involve nutrition. She made these comments in an editorial that accompanied the MomEE report (J Clin Invest. 2019;129[11]:4567-9).
The results reported by Dr. Redman from the MomEE study showed that women with obesity need not ingest surplus calories to gain weight during pregnancy. The findings indicate that pregnant women efficiently convert a portion of their accumulated fat mass to fat-free mass in the form of the fetus, uterus, blood volume, and other tissue. A deficit of about approximately 100 kcal/day effectively kept weight gain within the 11- to 20-pound target recommended by the Institute of Medicine in 2009.
But the weight gains recommended for women with obesity may be too high. The desire of the writers of the IOM recommendation to avoid negative perinatal outcomes for infants may instead lead to negative maternal outcomes, such as preeclampsia, gestational hypertension, and need for cesarean birth. Gestational weight gains below what the IOM recommended for women with obesity may be able to serve present-day standards and work better for these pregnant women by reducing their morbidity risk. Future studies should take into careful account overall nutrient values rather than just calorie intake, as well as physical activity.
The MomEE results showed that a striking two-thirds of women with obesity gained an excess of weight during pregnancy, beyond the 2009 recommendations. This finding highlights the need to identify strategies that can prevent excessive weight gain. Furthermore, results from several studies and systematic reviews suggest that the IOM recommendation for weight gain during pregnancy is too high for women with obesity, especially those with class II-III obesity, with a body mass index of 35 kg/m2 or greater. In my opinion, an appropriate weight-gain target to replace the current, blanket recommendation of 11-20 pounds gained for all women with obesity is a target of 5-15 pounds gained for women with class I obesity, less than 10 pounds for class II obesity, and no change in prepregnancy weight for women with class III obesity.
Sarah S. Comstock, PhD, is a nutrition researcher at Michigan State University, East Lansing. She is an inventor named on three patents that involve nutrition. She made these comments in an editorial that accompanied the MomEE report (J Clin Invest. 2019;129[11]:4567-9).
LAS VEGAS – Contrary to current U.S. dietary recommendations for pregnancy, women with obesity should not increase their energy intake during pregnancy to achieve the current recommended level of gestational weight gain, based on findings from an intensive assessment of 54 women with obesity during weeks 13-37 of pregnancy.
To achieve the gestational weight gain of 11-20 pounds (5-9.1 kg) recommended by the Institute of Medicine, women with obesity ‒ those with a body mass index of 30 kg/m2 or greater ‒ had an average energy intake during the second and third trimesters of 125 kcal/day less than their energy expenditure, Leanne M. Redman, PhD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, women in the study who had inadequate gestational weight gain had a daily calorie deficit that was only slightly larger, an average of 262 kcal/day below their energy expenditure. As a consequence, Dr. Redman believes the take-home message from her findings is that pregnant women with obesity should maintain their prepregnancy energy intake, though she also strongly recommended improvements in diet quality.
“Chasing a 100-kcal/day deficit in intake is extremely problematic,” Dr. Redman admitted, so she suggested that women with obesity be advised simply to not increase their calorie intake during pregnancy.
“The message is: Focus on improving diet quality rather than increasing calories,” she said in an interview. Pregnant women with obesity “do not need to increase calorie intake. They need to improve their diet quality,” with increased consumption of fruits and vegetables, said Dr. Redman, a professor and director of the Reproductive Endocrinology and Women’s Health Laboratory at Louisiana State University’s Pennington Biomedical Research Center in Baton Rouge.
The results she reported represent “the first time” researchers have examined energy expenditure and weight-gain trajectories in women with obesity throughout the second and third trimesters. Until now, dietary energy recommendations for women with obesity during pregnancy were based on observations made in women without obesity.
Those observations led the Institute of Medicine to call for a recommended pregnancy weight gain of 11-20 pounds in women with obesity, as well as gains of 25-35 pounds in women with a normal body mass index of 18.5-24.9 kg/m2 (Weight Gain During Pregnancy: Reexamining the Guidelines; May 2009). In that 2009 document, the IOM committee said that, in general, pregnant women should add 340 kcal/day to their prepregnancy intake during the second trimester and add 452 kcal/day during the third trimester without regard to their prepregnancy body mass index, a recommendation that clinicians continued to promote in subsequent years (Med Clin North Amer. 2016;100[6]:1199-215), and that was generally affirmed by the American College of Obstetricians and Gynecologists in 2013 and reaffirmed in 2018.*
The new evidence collected by Dr. Redman and associates “challenges current practice and argues that women with obesity should not be advised to consume additional energy during pregnancy as currently recommended,” they wrote in an article with their findings published a few days before Dr. Redman gave her talk (J Clin Invest. 2019;129[11]:4682-90).
