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For weight-loss apps, the evidence base is still small
NASHVILLE –
Beginning with a pool of 1,380 publications, Christina Hopkins and her colleagues at Duke University, Durham, N.C., eventually identified just nine trials of all-digital interventions for weight loss that met their inclusion criteria.
Presenting their findings at a late-breaking poster session during Obesity Week, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery, Ms. Hopkins, a clinical psychology graduate student at Duke, and her colleagues found that three of the nine studies showed statistically significant weight loss, compared with a control state. Absolute weight loss in these three trials ranged from 3 kg to about 7 kg (between-group differences, P less than .001 for all).
Participants in another trial didn’t lose a statistically significant amount of weight, compared with the control arm of the study. However, the mean 5 kg lost by those in the intervention arm was enough to be clinically significant, so Ms. Hopkins and her colleagues included this study in a subanalysis that looked for effective modalities and interventions among the studies with significant results.
The duration of the studies ranged from 6 to 24 months, though five of the trials were less than 1 year long. Women made up the majority of participants in all but one trial.
“There is limited evidence that standalone digital weight-loss interventions produce clinically meaningful outcomes,” wrote Ms. Hopkins and her coauthors. “Absolute magnitude of weight loss was low, and the short intervention lengths call into question the sustainability of these weight losses.”
The systematic review cast a broad net to include digital modalities such as wireless scales, text messaging, email, and web-based interventions, as well as the use of smartphone apps and tracking devices. All interventions used multiple digital modalities.
The most frequently used technologies were the use of a website, used in six (67%) of the trials, followed by text messaging and smartphone apps, each used in five (56%) of the trials. Tracking devices, email, message boards, and gamification of some sort were all used in three (33%) of the trials.
In terms of the specific interventions used in the trials, weight, diet, and activity were all tracked in eight trials (89%). Similarly, all but one trial gave feedback and weight and health education to participants. Behavior change education, as well as calorie goals, were each used in six trials (67%).
Ms. Hopkins and her colleagues looked at which trials incorporated which modalities and interventions, finding that “trials that integrated components unique to digital interventions, such as gamification, podcasts, or interactive features, yielded significantly greater and more clinically meaningful weight losses.”
To be included in the systematic review, trials had to include adult participants with a body mass index of at least 25 kg/m2 and use a standalone digital intervention of at least 6 months’ duration. The primary outcome of interest in the review was the change in participant weight from baseline to the end of the minimum 6-month follow-up period. Randomized, controlled trials and feasibility trials were included, so long as participants were allocated randomly.
Of the 126 trials reviewed at the full text level, the most frequent reason for exclusion was the inclusion of human coaching. Also, 30 of the trials didn’t report weight change as an outcome, the investigators said.
Future directions should include comparing digital interventions that “utilize features unique to digital delivery” with those that more closely resemble in-person weight-loss management interventions, suggested Ms. Hopkins and her collaborators.
The authors reported no outside sources of funding and no conflicts of interest.
SOURCE: Hopkins C et al. Obesity Week 2018, Abstract T-P-LB-3640.
NASHVILLE –
Beginning with a pool of 1,380 publications, Christina Hopkins and her colleagues at Duke University, Durham, N.C., eventually identified just nine trials of all-digital interventions for weight loss that met their inclusion criteria.
Presenting their findings at a late-breaking poster session during Obesity Week, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery, Ms. Hopkins, a clinical psychology graduate student at Duke, and her colleagues found that three of the nine studies showed statistically significant weight loss, compared with a control state. Absolute weight loss in these three trials ranged from 3 kg to about 7 kg (between-group differences, P less than .001 for all).
Participants in another trial didn’t lose a statistically significant amount of weight, compared with the control arm of the study. However, the mean 5 kg lost by those in the intervention arm was enough to be clinically significant, so Ms. Hopkins and her colleagues included this study in a subanalysis that looked for effective modalities and interventions among the studies with significant results.
The duration of the studies ranged from 6 to 24 months, though five of the trials were less than 1 year long. Women made up the majority of participants in all but one trial.
“There is limited evidence that standalone digital weight-loss interventions produce clinically meaningful outcomes,” wrote Ms. Hopkins and her coauthors. “Absolute magnitude of weight loss was low, and the short intervention lengths call into question the sustainability of these weight losses.”
The systematic review cast a broad net to include digital modalities such as wireless scales, text messaging, email, and web-based interventions, as well as the use of smartphone apps and tracking devices. All interventions used multiple digital modalities.
The most frequently used technologies were the use of a website, used in six (67%) of the trials, followed by text messaging and smartphone apps, each used in five (56%) of the trials. Tracking devices, email, message boards, and gamification of some sort were all used in three (33%) of the trials.
In terms of the specific interventions used in the trials, weight, diet, and activity were all tracked in eight trials (89%). Similarly, all but one trial gave feedback and weight and health education to participants. Behavior change education, as well as calorie goals, were each used in six trials (67%).
Ms. Hopkins and her colleagues looked at which trials incorporated which modalities and interventions, finding that “trials that integrated components unique to digital interventions, such as gamification, podcasts, or interactive features, yielded significantly greater and more clinically meaningful weight losses.”
To be included in the systematic review, trials had to include adult participants with a body mass index of at least 25 kg/m2 and use a standalone digital intervention of at least 6 months’ duration. The primary outcome of interest in the review was the change in participant weight from baseline to the end of the minimum 6-month follow-up period. Randomized, controlled trials and feasibility trials were included, so long as participants were allocated randomly.
Of the 126 trials reviewed at the full text level, the most frequent reason for exclusion was the inclusion of human coaching. Also, 30 of the trials didn’t report weight change as an outcome, the investigators said.
Future directions should include comparing digital interventions that “utilize features unique to digital delivery” with those that more closely resemble in-person weight-loss management interventions, suggested Ms. Hopkins and her collaborators.
The authors reported no outside sources of funding and no conflicts of interest.
SOURCE: Hopkins C et al. Obesity Week 2018, Abstract T-P-LB-3640.
NASHVILLE –
Beginning with a pool of 1,380 publications, Christina Hopkins and her colleagues at Duke University, Durham, N.C., eventually identified just nine trials of all-digital interventions for weight loss that met their inclusion criteria.
Presenting their findings at a late-breaking poster session during Obesity Week, presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery, Ms. Hopkins, a clinical psychology graduate student at Duke, and her colleagues found that three of the nine studies showed statistically significant weight loss, compared with a control state. Absolute weight loss in these three trials ranged from 3 kg to about 7 kg (between-group differences, P less than .001 for all).
Participants in another trial didn’t lose a statistically significant amount of weight, compared with the control arm of the study. However, the mean 5 kg lost by those in the intervention arm was enough to be clinically significant, so Ms. Hopkins and her colleagues included this study in a subanalysis that looked for effective modalities and interventions among the studies with significant results.
The duration of the studies ranged from 6 to 24 months, though five of the trials were less than 1 year long. Women made up the majority of participants in all but one trial.
“There is limited evidence that standalone digital weight-loss interventions produce clinically meaningful outcomes,” wrote Ms. Hopkins and her coauthors. “Absolute magnitude of weight loss was low, and the short intervention lengths call into question the sustainability of these weight losses.”
The systematic review cast a broad net to include digital modalities such as wireless scales, text messaging, email, and web-based interventions, as well as the use of smartphone apps and tracking devices. All interventions used multiple digital modalities.
The most frequently used technologies were the use of a website, used in six (67%) of the trials, followed by text messaging and smartphone apps, each used in five (56%) of the trials. Tracking devices, email, message boards, and gamification of some sort were all used in three (33%) of the trials.
In terms of the specific interventions used in the trials, weight, diet, and activity were all tracked in eight trials (89%). Similarly, all but one trial gave feedback and weight and health education to participants. Behavior change education, as well as calorie goals, were each used in six trials (67%).
Ms. Hopkins and her colleagues looked at which trials incorporated which modalities and interventions, finding that “trials that integrated components unique to digital interventions, such as gamification, podcasts, or interactive features, yielded significantly greater and more clinically meaningful weight losses.”
To be included in the systematic review, trials had to include adult participants with a body mass index of at least 25 kg/m2 and use a standalone digital intervention of at least 6 months’ duration. The primary outcome of interest in the review was the change in participant weight from baseline to the end of the minimum 6-month follow-up period. Randomized, controlled trials and feasibility trials were included, so long as participants were allocated randomly.
Of the 126 trials reviewed at the full text level, the most frequent reason for exclusion was the inclusion of human coaching. Also, 30 of the trials didn’t report weight change as an outcome, the investigators said.
Future directions should include comparing digital interventions that “utilize features unique to digital delivery” with those that more closely resemble in-person weight-loss management interventions, suggested Ms. Hopkins and her collaborators.
The authors reported no outside sources of funding and no conflicts of interest.
SOURCE: Hopkins C et al. Obesity Week 2018, Abstract T-P-LB-3640.
REPORTING FROM OBESITY WEEK 2018
Key clinical point: Three of nine studies found statistically significant weight loss with digital interventions.
Major finding: The largest effect was seen in one study showing 7 kg of long-term weight loss (P less than .001).
Study details: A systematic review of nine studies of digital-only interventions for weight loss.
Disclosures: The authors reported no outside sources of funding and no conflicts of interest.
Source: Hopkins C et al. Obesity Week 2018, Abstract T-P-PB-3640.
BMI compares favorably with body scanning for ID of cardiometabolic traits
Although body mass index is criticized for not distinguishing fat from lean mass, its ability to detect subclinical cardiometabolic abnormalities was on par with more sophisticated body scanning technology, according a recent analysis.
BMI and dual-energy x-ray absorptiometry (DXA) had similar associations with cardiometabolic traits associated with coronary heart disease in individuals evaluated at 10 and 18 years of age in a population-based birth cohort study, the study investigators said.
Changes over time in BMI and DXA also were strongly associated with changes in blood pressure, cholesterol, and other markers, according to Joshua A. Bell, PhD, of MRC Integrative Epidemiology Unit, University of Bristol, England, and his coinvestigators.
“Altogether, the results support abdominal fatness as a primary driver of cardiometabolic dysfunction and BMI as a useful tool for detecting its effects,” Dr. Bell and his colleagues said in a report on the study appearing in the Journal of the American College of Cardiology.
In their analysis, Dr. Bell and coinvestigators used Pearson correlation coefficients to compare BMI and total and regional fat indexes from DXA in offspring participants from ALSPAC, (the Avon Longitudinal Study of Parents and Children), in which BMI and DXA measurements were collected at 10 and 18 years of age.
Researchers identified a total of 2,840 participants with at least one measurement at each of those time points. The mean BMI was 17.5 kg/m2 at 10 years of age and 22.7 kg/m2 at 18 years of age, with greater than 10% of participants classified as obese at each of those time points.
High BMI and high total fat mass index were similarly associated with a variety of cardiometabolic traits, including systolic and diastolic blood pressure, higher low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) cholesterol levels and lower high-density lipoprotein (HDL) cholesterol levels, and more inflammation, investigators found.
BMI was strongly correlated with DXA total and regional fat indexes at 10 years of age, and again at 18 years of age, they reported.
Moreover, gains in BMI from 10 to 18 years of age were strongly associated with higher blood pressure, higher LDL and VLDL cholesterol, lower HDL cholesterol, and other cardiometabolic traits, while associations between DXA measurements and those traits closely tracked those of BMI in pattern and magnitude, investigators added.
Fatness is most often measured in populations using BMI, and causal analyses suggest linkage between higher BMI and coronary heart disease and its intermediates, including blood pressure, LDL and remnant cholesterol, and glucose; despite that, BMI is often disparaged as a tool for assessing cardiometabolic abnormalities because it does not distinguish fat from lean mass and cannot quantify fat distribution, investigators said.
However, based on results of this analysis, it is reasonable to depend on BMI to indirectly measure body and abdominal fatness in future studies, they said in their report.
Dr. Bell and his colleagues reported that they had no relationships relevant to the study publication.
SOURCE: Bell JA et al. J Am Coll Cardiol. 2018 Dec 18;72(24):3142-54.
This study reinforces fatness, quantified by body mass index, as the key modifiable factor for maintaining healthy metabolism in young people, according to Ville-Petteri Mäkinen, ScD.
“The good news is that a single BMI measurement may be enough to capture the same essential information as a detailed body scan and serial measurements,” Dr. Mäkinen wrote in an accompanying editorial.
One other important take-home message of the study is that fat gain is not beneficial in any body region; that finding is important with respect to changes in BMI and fat mass index observed in the second decade of life that were associated with cardiometabolic risk factors in the late teens, he noted.
However, the broader take-home message for society is that children are being exposed to an “adverse metabolic milieu” that predicts cardiovascular disease in adulthood, according to Dr. Mäkinen.
“Childhood obesity must not be seen as a phase that passes but as a looming public health crisis that needs to be addressed by all of us,” he concluded.
Dr. Mäkinen is with the South Australian Health and Medical Research Institute, Adelaide. He had no relationships relevant to the contents of his editorial (J Am College Cardiol. 2018 Dec 18;74[24]3155-7).
