Obesity

BALTIMORE – While rates of surgical site infections after bariatric surgery have been reported in the low single digits, SSIs have continued to be a persistent complication.

Richard Kirkner/MDedge News

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons, researchers reported on two strategies to reduce SSI in bariatric surgery: a predictive tool that identifies risk factors for wound infection, allowing surgeons to employ protective measures before and during surgery, and a change in surgical practice leading to a 78% reduction in wound infection rates that resulted from a single-center study.

Jerry Dang, MD, of the University of Alberta, Edmonton, reported that the BariWound predictive tool designed to stratify patients into risk categories showed a high level of accuracy with an area under the curve of 0.73. Cynthia Weber, MD, of University Hospitals, Cleveland, reported that changing the method for performing circular-stapled gastrojejunostomy (GJ) from the transoral to the transabdominal approach along with more vigilant use of wound protection reduced wound infection rates from 6% to 1.3%.

Dr. Dang noted that SSI has been reported as the most common hospital-acquired complication in bariatric surgery, with reported rates of between 1% and 10%. A 2014 analysis of the American College of Surgeons National Surgical Quality Improvement Program database reported an SSI rate of 1.8% (Surg Endosc. 2014;28:3285-92). Although these rates are low, Dr. Dang explained that his group wanted to identify factors associated with SSI within 30 days of bariatric surgery. They analyzed outcomes data of 274,187 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who had bariatric surgery in 2015 and 2016 (196,608 by laparoscopic sleeve gastrectomy [SG] and 77,579 laparoscopic Roux-en-Y gastric bypass [RYGB]). Their analysis determined an incisional SSI rate of 0.47% (n = 1,291). “Incisional SSI rates were four times higher for laparoscopic RYGB: 1.04% vs. 0.25%,” Dr. Dang said.

On multivariable logistic regression, the adjusted odds ratio of SSI after RYGB vs. SG was 3.13 (P less than .001). Other significant risk factors were chronic steroid or immunosuppressant use (odds ratio, 1.75; P = .001), female sex (OR, 1.48; P less than .001) and history of gastroesophageal reflux disease (OR, 1.45; P less than .001). Other factors with a 21%-31% greater risk of SSI were white race (P = .002), history of diabetes (P less than .001), hypertension (P less than .001), obstructive sleep apnea (P = .001), and longer operation times (P less than .001). Each single-digit increase in body mass index increased risk by 3%, and older age actually had a protective effect for unknown reasons, Dr. Dang noted.

The BariWound tool assigns points to each risk factor. Each hour of operation time and each 10 kg/m² of weight carry a value of 1 point, with partial points allowed. RYGB equals 5 points, and chronic steroid/immunosuppressant use, 4 points. The tool assigns risk to four categories based on score and 30-day SSI rate:

• Low, less than 15 (1% risk of SSI).
• Moderate, 15-21.9 (1%-5%).
• High, 22-26.9 (5%-10%).
• Very high, greater than 27 (greater than 10%).

“The BariWound tool can help to inform clinical decision making so patients can know they’re at higher risk, and this could allow for us to target high-risk patients with preventive packages, such as the Cleveland Clinic Technique of wound protection, wound irrigation, and wound packing as a resource-saving measure,” Dr. Dang said. “Targeting high-risk populations can reduce cost and operating time.”

Richard Kirkner/MDedge NEws

Dr. Weber reported on her institution’s study of SSIs using two different methods for circular stapling of GJ that involved two different surgeons who performed 333 RYGB procedures from January 2016 to March 2018. Surgeon “A” had traditionally used the transoral technique without wound protection to insert the anvil of the stapler; surgeon “B” used wound protection and the transabdominal technique for stapler insertion. Wound protection involves draping of the stapler with sterile plastic.

“In a quarterly review, we detected a higher than expected wound complication rate of 6%,” Dr. Weber said. “Of particular concern was the development of five recent wound infection cases, which all occurred in the transoral group for a rate of 8.9% in that cohort.”

That left the quality team questioning the safety profile of the transoral technique, Dr. Weber said. “We wanted to know why and whether or not the main contributor to the development of a wound infection was the technique for the anvil introduction or was it the difference between surgeons using wound protection.”

Halfway through the study period, surgeon A made two modifications: He adopted the transabdominal technique for a subset of patients; and because of the surgeon’s comfort level and expertise with the transoral approach, he continued using that approach but added wound protection. Surgeon B continued with the transabdominal approach with wound protection. The share of transabdominal insertions in the study population increased from 69.2% before the change to 75% after. Demographics between the pre- and postchange patient populations were similar, as were the rates of revision surgery between the two groups.

“We noticed a significant reduction in total wound complications from 6% to 1.3%, and we noticed a complete elimination of surgical site infections after adding wound protection to the transoral technique,” Dr. Weber said.

Dr. Weber noted a number of limitations with the study: its retrospective nature; the lack of control for other intraoperative factors that contribute to SSIs; relatively low incidence of SSI; and surgeon’s choice to determine the technique of anvil insertion.

“We found that our quality improvement intervention was efficacious and decided that it was not the technique of anvil insertion, but it was the wound protection that was key to preventing wound infections, as we saw complete elimination after we added wound protection to the transoral technique,” Dr. Weber said. “Using proper precautions with the circular stapler and anastomosis can be done using either technique for anvil insertion. Overall self-assessment of outcomes leads to best practice.”

Dr. Dang had no financial relationships to disclose. Dr. Weber’s coauthor Leena Khatian, MD, MPH, disclosed relationships with Torax Medical, Medtronic, and Gore.

SOURCES: Weber C et al. SAGES 2109, Presentation S049; Dang J et al. SAGES 2019, Presentation S050.

BALTIMORE – While rates of surgical site infections after bariatric surgery have been reported in the low single digits, SSIs have continued to be a persistent complication.

Richard Kirkner/MDedge News

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons, researchers reported on two strategies to reduce SSI in bariatric surgery: a predictive tool that identifies risk factors for wound infection, allowing surgeons to employ protective measures before and during surgery, and a change in surgical practice leading to a 78% reduction in wound infection rates that resulted from a single-center study.

Jerry Dang, MD, of the University of Alberta, Edmonton, reported that the BariWound predictive tool designed to stratify patients into risk categories showed a high level of accuracy with an area under the curve of 0.73. Cynthia Weber, MD, of University Hospitals, Cleveland, reported that changing the method for performing circular-stapled gastrojejunostomy (GJ) from the transoral to the transabdominal approach along with more vigilant use of wound protection reduced wound infection rates from 6% to 1.3%.

Dr. Dang noted that SSI has been reported as the most common hospital-acquired complication in bariatric surgery, with reported rates of between 1% and 10%. A 2014 analysis of the American College of Surgeons National Surgical Quality Improvement Program database reported an SSI rate of 1.8% (Surg Endosc. 2014;28:3285-92). Although these rates are low, Dr. Dang explained that his group wanted to identify factors associated with SSI within 30 days of bariatric surgery. They analyzed outcomes data of 274,187 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who had bariatric surgery in 2015 and 2016 (196,608 by laparoscopic sleeve gastrectomy [SG] and 77,579 laparoscopic Roux-en-Y gastric bypass [RYGB]). Their analysis determined an incisional SSI rate of 0.47% (n = 1,291). “Incisional SSI rates were four times higher for laparoscopic RYGB: 1.04% vs. 0.25%,” Dr. Dang said.

On multivariable logistic regression, the adjusted odds ratio of SSI after RYGB vs. SG was 3.13 (P less than .001). Other significant risk factors were chronic steroid or immunosuppressant use (odds ratio, 1.75; P = .001), female sex (OR, 1.48; P less than .001) and history of gastroesophageal reflux disease (OR, 1.45; P less than .001). Other factors with a 21%-31% greater risk of SSI were white race (P = .002), history of diabetes (P less than .001), hypertension (P less than .001), obstructive sleep apnea (P = .001), and longer operation times (P less than .001). Each single-digit increase in body mass index increased risk by 3%, and older age actually had a protective effect for unknown reasons, Dr. Dang noted.

The BariWound tool assigns points to each risk factor. Each hour of operation time and each 10 kg/m² of weight carry a value of 1 point, with partial points allowed. RYGB equals 5 points, and chronic steroid/immunosuppressant use, 4 points. The tool assigns risk to four categories based on score and 30-day SSI rate:

• Low, less than 15 (1% risk of SSI).
• Moderate, 15-21.9 (1%-5%).
• High, 22-26.9 (5%-10%).
• Very high, greater than 27 (greater than 10%).

“The BariWound tool can help to inform clinical decision making so patients can know they’re at higher risk, and this could allow for us to target high-risk patients with preventive packages, such as the Cleveland Clinic Technique of wound protection, wound irrigation, and wound packing as a resource-saving measure,” Dr. Dang said. “Targeting high-risk populations can reduce cost and operating time.”

Richard Kirkner/MDedge NEws

Dr. Weber reported on her institution’s study of SSIs using two different methods for circular stapling of GJ that involved two different surgeons who performed 333 RYGB procedures from January 2016 to March 2018. Surgeon “A” had traditionally used the transoral technique without wound protection to insert the anvil of the stapler; surgeon “B” used wound protection and the transabdominal technique for stapler insertion. Wound protection involves draping of the stapler with sterile plastic.

“In a quarterly review, we detected a higher than expected wound complication rate of 6%,” Dr. Weber said. “Of particular concern was the development of five recent wound infection cases, which all occurred in the transoral group for a rate of 8.9% in that cohort.”

That left the quality team questioning the safety profile of the transoral technique, Dr. Weber said. “We wanted to know why and whether or not the main contributor to the development of a wound infection was the technique for the anvil introduction or was it the difference between surgeons using wound protection.”

Halfway through the study period, surgeon A made two modifications: He adopted the transabdominal technique for a subset of patients; and because of the surgeon’s comfort level and expertise with the transoral approach, he continued using that approach but added wound protection. Surgeon B continued with the transabdominal approach with wound protection. The share of transabdominal insertions in the study population increased from 69.2% before the change to 75% after. Demographics between the pre- and postchange patient populations were similar, as were the rates of revision surgery between the two groups.

“We noticed a significant reduction in total wound complications from 6% to 1.3%, and we noticed a complete elimination of surgical site infections after adding wound protection to the transoral technique,” Dr. Weber said.

Dr. Weber noted a number of limitations with the study: its retrospective nature; the lack of control for other intraoperative factors that contribute to SSIs; relatively low incidence of SSI; and surgeon’s choice to determine the technique of anvil insertion.

“We found that our quality improvement intervention was efficacious and decided that it was not the technique of anvil insertion, but it was the wound protection that was key to preventing wound infections, as we saw complete elimination after we added wound protection to the transoral technique,” Dr. Weber said. “Using proper precautions with the circular stapler and anastomosis can be done using either technique for anvil insertion. Overall self-assessment of outcomes leads to best practice.”

Dr. Dang had no financial relationships to disclose. Dr. Weber’s coauthor Leena Khatian, MD, MPH, disclosed relationships with Torax Medical, Medtronic, and Gore.