The MomEE (Determinants of Gestational Weight Gain in Obese Pregnant Women) study enrolled 72 women with obesity during the first trimester of pregnancy and collected complete data through the end of the third trimester from 54 women. The researchers collected data on weight, body fat mass, and energy expenditure at multiple times during the second and third trimesters and calculated energy intake.
Based on body weights at the end of the third trimester, the researchers divided the 54 women into three subgroups: 10 women (19%) with inadequate weight gain by the IOM recommendations, 8 (15%) who had the IOM’s recommended weight gain of 11-20 pounds, and 36 women (67%; total is greater than 100% because of rounding) with excess weight gain, and within each group, they calculated the average level of energy intake relative to energy expenditure.
In addition to the daily calorie deficits associated with women who maintained recommended or inadequate weight, the researchers also found that women with excess weight gain averaged 186 more kcal/day than required to meet their daily energy expenditure.
The analyses showed that the increased energy demand of pregnancy and the fetus is compensated for by mobilization of the maternal fat mass in women with obesity, and that an imbalance between energy intake and expenditure is the main driver of weight gain during pregnancy. The results also highlighted how often pregnant women with obesity fail to follow a diet that results in the recommended weight gain of 11-20 pounds. In the MomEE cohort, two-thirds of enrolled women had excess weight gain.
The finding that women had the recommended weight gain on a diet that cut their daily calorie intake by about 100 kcal/day during the last two trimesters highlighted the nutritional challenge faced by women with obesity who are pregnant. “About three-quarters of women in the study had poor diet quality. There is an opportunity to improve diet with more fruits and vegetables to increase fullness, and [to reduce] energy-dense foods,” Dr. Redman said.
She is planning to collaborate on a study that will test the efficacy and safety of providing pregnant women with extreme obesity (class II-III) with defined meals to provide better control of energy intake and nutritional quality. Dr. Redman said she also hoped that the new findings she reported would be taken into account by the advisory committee assembled by the Department of Health & Human Services and the Department of Agriculture, which are currently preparing a revision of U.S. dietary guidelines for release in 2020.
The National Institutes of Health and the Clinical Research Cores at Pennington Biomedical Research Center funded the study. Dr. Redman had no disclosures.
SOURCE: Redman LM et al. Obesity Week 2019, Abstract T-OR-2079.
*This article was updated 2/7/2020.
LAS VEGAS – Contrary to current U.S. dietary recommendations for pregnancy, women with obesity should not increase their energy intake during pregnancy to achieve the current recommended level of gestational weight gain, based on findings from an intensive assessment of 54 women with obesity during weeks 13-37 of pregnancy.
To achieve the gestational weight gain of 11-20 pounds (5-9.1 kg) recommended by the Institute of Medicine, women with obesity ‒ those with a body mass index of 30 kg/m2 or greater ‒ had an average energy intake during the second and third trimesters of 125 kcal/day less than their energy expenditure, Leanne M. Redman, PhD, said at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, women in the study who had inadequate gestational weight gain had a daily calorie deficit that was only slightly larger, an average of 262 kcal/day below their energy expenditure. As a consequence, Dr. Redman believes the take-home message from her findings is that pregnant women with obesity should maintain their prepregnancy energy intake, though she also strongly recommended improvements in diet quality.
“Chasing a 100-kcal/day deficit in intake is extremely problematic,” Dr. Redman admitted, so she suggested that women with obesity be advised simply to not increase their calorie intake during pregnancy.
“The message is: Focus on improving diet quality rather than increasing calories,” she said in an interview. Pregnant women with obesity “do not need to increase calorie intake. They need to improve their diet quality,” with increased consumption of fruits and vegetables, said Dr. Redman, a professor and director of the Reproductive Endocrinology and Women’s Health Laboratory at Louisiana State University’s Pennington Biomedical Research Center in Baton Rouge.