This study reinforces fatness, quantified by body mass index, as the key modifiable factor for maintaining healthy metabolism in young people, according to Ville-Petteri Mäkinen, ScD.
“The good news is that a single BMI measurement may be enough to capture the same essential information as a detailed body scan and serial measurements,” Dr. Mäkinen wrote in an accompanying editorial.
One other important take-home message of the study is that fat gain is not beneficial in any body region; that finding is important with respect to changes in BMI and fat mass index observed in the second decade of life that were associated with cardiometabolic risk factors in the late teens, he noted.
However, the broader take-home message for society is that children are being exposed to an “adverse metabolic milieu” that predicts cardiovascular disease in adulthood, according to Dr. Mäkinen.
“Childhood obesity must not be seen as a phase that passes but as a looming public health crisis that needs to be addressed by all of us,” he concluded.
Dr. Mäkinen is with the South Australian Health and Medical Research Institute, Adelaide. He had no relationships relevant to the contents of his editorial (J Am College Cardiol. 2018 Dec 18;74[24]3155-7).
This study reinforces fatness, quantified by body mass index, as the key modifiable factor for maintaining healthy metabolism in young people, according to Ville-Petteri Mäkinen, ScD.
“The good news is that a single BMI measurement may be enough to capture the same essential information as a detailed body scan and serial measurements,” Dr. Mäkinen wrote in an accompanying editorial.
One other important take-home message of the study is that fat gain is not beneficial in any body region; that finding is important with respect to changes in BMI and fat mass index observed in the second decade of life that were associated with cardiometabolic risk factors in the late teens, he noted.
However, the broader take-home message for society is that children are being exposed to an “adverse metabolic milieu” that predicts cardiovascular disease in adulthood, according to Dr. Mäkinen.
“Childhood obesity must not be seen as a phase that passes but as a looming public health crisis that needs to be addressed by all of us,” he concluded.
Dr. Mäkinen is with the South Australian Health and Medical Research Institute, Adelaide. He had no relationships relevant to the contents of his editorial (J Am College Cardiol. 2018 Dec 18;74[24]3155-7).
Although body mass index is criticized for not distinguishing fat from lean mass, its ability to detect subclinical cardiometabolic abnormalities was on par with more sophisticated body scanning technology, according a recent analysis.
BMI and dual-energy x-ray absorptiometry (DXA) had similar associations with cardiometabolic traits associated with coronary heart disease in individuals evaluated at 10 and 18 years of age in a population-based birth cohort study, the study investigators said.
Changes over time in BMI and DXA also were strongly associated with changes in blood pressure, cholesterol, and other markers, according to Joshua A. Bell, PhD, of MRC Integrative Epidemiology Unit, University of Bristol, England, and his coinvestigators.
“Altogether, the results support abdominal fatness as a primary driver of cardiometabolic dysfunction and BMI as a useful tool for detecting its effects,” Dr. Bell and his colleagues said in a report on the study appearing in the Journal of the American College of Cardiology.
In their analysis, Dr. Bell and coinvestigators used Pearson correlation coefficients to compare BMI and total and regional fat indexes from DXA in offspring participants from ALSPAC, (the Avon Longitudinal Study of Parents and Children), in which BMI and DXA measurements were collected at 10 and 18 years of age.
Researchers identified a total of 2,840 participants with at least one measurement at each of those time points. The mean BMI was 17.5 kg/m2 at 10 years of age and 22.7 kg/m2 at 18 years of age, with greater than 10% of participants classified as obese at each of those time points.
High BMI and high total fat mass index were similarly associated with a variety of cardiometabolic traits, including systolic and diastolic blood pressure, higher low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) cholesterol levels and lower high-density lipoprotein (HDL) cholesterol levels, and more inflammation, investigators found.
BMI was strongly correlated with DXA total and regional fat indexes at 10 years of age, and again at 18 years of age, they reported.
Moreover, gains in BMI from 10 to 18 years of age were strongly associated with higher blood pressure, higher LDL and VLDL cholesterol, lower HDL cholesterol, and other cardiometabolic traits, while associations between DXA measurements and those traits closely tracked those of BMI in pattern and magnitude, investigators added.
Fatness is most often measured in populations using BMI, and causal analyses suggest linkage between higher BMI and coronary heart disease and its intermediates, including blood pressure, LDL and remnant cholesterol, and glucose; despite that, BMI is often disparaged as a tool for assessing cardiometabolic abnormalities because it does not distinguish fat from lean mass and cannot quantify fat distribution, investigators said.
However, based on results of this analysis, it is reasonable to depend on BMI to indirectly measure body and abdominal fatness in future studies, they said in their report.
Dr. Bell and his colleagues reported that they had no relationships relevant to the study publication.
SOURCE: Bell JA et al. J Am Coll Cardiol. 2018 Dec 18;72(24):3142-54.
Although body mass index is criticized for not distinguishing fat from lean mass, its ability to detect subclinical cardiometabolic abnormalities was on par with more sophisticated body scanning technology, according a recent analysis.
BMI and dual-energy x-ray absorptiometry (DXA) had similar associations with cardiometabolic traits associated with coronary heart disease in individuals evaluated at 10 and 18 years of age in a population-based birth cohort study, the study investigators said.
Changes over time in BMI and DXA also were strongly associated with changes in blood pressure, cholesterol, and other markers, according to Joshua A. Bell, PhD, of MRC Integrative Epidemiology Unit, University of Bristol, England, and his coinvestigators.
“Altogether, the results support abdominal fatness as a primary driver of cardiometabolic dysfunction and BMI as a useful tool for detecting its effects,” Dr. Bell and his colleagues said in a report on the study appearing in the Journal of the American College of Cardiology.
In their analysis, Dr. Bell and coinvestigators used Pearson correlation coefficients to compare BMI and total and regional fat indexes from DXA in offspring participants from ALSPAC, (the Avon Longitudinal Study of Parents and Children), in which BMI and DXA measurements were collected at 10 and 18 years of age.
Researchers identified a total of 2,840 participants with at least one measurement at each of those time points. The mean BMI was 17.5 kg/m2 at 10 years of age and 22.7 kg/m2 at 18 years of age, with greater than 10% of participants classified as obese at each of those time points.
High BMI and high total fat mass index were similarly associated with a variety of cardiometabolic traits, including systolic and diastolic blood pressure, higher low-density lipoprotein (LDL) and very-low-density lipoprotein (VLDL) cholesterol levels and lower high-density lipoprotein (HDL) cholesterol levels, and more inflammation, investigators found.
BMI was strongly correlated with DXA total and regional fat indexes at 10 years of age, and again at 18 years of age, they reported.
Moreover, gains in BMI from 10 to 18 years of age were strongly associated with higher blood pressure, higher LDL and VLDL cholesterol, lower HDL cholesterol, and other cardiometabolic traits, while associations between DXA measurements and those traits closely tracked those of BMI in pattern and magnitude, investigators added.
Fatness is most often measured in populations using BMI, and causal analyses suggest linkage between higher BMI and coronary heart disease and its intermediates, including blood pressure, LDL and remnant cholesterol, and glucose; despite that, BMI is often disparaged as a tool for assessing cardiometabolic abnormalities because it does not distinguish fat from lean mass and cannot quantify fat distribution, investigators said.
However, based on results of this analysis, it is reasonable to depend on BMI to indirectly measure body and abdominal fatness in future studies, they said in their report.
Dr. Bell and his colleagues reported that they had no relationships relevant to the study publication.
SOURCE: Bell JA et al. J Am Coll Cardiol. 2018 Dec 18;72(24):3142-54.
FROM THE JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY
Key clinical point: Body mass index and dual-energy x-ray absorptiometry had similar associations with cardiometabolic abnormalities in individuals evaluated at 10 and 18 years of age.
Major finding: BMI was strongly correlated with DXA total and regional fat indexes at age 10 years (0.9) and age 18 years.
Study details: Analysis of 2,840 offspring participants in ALSPAC (the Avon Longitudinal Study of Parents and Children).
Disclosures: Study authors reported that they had no relationships relevant to the study or its publication.
Source: Bell JA et al. J Am Coll Cardiol. 2018 Dec 10;72(24):3142-54.
ABIM sued over maintenance of certification
Also today, drug test results should not dictate treatment, duodenoscopes contain more bacteria than expected, and weight-loss medications may have a role following bariatric surgery.
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Also today, drug test results should not dictate treatment, duodenoscopes contain more bacteria than expected, and weight-loss medications may have a role following bariatric surgery.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Also today, drug test results should not dictate treatment, duodenoscopes contain more bacteria than expected, and weight-loss medications may have a role following bariatric surgery.
Amazon Alexa
Apple Podcasts
Google Podcasts
Spotify
Heavy drinkers have a harder time keeping the weight off
NASHVILLE – Advising patients in a comprehensive weight loss intervention to moderate their alcohol consumption did not change how much they drank over the long term. At the same time, abstinent patients kept off more weight over time than those who were classified as heavy drinkers, in a new analysis of data from a multicenter trial.
Abstinent individuals lost just 1.6% more of their body weight after 4 years than those who drank (P = .003), a figure with “uncertain clinical significance,” Ariana Chao, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “The results should be taken in the context of the potential – though controversial – benefits of light to moderate alcohol consumption,” she added.
Alcohol contains 7.1 kcal/g, and “calories from alcohol usually add, rather than substitute, for food intake,” said Dr. Chao. Alcohol’s disinhibiting effects are thought to contribute to increased food intake and the making of less healthy food choices. However, existing research has shown inconsistent findings about the relationship between alcohol consumption and body weight, she said.
Reducing or completely cutting out alcoholic beverage consumption is common advice for those trying to lose weight, but whether this advice is followed, and whether it makes a difference over the long term, has been an open question, said Dr. Chao.
She and her collaborators at the University of Pennsylvania, Philadelphia, used data from Look AHEAD, “a multicenter, randomized, clinical trial that compared an intensive lifestyle intervention (ILI) to a diabetes support and education (DSE) control group,” for 5,145 people with overweight or obesity and type 2 diabetes, explained Dr. Chao and her coinvestigators.
Dr. Chao and her colleagues looked at the effect that the lifestyle intervention had on alcohol consumption. Additionally, to see how drinkers and nondrinkers fared over the long term, they examined the interaction between alcohol consumption and weight loss at year 4, hypothesizing that individuals who received ILI would have a greater decrease in their alcohol consumption by year 4 than those who received DSE. The investigators had a second hypothesis that, among the ILI cohort, greater alcohol consumption would be associated with less weight loss over the 4 years studied.
To measure alcohol consumption, participants completed a questionnaire at baseline and annually thereafter. The questionnaire asked whether participants had consumed any alcoholic beverages in the past week, and how many drinks per week of wine, beer, or liquor per week were typical for those who did consume alcohol.
Respondents were grouped into four categories according to their baseline alcohol consumption: nondrinkers, light drinkers (fewer than 7 drinks weekly for men and 4 for women), moderate drinkers (7-14 drinks weekly for men and 4-7 for women), and heavy drinkers (more than 14 drinks weekly for men and 7 for women).
At baseline, 38% of participants reported being abstinent from alcohol, and about 54% reported being light drinkers. Moderate drinkers made up 6%, and 2% reported falling into the heavy drinking category. Females were more likely than males to be nondrinkers.
Heavy drinkers took in significantly more calories than nondrinkers at baseline (2,397 versus 1,907 kcal/day; P less than .001).
Individuals who had consistently been heavy drinkers throughout the study lost less weight than any other group, dropping just 2.4% of their body weight at year 4, compared with their baseline weight. Those who were abstinent from alcohol fared the best, losing 5.1% of their initial body weight (P = .04 for difference). “Heavy drinking is a risk factor for suboptimal long-term weight loss,” said Dr. Chao.
Even those who were consistent light drinkers lost a bit less than those who were abstinent, keeping off 4.2% of their baseline body weight at 4 years (P = .04).
Look AHEAD included individuals aged 45-76 years with type 2 diabetes mellitus and a body mass index of at least 25 kg/m2, or 27 kg/m2 for those on insulin. Excluded were those with hemoglobin A1c of at least 11%, blood pressure of at least 160/100 mm Hg, and triglycerides over 600 mg/dL. A total of 4,901 patients had complete data available in the public access data set and were included in the present analysis. Dr. Chao and her colleagues used statistical techniques to adjust for baseline differences among participants.
The three-part ILI in Look AHEAD began by encouraging a low-calorie diet of 1,200-1,500 kcal/day for those weighing under 250 pounds, and 1,500-1,800 kcal/day for those who were heavier at baseline. Advice was to consume a balanced diet with less than 30% fat, less than 10% saturated fat, and at least 15% protein.
Patients were advised to strive for 10,000 steps per day, with 175 minutes of moderate-intensity exercise each week. Exercise was unsupervised.
Behavioral modification techniques included goal-setting, stimulus control, self-monitoring, and ideas for problem solving and relapse prevention. The intervention used motivational interviewing techniques.
With regard to alcohol, the ILI group was given information about the number of calories in various alcoholic beverages and advised to reduce the amount of alcohol consumed, in order to reduce calories.
The DSE group participated in three group sessions annually, and received general information about nutrition, exercise, and general support.