SOURCES: Weber C et al. SAGES 2109, Presentation S049; Dang J et al. SAGES 2019, Presentation S050.

BALTIMORE – While rates of surgical site infections after bariatric surgery have been reported in the low single digits, SSIs have continued to be a persistent complication.

Richard Kirkner/MDedge News

At the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons, researchers reported on two strategies to reduce SSI in bariatric surgery: a predictive tool that identifies risk factors for wound infection, allowing surgeons to employ protective measures before and during surgery, and a change in surgical practice leading to a 78% reduction in wound infection rates that resulted from a single-center study.

Jerry Dang, MD, of the University of Alberta, Edmonton, reported that the BariWound predictive tool designed to stratify patients into risk categories showed a high level of accuracy with an area under the curve of 0.73. Cynthia Weber, MD, of University Hospitals, Cleveland, reported that changing the method for performing circular-stapled gastrojejunostomy (GJ) from the transoral to the transabdominal approach along with more vigilant use of wound protection reduced wound infection rates from 6% to 1.3%.

Dr. Dang noted that SSI has been reported as the most common hospital-acquired complication in bariatric surgery, with reported rates of between 1% and 10%. A 2014 analysis of the American College of Surgeons National Surgical Quality Improvement Program database reported an SSI rate of 1.8% (Surg Endosc. 2014;28:3285-92). Although these rates are low, Dr. Dang explained that his group wanted to identify factors associated with SSI within 30 days of bariatric surgery. They analyzed outcomes data of 274,187 patients in the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database who had bariatric surgery in 2015 and 2016 (196,608 by laparoscopic sleeve gastrectomy [SG] and 77,579 laparoscopic Roux-en-Y gastric bypass [RYGB]). Their analysis determined an incisional SSI rate of 0.47% (n = 1,291). “Incisional SSI rates were four times higher for laparoscopic RYGB: 1.04% vs. 0.25%,” Dr. Dang said.

On multivariable logistic regression, the adjusted odds ratio of SSI after RYGB vs. SG was 3.13 (P less than .001). Other significant risk factors were chronic steroid or immunosuppressant use (odds ratio, 1.75; P = .001), female sex (OR, 1.48; P less than .001) and history of gastroesophageal reflux disease (OR, 1.45; P less than .001). Other factors with a 21%-31% greater risk of SSI were white race (P = .002), history of diabetes (P less than .001), hypertension (P less than .001), obstructive sleep apnea (P = .001), and longer operation times (P less than .001). Each single-digit increase in body mass index increased risk by 3%, and older age actually had a protective effect for unknown reasons, Dr. Dang noted.

The BariWound tool assigns points to each risk factor. Each hour of operation time and each 10 kg/m² of weight carry a value of 1 point, with partial points allowed. RYGB equals 5 points, and chronic steroid/immunosuppressant use, 4 points. The tool assigns risk to four categories based on score and 30-day SSI rate:

• Low, less than 15 (1% risk of SSI).
• Moderate, 15-21.9 (1%-5%).
• High, 22-26.9 (5%-10%).
• Very high, greater than 27 (greater than 10%).

“The BariWound tool can help to inform clinical decision making so patients can know they’re at higher risk, and this could allow for us to target high-risk patients with preventive packages, such as the Cleveland Clinic Technique of wound protection, wound irrigation, and wound packing as a resource-saving measure,” Dr. Dang said. “Targeting high-risk populations can reduce cost and operating time.”

Richard Kirkner/MDedge NEws

Dr. Weber reported on her institution’s study of SSIs using two different methods for circular stapling of GJ that involved two different surgeons who performed 333 RYGB procedures from January 2016 to March 2018. Surgeon “A” had traditionally used the transoral technique without wound protection to insert the anvil of the stapler; surgeon “B” used wound protection and the transabdominal technique for stapler insertion. Wound protection involves draping of the stapler with sterile plastic.

“In a quarterly review, we detected a higher than expected wound complication rate of 6%,” Dr. Weber said. “Of particular concern was the development of five recent wound infection cases, which all occurred in the transoral group for a rate of 8.9% in that cohort.”

That left the quality team questioning the safety profile of the transoral technique, Dr. Weber said. “We wanted to know why and whether or not the main contributor to the development of a wound infection was the technique for the anvil introduction or was it the difference between surgeons using wound protection.”

Halfway through the study period, surgeon A made two modifications: He adopted the transabdominal technique for a subset of patients; and because of the surgeon’s comfort level and expertise with the transoral approach, he continued using that approach but added wound protection. Surgeon B continued with the transabdominal approach with wound protection. The share of transabdominal insertions in the study population increased from 69.2% before the change to 75% after. Demographics between the pre- and postchange patient populations were similar, as were the rates of revision surgery between the two groups.

“We noticed a significant reduction in total wound complications from 6% to 1.3%, and we noticed a complete elimination of surgical site infections after adding wound protection to the transoral technique,” Dr. Weber said.

Dr. Weber noted a number of limitations with the study: its retrospective nature; the lack of control for other intraoperative factors that contribute to SSIs; relatively low incidence of SSI; and surgeon’s choice to determine the technique of anvil insertion.

“We found that our quality improvement intervention was efficacious and decided that it was not the technique of anvil insertion, but it was the wound protection that was key to preventing wound infections, as we saw complete elimination after we added wound protection to the transoral technique,” Dr. Weber said. “Using proper precautions with the circular stapler and anastomosis can be done using either technique for anvil insertion. Overall self-assessment of outcomes leads to best practice.”

Dr. Dang had no financial relationships to disclose. Dr. Weber’s coauthor Leena Khatian, MD, MPH, disclosed relationships with Torax Medical, Medtronic, and Gore.

SOURCES: Weber C et al. SAGES 2109, Presentation S049; Dang J et al. SAGES 2019, Presentation S050.

BALTIMORE – A staging scale developed by the bariatric team at the University of Alberta has shown potential as a tool to accurately predict major complications 1 year after Roux-en-Y gastric bypass (RYGB) surgery, surpassing the predictability of body mass index alone, a researcher reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

monkeybusinessimages/Thinkstock

Researchers at the university validated the predictive utility of the scale, known as the Edmonton Obesity Staging System (EOSS), in a retrospective chart review of 378 patients who had RYGB between December 2009 and November 2015 at Royal Alexandra Hospital in Edmonton, Alt. The EOSS uses a scale from 0 to 4 to score a patient’s risk for complications: the higher the score, the greater the risk of complications.

“The EOSS may help determine risk of major complications after RYGB, and, given its overall simplicity, you can also think of it as analogous to the American Society of Anesthesiologists physical status classification system or the New York Heart Association classification system for congestive heart failure,” said Samuel Skulsky, a 3rd-year medical student at the University of Alberta. “It may have utility as well in communicating to patients their overall risk.”

A previous study applied the EOSS score to the National Health and Human Nutrition Examination Survey to compare it to use of body mass index (BMI) as a predictive marker of mortality (CMAJ. 2011;183:E1059-66). Where the four BMI classifications were clustered on the Kaplan-Meier between 0.7 and 0.9 at 200 months post examination, the four EOSS stages analyzed, 0-3, showed more of a spread, from around 0.55 for stage 3 to near 1.0 for stage 0. This gave the researchers the idea that EOSS could also be used to predict morbidity and mortality specifically in obese patients scheduled for surgery, Mr. Skulsky said. “With the Kaplan-Meier survival curves, the EOSS actually nicely stratifies the patients with their overall survival,” he said. “In comparison, BMI did not do as well in stratifying overall mortality.”

The study reported the following 1-year complication rates in the EOSS stages:

• Stage 0 (n = 14), 7.1%.
• Stage 1 (n = 41), 4.9%.
• Stage 2 (n = 297), 8.8%.
• Stage 3 (n = 26), 23.1%.

There were no stage 4 patients in the study population.

SOURCE: Skulsky SL et al. SAGES 2019, Session SS12.

BALTIMORE – A staging scale developed by the bariatric team at the University of Alberta has shown potential as a tool to accurately predict major complications 1 year after Roux-en-Y gastric bypass (RYGB) surgery, surpassing the predictability of body mass index alone, a researcher reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

monkeybusinessimages/Thinkstock

Researchers at the university validated the predictive utility of the scale, known as the Edmonton Obesity Staging System (EOSS), in a retrospective chart review of 378 patients who had RYGB between December 2009 and November 2015 at Royal Alexandra Hospital in Edmonton, Alt. The EOSS uses a scale from 0 to 4 to score a patient’s risk for complications: the higher the score, the greater the risk of complications.

“The EOSS may help determine risk of major complications after RYGB, and, given its overall simplicity, you can also think of it as analogous to the American Society of Anesthesiologists physical status classification system or the New York Heart Association classification system for congestive heart failure,” said Samuel Skulsky, a 3rd-year medical student at the University of Alberta. “It may have utility as well in communicating to patients their overall risk.”

A previous study applied the EOSS score to the National Health and Human Nutrition Examination Survey to compare it to use of body mass index (BMI) as a predictive marker of mortality (CMAJ. 2011;183:E1059-66). Where the four BMI classifications were clustered on the Kaplan-Meier between 0.7 and 0.9 at 200 months post examination, the four EOSS stages analyzed, 0-3, showed more of a spread, from around 0.55 for stage 3 to near 1.0 for stage 0. This gave the researchers the idea that EOSS could also be used to predict morbidity and mortality specifically in obese patients scheduled for surgery, Mr. Skulsky said. “With the Kaplan-Meier survival curves, the EOSS actually nicely stratifies the patients with their overall survival,” he said. “In comparison, BMI did not do as well in stratifying overall mortality.”

The study reported the following 1-year complication rates in the EOSS stages:

• Stage 0 (n = 14), 7.1%.
• Stage 1 (n = 41), 4.9%.
• Stage 2 (n = 297), 8.8%.
• Stage 3 (n = 26), 23.1%.

There were no stage 4 patients in the study population.

SOURCE: Skulsky SL et al. SAGES 2019, Session SS12.

BALTIMORE – A staging scale developed by the bariatric team at the University of Alberta has shown potential as a tool to accurately predict major complications 1 year after Roux-en-Y gastric bypass (RYGB) surgery, surpassing the predictability of body mass index alone, a researcher reported at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons.

monkeybusinessimages/Thinkstock

Researchers at the university validated the predictive utility of the scale, known as the Edmonton Obesity Staging System (EOSS), in a retrospective chart review of 378 patients who had RYGB between December 2009 and November 2015 at Royal Alexandra Hospital in Edmonton, Alt. The EOSS uses a scale from 0 to 4 to score a patient’s risk for complications: the higher the score, the greater the risk of complications.

“The EOSS may help determine risk of major complications after RYGB, and, given its overall simplicity, you can also think of it as analogous to the American Society of Anesthesiologists physical status classification system or the New York Heart Association classification system for congestive heart failure,” said Samuel Skulsky, a 3rd-year medical student at the University of Alberta. “It may have utility as well in communicating to patients their overall risk.”