The results she reported represent “the first time” researchers have examined energy expenditure and weight-gain trajectories in women with obesity throughout the second and third trimesters. Until now, dietary energy recommendations for women with obesity during pregnancy were based on observations made in women without obesity.
Those observations led the Institute of Medicine to call for a recommended pregnancy weight gain of 11-20 pounds in women with obesity, as well as gains of 25-35 pounds in women with a normal body mass index of 18.5-24.9 kg/m2 (Weight Gain During Pregnancy: Reexamining the Guidelines; May 2009). In that 2009 document, the IOM committee said that, in general, pregnant women should add 340 kcal/day to their prepregnancy intake during the second trimester and add 452 kcal/day during the third trimester without regard to their prepregnancy body mass index, a recommendation that clinicians continued to promote in subsequent years (Med Clin North Amer. 2016;100[6]:1199-215), and that was generally affirmed by the American College of Obstetricians and Gynecologists in 2013 and reaffirmed in 2018.*
The new evidence collected by Dr. Redman and associates “challenges current practice and argues that women with obesity should not be advised to consume additional energy during pregnancy as currently recommended,” they wrote in an article with their findings published a few days before Dr. Redman gave her talk (J Clin Invest. 2019;129[11]:4682-90).
The MomEE (Determinants of Gestational Weight Gain in Obese Pregnant Women) study enrolled 72 women with obesity during the first trimester of pregnancy and collected complete data through the end of the third trimester from 54 women. The researchers collected data on weight, body fat mass, and energy expenditure at multiple times during the second and third trimesters and calculated energy intake.
Based on body weights at the end of the third trimester, the researchers divided the 54 women into three subgroups: 10 women (19%) with inadequate weight gain by the IOM recommendations, 8 (15%) who had the IOM’s recommended weight gain of 11-20 pounds, and 36 women (67%; total is greater than 100% because of rounding) with excess weight gain, and within each group, they calculated the average level of energy intake relative to energy expenditure.
In addition to the daily calorie deficits associated with women who maintained recommended or inadequate weight, the researchers also found that women with excess weight gain averaged 186 more kcal/day than required to meet their daily energy expenditure.
The analyses showed that the increased energy demand of pregnancy and the fetus is compensated for by mobilization of the maternal fat mass in women with obesity, and that an imbalance between energy intake and expenditure is the main driver of weight gain during pregnancy. The results also highlighted how often pregnant women with obesity fail to follow a diet that results in the recommended weight gain of 11-20 pounds. In the MomEE cohort, two-thirds of enrolled women had excess weight gain.
The finding that women had the recommended weight gain on a diet that cut their daily calorie intake by about 100 kcal/day during the last two trimesters highlighted the nutritional challenge faced by women with obesity who are pregnant. “About three-quarters of women in the study had poor diet quality. There is an opportunity to improve diet with more fruits and vegetables to increase fullness, and [to reduce] energy-dense foods,” Dr. Redman said.
She is planning to collaborate on a study that will test the efficacy and safety of providing pregnant women with extreme obesity (class II-III) with defined meals to provide better control of energy intake and nutritional quality. Dr. Redman said she also hoped that the new findings she reported would be taken into account by the advisory committee assembled by the Department of Health & Human Services and the Department of Agriculture, which are currently preparing a revision of U.S. dietary guidelines for release in 2020.
The National Institutes of Health and the Clinical Research Cores at Pennington Biomedical Research Center funded the study. Dr. Redman had no disclosures.
SOURCE: Redman LM et al. Obesity Week 2019, Abstract T-OR-2079.
*This article was updated 2/7/2020.
REPORTING FROM OBESITY WEEK 2019
TARGET-NASH: One-third of NAFLD, NASH patients lost weight, but not all kept it off
BOSTON – While about one-third of overweight patients with nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) slimmed down after a weight-loss intervention, about 20% gained weight back within the next few years, according to results from a large, long-term observational cohort study.
Effectively, that meant about one-quarter of overweight subjects enrolled in the TARGET-NASH study were able to lose weight and keep it off, said investigator Miguel H. Malespin, MD, a transplant hepatologist at Tampa General Hospital.
These findings illustrate how challenging lifestyle interventions can be for patients with NAFLD and NASH, and have clinical implications for identifying those individuals who are more or less likely to respond to weight-loss intervention as an initial treatment, Dr. Malespin said.