A potentially important limitation of the study was that alcohol consumption was assessed by self-report and a request for annual recall of typical drinking habits. An audience member from the United Kingdom commented that she found the overall rate of reported alcohol consumption to be “shockingly low,” compared with what her patients report drinking in England. The average United States resident drinks 2.3 gallons of alcohol, or 494 standard drinks, annually, according to the National Institute on Alcohol Abuse and Alcoholism, said Dr. Chao.
The midlife age range of participants, their diabetes diagnosis, and the fact that depressive symptoms were overall low limits generalizability of the findings, said Dr. Chao, adding that psychosocial factors, other health conditions, and current or past alcohol use disorder could also cause some residual confounding of the data.
Dr. Chao has received research support from Shire Pharmaceuticals.
SOURCE: Chao A et al. Obesity Week 2018, Abstract T-OR-2017.
NASHVILLE – Advising patients in a comprehensive weight loss intervention to moderate their alcohol consumption did not change how much they drank over the long term. At the same time, abstinent patients kept off more weight over time than those who were classified as heavy drinkers, in a new analysis of data from a multicenter trial.
Abstinent individuals lost just 1.6% more of their body weight after 4 years than those who drank (P = .003), a figure with “uncertain clinical significance,” Ariana Chao, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “The results should be taken in the context of the potential – though controversial – benefits of light to moderate alcohol consumption,” she added.
Alcohol contains 7.1 kcal/g, and “calories from alcohol usually add, rather than substitute, for food intake,” said Dr. Chao. Alcohol’s disinhibiting effects are thought to contribute to increased food intake and the making of less healthy food choices. However, existing research has shown inconsistent findings about the relationship between alcohol consumption and body weight, she said.
Reducing or completely cutting out alcoholic beverage consumption is common advice for those trying to lose weight, but whether this advice is followed, and whether it makes a difference over the long term, has been an open question, said Dr. Chao.
She and her collaborators at the University of Pennsylvania, Philadelphia, used data from Look AHEAD, “a multicenter, randomized, clinical trial that compared an intensive lifestyle intervention (ILI) to a diabetes support and education (DSE) control group,” for 5,145 people with overweight or obesity and type 2 diabetes, explained Dr. Chao and her coinvestigators.
Dr. Chao and her colleagues looked at the effect that the lifestyle intervention had on alcohol consumption. Additionally, to see how drinkers and nondrinkers fared over the long term, they examined the interaction between alcohol consumption and weight loss at year 4, hypothesizing that individuals who received ILI would have a greater decrease in their alcohol consumption by year 4 than those who received DSE. The investigators had a second hypothesis that, among the ILI cohort, greater alcohol consumption would be associated with less weight loss over the 4 years studied.
To measure alcohol consumption, participants completed a questionnaire at baseline and annually thereafter. The questionnaire asked whether participants had consumed any alcoholic beverages in the past week, and how many drinks per week of wine, beer, or liquor per week were typical for those who did consume alcohol.
Respondents were grouped into four categories according to their baseline alcohol consumption: nondrinkers, light drinkers (fewer than 7 drinks weekly for men and 4 for women), moderate drinkers (7-14 drinks weekly for men and 4-7 for women), and heavy drinkers (more than 14 drinks weekly for men and 7 for women).
At baseline, 38% of participants reported being abstinent from alcohol, and about 54% reported being light drinkers. Moderate drinkers made up 6%, and 2% reported falling into the heavy drinking category. Females were more likely than males to be nondrinkers.
Heavy drinkers took in significantly more calories than nondrinkers at baseline (2,397 versus 1,907 kcal/day; P less than .001).
Individuals who had consistently been heavy drinkers throughout the study lost less weight than any other group, dropping just 2.4% of their body weight at year 4, compared with their baseline weight. Those who were abstinent from alcohol fared the best, losing 5.1% of their initial body weight (P = .04 for difference). “Heavy drinking is a risk factor for suboptimal long-term weight loss,” said Dr. Chao.
Even those who were consistent light drinkers lost a bit less than those who were abstinent, keeping off 4.2% of their baseline body weight at 4 years (P = .04).
Look AHEAD included individuals aged 45-76 years with type 2 diabetes mellitus and a body mass index of at least 25 kg/m2, or 27 kg/m2 for those on insulin. Excluded were those with hemoglobin A1c of at least 11%, blood pressure of at least 160/100 mm Hg, and triglycerides over 600 mg/dL. A total of 4,901 patients had complete data available in the public access data set and were included in the present analysis. Dr. Chao and her colleagues used statistical techniques to adjust for baseline differences among participants.
The three-part ILI in Look AHEAD began by encouraging a low-calorie diet of 1,200-1,500 kcal/day for those weighing under 250 pounds, and 1,500-1,800 kcal/day for those who were heavier at baseline. Advice was to consume a balanced diet with less than 30% fat, less than 10% saturated fat, and at least 15% protein.
Patients were advised to strive for 10,000 steps per day, with 175 minutes of moderate-intensity exercise each week. Exercise was unsupervised.
Behavioral modification techniques included goal-setting, stimulus control, self-monitoring, and ideas for problem solving and relapse prevention. The intervention used motivational interviewing techniques.
With regard to alcohol, the ILI group was given information about the number of calories in various alcoholic beverages and advised to reduce the amount of alcohol consumed, in order to reduce calories.
The DSE group participated in three group sessions annually, and received general information about nutrition, exercise, and general support.
A potentially important limitation of the study was that alcohol consumption was assessed by self-report and a request for annual recall of typical drinking habits. An audience member from the United Kingdom commented that she found the overall rate of reported alcohol consumption to be “shockingly low,” compared with what her patients report drinking in England. The average United States resident drinks 2.3 gallons of alcohol, or 494 standard drinks, annually, according to the National Institute on Alcohol Abuse and Alcoholism, said Dr. Chao.
The midlife age range of participants, their diabetes diagnosis, and the fact that depressive symptoms were overall low limits generalizability of the findings, said Dr. Chao, adding that psychosocial factors, other health conditions, and current or past alcohol use disorder could also cause some residual confounding of the data.
Dr. Chao has received research support from Shire Pharmaceuticals.
SOURCE: Chao A et al. Obesity Week 2018, Abstract T-OR-2017.
NASHVILLE – Advising patients in a comprehensive weight loss intervention to moderate their alcohol consumption did not change how much they drank over the long term. At the same time, abstinent patients kept off more weight over time than those who were classified as heavy drinkers, in a new analysis of data from a multicenter trial.
Abstinent individuals lost just 1.6% more of their body weight after 4 years than those who drank (P = .003), a figure with “uncertain clinical significance,” Ariana Chao, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “The results should be taken in the context of the potential – though controversial – benefits of light to moderate alcohol consumption,” she added.
Alcohol contains 7.1 kcal/g, and “calories from alcohol usually add, rather than substitute, for food intake,” said Dr. Chao. Alcohol’s disinhibiting effects are thought to contribute to increased food intake and the making of less healthy food choices. However, existing research has shown inconsistent findings about the relationship between alcohol consumption and body weight, she said.
Reducing or completely cutting out alcoholic beverage consumption is common advice for those trying to lose weight, but whether this advice is followed, and whether it makes a difference over the long term, has been an open question, said Dr. Chao.
She and her collaborators at the University of Pennsylvania, Philadelphia, used data from Look AHEAD, “a multicenter, randomized, clinical trial that compared an intensive lifestyle intervention (ILI) to a diabetes support and education (DSE) control group,” for 5,145 people with overweight or obesity and type 2 diabetes, explained Dr. Chao and her coinvestigators.
Dr. Chao and her colleagues looked at the effect that the lifestyle intervention had on alcohol consumption. Additionally, to see how drinkers and nondrinkers fared over the long term, they examined the interaction between alcohol consumption and weight loss at year 4, hypothesizing that individuals who received ILI would have a greater decrease in their alcohol consumption by year 4 than those who received DSE. The investigators had a second hypothesis that, among the ILI cohort, greater alcohol consumption would be associated with less weight loss over the 4 years studied.
To measure alcohol consumption, participants completed a questionnaire at baseline and annually thereafter. The questionnaire asked whether participants had consumed any alcoholic beverages in the past week, and how many drinks per week of wine, beer, or liquor per week were typical for those who did consume alcohol.
Respondents were grouped into four categories according to their baseline alcohol consumption: nondrinkers, light drinkers (fewer than 7 drinks weekly for men and 4 for women), moderate drinkers (7-14 drinks weekly for men and 4-7 for women), and heavy drinkers (more than 14 drinks weekly for men and 7 for women).
At baseline, 38% of participants reported being abstinent from alcohol, and about 54% reported being light drinkers. Moderate drinkers made up 6%, and 2% reported falling into the heavy drinking category. Females were more likely than males to be nondrinkers.
Heavy drinkers took in significantly more calories than nondrinkers at baseline (2,397 versus 1,907 kcal/day; P less than .001).
Individuals who had consistently been heavy drinkers throughout the study lost less weight than any other group, dropping just 2.4% of their body weight at year 4, compared with their baseline weight. Those who were abstinent from alcohol fared the best, losing 5.1% of their initial body weight (P = .04 for difference). “Heavy drinking is a risk factor for suboptimal long-term weight loss,” said Dr. Chao.
Even those who were consistent light drinkers lost a bit less than those who were abstinent, keeping off 4.2% of their baseline body weight at 4 years (P = .04).
Look AHEAD included individuals aged 45-76 years with type 2 diabetes mellitus and a body mass index of at least 25 kg/m2, or 27 kg/m2 for those on insulin. Excluded were those with hemoglobin A1c of at least 11%, blood pressure of at least 160/100 mm Hg, and triglycerides over 600 mg/dL. A total of 4,901 patients had complete data available in the public access data set and were included in the present analysis. Dr. Chao and her colleagues used statistical techniques to adjust for baseline differences among participants.
The three-part ILI in Look AHEAD began by encouraging a low-calorie diet of 1,200-1,500 kcal/day for those weighing under 250 pounds, and 1,500-1,800 kcal/day for those who were heavier at baseline. Advice was to consume a balanced diet with less than 30% fat, less than 10% saturated fat, and at least 15% protein.
Patients were advised to strive for 10,000 steps per day, with 175 minutes of moderate-intensity exercise each week. Exercise was unsupervised.
Behavioral modification techniques included goal-setting, stimulus control, self-monitoring, and ideas for problem solving and relapse prevention. The intervention used motivational interviewing techniques.
With regard to alcohol, the ILI group was given information about the number of calories in various alcoholic beverages and advised to reduce the amount of alcohol consumed, in order to reduce calories.
The DSE group participated in three group sessions annually, and received general information about nutrition, exercise, and general support.
A potentially important limitation of the study was that alcohol consumption was assessed by self-report and a request for annual recall of typical drinking habits. An audience member from the United Kingdom commented that she found the overall rate of reported alcohol consumption to be “shockingly low,” compared with what her patients report drinking in England. The average United States resident drinks 2.3 gallons of alcohol, or 494 standard drinks, annually, according to the National Institute on Alcohol Abuse and Alcoholism, said Dr. Chao.
The midlife age range of participants, their diabetes diagnosis, and the fact that depressive symptoms were overall low limits generalizability of the findings, said Dr. Chao, adding that psychosocial factors, other health conditions, and current or past alcohol use disorder could also cause some residual confounding of the data.
Dr. Chao has received research support from Shire Pharmaceuticals.
SOURCE: Chao A et al. Obesity Week 2018, Abstract T-OR-2017.
REPORTING FROM OBESITY WEEK 2018
Key clinical point: After 4 years of an intervention program, heavy drinkers had the smallest net loss in body weight.
Major finding: Heavy drinkers kept off less than half as much weight as teetotalers (2.4% versus 5.1% of baseline weight, P = .04).
Study details: Analysis of public data from Look AHEAD, a multicenter randomized trial of intensive lifestyle intervention for weight loss that enrolled 5,145 people.
Disclosures: Dr. Chao reported receiving research funding from Shire Pharmaceuticals.
Source: Chao A et al. Obesity Week 2018, Abstract T-OR-2017.
Weight loss medications may have a role after bariatric surgery
NASHVILLE – .
Phentermine and topiramate were each prescribed to between 10% and 12.5% of bariatric surgery patients at Boston Medical Center in recent years. That figure had been steadily increasing since 2004, when data collection began, Nawfal W. Istfan, MD, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, the center didn’t know how patients who had received medication fared for long-term maintenance of weight loss, compared with those who had surgery alone; also, there were no clinical guidelines for prescribing weight loss medications (WLMs). “Have we done those patients any benefit by prescribing weight loss medications after gastric bypass surgery?” asked Dr. Istfan. The answer from the Boston Medical Center data is a qualified “yes;” patients with the highest rates of weight regain who were adherent to their medication did see lower rates of regain, and fewer rapid weight regain events.
Comparing patients who received prescriptions with those who did not, patients with less weight loss at nadir were more likely to receive a prescription. “This could very well be the reason they were prescribed a medication: They did not lose as much weight, and they are more likely to ask us” for WLMs, said Dr. Istfan, an endocrinologist at Boston University. However, for those who were prescribed WLMs, the slope of regain was flatter than for those who didn’t receive medication. Of the 626 patients included in the study, 91 received phentermine alone, 54 topiramate alone, and 113 were prescribed both phentermine and topiramate. Three received lorcaserin.