A previous study applied the EOSS score to the National Health and Human Nutrition Examination Survey to compare it to use of body mass index (BMI) as a predictive marker of mortality (CMAJ. 2011;183:E1059-66). Where the four BMI classifications were clustered on the Kaplan-Meier between 0.7 and 0.9 at 200 months post examination, the four EOSS stages analyzed, 0-3, showed more of a spread, from around 0.55 for stage 3 to near 1.0 for stage 0. This gave the researchers the idea that EOSS could also be used to predict morbidity and mortality specifically in obese patients scheduled for surgery, Mr. Skulsky said. “With the Kaplan-Meier survival curves, the EOSS actually nicely stratifies the patients with their overall survival,” he said. “In comparison, BMI did not do as well in stratifying overall mortality.”

The study reported the following 1-year complication rates in the EOSS stages:

• Stage 0 (n = 14), 7.1%.
• Stage 1 (n = 41), 4.9%.
• Stage 2 (n = 297), 8.8%.
• Stage 3 (n = 26), 23.1%.

There were no stage 4 patients in the study population.

SOURCE: Skulsky SL et al. SAGES 2019, Session SS12.

High body mass index (BMI) is associated with reduced mortality and reduced disability after acute ischemic stroke, according to research that will be presented at the annual meeting of the American Academy of Neurology.

“One possible explanation is that people who are overweight or obese may have a nutritional reserve that may help them survive during prolonged illness,” said Zuolu Liu, MD, of the University of California, Los Angeles, in a press release. “More research is needed to investigate the relationship between BMI and stroke.”

The obesity paradox was first noted when studies suggested that being overweight improved survival in patients with kidney disease or heart disease. Investigators previously examined whether the obesity paradox is observed in stroke, but their studies were underpowered and produced ambiguous results.

Dr. Liu and colleagues sought to evaluate the relationship between BMI and 90-day outcomes of acute ischemic stroke. They examined data for all participants in the FAST-MAG trial, which studied whether prehospital treatment with magnesium improved disability outcomes of acute ischemic stroke. Dr. Liu and colleagues focused on the outcomes of death, disability or death (that is, modified Rankin Scale score of 2-6), and low stroke-related quality of life (that is, Stroke Impact Scale score less than 70). They analyzed potential relationships with BMI univariately and in multivariate models that adjusted for 12 prognostic variables, such as high blood pressure, high cholesterol, and smoking.

Dr. Liu’s group included 1,033 participants in its study. The population’s mean age was 71 years, and 45.1% of the population was female. Mean National Institutes of Health Stroke Scale (NIHSS) score was 10.6, and mean BMI was 27.5 kg/m².

The investigators found an inverse association between the risk of death and BMI. Adjusted odds ratios for mortality were 1.67 for underweight participants, 0.85 for overweight participants, 0.54 for obese participants, and 0.38 for severely obese participants, compared with participants of normal weight. Similarly, the risk of disability had a U-shaped relationship with BMI. Odds ratios for disability or death were 1.19 for underweight participants, 0.78 for overweight participants, 0.72 for obese participants, and 0.96 for severely obese participants, compared with participants of normal weight. This relationship was attenuated after adjustment for other prognostic factors, however. Dr. Liu’s group did not find a significant association between BMI and low stroke-related quality of life.

The study was limited by the fact that all participants were from Southern California, which potentially reduced the generalizability of the results. The racial and ethnic composition of the study population, however, is similar to that of the national population, said the researchers.

No study sponsor was reported.
 

egreb@mdedge.com

SOURCE: Liu Z et al. AAN 2019, Abstract P3.3-01.

High body mass index (BMI) is associated with reduced mortality and reduced disability after acute ischemic stroke, according to research that will be presented at the annual meeting of the American Academy of Neurology.

“One possible explanation is that people who are overweight or obese may have a nutritional reserve that may help them survive during prolonged illness,” said Zuolu Liu, MD, of the University of California, Los Angeles, in a press release. “More research is needed to investigate the relationship between BMI and stroke.”

The obesity paradox was first noted when studies suggested that being overweight improved survival in patients with kidney disease or heart disease. Investigators previously examined whether the obesity paradox is observed in stroke, but their studies were underpowered and produced ambiguous results.

Dr. Liu and colleagues sought to evaluate the relationship between BMI and 90-day outcomes of acute ischemic stroke. They examined data for all participants in the FAST-MAG trial, which studied whether prehospital treatment with magnesium improved disability outcomes of acute ischemic stroke. Dr. Liu and colleagues focused on the outcomes of death, disability or death (that is, modified Rankin Scale score of 2-6), and low stroke-related quality of life (that is, Stroke Impact Scale score less than 70). They analyzed potential relationships with BMI univariately and in multivariate models that adjusted for 12 prognostic variables, such as high blood pressure, high cholesterol, and smoking.

Dr. Liu’s group included 1,033 participants in its study. The population’s mean age was 71 years, and 45.1% of the population was female. Mean National Institutes of Health Stroke Scale (NIHSS) score was 10.6, and mean BMI was 27.5 kg/m².

The investigators found an inverse association between the risk of death and BMI. Adjusted odds ratios for mortality were 1.67 for underweight participants, 0.85 for overweight participants, 0.54 for obese participants, and 0.38 for severely obese participants, compared with participants of normal weight. Similarly, the risk of disability had a U-shaped relationship with BMI. Odds ratios for disability or death were 1.19 for underweight participants, 0.78 for overweight participants, 0.72 for obese participants, and 0.96 for severely obese participants, compared with participants of normal weight. This relationship was attenuated after adjustment for other prognostic factors, however. Dr. Liu’s group did not find a significant association between BMI and low stroke-related quality of life.

The study was limited by the fact that all participants were from Southern California, which potentially reduced the generalizability of the results. The racial and ethnic composition of the study population, however, is similar to that of the national population, said the researchers.

No study sponsor was reported.
 

egreb@mdedge.com

SOURCE: Liu Z et al. AAN 2019, Abstract P3.3-01.

High body mass index (BMI) is associated with reduced mortality and reduced disability after acute ischemic stroke, according to research that will be presented at the annual meeting of the American Academy of Neurology.

“One possible explanation is that people who are overweight or obese may have a nutritional reserve that may help them survive during prolonged illness,” said Zuolu Liu, MD, of the University of California, Los Angeles, in a press release. “More research is needed to investigate the relationship between BMI and stroke.”

The obesity paradox was first noted when studies suggested that being overweight improved survival in patients with kidney disease or heart disease. Investigators previously examined whether the obesity paradox is observed in stroke, but their studies were underpowered and produced ambiguous results.

Dr. Liu and colleagues sought to evaluate the relationship between BMI and 90-day outcomes of acute ischemic stroke. They examined data for all participants in the FAST-MAG trial, which studied whether prehospital treatment with magnesium improved disability outcomes of acute ischemic stroke. Dr. Liu and colleagues focused on the outcomes of death, disability or death (that is, modified Rankin Scale score of 2-6), and low stroke-related quality of life (that is, Stroke Impact Scale score less than 70). They analyzed potential relationships with BMI univariately and in multivariate models that adjusted for 12 prognostic variables, such as high blood pressure, high cholesterol, and smoking.

Dr. Liu’s group included 1,033 participants in its study. The population’s mean age was 71 years, and 45.1% of the population was female. Mean National Institutes of Health Stroke Scale (NIHSS) score was 10.6, and mean BMI was 27.5 kg/m².

The investigators found an inverse association between the risk of death and BMI. Adjusted odds ratios for mortality were 1.67 for underweight participants, 0.85 for overweight participants, 0.54 for obese participants, and 0.38 for severely obese participants, compared with participants of normal weight. Similarly, the risk of disability had a U-shaped relationship with BMI. Odds ratios for disability or death were 1.19 for underweight participants, 0.78 for overweight participants, 0.72 for obese participants, and 0.96 for severely obese participants, compared with participants of normal weight. This relationship was attenuated after adjustment for other prognostic factors, however. Dr. Liu’s group did not find a significant association between BMI and low stroke-related quality of life.

The study was limited by the fact that all participants were from Southern California, which potentially reduced the generalizability of the results. The racial and ethnic composition of the study population, however, is similar to that of the national population, said the researchers.

No study sponsor was reported.
 

egreb@mdedge.com

SOURCE: Liu Z et al. AAN 2019, Abstract P3.3-01.

PHILADELPHIA – Intermittent fasting may help improve weight status and metabolic health, but it is very challenging to adhere to and is possibly associated with certain risks, a physician with expertise in obesity and nutrition said during a presentation.

Andrew D. Bowser/MDedge News

“I do not necessarily recommend intermittent fasting to my patients, but I do have a lot of patients that will come to me asking about intermittent fasting,” said Fatima Cody Stanford, MD, MPH, of Massachusetts General Hospital Weight Center and Harvard Medical School, both in Boston, at the annual meeting of the American College of Physicians.

Intermittent fasting, which can take several forms including partial-day fasting, every-other-day fasting, or fasting two days per week, has been associated with positive physiological effects in an increasing number of recent studies, Dr. Stanford said.

Those physiological effects, reported in animals or humans, have included a potentially increased lifespan, decreased mortality related to cancers or cardiovascular disease, an improved insulin sensitivity, and reduced oxidative stress and inflammation, she said.

Additionally, weight loss and improvement in other health indicators, including insulin resistance, have been demonstrated in some studies of intermittent fasting that included normal weight or overweight human subjects.

In one systematic review and meta-analysis, intermittent fasting was found to be comparable with continuous energy restriction in overweight and obese adults for short-term weight loss.

Compared with no treatment, intermittent energy restriction was associated with a 4.14-kg drop in weight (95% confidence interval, 6.30-1.99; P less than or equal to 0.001), according to that meta-analysis.

In patients with type 2 diabetes, 12 months of intermittent energy restriction resulted in glycemic control comparable with continuous energy restriction, according to results of a randomized, 137-patient, noninferiority trial.

On the flip side, intermittent fasting has been associated with possible health risks, including having “a deleterious impact on fertility” and “a negative impact on bone health,” according to Dr. Stanford.

“These are things that I bring up with my patients,” she told her audience.

Lean mass may also be in jeopardy in intermittent fasters, according to authors of one systematic review and meta-analysis of randomized controlled trials published in the International Journal of Obesity.

Those investigators found that lean mass was decreased in intermittent dieters as compared with continuous dieters in the 9 trials they included. The mean difference was –0.86 kg (95% CI, –1.62 to –0.10; P = 0.03).

Even if intermittent fasting is comparable with continuous energy restriction in weight loss, getting to that point may be more difficult because of increased hunger, at least according to researchers in one randomized 1-year trial, Dr. Sanford noted.

Subjective hunger scores were higher at 4.7 for intermittent fasters versus 3.6 for continuous restriction participants (P = 0.002), results of that trial showed.

“It’s very difficult for most of us to sustain this,” Dr. Stanford said.

Dr. Stanford reported no relevant disclosures.

PHILADELPHIA – Intermittent fasting may help improve weight status and metabolic health, but it is very challenging to adhere to and is possibly associated with certain risks, a physician with expertise in obesity and nutrition said during a presentation.