“I think we as providers need to better identify what are the barriers for weight loss for these patients, and try to use data, such as this data from TARGET-NASH, to help our clinical judgment and to learn strategies to be able to help these patients optimize their weight loss,” he added in an interview.
With no approved pharmacologic treatments for NAFLD and NASH, weight reduction remains one of the mainstays of treatment, Dr. Malespin said.
However, there are few studies evaluating structured programs designed to achieve such weight loss, and the long-term sustainability of this approach remains in question, according to Dr. Malespin, who presented findings of TARGET-NASH at the annual meeting of the American Association for the Study of Liver Diseases.
To date, more than 4,500 patients have been enrolled in TARGET-NASH at 59 U.S. centers. The present analysis, which Dr. Malespin described in an oral abstract presentation, included 2,037 patients with a body mass index of at least 25 kg/m2 and no decompensated cirrhosis, bariatric surgery, weight-loss medication use, or cancer diagnoses.
In sum, 34% of patients had 5% or more weight loss over about 3 years of follow-up, while about 10% had a 10% or greater weight loss, Dr. Malespin reported.
It took patients about 18 months, on average, to achieve 5% or greater weight loss. Those who achieved weight loss tended to be older, according to the investigator, and were about 1.5 times as likely to be obese class II or III, as opposed to just being overweight.
Patients were significantly more likely to lose weight, Dr. Malespin and coauthors found, if they had cirrhosis or comorbid medical conditions such as diabetes, osteoarthritis, or cardiovascular disease.
“All these factors essentially imply that these patients are hopefully being seen by multiple providers,” Dr. Malespin said, “so hopefully they’re getting the message [on the need for lifestyle modifications] from multiple different providers, and this is contributing to why we’re seeing some of this weight loss.”
However, weight loss did not persist in all patients, with 20.2% regaining weight back up to baseline or greater, according to the report. The median time to weight regain was 24-31 months, depending on initial weight class.
TARGET-NASH, sponsored by TARGET PharmaSolutions, is a 5-year longitudinal observational study with an enrollment goal of 15,000 patients with NAFLD or NASH and an estimated study completion date of 2021, according to a ClinicalTrials.gov listing.
Dr. Malespin reported disclosures with Gilead (speaker board), Intercept (speaker board, advisory committee), and TARGET PharmaSolutions (research grant paid to institution).
SOURCE: Malespin MH et al. The Liver Meeting 2019, Abstract 240.
BOSTON – While about one-third of overweight patients with nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) slimmed down after a weight-loss intervention, about 20% gained weight back within the next few years, according to results from a large, long-term observational cohort study.
Effectively, that meant about one-quarter of overweight subjects enrolled in the TARGET-NASH study were able to lose weight and keep it off, said investigator Miguel H. Malespin, MD, a transplant hepatologist at Tampa General Hospital.
These findings illustrate how challenging lifestyle interventions can be for patients with NAFLD and NASH, and have clinical implications for identifying those individuals who are more or less likely to respond to weight-loss intervention as an initial treatment, Dr. Malespin said.
“I think we as providers need to better identify what are the barriers for weight loss for these patients, and try to use data, such as this data from TARGET-NASH, to help our clinical judgment and to learn strategies to be able to help these patients optimize their weight loss,” he added in an interview.
With no approved pharmacologic treatments for NAFLD and NASH, weight reduction remains one of the mainstays of treatment, Dr. Malespin said.
However, there are few studies evaluating structured programs designed to achieve such weight loss, and the long-term sustainability of this approach remains in question, according to Dr. Malespin, who presented findings of TARGET-NASH at the annual meeting of the American Association for the Study of Liver Diseases.
To date, more than 4,500 patients have been enrolled in TARGET-NASH at 59 U.S. centers. The present analysis, which Dr. Malespin described in an oral abstract presentation, included 2,037 patients with a body mass index of at least 25 kg/m2 and no decompensated cirrhosis, bariatric surgery, weight-loss medication use, or cancer diagnoses.
In sum, 34% of patients had 5% or more weight loss over about 3 years of follow-up, while about 10% had a 10% or greater weight loss, Dr. Malespin reported.
It took patients about 18 months, on average, to achieve 5% or greater weight loss. Those who achieved weight loss tended to be older, according to the investigator, and were about 1.5 times as likely to be obese class II or III, as opposed to just being overweight.