Those receiving medication were similar to the total bariatric surgery population in terms of age, sex, comorbidities, socioeconomic status, and preoperative body mass index, said Dr. Istfan, the senior author in the study. However, Hispanic individuals were more likely to receive WLMs, he said.
Recognizing that “the ratio of weight regain to nadir weight is more indicative of overfeeding than other parameters,” Dr. Istfan said that he and his colleagues divided patients into quartiles of regain, based on this ratio. The quartiles fell out so that those who had the least regain either lost weight or regained less than 1.4%, to make up the first quartile. The second quartile included those who regained from 1.5% to 6.26%, while the third quartile ranged up to 14.29% regain. Those who regained 14.3% or more were in the highest quartile of weight regain.
In comparing characteristics of the quartiles, there were more African Americans in the two higher quartiles (P = .017). More patients had achieved maximal weight loss in the highest quartile of regain (P less than .0001), though preoperative BMI had also been higher in this group (P = .0008).
After statistical adjustment, the investigators found that for individuals who had the highest quartile of regain, patients who were adherent to their WLMs had significantly less weight regain than those who took no medication (P = .014). However, patients considered nonadherent saw no medication effect on weight regain. The differences were small overall, with adherent patients regaining about 27% of weight relative to their nadir and those who didn’t take WLMs regaining about 30%. These significant results were seen long after bariatric surgery, at about 7 years post surgery.
In another analysis that looked just at the quartile of patients with the highest regain rate, weight regain was significantly delayed among those who were prescribed – and were adherent to – WLMs (P = .023). The analysis used a threshold weight regain rate of 1.22% per month; levels lower than that did not see a significant drug effect, and the effect was not seen for those not adherent to their WLMs.
Finally, an adjusted statistical analysis compared those taking and not taking WLMs to see whether WLMs were effective at preventing weight regain in rolling 90-day intervals throughout the study period. Again, in the highest quartile, those who were adherent to WLMs had a lower odds ratio of hitting the 1.22%/month regain rate, compared with those not taking medication (OR, 0.570; 95% confidence interval, 0.371-0.877; P = .01). The effect was not significant for the nonadherent group (OR, 0.872; 95% CI, 0.593-1.284; P = .489).
As more bariatric procedures are being done, and as more patients are living with their surgeries, physicians are seeing more weight regain, said Dr. Istfan, noting that it’s important to assess efficacy of WLMs in the postsurgical population. “Recent work showed that by 5 years after gastric bypass, half of patients had regained more than 15% of their nadir weight, and two-thirds of patients had regained more than 20% of their total maximum weight loss, said Dr. Istfan (King WC et al. JAMA.2018;320:1560).
Typically, patients will see about a 35% weight loss at their nadir, with a gradual increase in weight gain beginning about 2 years after surgery. Though it’s true that a net weight loss of 25% is still good, it can be a misleading way to look at the data, “because it does not focus on the process of weight regain itself,” said Dr. Istfan.
“Despite the maintenance of substantial weight loss, weight regain is concerning: It’s the present and future, not the past,” he said.
Regaining weight necessarily means that patients are having excess nutrient intake and a net-positive energy balance; this state can be associated with oxidative stress, inflammation, and insulin resistance – all potential contributors to the recurrence of comorbidities.
What’s to be done about weight regain, if it’s a point of concern? One option, said Dr. Istfan, is to consider more surgery. Patients might want a “re-do;” techniques that have been tried include reshaping the pouch and doing an anastomosis plication. If a gastro-gastric fistula’s developed, that can be corrected, he said.
Some factors influencing regain can be targeted by behavioral therapy. These include addressing alcohol consumption, discouraging grazing, encouraging exercise, and assessing and modifying diet quality in general.
“There is a general reluctance on the part of physicians to use weight loss medications after bariatric surgery,” said Dr. Istfan. Reasons can include concern about further nutritional compromise, especially when thinking about long-term use of appetite-suppressing medications. Importantly, there aren’t clinical guidelines for prescribing WLMs after bariatric surgery, nor is there a strong body of prospective studies in this area.
Dr. Istfan noted that the medical and surgical bariatric teams collaborate closely at Boston Medical Center to provide pre- and postoperative assessment and management.
The long observational interval and ethnic and socioeconomic diversity of the study population are strengths, said Dr. Istfan. Also, the three different multivariable models converged to similar findings.
However, the study was retrospective, with some confounding likely, and each prescriber involved in the study may have varying prescribing practices. Also, adherence was assessed by follow-up medication appointments, a measure that likely introduced some inaccuracy.
“Weight loss medications are potentially effective tools to counter weight regain after bariatric surgery; prospective studies are needed to optimize the use of weight loss medications after bariatric surgery,” said Dr. Istfan.
Dr. Istfan reported no outside sources of funding, and no conflicts of interest.
SOURCE: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
NASHVILLE – .
Phentermine and topiramate were each prescribed to between 10% and 12.5% of bariatric surgery patients at Boston Medical Center in recent years. That figure had been steadily increasing since 2004, when data collection began, Nawfal W. Istfan, MD, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, the center didn’t know how patients who had received medication fared for long-term maintenance of weight loss, compared with those who had surgery alone; also, there were no clinical guidelines for prescribing weight loss medications (WLMs). “Have we done those patients any benefit by prescribing weight loss medications after gastric bypass surgery?” asked Dr. Istfan. The answer from the Boston Medical Center data is a qualified “yes;” patients with the highest rates of weight regain who were adherent to their medication did see lower rates of regain, and fewer rapid weight regain events.
Comparing patients who received prescriptions with those who did not, patients with less weight loss at nadir were more likely to receive a prescription. “This could very well be the reason they were prescribed a medication: They did not lose as much weight, and they are more likely to ask us” for WLMs, said Dr. Istfan, an endocrinologist at Boston University. However, for those who were prescribed WLMs, the slope of regain was flatter than for those who didn’t receive medication. Of the 626 patients included in the study, 91 received phentermine alone, 54 topiramate alone, and 113 were prescribed both phentermine and topiramate. Three received lorcaserin.
Those receiving medication were similar to the total bariatric surgery population in terms of age, sex, comorbidities, socioeconomic status, and preoperative body mass index, said Dr. Istfan, the senior author in the study. However, Hispanic individuals were more likely to receive WLMs, he said.
Recognizing that “the ratio of weight regain to nadir weight is more indicative of overfeeding than other parameters,” Dr. Istfan said that he and his colleagues divided patients into quartiles of regain, based on this ratio. The quartiles fell out so that those who had the least regain either lost weight or regained less than 1.4%, to make up the first quartile. The second quartile included those who regained from 1.5% to 6.26%, while the third quartile ranged up to 14.29% regain. Those who regained 14.3% or more were in the highest quartile of weight regain.
In comparing characteristics of the quartiles, there were more African Americans in the two higher quartiles (P = .017). More patients had achieved maximal weight loss in the highest quartile of regain (P less than .0001), though preoperative BMI had also been higher in this group (P = .0008).
After statistical adjustment, the investigators found that for individuals who had the highest quartile of regain, patients who were adherent to their WLMs had significantly less weight regain than those who took no medication (P = .014). However, patients considered nonadherent saw no medication effect on weight regain. The differences were small overall, with adherent patients regaining about 27% of weight relative to their nadir and those who didn’t take WLMs regaining about 30%. These significant results were seen long after bariatric surgery, at about 7 years post surgery.
In another analysis that looked just at the quartile of patients with the highest regain rate, weight regain was significantly delayed among those who were prescribed – and were adherent to – WLMs (P = .023). The analysis used a threshold weight regain rate of 1.22% per month; levels lower than that did not see a significant drug effect, and the effect was not seen for those not adherent to their WLMs.
Finally, an adjusted statistical analysis compared those taking and not taking WLMs to see whether WLMs were effective at preventing weight regain in rolling 90-day intervals throughout the study period. Again, in the highest quartile, those who were adherent to WLMs had a lower odds ratio of hitting the 1.22%/month regain rate, compared with those not taking medication (OR, 0.570; 95% confidence interval, 0.371-0.877; P = .01). The effect was not significant for the nonadherent group (OR, 0.872; 95% CI, 0.593-1.284; P = .489).
As more bariatric procedures are being done, and as more patients are living with their surgeries, physicians are seeing more weight regain, said Dr. Istfan, noting that it’s important to assess efficacy of WLMs in the postsurgical population. “Recent work showed that by 5 years after gastric bypass, half of patients had regained more than 15% of their nadir weight, and two-thirds of patients had regained more than 20% of their total maximum weight loss, said Dr. Istfan (King WC et al. JAMA.2018;320:1560).
Typically, patients will see about a 35% weight loss at their nadir, with a gradual increase in weight gain beginning about 2 years after surgery. Though it’s true that a net weight loss of 25% is still good, it can be a misleading way to look at the data, “because it does not focus on the process of weight regain itself,” said Dr. Istfan.
“Despite the maintenance of substantial weight loss, weight regain is concerning: It’s the present and future, not the past,” he said.
Regaining weight necessarily means that patients are having excess nutrient intake and a net-positive energy balance; this state can be associated with oxidative stress, inflammation, and insulin resistance – all potential contributors to the recurrence of comorbidities.
What’s to be done about weight regain, if it’s a point of concern? One option, said Dr. Istfan, is to consider more surgery. Patients might want a “re-do;” techniques that have been tried include reshaping the pouch and doing an anastomosis plication. If a gastro-gastric fistula’s developed, that can be corrected, he said.
Some factors influencing regain can be targeted by behavioral therapy. These include addressing alcohol consumption, discouraging grazing, encouraging exercise, and assessing and modifying diet quality in general.
“There is a general reluctance on the part of physicians to use weight loss medications after bariatric surgery,” said Dr. Istfan. Reasons can include concern about further nutritional compromise, especially when thinking about long-term use of appetite-suppressing medications. Importantly, there aren’t clinical guidelines for prescribing WLMs after bariatric surgery, nor is there a strong body of prospective studies in this area.
Dr. Istfan noted that the medical and surgical bariatric teams collaborate closely at Boston Medical Center to provide pre- and postoperative assessment and management.
The long observational interval and ethnic and socioeconomic diversity of the study population are strengths, said Dr. Istfan. Also, the three different multivariable models converged to similar findings.
However, the study was retrospective, with some confounding likely, and each prescriber involved in the study may have varying prescribing practices. Also, adherence was assessed by follow-up medication appointments, a measure that likely introduced some inaccuracy.
“Weight loss medications are potentially effective tools to counter weight regain after bariatric surgery; prospective studies are needed to optimize the use of weight loss medications after bariatric surgery,” said Dr. Istfan.
Dr. Istfan reported no outside sources of funding, and no conflicts of interest.
SOURCE: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
NASHVILLE – .
Phentermine and topiramate were each prescribed to between 10% and 12.5% of bariatric surgery patients at Boston Medical Center in recent years. That figure had been steadily increasing since 2004, when data collection began, Nawfal W. Istfan, MD, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, the center didn’t know how patients who had received medication fared for long-term maintenance of weight loss, compared with those who had surgery alone; also, there were no clinical guidelines for prescribing weight loss medications (WLMs). “Have we done those patients any benefit by prescribing weight loss medications after gastric bypass surgery?” asked Dr. Istfan. The answer from the Boston Medical Center data is a qualified “yes;” patients with the highest rates of weight regain who were adherent to their medication did see lower rates of regain, and fewer rapid weight regain events.
Comparing patients who received prescriptions with those who did not, patients with less weight loss at nadir were more likely to receive a prescription. “This could very well be the reason they were prescribed a medication: They did not lose as much weight, and they are more likely to ask us” for WLMs, said Dr. Istfan, an endocrinologist at Boston University. However, for those who were prescribed WLMs, the slope of regain was flatter than for those who didn’t receive medication. Of the 626 patients included in the study, 91 received phentermine alone, 54 topiramate alone, and 113 were prescribed both phentermine and topiramate. Three received lorcaserin.
Those receiving medication were similar to the total bariatric surgery population in terms of age, sex, comorbidities, socioeconomic status, and preoperative body mass index, said Dr. Istfan, the senior author in the study. However, Hispanic individuals were more likely to receive WLMs, he said.
Recognizing that “the ratio of weight regain to nadir weight is more indicative of overfeeding than other parameters,” Dr. Istfan said that he and his colleagues divided patients into quartiles of regain, based on this ratio. The quartiles fell out so that those who had the least regain either lost weight or regained less than 1.4%, to make up the first quartile. The second quartile included those who regained from 1.5% to 6.26%, while the third quartile ranged up to 14.29% regain. Those who regained 14.3% or more were in the highest quartile of weight regain.
In comparing characteristics of the quartiles, there were more African Americans in the two higher quartiles (P = .017). More patients had achieved maximal weight loss in the highest quartile of regain (P less than .0001), though preoperative BMI had also been higher in this group (P = .0008).