Andrew D. Bowser/MDedge News

“I do not necessarily recommend intermittent fasting to my patients, but I do have a lot of patients that will come to me asking about intermittent fasting,” said Fatima Cody Stanford, MD, MPH, of Massachusetts General Hospital Weight Center and Harvard Medical School, both in Boston, at the annual meeting of the American College of Physicians.

Intermittent fasting, which can take several forms including partial-day fasting, every-other-day fasting, or fasting two days per week, has been associated with positive physiological effects in an increasing number of recent studies, Dr. Stanford said.

Those physiological effects, reported in animals or humans, have included a potentially increased lifespan, decreased mortality related to cancers or cardiovascular disease, an improved insulin sensitivity, and reduced oxidative stress and inflammation, she said.

Additionally, weight loss and improvement in other health indicators, including insulin resistance, have been demonstrated in some studies of intermittent fasting that included normal weight or overweight human subjects.

In one systematic review and meta-analysis, intermittent fasting was found to be comparable with continuous energy restriction in overweight and obese adults for short-term weight loss.

Compared with no treatment, intermittent energy restriction was associated with a 4.14-kg drop in weight (95% confidence interval, 6.30-1.99; P less than or equal to 0.001), according to that meta-analysis.

In patients with type 2 diabetes, 12 months of intermittent energy restriction resulted in glycemic control comparable with continuous energy restriction, according to results of a randomized, 137-patient, noninferiority trial.

On the flip side, intermittent fasting has been associated with possible health risks, including having “a deleterious impact on fertility” and “a negative impact on bone health,” according to Dr. Stanford.

“These are things that I bring up with my patients,” she told her audience.

Lean mass may also be in jeopardy in intermittent fasters, according to authors of one systematic review and meta-analysis of randomized controlled trials published in the International Journal of Obesity.

Those investigators found that lean mass was decreased in intermittent dieters as compared with continuous dieters in the 9 trials they included. The mean difference was –0.86 kg (95% CI, –1.62 to –0.10; P = 0.03).

Even if intermittent fasting is comparable with continuous energy restriction in weight loss, getting to that point may be more difficult because of increased hunger, at least according to researchers in one randomized 1-year trial, Dr. Sanford noted.

Subjective hunger scores were higher at 4.7 for intermittent fasters versus 3.6 for continuous restriction participants (P = 0.002), results of that trial showed.

“It’s very difficult for most of us to sustain this,” Dr. Stanford said.

Dr. Stanford reported no relevant disclosures.

PHILADELPHIA – Intermittent fasting may help improve weight status and metabolic health, but it is very challenging to adhere to and is possibly associated with certain risks, a physician with expertise in obesity and nutrition said during a presentation.

Andrew D. Bowser/MDedge News

“I do not necessarily recommend intermittent fasting to my patients, but I do have a lot of patients that will come to me asking about intermittent fasting,” said Fatima Cody Stanford, MD, MPH, of Massachusetts General Hospital Weight Center and Harvard Medical School, both in Boston, at the annual meeting of the American College of Physicians.

Intermittent fasting, which can take several forms including partial-day fasting, every-other-day fasting, or fasting two days per week, has been associated with positive physiological effects in an increasing number of recent studies, Dr. Stanford said.

Those physiological effects, reported in animals or humans, have included a potentially increased lifespan, decreased mortality related to cancers or cardiovascular disease, an improved insulin sensitivity, and reduced oxidative stress and inflammation, she said.

Additionally, weight loss and improvement in other health indicators, including insulin resistance, have been demonstrated in some studies of intermittent fasting that included normal weight or overweight human subjects.

In one systematic review and meta-analysis, intermittent fasting was found to be comparable with continuous energy restriction in overweight and obese adults for short-term weight loss.

Compared with no treatment, intermittent energy restriction was associated with a 4.14-kg drop in weight (95% confidence interval, 6.30-1.99; P less than or equal to 0.001), according to that meta-analysis.

In patients with type 2 diabetes, 12 months of intermittent energy restriction resulted in glycemic control comparable with continuous energy restriction, according to results of a randomized, 137-patient, noninferiority trial.

On the flip side, intermittent fasting has been associated with possible health risks, including having “a deleterious impact on fertility” and “a negative impact on bone health,” according to Dr. Stanford.

“These are things that I bring up with my patients,” she told her audience.

Lean mass may also be in jeopardy in intermittent fasters, according to authors of one systematic review and meta-analysis of randomized controlled trials published in the International Journal of Obesity.

Those investigators found that lean mass was decreased in intermittent dieters as compared with continuous dieters in the 9 trials they included. The mean difference was –0.86 kg (95% CI, –1.62 to –0.10; P = 0.03).

Even if intermittent fasting is comparable with continuous energy restriction in weight loss, getting to that point may be more difficult because of increased hunger, at least according to researchers in one randomized 1-year trial, Dr. Sanford noted.

Subjective hunger scores were higher at 4.7 for intermittent fasters versus 3.6 for continuous restriction participants (P = 0.002), results of that trial showed.

“It’s very difficult for most of us to sustain this,” Dr. Stanford said.

Dr. Stanford reported no relevant disclosures.

The prescription of positive airway pressure is associated with reduced all-cause mortality, according to the results of a cohort study published in JAMA Otolaryngology–Head & Neck Surgery.

The association becomes evident several years after positive airway pressure (PAP) initiation, according to the researchers. Obstructive sleep apnea (OSA) is among the top 10 modifiable cardiovascular risk factors, and is associated with increased risks of coronary artery disease, stroke, and death. PAP is the most effective treatment for OSA, but this treatment’s effect on all-cause and cardiovascular mortality is uncertain. Randomized trials have yielded inconclusive answers to this question, and evidence from observational studies has been weak.

To investigate the association between PAP prescription and mortality in patients with obesity and severe OSA, Quentin Lisan, MD, of the Paris Cardiovascular Research Center and his colleagues conducted a multicenter, population-based cohort study. The researchers examined data for 392 participants in the Sleep Heart Health Study, in which adult men and women age 40 years or older were recruited from nine population-based studies between 1995 and 1998 and followed for a mean of 11.1 years. With each participant who had been prescribed PAP, the investigators matched as many as four participants who had not been prescribed PAP, on the basis of age, sex, and apnea-hypopnea index. Of this sample, 81 patients were prescribed PAP, and 311 were not.

All participants had a clinic visit and underwent overnight polysomnography at baseline. At 2-3 years, participants had a follow-up visit or phone call, during which they were asked whether their physicians had prescribed PAP. Participants were monitored for cardiovascular and all-cause mortality.

In all, 319 of the 392 participants were men; the population’s mean age was 63 years. Patients who had received a PAP prescription had a higher body mass index and more education, compared with patients who had not received a prescription. Mean follow-up duration was 11.6 years in the PAP-prescribed group and 10.9 years in the nonprescribed group.

A total of 96 deaths occurred during follow-up: 12 in the PAP-prescribed group and 84 in the nonprescribed PAP group. The crude incidence rate of mortality was 24.7 deaths per 1,000 person-years in the nonprescribed group and 12.8 deaths per 1,000 person-years in the PAP-prescribed group. The difference in survival between the prescribed and nonprescribed groups was evident in survival curves after 6-7 years of follow-up. After adjustments for prevalent cardiovascular disease, hypertension, diabetes, body mass index, education level, smoking status, and alcohol consumption, the hazard ratio of all-cause mortality for the prescribed group was 0.38, compared with the nonprescribed group.

Dr. Lisan and his colleagues identified 27 deaths of cardiovascular origin, one of which occurred in the prescribed group. After adjusting for prevalent cardiovascular disease, the hazard ratio of cardiovascular mortality for the prescribed group was 0.06, compared with the nonprescribed group.

One reason that the reduction in mortality associated with PAP was not found in previous randomized, controlled trials could be that their mean length of follow-up was not long enough, the researchers wrote. For example, the mean length of follow-up in the SAVE trial was 3.7 years, but the survival benefit was not apparent in the present analysis until 6-7 years after treatment initiation.

These results are exploratory and require confirmation in future research, Dr. Lisan and his colleagues wrote. No information on adherence to PAP was available, and the researchers could not account for initiation and interruption of PAP therapy. Nevertheless, “prescribing PAP in patients with OSA should be pursued and encouraged, given its potential major public health implication,” they concluded.

The Sleep Heart Health Study was supported by grants from the National Institutes of Health.

egreb@mdedge.com

SOURCE: Lisan Q et al. JAMA Otolaryngol Head Neck Surg. 2019 Apr 11. doi: 10.1001/jamaoto.2019.0281.

The prescription of positive airway pressure is associated with reduced all-cause mortality, according to the results of a cohort study published in JAMA Otolaryngology–Head & Neck Surgery.

The association becomes evident several years after positive airway pressure (PAP) initiation, according to the researchers. Obstructive sleep apnea (OSA) is among the top 10 modifiable cardiovascular risk factors, and is associated with increased risks of coronary artery disease, stroke, and death. PAP is the most effective treatment for OSA, but this treatment’s effect on all-cause and cardiovascular mortality is uncertain. Randomized trials have yielded inconclusive answers to this question, and evidence from observational studies has been weak.

To investigate the association between PAP prescription and mortality in patients with obesity and severe OSA, Quentin Lisan, MD, of the Paris Cardiovascular Research Center and his colleagues conducted a multicenter, population-based cohort study. The researchers examined data for 392 participants in the Sleep Heart Health Study, in which adult men and women age 40 years or older were recruited from nine population-based studies between 1995 and 1998 and followed for a mean of 11.1 years. With each participant who had been prescribed PAP, the investigators matched as many as four participants who had not been prescribed PAP, on the basis of age, sex, and apnea-hypopnea index. Of this sample, 81 patients were prescribed PAP, and 311 were not.

All participants had a clinic visit and underwent overnight polysomnography at baseline. At 2-3 years, participants had a follow-up visit or phone call, during which they were asked whether their physicians had prescribed PAP. Participants were monitored for cardiovascular and all-cause mortality.

In all, 319 of the 392 participants were men; the population’s mean age was 63 years. Patients who had received a PAP prescription had a higher body mass index and more education, compared with patients who had not received a prescription. Mean follow-up duration was 11.6 years in the PAP-prescribed group and 10.9 years in the nonprescribed group.

A total of 96 deaths occurred during follow-up: 12 in the PAP-prescribed group and 84 in the nonprescribed PAP group. The crude incidence rate of mortality was 24.7 deaths per 1,000 person-years in the nonprescribed group and 12.8 deaths per 1,000 person-years in the PAP-prescribed group. The difference in survival between the prescribed and nonprescribed groups was evident in survival curves after 6-7 years of follow-up. After adjustments for prevalent cardiovascular disease, hypertension, diabetes, body mass index, education level, smoking status, and alcohol consumption, the hazard ratio of all-cause mortality for the prescribed group was 0.38, compared with the nonprescribed group.