Patients were significantly more likely to lose weight, Dr. Malespin and coauthors found, if they had cirrhosis or comorbid medical conditions such as diabetes, osteoarthritis, or cardiovascular disease.
“All these factors essentially imply that these patients are hopefully being seen by multiple providers,” Dr. Malespin said, “so hopefully they’re getting the message [on the need for lifestyle modifications] from multiple different providers, and this is contributing to why we’re seeing some of this weight loss.”
However, weight loss did not persist in all patients, with 20.2% regaining weight back up to baseline or greater, according to the report. The median time to weight regain was 24-31 months, depending on initial weight class.
TARGET-NASH, sponsored by TARGET PharmaSolutions, is a 5-year longitudinal observational study with an enrollment goal of 15,000 patients with NAFLD or NASH and an estimated study completion date of 2021, according to a ClinicalTrials.gov listing.
Dr. Malespin reported disclosures with Gilead (speaker board), Intercept (speaker board, advisory committee), and TARGET PharmaSolutions (research grant paid to institution).
SOURCE: Malespin MH et al. The Liver Meeting 2019, Abstract 240.
BOSTON – While about one-third of overweight patients with nonalcoholic fatty liver disease (NAFLD) or nonalcoholic steatohepatitis (NASH) slimmed down after a weight-loss intervention, about 20% gained weight back within the next few years, according to results from a large, long-term observational cohort study.
Effectively, that meant about one-quarter of overweight subjects enrolled in the TARGET-NASH study were able to lose weight and keep it off, said investigator Miguel H. Malespin, MD, a transplant hepatologist at Tampa General Hospital.
These findings illustrate how challenging lifestyle interventions can be for patients with NAFLD and NASH, and have clinical implications for identifying those individuals who are more or less likely to respond to weight-loss intervention as an initial treatment, Dr. Malespin said.
“I think we as providers need to better identify what are the barriers for weight loss for these patients, and try to use data, such as this data from TARGET-NASH, to help our clinical judgment and to learn strategies to be able to help these patients optimize their weight loss,” he added in an interview.
With no approved pharmacologic treatments for NAFLD and NASH, weight reduction remains one of the mainstays of treatment, Dr. Malespin said.
However, there are few studies evaluating structured programs designed to achieve such weight loss, and the long-term sustainability of this approach remains in question, according to Dr. Malespin, who presented findings of TARGET-NASH at the annual meeting of the American Association for the Study of Liver Diseases.
To date, more than 4,500 patients have been enrolled in TARGET-NASH at 59 U.S. centers. The present analysis, which Dr. Malespin described in an oral abstract presentation, included 2,037 patients with a body mass index of at least 25 kg/m2 and no decompensated cirrhosis, bariatric surgery, weight-loss medication use, or cancer diagnoses.
In sum, 34% of patients had 5% or more weight loss over about 3 years of follow-up, while about 10% had a 10% or greater weight loss, Dr. Malespin reported.
It took patients about 18 months, on average, to achieve 5% or greater weight loss. Those who achieved weight loss tended to be older, according to the investigator, and were about 1.5 times as likely to be obese class II or III, as opposed to just being overweight.
Patients were significantly more likely to lose weight, Dr. Malespin and coauthors found, if they had cirrhosis or comorbid medical conditions such as diabetes, osteoarthritis, or cardiovascular disease.
“All these factors essentially imply that these patients are hopefully being seen by multiple providers,” Dr. Malespin said, “so hopefully they’re getting the message [on the need for lifestyle modifications] from multiple different providers, and this is contributing to why we’re seeing some of this weight loss.”
However, weight loss did not persist in all patients, with 20.2% regaining weight back up to baseline or greater, according to the report. The median time to weight regain was 24-31 months, depending on initial weight class.
TARGET-NASH, sponsored by TARGET PharmaSolutions, is a 5-year longitudinal observational study with an enrollment goal of 15,000 patients with NAFLD or NASH and an estimated study completion date of 2021, according to a ClinicalTrials.gov listing.
Dr. Malespin reported disclosures with Gilead (speaker board), Intercept (speaker board, advisory committee), and TARGET PharmaSolutions (research grant paid to institution).
SOURCE: Malespin MH et al. The Liver Meeting 2019, Abstract 240.
REPORTING FROM THE LIVER MEETING 2019