After statistical adjustment, the investigators found that for individuals who had the highest quartile of regain, patients who were adherent to their WLMs had significantly less weight regain than those who took no medication (P = .014). However, patients considered nonadherent saw no medication effect on weight regain. The differences were small overall, with adherent patients regaining about 27% of weight relative to their nadir and those who didn’t take WLMs regaining about 30%. These significant results were seen long after bariatric surgery, at about 7 years post surgery.
In another analysis that looked just at the quartile of patients with the highest regain rate, weight regain was significantly delayed among those who were prescribed – and were adherent to – WLMs (P = .023). The analysis used a threshold weight regain rate of 1.22% per month; levels lower than that did not see a significant drug effect, and the effect was not seen for those not adherent to their WLMs.
Finally, an adjusted statistical analysis compared those taking and not taking WLMs to see whether WLMs were effective at preventing weight regain in rolling 90-day intervals throughout the study period. Again, in the highest quartile, those who were adherent to WLMs had a lower odds ratio of hitting the 1.22%/month regain rate, compared with those not taking medication (OR, 0.570; 95% confidence interval, 0.371-0.877; P = .01). The effect was not significant for the nonadherent group (OR, 0.872; 95% CI, 0.593-1.284; P = .489).
As more bariatric procedures are being done, and as more patients are living with their surgeries, physicians are seeing more weight regain, said Dr. Istfan, noting that it’s important to assess efficacy of WLMs in the postsurgical population. “Recent work showed that by 5 years after gastric bypass, half of patients had regained more than 15% of their nadir weight, and two-thirds of patients had regained more than 20% of their total maximum weight loss, said Dr. Istfan (King WC et al. JAMA.2018;320:1560).
Typically, patients will see about a 35% weight loss at their nadir, with a gradual increase in weight gain beginning about 2 years after surgery. Though it’s true that a net weight loss of 25% is still good, it can be a misleading way to look at the data, “because it does not focus on the process of weight regain itself,” said Dr. Istfan.
“Despite the maintenance of substantial weight loss, weight regain is concerning: It’s the present and future, not the past,” he said.
Regaining weight necessarily means that patients are having excess nutrient intake and a net-positive energy balance; this state can be associated with oxidative stress, inflammation, and insulin resistance – all potential contributors to the recurrence of comorbidities.
What’s to be done about weight regain, if it’s a point of concern? One option, said Dr. Istfan, is to consider more surgery. Patients might want a “re-do;” techniques that have been tried include reshaping the pouch and doing an anastomosis plication. If a gastro-gastric fistula’s developed, that can be corrected, he said.
Some factors influencing regain can be targeted by behavioral therapy. These include addressing alcohol consumption, discouraging grazing, encouraging exercise, and assessing and modifying diet quality in general.
“There is a general reluctance on the part of physicians to use weight loss medications after bariatric surgery,” said Dr. Istfan. Reasons can include concern about further nutritional compromise, especially when thinking about long-term use of appetite-suppressing medications. Importantly, there aren’t clinical guidelines for prescribing WLMs after bariatric surgery, nor is there a strong body of prospective studies in this area.
Dr. Istfan noted that the medical and surgical bariatric teams collaborate closely at Boston Medical Center to provide pre- and postoperative assessment and management.
The long observational interval and ethnic and socioeconomic diversity of the study population are strengths, said Dr. Istfan. Also, the three different multivariable models converged to similar findings.
However, the study was retrospective, with some confounding likely, and each prescriber involved in the study may have varying prescribing practices. Also, adherence was assessed by follow-up medication appointments, a measure that likely introduced some inaccuracy.
“Weight loss medications are potentially effective tools to counter weight regain after bariatric surgery; prospective studies are needed to optimize the use of weight loss medications after bariatric surgery,” said Dr. Istfan.
Dr. Istfan reported no outside sources of funding, and no conflicts of interest.
SOURCE: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
REPORTING FROM OBESITY WEEK 2018
Key clinical point: Weight loss medication flattened the curve of weight regain after bariatric surgery – for some patients.
Major finding: Weight loss medicine reduced regain among those who had the most weight regain (P =.014).
Study details: Retrospective single-center cohort study of 626 bariatric surgery patients.
Disclosures: The study authors reported no external sources of funding. Dr. Istfan reported no conflicts of interest.
Source: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
Biomarker algorithm may offer noninvasive look at liver fibrosis
Serum biomarkers may enable a noninvasive method of detecting advanced hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD), according to results from a recent study.
An algorithm created by the investigators distinguished NAFLD patients with advanced liver fibrosis from those with mild to moderate fibrosis, reported lead author Rohit Loomba, MD, of the University of California at San Diego and his colleagues.
“Liver biopsy is currently the gold standard for diagnosing NASH [nonalcoholic steatohepatitis] and staging liver fibrosis,” the investigators wrote in Clinical Gastroenterology and Hepatology. “However, it is a costly and invasive procedure with an all-cause mortality risk of approximately 0.2%. Liver biopsy typically samples only 1/50,000th of the organ, and it is liable to sampling error with an error rate of 25% for diagnosis of hepatic fibrosis.”
Existing serum-based tests are reliable for diagnosing nonfibrotic NAFLD, but they may misdiagnosis patients with advanced fibrosis. Although imaging-based techniques may provide better diagnostic accuracy, some are available only for subgroups of patients, while others come with a high financial burden. Diagnostic shortcomings may have a major effect on patient outcomes, particularly when risk groups are considered.
“Fibrosis stages F3 and F4 (advanced fibrosis) are primary predictors of liver-related morbidity and mortality, with 11%-22% of NASH patients reported to have advanced fibrosis,” the investigators noted.
The investigators therefore aimed to distinguish such high-risk NAFLD patients from those with mild or moderate liver fibrosis. Three biomarkers were included: hyaluronic acid (HA), TIMP metallopeptidase inhibitor 1 (TIMP-1), and alpha2-macroglobulin (A2M). Each biomarker has documented associations with liver fibrosis. For instance, higher A2M concentrations inhibit fibrinolysis, HA is associated with excessive extracellular matrix and fibrotic tissue, and TIMP-1 is a known liver fibrosis marker and inhibitor of extracellular matrix degradation. The relative strengths of each in detecting advanced liver fibrosis was determined through an algorithm.
The investigators relied on archived serum samples from Duke University, Durham, N.C., (n = 792) and University of California at San Diego (n = 244) that were collected within 11 days of liver biopsy. Biopsies were performed with 15- to 16-gauge needles using at least eight portal tracts, and these samples were used to diagnose NAFLD. Patients with alcoholic liver disease or hepatitis C virus were excluded.
Algorithm training was based on serum measurements from 396 patients treated at Duke University. Samples were divided into mild to moderate (F0-F2) or advanced (F3-F4) fibrosis and split into 10 subsets. The logical regression model was trained on nine subsets and tested on the 10th, with iterations 10 times through this sequence until all 10 samples were tested. This process was repeated 10,000 times. Using the median coefficients from 100,000 logistical regression models, the samples were scored using the algorithm from 0 to 100, with higher numbers representing more advanced fibrosis, and the relative weights of each biomarker measurement were determined.
A noninferiority protocol was used to validate the algorithm, through which the area under the receiver operating characteristic (AUROC) curve was calculated. The AUROC curve of the validation samples was 0.856, with 0.5 being the score for a random algorithm. The algorithm correctly classified 90.0% of F0 cases, 75.0% of F1 cases, 53.8% of F2 cases, 77.4% of F3 cases, and 94.4% of F4 cases. The sensitivity was 79.7% and the specificity was 75.7%.
The algorithm was superior to Fibrosis-4 (FIB-4) and NAFLD Fibrosis Score (NFS) in two validation cohorts. In a combination of validation cohorts, the algorithm correctly identified 79.5% of F3-F4 patients, compared with rates of 25.8% and 28.0% from FIB-4 and NFS, respectively. The investigators noted that the algorithm was unaffected by sex or age. In contrast, FIB-4 is biased toward females, and both FIB-4 and NFS are less accurate with patients aged 35 years or younger.
“Performance of the training and validation sets was robust and well matched, enabling the reliable differentiation of NAFLD patients with and without advanced fibrosis,” the investigators concluded.
The study was supported by Prometheus Laboratories. Authors not employed by Prometheus Laboratories were employed by Duke University or the University of California, San Diego; each institution received funding from Prometheus Laboratories.
SOURCE: Loomba R et al. Clin Gastroenterol Hepatol. 2018 Nov 15. doi: 10.1016/j.cgh.2018.11.004.
Serum biomarkers may enable a noninvasive method of detecting advanced hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD), according to results from a recent study.
An algorithm created by the investigators distinguished NAFLD patients with advanced liver fibrosis from those with mild to moderate fibrosis, reported lead author Rohit Loomba, MD, of the University of California at San Diego and his colleagues.
“Liver biopsy is currently the gold standard for diagnosing NASH [nonalcoholic steatohepatitis] and staging liver fibrosis,” the investigators wrote in Clinical Gastroenterology and Hepatology. “However, it is a costly and invasive procedure with an all-cause mortality risk of approximately 0.2%. Liver biopsy typically samples only 1/50,000th of the organ, and it is liable to sampling error with an error rate of 25% for diagnosis of hepatic fibrosis.”
Existing serum-based tests are reliable for diagnosing nonfibrotic NAFLD, but they may misdiagnosis patients with advanced fibrosis. Although imaging-based techniques may provide better diagnostic accuracy, some are available only for subgroups of patients, while others come with a high financial burden. Diagnostic shortcomings may have a major effect on patient outcomes, particularly when risk groups are considered.
“Fibrosis stages F3 and F4 (advanced fibrosis) are primary predictors of liver-related morbidity and mortality, with 11%-22% of NASH patients reported to have advanced fibrosis,” the investigators noted.
The investigators therefore aimed to distinguish such high-risk NAFLD patients from those with mild or moderate liver fibrosis. Three biomarkers were included: hyaluronic acid (HA), TIMP metallopeptidase inhibitor 1 (TIMP-1), and alpha2-macroglobulin (A2M). Each biomarker has documented associations with liver fibrosis. For instance, higher A2M concentrations inhibit fibrinolysis, HA is associated with excessive extracellular matrix and fibrotic tissue, and TIMP-1 is a known liver fibrosis marker and inhibitor of extracellular matrix degradation. The relative strengths of each in detecting advanced liver fibrosis was determined through an algorithm.
The investigators relied on archived serum samples from Duke University, Durham, N.C., (n = 792) and University of California at San Diego (n = 244) that were collected within 11 days of liver biopsy. Biopsies were performed with 15- to 16-gauge needles using at least eight portal tracts, and these samples were used to diagnose NAFLD. Patients with alcoholic liver disease or hepatitis C virus were excluded.
Algorithm training was based on serum measurements from 396 patients treated at Duke University. Samples were divided into mild to moderate (F0-F2) or advanced (F3-F4) fibrosis and split into 10 subsets. The logical regression model was trained on nine subsets and tested on the 10th, with iterations 10 times through this sequence until all 10 samples were tested. This process was repeated 10,000 times. Using the median coefficients from 100,000 logistical regression models, the samples were scored using the algorithm from 0 to 100, with higher numbers representing more advanced fibrosis, and the relative weights of each biomarker measurement were determined.
A noninferiority protocol was used to validate the algorithm, through which the area under the receiver operating characteristic (AUROC) curve was calculated. The AUROC curve of the validation samples was 0.856, with 0.5 being the score for a random algorithm. The algorithm correctly classified 90.0% of F0 cases, 75.0% of F1 cases, 53.8% of F2 cases, 77.4% of F3 cases, and 94.4% of F4 cases. The sensitivity was 79.7% and the specificity was 75.7%.
The algorithm was superior to Fibrosis-4 (FIB-4) and NAFLD Fibrosis Score (NFS) in two validation cohorts. In a combination of validation cohorts, the algorithm correctly identified 79.5% of F3-F4 patients, compared with rates of 25.8% and 28.0% from FIB-4 and NFS, respectively. The investigators noted that the algorithm was unaffected by sex or age. In contrast, FIB-4 is biased toward females, and both FIB-4 and NFS are less accurate with patients aged 35 years or younger.
“Performance of the training and validation sets was robust and well matched, enabling the reliable differentiation of NAFLD patients with and without advanced fibrosis,” the investigators concluded.
The study was supported by Prometheus Laboratories. Authors not employed by Prometheus Laboratories were employed by Duke University or the University of California, San Diego; each institution received funding from Prometheus Laboratories.
SOURCE: Loomba R et al. Clin Gastroenterol Hepatol. 2018 Nov 15. doi: 10.1016/j.cgh.2018.11.004.
Serum biomarkers may enable a noninvasive method of detecting advanced hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD), according to results from a recent study.
An algorithm created by the investigators distinguished NAFLD patients with advanced liver fibrosis from those with mild to moderate fibrosis, reported lead author Rohit Loomba, MD, of the University of California at San Diego and his colleagues.
“Liver biopsy is currently the gold standard for diagnosing NASH [nonalcoholic steatohepatitis] and staging liver fibrosis,” the investigators wrote in Clinical Gastroenterology and Hepatology. “However, it is a costly and invasive procedure with an all-cause mortality risk of approximately 0.2%. Liver biopsy typically samples only 1/50,000th of the organ, and it is liable to sampling error with an error rate of 25% for diagnosis of hepatic fibrosis.”