Dr. Lisan and his colleagues identified 27 deaths of cardiovascular origin, one of which occurred in the prescribed group. After adjusting for prevalent cardiovascular disease, the hazard ratio of cardiovascular mortality for the prescribed group was 0.06, compared with the nonprescribed group.

One reason that the reduction in mortality associated with PAP was not found in previous randomized, controlled trials could be that their mean length of follow-up was not long enough, the researchers wrote. For example, the mean length of follow-up in the SAVE trial was 3.7 years, but the survival benefit was not apparent in the present analysis until 6-7 years after treatment initiation.

These results are exploratory and require confirmation in future research, Dr. Lisan and his colleagues wrote. No information on adherence to PAP was available, and the researchers could not account for initiation and interruption of PAP therapy. Nevertheless, “prescribing PAP in patients with OSA should be pursued and encouraged, given its potential major public health implication,” they concluded.

The Sleep Heart Health Study was supported by grants from the National Institutes of Health.

egreb@mdedge.com

SOURCE: Lisan Q et al. JAMA Otolaryngol Head Neck Surg. 2019 Apr 11. doi: 10.1001/jamaoto.2019.0281.

The prescription of positive airway pressure is associated with reduced all-cause mortality, according to the results of a cohort study published in JAMA Otolaryngology–Head & Neck Surgery.

The association becomes evident several years after positive airway pressure (PAP) initiation, according to the researchers. Obstructive sleep apnea (OSA) is among the top 10 modifiable cardiovascular risk factors, and is associated with increased risks of coronary artery disease, stroke, and death. PAP is the most effective treatment for OSA, but this treatment’s effect on all-cause and cardiovascular mortality is uncertain. Randomized trials have yielded inconclusive answers to this question, and evidence from observational studies has been weak.

To investigate the association between PAP prescription and mortality in patients with obesity and severe OSA, Quentin Lisan, MD, of the Paris Cardiovascular Research Center and his colleagues conducted a multicenter, population-based cohort study. The researchers examined data for 392 participants in the Sleep Heart Health Study, in which adult men and women age 40 years or older were recruited from nine population-based studies between 1995 and 1998 and followed for a mean of 11.1 years. With each participant who had been prescribed PAP, the investigators matched as many as four participants who had not been prescribed PAP, on the basis of age, sex, and apnea-hypopnea index. Of this sample, 81 patients were prescribed PAP, and 311 were not.

All participants had a clinic visit and underwent overnight polysomnography at baseline. At 2-3 years, participants had a follow-up visit or phone call, during which they were asked whether their physicians had prescribed PAP. Participants were monitored for cardiovascular and all-cause mortality.

In all, 319 of the 392 participants were men; the population’s mean age was 63 years. Patients who had received a PAP prescription had a higher body mass index and more education, compared with patients who had not received a prescription. Mean follow-up duration was 11.6 years in the PAP-prescribed group and 10.9 years in the nonprescribed group.

A total of 96 deaths occurred during follow-up: 12 in the PAP-prescribed group and 84 in the nonprescribed PAP group. The crude incidence rate of mortality was 24.7 deaths per 1,000 person-years in the nonprescribed group and 12.8 deaths per 1,000 person-years in the PAP-prescribed group. The difference in survival between the prescribed and nonprescribed groups was evident in survival curves after 6-7 years of follow-up. After adjustments for prevalent cardiovascular disease, hypertension, diabetes, body mass index, education level, smoking status, and alcohol consumption, the hazard ratio of all-cause mortality for the prescribed group was 0.38, compared with the nonprescribed group.

Dr. Lisan and his colleagues identified 27 deaths of cardiovascular origin, one of which occurred in the prescribed group. After adjusting for prevalent cardiovascular disease, the hazard ratio of cardiovascular mortality for the prescribed group was 0.06, compared with the nonprescribed group.

One reason that the reduction in mortality associated with PAP was not found in previous randomized, controlled trials could be that their mean length of follow-up was not long enough, the researchers wrote. For example, the mean length of follow-up in the SAVE trial was 3.7 years, but the survival benefit was not apparent in the present analysis until 6-7 years after treatment initiation.

These results are exploratory and require confirmation in future research, Dr. Lisan and his colleagues wrote. No information on adherence to PAP was available, and the researchers could not account for initiation and interruption of PAP therapy. Nevertheless, “prescribing PAP in patients with OSA should be pursued and encouraged, given its potential major public health implication,” they concluded.

The Sleep Heart Health Study was supported by grants from the National Institutes of Health.

egreb@mdedge.com

SOURCE: Lisan Q et al. JAMA Otolaryngol Head Neck Surg. 2019 Apr 11. doi: 10.1001/jamaoto.2019.0281.

Adherence to a plant-based diet is inversely linked with the risk of incident heart failure, according to an analysis published online in the Journal of the American College of Cardiology.

Ron Chapple Studios/thinkstockphotos.com

Conversely, a Southern diet, defined as favoring fried and processed foods, is associated with an increased risk of heart failure. The results support a population-based dietary strategy for decreasing the risk of incident heart failure, according to the investigators.

Campaigns to prevent heart failure often emphasize the maintenance of a healthy diet and weight; however, little research has examined the relationship between dietary patterns and incident heart failure in patients without coronary heart disease.

Kyla M. Lara, MD, postgraduate fellow of cardiology and general internal medicine at the Icahn School of Medicine at Mount Sinai, New York, and colleagues sought to analyze the associations between five dietary patterns and incident hospitalizations for heart failure among adults in the United States. They examined data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) trial, a prospective study of black and white adults who were followed from 2003-2007 to 2014. Eligible participants completed a food frequency questionnaire and had no coronary heart disease or heart failure at baseline.

The REGARDS researchers’ principal component analysis identified the following five dietary patterns: convenience (for example, Mexican and Chinese dishes and fast food), plant based (for example, vegetables, fruit, and fish), sweets (for example, desserts, breads, and candy), Southern (for example, fried food, processed meats, and sugary beverages), and alcohol/salads. Dr. Lara and colleagues chose incident heart failure hospitalization as their primary endpoint.

The investigators included 16,068 participants in their analysis. Mean age was 64 years, roughly 59% of the sample were women, and 34% were black.

After a median 8.7 years of follow-up, 363 participants had incident heart failure hospitalizations. The highest quartile of adherence to the plant-based dietary pattern was associated with a 41% lower risk of heart failure in multivariate models, compared with the lowest quartile. The highest adherence to the Southern dietary pattern was linked with a 72% higher risk of heart failure after adjustments for age, sex, race, and other potential confounders such as education, income, smoking, and physical activity.

After further adjustments for body mass index, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease, the association was attenuated and no longer statistically significant. Dr. Lara and colleagues found no statistically significant associations between incident heart failure with reduced or preserved ejection fraction hospitalizations and the dietary patterns. They also found no associations with the other three dietary patterns.

One researcher reported receiving research funding from Amgen and has consulted for Novartis. The other researchers reported no relevant conflicts.

SOURCE: Lara KM et al. J Am Coll Cardiol. 2019 Apr 30;73(16):2036-45.

Adherence to a plant-based diet is inversely linked with the risk of incident heart failure, according to an analysis published online in the Journal of the American College of Cardiology.

Ron Chapple Studios/thinkstockphotos.com

Conversely, a Southern diet, defined as favoring fried and processed foods, is associated with an increased risk of heart failure. The results support a population-based dietary strategy for decreasing the risk of incident heart failure, according to the investigators.

Campaigns to prevent heart failure often emphasize the maintenance of a healthy diet and weight; however, little research has examined the relationship between dietary patterns and incident heart failure in patients without coronary heart disease.

Kyla M. Lara, MD, postgraduate fellow of cardiology and general internal medicine at the Icahn School of Medicine at Mount Sinai, New York, and colleagues sought to analyze the associations between five dietary patterns and incident hospitalizations for heart failure among adults in the United States. They examined data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) trial, a prospective study of black and white adults who were followed from 2003-2007 to 2014. Eligible participants completed a food frequency questionnaire and had no coronary heart disease or heart failure at baseline.

The REGARDS researchers’ principal component analysis identified the following five dietary patterns: convenience (for example, Mexican and Chinese dishes and fast food), plant based (for example, vegetables, fruit, and fish), sweets (for example, desserts, breads, and candy), Southern (for example, fried food, processed meats, and sugary beverages), and alcohol/salads. Dr. Lara and colleagues chose incident heart failure hospitalization as their primary endpoint.

The investigators included 16,068 participants in their analysis. Mean age was 64 years, roughly 59% of the sample were women, and 34% were black.

After a median 8.7 years of follow-up, 363 participants had incident heart failure hospitalizations. The highest quartile of adherence to the plant-based dietary pattern was associated with a 41% lower risk of heart failure in multivariate models, compared with the lowest quartile. The highest adherence to the Southern dietary pattern was linked with a 72% higher risk of heart failure after adjustments for age, sex, race, and other potential confounders such as education, income, smoking, and physical activity.

After further adjustments for body mass index, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease, the association was attenuated and no longer statistically significant. Dr. Lara and colleagues found no statistically significant associations between incident heart failure with reduced or preserved ejection fraction hospitalizations and the dietary patterns. They also found no associations with the other three dietary patterns.

One researcher reported receiving research funding from Amgen and has consulted for Novartis. The other researchers reported no relevant conflicts.

SOURCE: Lara KM et al. J Am Coll Cardiol. 2019 Apr 30;73(16):2036-45.

Adherence to a plant-based diet is inversely linked with the risk of incident heart failure, according to an analysis published online in the Journal of the American College of Cardiology.

Ron Chapple Studios/thinkstockphotos.com

Conversely, a Southern diet, defined as favoring fried and processed foods, is associated with an increased risk of heart failure. The results support a population-based dietary strategy for decreasing the risk of incident heart failure, according to the investigators.

Campaigns to prevent heart failure often emphasize the maintenance of a healthy diet and weight; however, little research has examined the relationship between dietary patterns and incident heart failure in patients without coronary heart disease.

Kyla M. Lara, MD, postgraduate fellow of cardiology and general internal medicine at the Icahn School of Medicine at Mount Sinai, New York, and colleagues sought to analyze the associations between five dietary patterns and incident hospitalizations for heart failure among adults in the United States. They examined data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) trial, a prospective study of black and white adults who were followed from 2003-2007 to 2014. Eligible participants completed a food frequency questionnaire and had no coronary heart disease or heart failure at baseline.

The REGARDS researchers’ principal component analysis identified the following five dietary patterns: convenience (for example, Mexican and Chinese dishes and fast food), plant based (for example, vegetables, fruit, and fish), sweets (for example, desserts, breads, and candy), Southern (for example, fried food, processed meats, and sugary beverages), and alcohol/salads. Dr. Lara and colleagues chose incident heart failure hospitalization as their primary endpoint.

The investigators included 16,068 participants in their analysis. Mean age was 64 years, roughly 59% of the sample were women, and 34% were black.

After a median 8.7 years of follow-up, 363 participants had incident heart failure hospitalizations. The highest quartile of adherence to the plant-based dietary pattern was associated with a 41% lower risk of heart failure in multivariate models, compared with the lowest quartile. The highest adherence to the Southern dietary pattern was linked with a 72% higher risk of heart failure after adjustments for age, sex, race, and other potential confounders such as education, income, smoking, and physical activity.

After further adjustments for body mass index, waist circumference, hypertension, dyslipidemia, diabetes mellitus, atrial fibrillation, and chronic kidney disease, the association was attenuated and no longer statistically significant. Dr. Lara and colleagues found no statistically significant associations between incident heart failure with reduced or preserved ejection fraction hospitalizations and the dietary patterns. They also found no associations with the other three dietary patterns.

One researcher reported receiving research funding from Amgen and has consulted for Novartis. The other researchers reported no relevant conflicts.

SOURCE: Lara KM et al. J Am Coll Cardiol. 2019 Apr 30;73(16):2036-45.

Adolescents with severe obesity and cognitive impairment or developmental delay (CI/DD) lost as much weight, and at a similar rate, as their typically developing peers following laparoscopic sleeve gastrectomy (LSG), according in an observational study.

“On the basis of these new data, LSG appears to be a viable and successful short-term weight-management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns,” wrote Sarah E. Hornack, PhD, a psychologist with Children’s National Health System and George Washington University, both in Washington, and her associates.

“In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population,” they wrote in the journal Pediatrics. With more supports likely in place for teens undergoing this surgery, they won’t be “going it alone,” the authors noted, which “could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations.”

Despite higher rates of obesity and related medical issues among youth with CI/DD, little research explores effective interventions in this population, the authors wrote.

They therefore compared outcomes among a group of 63 teens with obesity who underwent bariatric surgery during 2010-2017. The adolescents, who had a body mass index (BMI) of at least 40 kg/m² or one of at least 35 kg/m² with a medical comorbidity, first underwent preoperative psychological evaluations involving a cognitive assessment. The 17 adolescents with an IQ less than 80 were classified as having CI/DD, leaving 46 without CI/DD. Three teens had Down syndrome.

Age, sex, and BMI before surgery were similar in those with CI/DD versus those without. The majority of participants overall were female (65%) and black (57%) with an average age of 17 years and an average BMI of 51.2. Whites comprised 24% of participants while 17% were Hispanic and 1% another race/ethnicity.

The findings revealed that IQ did not predict weight loss. The percentage of excess BMI lost (%EBMIL) and rate of excess weight loss remained similar between those with and without CI/DD, though “a trend for a higher rate of change in %EBMIL for those individuals with CI/DD” suggested “they may experience greater rates of weight loss over time than their typically developing peers,” the authors reported. However, the proportion of participants assessed decreased with each follow-up, from 59 at 3 months to 14 at 24 months.

In addition to the small population, short-term follow-up and loss to follow-up, another study limitation is the lack of a control group of CI/DD patients who did not undergo bariatric surgery and instead received a behavioral intervention or other therapy.

But the authors noted existing evidence that “younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.” In addition, “bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental,” they wrote.
 

SOURCE: Hornack SE et al. Pediatrics. 2019 Apr 15. doi: 10.1542/peds.2018-2908.

Adolescents with severe obesity and cognitive impairment or developmental delay (CI/DD) lost as much weight, and at a similar rate, as their typically developing peers following laparoscopic sleeve gastrectomy (LSG), according in an observational study.

“On the basis of these new data, LSG appears to be a viable and successful short-term weight-management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns,” wrote Sarah E. Hornack, PhD, a psychologist with Children’s National Health System and George Washington University, both in Washington, and her associates.

“In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population,” they wrote in the journal Pediatrics. With more supports likely in place for teens undergoing this surgery, they won’t be “going it alone,” the authors noted, which “could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations.”

Despite higher rates of obesity and related medical issues among youth with CI/DD, little research explores effective interventions in this population, the authors wrote.

They therefore compared outcomes among a group of 63 teens with obesity who underwent bariatric surgery during 2010-2017. The adolescents, who had a body mass index (BMI) of at least 40 kg/m² or one of at least 35 kg/m² with a medical comorbidity, first underwent preoperative psychological evaluations involving a cognitive assessment. The 17 adolescents with an IQ less than 80 were classified as having CI/DD, leaving 46 without CI/DD. Three teens had Down syndrome.

Age, sex, and BMI before surgery were similar in those with CI/DD versus those without. The majority of participants overall were female (65%) and black (57%) with an average age of 17 years and an average BMI of 51.2. Whites comprised 24% of participants while 17% were Hispanic and 1% another race/ethnicity.

The findings revealed that IQ did not predict weight loss. The percentage of excess BMI lost (%EBMIL) and rate of excess weight loss remained similar between those with and without CI/DD, though “a trend for a higher rate of change in %EBMIL for those individuals with CI/DD” suggested “they may experience greater rates of weight loss over time than their typically developing peers,” the authors reported. However, the proportion of participants assessed decreased with each follow-up, from 59 at 3 months to 14 at 24 months.

In addition to the small population, short-term follow-up and loss to follow-up, another study limitation is the lack of a control group of CI/DD patients who did not undergo bariatric surgery and instead received a behavioral intervention or other therapy.

But the authors noted existing evidence that “younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.” In addition, “bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental,” they wrote.
 

SOURCE: Hornack SE et al. Pediatrics. 2019 Apr 15. doi: 10.1542/peds.2018-2908.

Adolescents with severe obesity and cognitive impairment or developmental delay (CI/DD) lost as much weight, and at a similar rate, as their typically developing peers following laparoscopic sleeve gastrectomy (LSG), according in an observational study.

“On the basis of these new data, LSG appears to be a viable and successful short-term weight-management tool for adolescents with CI/DD, who are established as particularly vulnerable to obesity and secondary health concerns,” wrote Sarah E. Hornack, PhD, a psychologist with Children’s National Health System and George Washington University, both in Washington, and her associates.

“In fact, there may be advantages to undergoing surgery during adolescence rather than waiting until adulthood for this population,” they wrote in the journal Pediatrics. With more supports likely in place for teens undergoing this surgery, they won’t be “going it alone,” the authors noted, which “could translate to better cooperation with parental guidance regarding surgery requirements, including diet and exercise recommendations.”

Despite higher rates of obesity and related medical issues among youth with CI/DD, little research explores effective interventions in this population, the authors wrote.

They therefore compared outcomes among a group of 63 teens with obesity who underwent bariatric surgery during 2010-2017. The adolescents, who had a body mass index (BMI) of at least 40 kg/m² or one of at least 35 kg/m² with a medical comorbidity, first underwent preoperative psychological evaluations involving a cognitive assessment. The 17 adolescents with an IQ less than 80 were classified as having CI/DD, leaving 46 without CI/DD. Three teens had Down syndrome.

Age, sex, and BMI before surgery were similar in those with CI/DD versus those without. The majority of participants overall were female (65%) and black (57%) with an average age of 17 years and an average BMI of 51.2. Whites comprised 24% of participants while 17% were Hispanic and 1% another race/ethnicity.

The findings revealed that IQ did not predict weight loss. The percentage of excess BMI lost (%EBMIL) and rate of excess weight loss remained similar between those with and without CI/DD, though “a trend for a higher rate of change in %EBMIL for those individuals with CI/DD” suggested “they may experience greater rates of weight loss over time than their typically developing peers,” the authors reported. However, the proportion of participants assessed decreased with each follow-up, from 59 at 3 months to 14 at 24 months.

In addition to the small population, short-term follow-up and loss to follow-up, another study limitation is the lack of a control group of CI/DD patients who did not undergo bariatric surgery and instead received a behavioral intervention or other therapy.

But the authors noted existing evidence that “younger children respond better to behavioral interventions than adolescents do, suggesting that older youth may require a different treatment approach.” In addition, “bariatric surgery performed earlier in the trajectory of large weight gain has also been shown to lead to greater resolution of obesity, suggesting that waiting for adulthood can be detrimental,” they wrote.
 

SOURCE: Hornack SE et al. Pediatrics. 2019 Apr 15. doi: 10.1542/peds.2018-2908.

NEW ORLEANS – Can a physician-supervised, intermittent fasting strategy improve metabolic risk? Yes, according to Valter Longo, PhD.

Dr. Longo is a proponent of 5 days of reduced calories, performed once monthly or even less frequently for at-risk individuals. He calls this the “fasting-mimicking diet.”

“If somebody is obese or overweight, and has high cholesterol, high fasting glucose, and is perhaps prediabetic, then a doctor may decide to do the diet once a month for 5 days, and for the rest of the month, the person can go back to whatever it is that they do,” he said in a video interview at the annual meeting of the Endocrine Society.

“We think we are going to see more and more of this approach in the future,” said Dr. Longo, the Edna M. Jones Professor of Gerontology at the University of Southern California, Los Angeles.

Dr. Longo sees two chief practical benefits from the diet. First, patients “don’t feel they are being pushed to revolutionize their lives” because they aren’t asked to make radical lifestyle changes that have to be adhered to on a daily basis, and second, “we are starting to see that the patient slowly moves in the direction of a better diet without being asked to do it.”

A clinical trial with about 100 patients showed improvements in many metabolic markers after 3 months of a once-monthly, 5-day cycle of the low-calorie diet, which includes some healthy fats from olive oil and nuts. Fasting blood glucose, blood pressure, and insulinlike growth factor 1 levels and other metabolic markers were all reduced in the randomized crossover trial after 3 months of the diet plan.

Dr. Longo noted that in the clinical trial, effects were more pronounced for individuals with a higher risk for disease.

Dr. Longo has a majority stake in L-Nutra, which markets a commercially available fasting-mimicking diet package. He donates his proceeds to a nonprofit corporation he founded.

koakes@mdedge.com

NEW ORLEANS – Can a physician-supervised, intermittent fasting strategy improve metabolic risk? Yes, according to Valter Longo, PhD.

Dr. Longo is a proponent of 5 days of reduced calories, performed once monthly or even less frequently for at-risk individuals. He calls this the “fasting-mimicking diet.”

“If somebody is obese or overweight, and has high cholesterol, high fasting glucose, and is perhaps prediabetic, then a doctor may decide to do the diet once a month for 5 days, and for the rest of the month, the person can go back to whatever it is that they do,” he said in a video interview at the annual meeting of the Endocrine Society.

“We think we are going to see more and more of this approach in the future,” said Dr. Longo, the Edna M. Jones Professor of Gerontology at the University of Southern California, Los Angeles.

Dr. Longo sees two chief practical benefits from the diet. First, patients “don’t feel they are being pushed to revolutionize their lives” because they aren’t asked to make radical lifestyle changes that have to be adhered to on a daily basis, and second, “we are starting to see that the patient slowly moves in the direction of a better diet without being asked to do it.”

A clinical trial with about 100 patients showed improvements in many metabolic markers after 3 months of a once-monthly, 5-day cycle of the low-calorie diet, which includes some healthy fats from olive oil and nuts. Fasting blood glucose, blood pressure, and insulinlike growth factor 1 levels and other metabolic markers were all reduced in the randomized crossover trial after 3 months of the diet plan.