Existing serum-based tests are reliable for diagnosing nonfibrotic NAFLD, but they may misdiagnosis patients with advanced fibrosis. Although imaging-based techniques may provide better diagnostic accuracy, some are available only for subgroups of patients, while others come with a high financial burden. Diagnostic shortcomings may have a major effect on patient outcomes, particularly when risk groups are considered.
“Fibrosis stages F3 and F4 (advanced fibrosis) are primary predictors of liver-related morbidity and mortality, with 11%-22% of NASH patients reported to have advanced fibrosis,” the investigators noted.
The investigators therefore aimed to distinguish such high-risk NAFLD patients from those with mild or moderate liver fibrosis. Three biomarkers were included: hyaluronic acid (HA), TIMP metallopeptidase inhibitor 1 (TIMP-1), and alpha2-macroglobulin (A2M). Each biomarker has documented associations with liver fibrosis. For instance, higher A2M concentrations inhibit fibrinolysis, HA is associated with excessive extracellular matrix and fibrotic tissue, and TIMP-1 is a known liver fibrosis marker and inhibitor of extracellular matrix degradation. The relative strengths of each in detecting advanced liver fibrosis was determined through an algorithm.
The investigators relied on archived serum samples from Duke University, Durham, N.C., (n = 792) and University of California at San Diego (n = 244) that were collected within 11 days of liver biopsy. Biopsies were performed with 15- to 16-gauge needles using at least eight portal tracts, and these samples were used to diagnose NAFLD. Patients with alcoholic liver disease or hepatitis C virus were excluded.
Algorithm training was based on serum measurements from 396 patients treated at Duke University. Samples were divided into mild to moderate (F0-F2) or advanced (F3-F4) fibrosis and split into 10 subsets. The logical regression model was trained on nine subsets and tested on the 10th, with iterations 10 times through this sequence until all 10 samples were tested. This process was repeated 10,000 times. Using the median coefficients from 100,000 logistical regression models, the samples were scored using the algorithm from 0 to 100, with higher numbers representing more advanced fibrosis, and the relative weights of each biomarker measurement were determined.
A noninferiority protocol was used to validate the algorithm, through which the area under the receiver operating characteristic (AUROC) curve was calculated. The AUROC curve of the validation samples was 0.856, with 0.5 being the score for a random algorithm. The algorithm correctly classified 90.0% of F0 cases, 75.0% of F1 cases, 53.8% of F2 cases, 77.4% of F3 cases, and 94.4% of F4 cases. The sensitivity was 79.7% and the specificity was 75.7%.
The algorithm was superior to Fibrosis-4 (FIB-4) and NAFLD Fibrosis Score (NFS) in two validation cohorts. In a combination of validation cohorts, the algorithm correctly identified 79.5% of F3-F4 patients, compared with rates of 25.8% and 28.0% from FIB-4 and NFS, respectively. The investigators noted that the algorithm was unaffected by sex or age. In contrast, FIB-4 is biased toward females, and both FIB-4 and NFS are less accurate with patients aged 35 years or younger.
“Performance of the training and validation sets was robust and well matched, enabling the reliable differentiation of NAFLD patients with and without advanced fibrosis,” the investigators concluded.
The study was supported by Prometheus Laboratories. Authors not employed by Prometheus Laboratories were employed by Duke University or the University of California, San Diego; each institution received funding from Prometheus Laboratories.
SOURCE: Loomba R et al. Clin Gastroenterol Hepatol. 2018 Nov 15. doi: 10.1016/j.cgh.2018.11.004.
FROM CLINICAL GASTROENTEROLOGY AND HEPATOLOGY
Key clinical point: A serum biomarker–based algorithm may provide a noninvasive method of detecting advanced hepatic fibrosis in patients with nonalcoholic fatty liver disease (NAFLD).
Major finding: The area under the receiver operator characteristic (AUROC) curve for a combination of validation samples was 0.856.
Study details: A retrospective study of liver fibrosis serum markers and clinical data from 396 patients with NAFLD and various stages of fibrosis.
Disclosures: The study was supported by Prometheus Laboratories. Authors not employed by Prometheus Laboratories were employed by Duke University or the University of California, San Diego; each institution received funding from Prometheus Laboratories.
Source: Loomba R et al. Clin Gastroenterol Hepatol. 2018 Nov 15. doi: 10.1016/j.cgh.2018.11.004.
Weight loss medications may have a role after bariatric surgery
NASHVILLE – .
Phentermine and topiramate were each prescribed to between 10% and 12.5% of bariatric surgery patients at Boston Medical Center in recent years. That figure had been steadily increasing since 2004, when data collection began, Nawfal W. Istfan, MD, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, the center didn’t know how patients who had received medication fared for long-term maintenance of weight loss, compared with those who had surgery alone; also, there were no clinical guidelines for prescribing weight loss medications (WLMs). “Have we done those patients any benefit by prescribing weight loss medications after gastric bypass surgery?” asked Dr. Istfan. The answer from the Boston Medical Center data is a qualified “yes;” patients with the highest rates of weight regain who were adherent to their medication did see lower rates of regain, and fewer rapid weight regain events.
Comparing patients who received prescriptions with those who did not, patients with less weight loss at nadir were more likely to receive a prescription. “This could very well be the reason they were prescribed a medication: They did not lose as much weight, and they are more likely to ask us” for WLMs, said Dr. Istfan, an endocrinologist at Boston University. However, for those who were prescribed WLMs, the slope of regain was flatter than for those who didn’t receive medication. Of the 626 patients included in the study, 91 received phentermine alone, 54 topiramate alone, and 113 were prescribed both phentermine and topiramate. Three received lorcaserin.
Those receiving medication were similar to the total bariatric surgery population in terms of age, sex, comorbidities, socioeconomic status, and preoperative body mass index, said Dr. Istfan, the senior author in the study. However, Hispanic individuals were more likely to receive WLMs, he said.
Recognizing that “the ratio of weight regain to nadir weight is more indicative of overfeeding than other parameters,” Dr. Istfan said that he and his colleagues divided patients into quartiles of regain, based on this ratio. The quartiles fell out so that those who had the least regain either lost weight or regained less than 1.4%, to make up the first quartile. The second quartile included those who regained from 1.5% to 6.26%, while the third quartile ranged up to 14.29% regain. Those who regained 14.3% or more were in the highest quartile of weight regain.
In comparing characteristics of the quartiles, there were more African Americans in the two higher quartiles (P = .017). More patients had achieved maximal weight loss in the highest quartile of regain (P less than .0001), though preoperative BMI had also been higher in this group (P = .0008).
After statistical adjustment, the investigators found that for individuals who had the highest quartile of regain, patients who were adherent to their WLMs had significantly less weight regain than those who took no medication (P = .014). However, patients considered nonadherent saw no medication effect on weight regain. The differences were small overall, with adherent patients regaining about 27% of weight relative to their nadir and those who didn’t take WLMs regaining about 30%. These significant results were seen long after bariatric surgery, at about 7 years post surgery.
In another analysis that looked just at the quartile of patients with the highest regain rate, weight regain was significantly delayed among those who were prescribed – and were adherent to – WLMs (P = .023). The analysis used a threshold weight regain rate of 1.22% per month; levels lower than that did not see a significant drug effect, and the effect was not seen for those not adherent to their WLMs.
Finally, an adjusted statistical analysis compared those taking and not taking WLMs to see whether WLMs were effective at preventing weight regain in rolling 90-day intervals throughout the study period. Again, in the highest quartile, those who were adherent to WLMs had a lower odds ratio of hitting the 1.22%/month regain rate, compared with those not taking medication (OR, 0.570; 95% confidence interval, 0.371-0.877; P = .01). The effect was not significant for the nonadherent group (OR, 0.872; 95% CI, 0.593-1.284; P = .489).
As more bariatric procedures are being done, and as more patients are living with their surgeries, physicians are seeing more weight regain, said Dr. Istfan, noting that it’s important to assess efficacy of WLMs in the postsurgical population. “Recent work showed that by 5 years after gastric bypass, half of patients had regained more than 15% of their nadir weight, and two-thirds of patients had regained more than 20% of their total maximum weight loss, said Dr. Istfan (King WC et al. JAMA.2018;320:1560).
Typically, patients will see about a 35% weight loss at their nadir, with a gradual increase in weight gain beginning about 2 years after surgery. Though it’s true that a net weight loss of 25% is still good, it can be a misleading way to look at the data, “because it does not focus on the process of weight regain itself,” said Dr. Istfan.
“Despite the maintenance of substantial weight loss, weight regain is concerning: It’s the present and future, not the past,” he said.
Regaining weight necessarily means that patients are having excess nutrient intake and a net-positive energy balance; this state can be associated with oxidative stress, inflammation, and insulin resistance – all potential contributors to the recurrence of comorbidities.
What’s to be done about weight regain, if it’s a point of concern? One option, said Dr. Istfan, is to consider more surgery. Patients might want a “re-do;” techniques that have been tried include reshaping the pouch and doing an anastomosis plication. If a gastro-gastric fistula’s developed, that can be corrected, he said.
Some factors influencing regain can be targeted by behavioral therapy. These include addressing alcohol consumption, discouraging grazing, encouraging exercise, and assessing and modifying diet quality in general.
“There is a general reluctance on the part of physicians to use weight loss medications after bariatric surgery,” said Dr. Istfan. Reasons can include concern about further nutritional compromise, especially when thinking about long-term use of appetite-suppressing medications. Importantly, there aren’t clinical guidelines for prescribing WLMs after bariatric surgery, nor is there a strong body of prospective studies in this area.
Dr. Istfan noted that the medical and surgical bariatric teams collaborate closely at Boston Medical Center to provide pre- and postoperative assessment and management.
The long observational interval and ethnic and socioeconomic diversity of the study population are strengths, said Dr. Istfan. Also, the three different multivariable models converged to similar findings.
However, the study was retrospective, with some confounding likely, and each prescriber involved in the study may have varying prescribing practices. Also, adherence was assessed by follow-up medication appointments, a measure that likely introduced some inaccuracy.
“Weight loss medications are potentially effective tools to counter weight regain after bariatric surgery; prospective studies are needed to optimize the use of weight loss medications after bariatric surgery,” said Dr. Istfan.
Dr. Istfan reported no outside sources of funding, and no conflicts of interest.
AGA provides GIs with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/fFA330mWKCn.
SOURCE: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
NASHVILLE – .
Phentermine and topiramate were each prescribed to between 10% and 12.5% of bariatric surgery patients at Boston Medical Center in recent years. That figure had been steadily increasing since 2004, when data collection began, Nawfal W. Istfan, MD, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, the center didn’t know how patients who had received medication fared for long-term maintenance of weight loss, compared with those who had surgery alone; also, there were no clinical guidelines for prescribing weight loss medications (WLMs). “Have we done those patients any benefit by prescribing weight loss medications after gastric bypass surgery?” asked Dr. Istfan. The answer from the Boston Medical Center data is a qualified “yes;” patients with the highest rates of weight regain who were adherent to their medication did see lower rates of regain, and fewer rapid weight regain events.
Comparing patients who received prescriptions with those who did not, patients with less weight loss at nadir were more likely to receive a prescription. “This could very well be the reason they were prescribed a medication: They did not lose as much weight, and they are more likely to ask us” for WLMs, said Dr. Istfan, an endocrinologist at Boston University. However, for those who were prescribed WLMs, the slope of regain was flatter than for those who didn’t receive medication. Of the 626 patients included in the study, 91 received phentermine alone, 54 topiramate alone, and 113 were prescribed both phentermine and topiramate. Three received lorcaserin.
Those receiving medication were similar to the total bariatric surgery population in terms of age, sex, comorbidities, socioeconomic status, and preoperative body mass index, said Dr. Istfan, the senior author in the study. However, Hispanic individuals were more likely to receive WLMs, he said.
Recognizing that “the ratio of weight regain to nadir weight is more indicative of overfeeding than other parameters,” Dr. Istfan said that he and his colleagues divided patients into quartiles of regain, based on this ratio. The quartiles fell out so that those who had the least regain either lost weight or regained less than 1.4%, to make up the first quartile. The second quartile included those who regained from 1.5% to 6.26%, while the third quartile ranged up to 14.29% regain. Those who regained 14.3% or more were in the highest quartile of weight regain.
In comparing characteristics of the quartiles, there were more African Americans in the two higher quartiles (P = .017). More patients had achieved maximal weight loss in the highest quartile of regain (P less than .0001), though preoperative BMI had also been higher in this group (P = .0008).
After statistical adjustment, the investigators found that for individuals who had the highest quartile of regain, patients who were adherent to their WLMs had significantly less weight regain than those who took no medication (P = .014). However, patients considered nonadherent saw no medication effect on weight regain. The differences were small overall, with adherent patients regaining about 27% of weight relative to their nadir and those who didn’t take WLMs regaining about 30%. These significant results were seen long after bariatric surgery, at about 7 years post surgery.
In another analysis that looked just at the quartile of patients with the highest regain rate, weight regain was significantly delayed among those who were prescribed – and were adherent to – WLMs (P = .023). The analysis used a threshold weight regain rate of 1.22% per month; levels lower than that did not see a significant drug effect, and the effect was not seen for those not adherent to their WLMs.
Finally, an adjusted statistical analysis compared those taking and not taking WLMs to see whether WLMs were effective at preventing weight regain in rolling 90-day intervals throughout the study period. Again, in the highest quartile, those who were adherent to WLMs had a lower odds ratio of hitting the 1.22%/month regain rate, compared with those not taking medication (OR, 0.570; 95% confidence interval, 0.371-0.877; P = .01). The effect was not significant for the nonadherent group (OR, 0.872; 95% CI, 0.593-1.284; P = .489).
As more bariatric procedures are being done, and as more patients are living with their surgeries, physicians are seeing more weight regain, said Dr. Istfan, noting that it’s important to assess efficacy of WLMs in the postsurgical population. “Recent work showed that by 5 years after gastric bypass, half of patients had regained more than 15% of their nadir weight, and two-thirds of patients had regained more than 20% of their total maximum weight loss, said Dr. Istfan (King WC et al. JAMA.2018;320:1560).
Typically, patients will see about a 35% weight loss at their nadir, with a gradual increase in weight gain beginning about 2 years after surgery. Though it’s true that a net weight loss of 25% is still good, it can be a misleading way to look at the data, “because it does not focus on the process of weight regain itself,” said Dr. Istfan.
“Despite the maintenance of substantial weight loss, weight regain is concerning: It’s the present and future, not the past,” he said.
Regaining weight necessarily means that patients are having excess nutrient intake and a net-positive energy balance; this state can be associated with oxidative stress, inflammation, and insulin resistance – all potential contributors to the recurrence of comorbidities.
What’s to be done about weight regain, if it’s a point of concern? One option, said Dr. Istfan, is to consider more surgery. Patients might want a “re-do;” techniques that have been tried include reshaping the pouch and doing an anastomosis plication. If a gastro-gastric fistula’s developed, that can be corrected, he said.
Some factors influencing regain can be targeted by behavioral therapy. These include addressing alcohol consumption, discouraging grazing, encouraging exercise, and assessing and modifying diet quality in general.
“There is a general reluctance on the part of physicians to use weight loss medications after bariatric surgery,” said Dr. Istfan. Reasons can include concern about further nutritional compromise, especially when thinking about long-term use of appetite-suppressing medications. Importantly, there aren’t clinical guidelines for prescribing WLMs after bariatric surgery, nor is there a strong body of prospective studies in this area.
Dr. Istfan noted that the medical and surgical bariatric teams collaborate closely at Boston Medical Center to provide pre- and postoperative assessment and management.
The long observational interval and ethnic and socioeconomic diversity of the study population are strengths, said Dr. Istfan. Also, the three different multivariable models converged to similar findings.
However, the study was retrospective, with some confounding likely, and each prescriber involved in the study may have varying prescribing practices. Also, adherence was assessed by follow-up medication appointments, a measure that likely introduced some inaccuracy.
“Weight loss medications are potentially effective tools to counter weight regain after bariatric surgery; prospective studies are needed to optimize the use of weight loss medications after bariatric surgery,” said Dr. Istfan.
Dr. Istfan reported no outside sources of funding, and no conflicts of interest.
AGA provides GIs with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/fFA330mWKCn.
SOURCE: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
NASHVILLE – .
Phentermine and topiramate were each prescribed to between 10% and 12.5% of bariatric surgery patients at Boston Medical Center in recent years. That figure had been steadily increasing since 2004, when data collection began, Nawfal W. Istfan, MD, PhD, said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
However, the center didn’t know how patients who had received medication fared for long-term maintenance of weight loss, compared with those who had surgery alone; also, there were no clinical guidelines for prescribing weight loss medications (WLMs). “Have we done those patients any benefit by prescribing weight loss medications after gastric bypass surgery?” asked Dr. Istfan. The answer from the Boston Medical Center data is a qualified “yes;” patients with the highest rates of weight regain who were adherent to their medication did see lower rates of regain, and fewer rapid weight regain events.
Comparing patients who received prescriptions with those who did not, patients with less weight loss at nadir were more likely to receive a prescription. “This could very well be the reason they were prescribed a medication: They did not lose as much weight, and they are more likely to ask us” for WLMs, said Dr. Istfan, an endocrinologist at Boston University. However, for those who were prescribed WLMs, the slope of regain was flatter than for those who didn’t receive medication. Of the 626 patients included in the study, 91 received phentermine alone, 54 topiramate alone, and 113 were prescribed both phentermine and topiramate. Three received lorcaserin.
Those receiving medication were similar to the total bariatric surgery population in terms of age, sex, comorbidities, socioeconomic status, and preoperative body mass index, said Dr. Istfan, the senior author in the study. However, Hispanic individuals were more likely to receive WLMs, he said.
Recognizing that “the ratio of weight regain to nadir weight is more indicative of overfeeding than other parameters,” Dr. Istfan said that he and his colleagues divided patients into quartiles of regain, based on this ratio. The quartiles fell out so that those who had the least regain either lost weight or regained less than 1.4%, to make up the first quartile. The second quartile included those who regained from 1.5% to 6.26%, while the third quartile ranged up to 14.29% regain. Those who regained 14.3% or more were in the highest quartile of weight regain.
In comparing characteristics of the quartiles, there were more African Americans in the two higher quartiles (P = .017). More patients had achieved maximal weight loss in the highest quartile of regain (P less than .0001), though preoperative BMI had also been higher in this group (P = .0008).
After statistical adjustment, the investigators found that for individuals who had the highest quartile of regain, patients who were adherent to their WLMs had significantly less weight regain than those who took no medication (P = .014). However, patients considered nonadherent saw no medication effect on weight regain. The differences were small overall, with adherent patients regaining about 27% of weight relative to their nadir and those who didn’t take WLMs regaining about 30%. These significant results were seen long after bariatric surgery, at about 7 years post surgery.
In another analysis that looked just at the quartile of patients with the highest regain rate, weight regain was significantly delayed among those who were prescribed – and were adherent to – WLMs (P = .023). The analysis used a threshold weight regain rate of 1.22% per month; levels lower than that did not see a significant drug effect, and the effect was not seen for those not adherent to their WLMs.
Finally, an adjusted statistical analysis compared those taking and not taking WLMs to see whether WLMs were effective at preventing weight regain in rolling 90-day intervals throughout the study period. Again, in the highest quartile, those who were adherent to WLMs had a lower odds ratio of hitting the 1.22%/month regain rate, compared with those not taking medication (OR, 0.570; 95% confidence interval, 0.371-0.877; P = .01). The effect was not significant for the nonadherent group (OR, 0.872; 95% CI, 0.593-1.284; P = .489).
As more bariatric procedures are being done, and as more patients are living with their surgeries, physicians are seeing more weight regain, said Dr. Istfan, noting that it’s important to assess efficacy of WLMs in the postsurgical population. “Recent work showed that by 5 years after gastric bypass, half of patients had regained more than 15% of their nadir weight, and two-thirds of patients had regained more than 20% of their total maximum weight loss, said Dr. Istfan (King WC et al. JAMA.2018;320:1560).
Typically, patients will see about a 35% weight loss at their nadir, with a gradual increase in weight gain beginning about 2 years after surgery. Though it’s true that a net weight loss of 25% is still good, it can be a misleading way to look at the data, “because it does not focus on the process of weight regain itself,” said Dr. Istfan.
“Despite the maintenance of substantial weight loss, weight regain is concerning: It’s the present and future, not the past,” he said.
Regaining weight necessarily means that patients are having excess nutrient intake and a net-positive energy balance; this state can be associated with oxidative stress, inflammation, and insulin resistance – all potential contributors to the recurrence of comorbidities.
What’s to be done about weight regain, if it’s a point of concern? One option, said Dr. Istfan, is to consider more surgery. Patients might want a “re-do;” techniques that have been tried include reshaping the pouch and doing an anastomosis plication. If a gastro-gastric fistula’s developed, that can be corrected, he said.
Some factors influencing regain can be targeted by behavioral therapy. These include addressing alcohol consumption, discouraging grazing, encouraging exercise, and assessing and modifying diet quality in general.
“There is a general reluctance on the part of physicians to use weight loss medications after bariatric surgery,” said Dr. Istfan. Reasons can include concern about further nutritional compromise, especially when thinking about long-term use of appetite-suppressing medications. Importantly, there aren’t clinical guidelines for prescribing WLMs after bariatric surgery, nor is there a strong body of prospective studies in this area.
Dr. Istfan noted that the medical and surgical bariatric teams collaborate closely at Boston Medical Center to provide pre- and postoperative assessment and management.
The long observational interval and ethnic and socioeconomic diversity of the study population are strengths, said Dr. Istfan. Also, the three different multivariable models converged to similar findings.
However, the study was retrospective, with some confounding likely, and each prescriber involved in the study may have varying prescribing practices. Also, adherence was assessed by follow-up medication appointments, a measure that likely introduced some inaccuracy.
“Weight loss medications are potentially effective tools to counter weight regain after bariatric surgery; prospective studies are needed to optimize the use of weight loss medications after bariatric surgery,” said Dr. Istfan.
Dr. Istfan reported no outside sources of funding, and no conflicts of interest.
AGA provides GIs with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/fFA330mWKCn.
SOURCE: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
REPORTING FROM OBESITY WEEK 2018
Key clinical point: Weight loss medication flattened the curve of weight regain after bariatric surgery – for some patients.
Major finding: Weight loss medicine reduced regain among those who had the most weight regain (P =.014).
Study details: Retrospective single-center cohort study of 626 bariatric surgery patients.
Disclosures: The study authors reported no external sources of funding. Dr. Istfan reported no conflicts of interest.
Source: Anderson W et al. Obesity Week 2018, Abstract T-OR-2016.
Obesity meds used by just over half of pediatric obesity programs
NASHVILLE, TENN. –
Programs that didn’t offer pharmacotherapy for children and adolescents with obesity cited a variety of reasons in responses to a survey of 33 multicomponent pediatric weight management programs (PWMPs).
Simply not being in favor of using pharmacotherapy for obesity treatment was the most frequently cited reason, named by seven PWMPs that didn’t prescribe obesity medications.
The second most common response to the survey, cited by six programs, was a lack of knowledge about prescribing medications for obesity, and concerns about insurance coverage were noted by five programs, said Claudia Fox, MD, and her colleagues in a poster presentation at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “Despite recommendations, few youth with severe obesity are treated with medications.”
Of the programs that did offer pharmacotherapy, 14 prescribed topiramate, and 13 prescribed phentermine. Metformin was used by 11 programs, and orlistat by eight. Six programs prescribed the fixed-dose combination of topiramate and phentermine.
Lorcaserin, naltrexone/bupropion, liraglutide, phendimetrazine, and naltrexone alone all were used by fewer than five programs each.
The national Pediatric Obesity Weight Evaluation Registry (POWER) “was established in 2013 to identify and promote effective intervention strategies for pediatric obesity,” wrote Dr. Fox and her colleagues
Of the 33 POWER PWMPs who were invited to participate, 30 completed a program profile survey. Of these, 16 programs (53%) offered pharmacotherapy, wrote Dr. Fox, the codirector of the University of Minnesota’s Center for Pediatric Obesity Medicine, Minneapolis, and her colleagues in the POWER work group.
In addition to not being in favor of prescribing obesity medication for pediatric patients, lack of knowledge, and insurance concerns, one program cited limited outcome studies for pediatric obesity pharmacotherapy. One other program’s response noted that patients couldn’t be seen frequently enough to assess the safety of obesity medications.
Taken together, the POWER sites had 7,880 patients. Just 5% were aged 2- 5 years, 48% were aged 6-11 years, and 47% were aged 12-18 years. Just over half (53%) were female.
At baseline, about a quarter of patients (26.4%) had class 1 obesity, defined as a body mass index of at least the 95th age- and sex-adjusted percentile. Children and adolescents with class 2 obesity (BMI of at least 1.2-1.4 times the 95th percentile) made up 35.3% of patients; 38.3% had class 3 obesity, with BMIs greater than 1.4 times the 95th percentile.
In 2017, the Endocrine Society published updated clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity (J Clin Endocrin Metab. 2017 Mar;102:3;709-57). The guidelines for pediatric obesity treatment recommend intensive lifestyle modifications including dietary, physical activity, and behavioral interventions. Pharmacotherapy is suggested “only after a formal program of intensive lifestyle modification has failed to limit weight gain or to ameliorate comorbidities.” Additionally, say the guidelines, Food and Drug Administration–approved pharmacotherapy should be used only “with a concomitant lifestyle modification program of the highest intensity available and only by clinicians who are experienced in the use of anti-obesity agents and are aware of the potential for adverse reactions.”
“Most commonly prescribed medications are not FDA approved for indication of obesity in pediatrics,” noted Dr. Fox and her coauthors. “Further research is needed to evaluate efficacy of pharmacotherapy in the pediatric population and to understand factors impacting prescribing practices.”
Dr. Fox reported no outside sources of funding and had no relevant financial disclosures.
NASHVILLE, TENN. –
Programs that didn’t offer pharmacotherapy for children and adolescents with obesity cited a variety of reasons in responses to a survey of 33 multicomponent pediatric weight management programs (PWMPs).