Dr. Longo noted that in the clinical trial, effects were more pronounced for individuals with a higher risk for disease.

Dr. Longo has a majority stake in L-Nutra, which markets a commercially available fasting-mimicking diet package. He donates his proceeds to a nonprofit corporation he founded.

koakes@mdedge.com

NEW ORLEANS – Can a physician-supervised, intermittent fasting strategy improve metabolic risk? Yes, according to Valter Longo, PhD.

Dr. Longo is a proponent of 5 days of reduced calories, performed once monthly or even less frequently for at-risk individuals. He calls this the “fasting-mimicking diet.”

“If somebody is obese or overweight, and has high cholesterol, high fasting glucose, and is perhaps prediabetic, then a doctor may decide to do the diet once a month for 5 days, and for the rest of the month, the person can go back to whatever it is that they do,” he said in a video interview at the annual meeting of the Endocrine Society.

“We think we are going to see more and more of this approach in the future,” said Dr. Longo, the Edna M. Jones Professor of Gerontology at the University of Southern California, Los Angeles.

Dr. Longo sees two chief practical benefits from the diet. First, patients “don’t feel they are being pushed to revolutionize their lives” because they aren’t asked to make radical lifestyle changes that have to be adhered to on a daily basis, and second, “we are starting to see that the patient slowly moves in the direction of a better diet without being asked to do it.”

A clinical trial with about 100 patients showed improvements in many metabolic markers after 3 months of a once-monthly, 5-day cycle of the low-calorie diet, which includes some healthy fats from olive oil and nuts. Fasting blood glucose, blood pressure, and insulinlike growth factor 1 levels and other metabolic markers were all reduced in the randomized crossover trial after 3 months of the diet plan.

Dr. Longo noted that in the clinical trial, effects were more pronounced for individuals with a higher risk for disease.

Dr. Longo has a majority stake in L-Nutra, which markets a commercially available fasting-mimicking diet package. He donates his proceeds to a nonprofit corporation he founded.

koakes@mdedge.com

NEW ORLEANS – Oxytocin shows promise as a weight-loss medication, with encouraging results in animal models and small human studies. Now, new imaging results show that the hormone inhibits food-related reward circuitry in the brain, tackling the hedonic, nonnutritive eating that can contribute to overweight and obesity in a calorie-rich environment.

“It is clear by now that obesity is a very serious health concern,” Liya Kerem, MD, said in a video interview at the annual meeting of the Endocrine Society. “The most adopted strategy, which is lifestyle modification, does not help [with losing or maintaining] weight in many cases, so we really need to find new treatments for obesity.”

Functional magnetic resonance imaging (fMRI) is a good tool for investigating the neurobiologic basis of overeating, said Dr. Kerem, a pediatric endocrinology fellow at Massachusetts General Hospital, Boston. In previous studies, fMRI has shown that “individuals with obesity have hyperactivation of the reward circuitry in the brain.”

Oxytocin is produced in the hypothalamus and is active in many brain areas associated with reward processing, said Dr. Kerem. Animal studies have shown a decrease in food intake and weight gain with oxytocin administration.

The hormone, which is generally seen as very safe, has had limited study in humans as a weight-loss strategy. Findings from one small study have shown that in men, a single intranasal dose of 24 IU of oxytocin resulted in less hunger-driven eating as well as lower consumption of a postmeal palatable snack, with the latter representing hedonic eating, said Dr. Kerem. A second small pilot study showed that significant weight loss occurred in obese humans after 8 weeks of daily oxytocin administration.

Findings from another study showed that participants who were overweight or obese, unlike their normal-weight counterparts, had reduced activation in the ventral tegmental area (VTA) after oxytocin administration. The VTA is an important region in the brain’s reward network, explained Dr. Kerem.

She and her colleagues used fMRI to probe dynamic changes in brain reward circuitry under the effect of oxytocin. They wanted to understand how oxytocin would “change the dialog between the VTA and the key brain areas involved in processing visual food stimuli.”

The hypothesis was that oxytocin would reduce functional connectivity between the VTA and other brain areas that are important for food reward and sensory processing when the participants were exposed to pictures of high-calorie food.

To test that hypothesis, the researchers showed the participants 100 each of four different kinds of images: high-calorie foods, low-calorie foods, nonfood images, and “fixation” images, used for calibration. The 10 participants had a mean body mass index of 29 kg/m², and the mean age was 31 years.

Oxytocin did indeed attenuate functional connectivity between the VTA and several brain regions that are “key food motivation areas,” said Dr. Kerem. In particular, connections between the VTA and the insula were reduced with oxytocin. The insula is the “gustatory hub of the brain, key to subjective perception of food stimuli,” she explained.

Other attenuated associations included the oral area of the somatosensory cortex; the operculum, which shows fMRI activation to taste; the temporal gyrus, which is important for sensory processing; and, importantly, both the amygdala and hippocampus, known to be important for stimulus-reward learning, said Dr. Kerem. “We found that oxytocin targets exactly that hyperactivation in an overweight and obese population.”

It “reduced the functional connectivity between the VTA, a key hedonic brain region that drives efforts to obtain desired foods, and multiple brain areas involved in the cognitive, sensory, and emotional processing of food cues in men with overweight and obesity,” she said at a press conference highlighting the research. She emphasized that the effect was seen only with exposure to high-calorie food images. “Targeting hyperactivation of reward areas with oxytocin may inhibit overeating behavior,” she added.

Dr. Kerem and her colleagues are currently enrolling men and women for a larger clinical trial of oxytocin for weight loss.

Dr. Kerem reported no conflicts of interest. One of the study’s coauthors is a consultant for OXT Therapeutics, which is investigating obesity-related uses for oxytocin.

koakes@mdedge.com

NEW ORLEANS – Oxytocin shows promise as a weight-loss medication, with encouraging results in animal models and small human studies. Now, new imaging results show that the hormone inhibits food-related reward circuitry in the brain, tackling the hedonic, nonnutritive eating that can contribute to overweight and obesity in a calorie-rich environment.

“It is clear by now that obesity is a very serious health concern,” Liya Kerem, MD, said in a video interview at the annual meeting of the Endocrine Society. “The most adopted strategy, which is lifestyle modification, does not help [with losing or maintaining] weight in many cases, so we really need to find new treatments for obesity.”

Functional magnetic resonance imaging (fMRI) is a good tool for investigating the neurobiologic basis of overeating, said Dr. Kerem, a pediatric endocrinology fellow at Massachusetts General Hospital, Boston. In previous studies, fMRI has shown that “individuals with obesity have hyperactivation of the reward circuitry in the brain.”

Oxytocin is produced in the hypothalamus and is active in many brain areas associated with reward processing, said Dr. Kerem. Animal studies have shown a decrease in food intake and weight gain with oxytocin administration.

The hormone, which is generally seen as very safe, has had limited study in humans as a weight-loss strategy. Findings from one small study have shown that in men, a single intranasal dose of 24 IU of oxytocin resulted in less hunger-driven eating as well as lower consumption of a postmeal palatable snack, with the latter representing hedonic eating, said Dr. Kerem. A second small pilot study showed that significant weight loss occurred in obese humans after 8 weeks of daily oxytocin administration.

Findings from another study showed that participants who were overweight or obese, unlike their normal-weight counterparts, had reduced activation in the ventral tegmental area (VTA) after oxytocin administration. The VTA is an important region in the brain’s reward network, explained Dr. Kerem.

She and her colleagues used fMRI to probe dynamic changes in brain reward circuitry under the effect of oxytocin. They wanted to understand how oxytocin would “change the dialog between the VTA and the key brain areas involved in processing visual food stimuli.”

The hypothesis was that oxytocin would reduce functional connectivity between the VTA and other brain areas that are important for food reward and sensory processing when the participants were exposed to pictures of high-calorie food.

To test that hypothesis, the researchers showed the participants 100 each of four different kinds of images: high-calorie foods, low-calorie foods, nonfood images, and “fixation” images, used for calibration. The 10 participants had a mean body mass index of 29 kg/m², and the mean age was 31 years.

Oxytocin did indeed attenuate functional connectivity between the VTA and several brain regions that are “key food motivation areas,” said Dr. Kerem. In particular, connections between the VTA and the insula were reduced with oxytocin. The insula is the “gustatory hub of the brain, key to subjective perception of food stimuli,” she explained.

Other attenuated associations included the oral area of the somatosensory cortex; the operculum, which shows fMRI activation to taste; the temporal gyrus, which is important for sensory processing; and, importantly, both the amygdala and hippocampus, known to be important for stimulus-reward learning, said Dr. Kerem. “We found that oxytocin targets exactly that hyperactivation in an overweight and obese population.”

It “reduced the functional connectivity between the VTA, a key hedonic brain region that drives efforts to obtain desired foods, and multiple brain areas involved in the cognitive, sensory, and emotional processing of food cues in men with overweight and obesity,” she said at a press conference highlighting the research. She emphasized that the effect was seen only with exposure to high-calorie food images. “Targeting hyperactivation of reward areas with oxytocin may inhibit overeating behavior,” she added.

Dr. Kerem and her colleagues are currently enrolling men and women for a larger clinical trial of oxytocin for weight loss.

Dr. Kerem reported no conflicts of interest. One of the study’s coauthors is a consultant for OXT Therapeutics, which is investigating obesity-related uses for oxytocin.

koakes@mdedge.com

NEW ORLEANS – Oxytocin shows promise as a weight-loss medication, with encouraging results in animal models and small human studies. Now, new imaging results show that the hormone inhibits food-related reward circuitry in the brain, tackling the hedonic, nonnutritive eating that can contribute to overweight and obesity in a calorie-rich environment.

“It is clear by now that obesity is a very serious health concern,” Liya Kerem, MD, said in a video interview at the annual meeting of the Endocrine Society. “The most adopted strategy, which is lifestyle modification, does not help [with losing or maintaining] weight in many cases, so we really need to find new treatments for obesity.”

Functional magnetic resonance imaging (fMRI) is a good tool for investigating the neurobiologic basis of overeating, said Dr. Kerem, a pediatric endocrinology fellow at Massachusetts General Hospital, Boston. In previous studies, fMRI has shown that “individuals with obesity have hyperactivation of the reward circuitry in the brain.”

Oxytocin is produced in the hypothalamus and is active in many brain areas associated with reward processing, said Dr. Kerem. Animal studies have shown a decrease in food intake and weight gain with oxytocin administration.

The hormone, which is generally seen as very safe, has had limited study in humans as a weight-loss strategy. Findings from one small study have shown that in men, a single intranasal dose of 24 IU of oxytocin resulted in less hunger-driven eating as well as lower consumption of a postmeal palatable snack, with the latter representing hedonic eating, said Dr. Kerem. A second small pilot study showed that significant weight loss occurred in obese humans after 8 weeks of daily oxytocin administration.

Findings from another study showed that participants who were overweight or obese, unlike their normal-weight counterparts, had reduced activation in the ventral tegmental area (VTA) after oxytocin administration. The VTA is an important region in the brain’s reward network, explained Dr. Kerem.

She and her colleagues used fMRI to probe dynamic changes in brain reward circuitry under the effect of oxytocin. They wanted to understand how oxytocin would “change the dialog between the VTA and the key brain areas involved in processing visual food stimuli.”

The hypothesis was that oxytocin would reduce functional connectivity between the VTA and other brain areas that are important for food reward and sensory processing when the participants were exposed to pictures of high-calorie food.

To test that hypothesis, the researchers showed the participants 100 each of four different kinds of images: high-calorie foods, low-calorie foods, nonfood images, and “fixation” images, used for calibration. The 10 participants had a mean body mass index of 29 kg/m², and the mean age was 31 years.

Oxytocin did indeed attenuate functional connectivity between the VTA and several brain regions that are “key food motivation areas,” said Dr. Kerem. In particular, connections between the VTA and the insula were reduced with oxytocin. The insula is the “gustatory hub of the brain, key to subjective perception of food stimuli,” she explained.

Other attenuated associations included the oral area of the somatosensory cortex; the operculum, which shows fMRI activation to taste; the temporal gyrus, which is important for sensory processing; and, importantly, both the amygdala and hippocampus, known to be important for stimulus-reward learning, said Dr. Kerem. “We found that oxytocin targets exactly that hyperactivation in an overweight and obese population.”

It “reduced the functional connectivity between the VTA, a key hedonic brain region that drives efforts to obtain desired foods, and multiple brain areas involved in the cognitive, sensory, and emotional processing of food cues in men with overweight and obesity,” she said at a press conference highlighting the research. She emphasized that the effect was seen only with exposure to high-calorie food images. “Targeting hyperactivation of reward areas with oxytocin may inhibit overeating behavior,” she added.

Dr. Kerem and her colleagues are currently enrolling men and women for a larger clinical trial of oxytocin for weight loss.

Dr. Kerem reported no conflicts of interest. One of the study’s coauthors is a consultant for OXT Therapeutics, which is investigating obesity-related uses for oxytocin.

koakes@mdedge.com

Continuous positive airway pressure (CPAP) over several years did not lead to clinically concerning levels of weight gain among patients with obstructive sleep apnea and comorbid cardiovascular disease enrolled in a large international trial, findings from a large, multicenter trial show.

Courtesy ResMed

No differences in weight, body mass index (BMI), or other body measurements were found when comparing CPAP and control groups in a post hoc analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, which included 2,483 adults enrolled at 89 centers in seven countries.

In a subanalysis, there was a small but statistically significant weight gain of less than 400 g in men who used CPAP at least 4 hours per night as compared to matched controls. However, there were no differences in BMI or neck and waist circumferences for these men, and no such changes were observed in women, according to the investigators, led by Qiong Ou, MD, of Guangdong (China) General Hospital and R. Doug McEvoy, MD, of the Adelaide Institute for Sleep Health at Flinders University, Adelaide, Australia.

“Such a small change in weight, even with good adherence over several years, is highly unlikely to have any serious clinical ramifications,” wrote the investigators of the study published in Chest.

“Taken together, these results indicate that long-term CPAP treatment is unlikely to exacerbate the problems of overweight and obesity that are common among patients with OSA,” they added.

In a previous meta-analysis of randomized trials, investigators concluded that CPAP promoted significant increases in BMI and weight. However, the median study duration was only 3 months.

In contrast, the analysis of the SAVE trial included adults who had regular body measurements over a mean follow-up of nearly 4 years.

That long-term follow-up provided an “ideal opportunity” to assess whether CPAP treatment promotes weight gain in OSA patients over the course of several years, the authors of the SAVE trial analysis wrote.

For men in the SAVE trial, the difference in weight change for the CPAP group vs. the control group was just 0.07 kg (95% confidence interval, –0.40 to 0.54; P = .773) while in women, the difference for CPAP vs. controls was –0.14 kg (95% CI, –0.37 to 0.09; P = .233), the investigators reported.

Weight gain was significantly higher among men with good CPAP adherence, defined as use for at least 4 hours per night, investigators said, noting a mean difference of 0.38 kg (95% CI, 0.04-0.73; P = .031), though no other differences were found in body measurements for men, and no such associations were found in women with good CPAP adherence.

It’s not exactly clear why this SAVE analysis would find no evidence of CPAP promoting weight gain over the long term, in contrast to the earlier meta-analysis of short-term studies finding a significant risk of weight gain.

However, it is possible that differences in study populations such as ethnicity, age, or comorbidities contributed to the differences, said investigators.

For example, results of regression analysis in the present study showed that, compared with recruitment in Australia, recruitment in China and India was significantly linked to weight loss, while recruitment in New Zealand was linked to weight gain.

Dr. Ou had no disclosures related to the study, while Dr. McEvoy reported disclosures related to Philips Respironics, ResMed, Fisher & Paykel, Air Liquide, and the National Health and Medical Research Council of Australia.

chestphysiciannews@chestnet.org

SOURCE: Ou Q et al. Chest. 2019 Apr;155(4):720-9.

Continuous positive airway pressure (CPAP) over several years did not lead to clinically concerning levels of weight gain among patients with obstructive sleep apnea and comorbid cardiovascular disease enrolled in a large international trial, findings from a large, multicenter trial show.

Courtesy ResMed

No differences in weight, body mass index (BMI), or other body measurements were found when comparing CPAP and control groups in a post hoc analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, which included 2,483 adults enrolled at 89 centers in seven countries.

In a subanalysis, there was a small but statistically significant weight gain of less than 400 g in men who used CPAP at least 4 hours per night as compared to matched controls. However, there were no differences in BMI or neck and waist circumferences for these men, and no such changes were observed in women, according to the investigators, led by Qiong Ou, MD, of Guangdong (China) General Hospital and R. Doug McEvoy, MD, of the Adelaide Institute for Sleep Health at Flinders University, Adelaide, Australia.

“Such a small change in weight, even with good adherence over several years, is highly unlikely to have any serious clinical ramifications,” wrote the investigators of the study published in Chest.

“Taken together, these results indicate that long-term CPAP treatment is unlikely to exacerbate the problems of overweight and obesity that are common among patients with OSA,” they added.

In a previous meta-analysis of randomized trials, investigators concluded that CPAP promoted significant increases in BMI and weight. However, the median study duration was only 3 months.

In contrast, the analysis of the SAVE trial included adults who had regular body measurements over a mean follow-up of nearly 4 years.

That long-term follow-up provided an “ideal opportunity” to assess whether CPAP treatment promotes weight gain in OSA patients over the course of several years, the authors of the SAVE trial analysis wrote.

For men in the SAVE trial, the difference in weight change for the CPAP group vs. the control group was just 0.07 kg (95% confidence interval, –0.40 to 0.54; P = .773) while in women, the difference for CPAP vs. controls was –0.14 kg (95% CI, –0.37 to 0.09; P = .233), the investigators reported.

Weight gain was significantly higher among men with good CPAP adherence, defined as use for at least 4 hours per night, investigators said, noting a mean difference of 0.38 kg (95% CI, 0.04-0.73; P = .031), though no other differences were found in body measurements for men, and no such associations were found in women with good CPAP adherence.

It’s not exactly clear why this SAVE analysis would find no evidence of CPAP promoting weight gain over the long term, in contrast to the earlier meta-analysis of short-term studies finding a significant risk of weight gain.

However, it is possible that differences in study populations such as ethnicity, age, or comorbidities contributed to the differences, said investigators.

For example, results of regression analysis in the present study showed that, compared with recruitment in Australia, recruitment in China and India was significantly linked to weight loss, while recruitment in New Zealand was linked to weight gain.

Dr. Ou had no disclosures related to the study, while Dr. McEvoy reported disclosures related to Philips Respironics, ResMed, Fisher & Paykel, Air Liquide, and the National Health and Medical Research Council of Australia.

chestphysiciannews@chestnet.org

SOURCE: Ou Q et al. Chest. 2019 Apr;155(4):720-9.

Continuous positive airway pressure (CPAP) over several years did not lead to clinically concerning levels of weight gain among patients with obstructive sleep apnea and comorbid cardiovascular disease enrolled in a large international trial, findings from a large, multicenter trial show.

Courtesy ResMed

No differences in weight, body mass index (BMI), or other body measurements were found when comparing CPAP and control groups in a post hoc analysis of the Sleep Apnea Cardiovascular Endpoints (SAVE) trial, which included 2,483 adults enrolled at 89 centers in seven countries.

In a subanalysis, there was a small but statistically significant weight gain of less than 400 g in men who used CPAP at least 4 hours per night as compared to matched controls. However, there were no differences in BMI or neck and waist circumferences for these men, and no such changes were observed in women, according to the investigators, led by Qiong Ou, MD, of Guangdong (China) General Hospital and R. Doug McEvoy, MD, of the Adelaide Institute for Sleep Health at Flinders University, Adelaide, Australia.

“Such a small change in weight, even with good adherence over several years, is highly unlikely to have any serious clinical ramifications,” wrote the investigators of the study published in Chest.

“Taken together, these results indicate that long-term CPAP treatment is unlikely to exacerbate the problems of overweight and obesity that are common among patients with OSA,” they added.

In a previous meta-analysis of randomized trials, investigators concluded that CPAP promoted significant increases in BMI and weight. However, the median study duration was only 3 months.

In contrast, the analysis of the SAVE trial included adults who had regular body measurements over a mean follow-up of nearly 4 years.

That long-term follow-up provided an “ideal opportunity” to assess whether CPAP treatment promotes weight gain in OSA patients over the course of several years, the authors of the SAVE trial analysis wrote.

For men in the SAVE trial, the difference in weight change for the CPAP group vs. the control group was just 0.07 kg (95% confidence interval, –0.40 to 0.54; P = .773) while in women, the difference for CPAP vs. controls was –0.14 kg (95% CI, –0.37 to 0.09; P = .233), the investigators reported.

Weight gain was significantly higher among men with good CPAP adherence, defined as use for at least 4 hours per night, investigators said, noting a mean difference of 0.38 kg (95% CI, 0.04-0.73; P = .031), though no other differences were found in body measurements for men, and no such associations were found in women with good CPAP adherence.

It’s not exactly clear why this SAVE analysis would find no evidence of CPAP promoting weight gain over the long term, in contrast to the earlier meta-analysis of short-term studies finding a significant risk of weight gain.

However, it is possible that differences in study populations such as ethnicity, age, or comorbidities contributed to the differences, said investigators.

For example, results of regression analysis in the present study showed that, compared with recruitment in Australia, recruitment in China and India was significantly linked to weight loss, while recruitment in New Zealand was linked to weight gain.

Dr. Ou had no disclosures related to the study, while Dr. McEvoy reported disclosures related to Philips Respironics, ResMed, Fisher & Paykel, Air Liquide, and the National Health and Medical Research Council of Australia.

chestphysiciannews@chestnet.org

SOURCE: Ou Q et al. Chest. 2019 Apr;155(4):720-9.