Simply not being in favor of using pharmacotherapy for obesity treatment was the most frequently cited reason, named by seven PWMPs that didn’t prescribe obesity medications.
The second most common response to the survey, cited by six programs, was a lack of knowledge about prescribing medications for obesity, and concerns about insurance coverage were noted by five programs, said Claudia Fox, MD, and her colleagues in a poster presentation at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “Despite recommendations, few youth with severe obesity are treated with medications.”
Of the programs that did offer pharmacotherapy, 14 prescribed topiramate, and 13 prescribed phentermine. Metformin was used by 11 programs, and orlistat by eight. Six programs prescribed the fixed-dose combination of topiramate and phentermine.
Lorcaserin, naltrexone/bupropion, liraglutide, phendimetrazine, and naltrexone alone all were used by fewer than five programs each.
The national Pediatric Obesity Weight Evaluation Registry (POWER) “was established in 2013 to identify and promote effective intervention strategies for pediatric obesity,” wrote Dr. Fox and her colleagues
Of the 33 POWER PWMPs who were invited to participate, 30 completed a program profile survey. Of these, 16 programs (53%) offered pharmacotherapy, wrote Dr. Fox, the codirector of the University of Minnesota’s Center for Pediatric Obesity Medicine, Minneapolis, and her colleagues in the POWER work group.
In addition to not being in favor of prescribing obesity medication for pediatric patients, lack of knowledge, and insurance concerns, one program cited limited outcome studies for pediatric obesity pharmacotherapy. One other program’s response noted that patients couldn’t be seen frequently enough to assess the safety of obesity medications.
Taken together, the POWER sites had 7,880 patients. Just 5% were aged 2- 5 years, 48% were aged 6-11 years, and 47% were aged 12-18 years. Just over half (53%) were female.
At baseline, about a quarter of patients (26.4%) had class 1 obesity, defined as a body mass index of at least the 95th age- and sex-adjusted percentile. Children and adolescents with class 2 obesity (BMI of at least 1.2-1.4 times the 95th percentile) made up 35.3% of patients; 38.3% had class 3 obesity, with BMIs greater than 1.4 times the 95th percentile.
In 2017, the Endocrine Society published updated clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity (J Clin Endocrin Metab. 2017 Mar;102:3;709-57). The guidelines for pediatric obesity treatment recommend intensive lifestyle modifications including dietary, physical activity, and behavioral interventions. Pharmacotherapy is suggested “only after a formal program of intensive lifestyle modification has failed to limit weight gain or to ameliorate comorbidities.” Additionally, say the guidelines, Food and Drug Administration–approved pharmacotherapy should be used only “with a concomitant lifestyle modification program of the highest intensity available and only by clinicians who are experienced in the use of anti-obesity agents and are aware of the potential for adverse reactions.”
“Most commonly prescribed medications are not FDA approved for indication of obesity in pediatrics,” noted Dr. Fox and her coauthors. “Further research is needed to evaluate efficacy of pharmacotherapy in the pediatric population and to understand factors impacting prescribing practices.”
Dr. Fox reported no outside sources of funding and had no relevant financial disclosures.
NASHVILLE, TENN. –
Programs that didn’t offer pharmacotherapy for children and adolescents with obesity cited a variety of reasons in responses to a survey of 33 multicomponent pediatric weight management programs (PWMPs).
Simply not being in favor of using pharmacotherapy for obesity treatment was the most frequently cited reason, named by seven PWMPs that didn’t prescribe obesity medications.
The second most common response to the survey, cited by six programs, was a lack of knowledge about prescribing medications for obesity, and concerns about insurance coverage were noted by five programs, said Claudia Fox, MD, and her colleagues in a poster presentation at a meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery. “Despite recommendations, few youth with severe obesity are treated with medications.”
Of the programs that did offer pharmacotherapy, 14 prescribed topiramate, and 13 prescribed phentermine. Metformin was used by 11 programs, and orlistat by eight. Six programs prescribed the fixed-dose combination of topiramate and phentermine.
Lorcaserin, naltrexone/bupropion, liraglutide, phendimetrazine, and naltrexone alone all were used by fewer than five programs each.
The national Pediatric Obesity Weight Evaluation Registry (POWER) “was established in 2013 to identify and promote effective intervention strategies for pediatric obesity,” wrote Dr. Fox and her colleagues
Of the 33 POWER PWMPs who were invited to participate, 30 completed a program profile survey. Of these, 16 programs (53%) offered pharmacotherapy, wrote Dr. Fox, the codirector of the University of Minnesota’s Center for Pediatric Obesity Medicine, Minneapolis, and her colleagues in the POWER work group.
In addition to not being in favor of prescribing obesity medication for pediatric patients, lack of knowledge, and insurance concerns, one program cited limited outcome studies for pediatric obesity pharmacotherapy. One other program’s response noted that patients couldn’t be seen frequently enough to assess the safety of obesity medications.
Taken together, the POWER sites had 7,880 patients. Just 5% were aged 2- 5 years, 48% were aged 6-11 years, and 47% were aged 12-18 years. Just over half (53%) were female.
At baseline, about a quarter of patients (26.4%) had class 1 obesity, defined as a body mass index of at least the 95th age- and sex-adjusted percentile. Children and adolescents with class 2 obesity (BMI of at least 1.2-1.4 times the 95th percentile) made up 35.3% of patients; 38.3% had class 3 obesity, with BMIs greater than 1.4 times the 95th percentile.
In 2017, the Endocrine Society published updated clinical practice guidelines for the assessment, treatment, and prevention of pediatric obesity (J Clin Endocrin Metab. 2017 Mar;102:3;709-57). The guidelines for pediatric obesity treatment recommend intensive lifestyle modifications including dietary, physical activity, and behavioral interventions. Pharmacotherapy is suggested “only after a formal program of intensive lifestyle modification has failed to limit weight gain or to ameliorate comorbidities.” Additionally, say the guidelines, Food and Drug Administration–approved pharmacotherapy should be used only “with a concomitant lifestyle modification program of the highest intensity available and only by clinicians who are experienced in the use of anti-obesity agents and are aware of the potential for adverse reactions.”
“Most commonly prescribed medications are not FDA approved for indication of obesity in pediatrics,” noted Dr. Fox and her coauthors. “Further research is needed to evaluate efficacy of pharmacotherapy in the pediatric population and to understand factors impacting prescribing practices.”
Dr. Fox reported no outside sources of funding and had no relevant financial disclosures.
REPORTING FROM OBESITY WEEK 2018
Key clinical point: Just over half of pediatric weight management programs prescribed obesity medications.
Major finding: Of 30 programs responding, 16 (53%) prescribed obesity medication.
Study details: Survey of 33 programs in the Pediatric Obesity Weight Evaluation Registry (POWER).
Disclosures: Dr. Fox reported no outside sources of funding and no conflicts of interest.
True postbariatric hyperinsulinemic hypoglycemia is rare
based on a decade’s worth of experience from the Mayo Clinic, Rochester, Minn.
Of 2,386 patients who had bariatric surgery at Mayo, 60 (2.6%) had a postsurgical diagnosis code associated with hypoglycemia in their medical record. However, just five of them (0.25%) had documentation meeting the criteria for Whipple’s Triad, which consists of low blood glucose levels, symptoms associated with the low glucose levels, and symptom resolution when glucose levels are corrected, Tiffany Cortes, MD, reported in an oral presentation at Obesity Week, which is presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery .
“Postbariatric hypoglycemia is an infrequent occurrence among patients who present with suspicious symptoms,” said Dr. Cortes, an endocrinology fellow at the clinic.
Post–bariatric surgery hypoglycemia is characterized by neuroglycopenia with a documented plasma glucose of less than 54 mg/dL with symptom resolution after a rise in glucose levels; neuroglycopenia that occurs 1-3 hours after a meal; and symptom onset more than 6 months after bariatric surgery, said Dr. Cortes.
Previous work had found that the overall prevalence of post–bariatric surgery hyperinsulinemic hypoglycemia ranged from 17%-34%, with severe symptoms seen in fewer than 1% of surgery recipients.
Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), may result in wide postprandial blood glucose excursions, with a spike occurring about 30 minutes after eating. For symptomatic individuals, this postprandial glucose peak will prompt an insulin surge followed by a rapid and steep decline in serum glucose.
Looking at Mayo Clinic medical records from mid-2008 to the end of 2017, Dr. Cortes and her colleagues wanted to determine the prevalence of hyperinsulinemic hypoglycemia in the bariatric surgery population.
Additionally, the researchers wanted to see how patients who presented with symptoms suspicious for the syndrome were evaluated and to understand the efficacy of treatments.
Patients who had a diagnosis of type 1 diabetes mellitus and those who were on insulin or sulfonylureas were excluded from the retrospective chart review.
Of the 60 patients evaluated in the endocrinology clinic for symptoms suspicious for hyperinsulinemic hypoglycemia, 51 (85%) were female, and 14 had a diagnosis of diabetes before surgery. Mean patient age at surgery was 43 years.
These symptomatic patients had a mean presurgical body mass index (BMI) of 42.8 kg/m2 (range, 38.6-49.3 kg/m2). Their mean time to maximal weight loss was 1.3 years after surgery, with symptoms beginning at 1.4 years after surgery. Patients lost a mean 37.4% of their body mass to reach a mean nadir BMI of 26.2.
Overall, about two-thirds of the surgeries performed were RYGB. Of patients with hypoglycemic symptoms, 73.3% had an RYGB. Revision of gastric bypass was the next most common surgery, at 21.8% overall; these patients constituted 15% of the hypoglycemic symptom group.
Of the patients with symptoms, 80% noted symptoms only after eating, with half of patients describing symptoms coming on 1-3 hours after eating. A little over a third of the patients didn’t describe the exact timing of symptoms.
Just 20 patients had a complete hypoglycemia work up bundle documented in their medical record, said Dr. Cortes. This consisted of measures of serum glucose, insulin, and C-peptide levels. Of the 20 patients, 5 met Whipple’s Triad criteria, and 4 of these patients received a diagnosis of hyperinsulinemic hypoglycemia.
Two patients had a 72-hour fast, and neither of them met diagnostic criteria. Seventeen patients had a mixed meal tolerance test, with one individual meeting diagnostic criteria for and receiving a diagnosis of hypoinsulinemic hyperglycemia.
Of the five patients meeting diagnostic criteria (0.20% of surgical population), all had received RYGB, and two had previous weight loss procedures, said Dr. Cortes. For four of the patients, the surgical indication was weight loss; the other patient had an indication of gastroesophageal reflux disease (GERD).
“Dietary interventions are the most effective treatment” for post–bariatric surgery hyperinsulinemic hypoglycemia in the Mayo Clinic experience, said Dr. Cortes.
Turning to the investigators’ examination of treatment recommendations for the 60 patients who reported hypoglycemic symptoms, most (95%) received an initial recommendation to manage symptoms by diet changes.
Most patients (77%) had at least one follow-up visit, with over half of these patients (61%) reporting improvement in symptoms, and seven patients (16%) reporting resolution. Twelve patients (27%) either remained the same or had not had a recurrence of symptoms.
Medication was prescribed for 12 patients; of them, 8 received the alpha glucosidase inhibitor acarbose and 7 responded, according to the record review. No one reported worsening of symptoms on acarbose.
Other individual patients were prescribed octreotide alone, or octreotide, pasireotide, or diazoxide in combination with acarbose, with variable results.
Dr. Cortes reported no conflicts of interest and no external sources of funding.
SOURCE: Cortes T et al. Obesity Week 2018, Abstract T-OR-2015.
based on a decade’s worth of experience from the Mayo Clinic, Rochester, Minn.
Of 2,386 patients who had bariatric surgery at Mayo, 60 (2.6%) had a postsurgical diagnosis code associated with hypoglycemia in their medical record. However, just five of them (0.25%) had documentation meeting the criteria for Whipple’s Triad, which consists of low blood glucose levels, symptoms associated with the low glucose levels, and symptom resolution when glucose levels are corrected, Tiffany Cortes, MD, reported in an oral presentation at Obesity Week, which is presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery .
“Postbariatric hypoglycemia is an infrequent occurrence among patients who present with suspicious symptoms,” said Dr. Cortes, an endocrinology fellow at the clinic.
Post–bariatric surgery hypoglycemia is characterized by neuroglycopenia with a documented plasma glucose of less than 54 mg/dL with symptom resolution after a rise in glucose levels; neuroglycopenia that occurs 1-3 hours after a meal; and symptom onset more than 6 months after bariatric surgery, said Dr. Cortes.
Previous work had found that the overall prevalence of post–bariatric surgery hyperinsulinemic hypoglycemia ranged from 17%-34%, with severe symptoms seen in fewer than 1% of surgery recipients.
Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), may result in wide postprandial blood glucose excursions, with a spike occurring about 30 minutes after eating. For symptomatic individuals, this postprandial glucose peak will prompt an insulin surge followed by a rapid and steep decline in serum glucose.
Looking at Mayo Clinic medical records from mid-2008 to the end of 2017, Dr. Cortes and her colleagues wanted to determine the prevalence of hyperinsulinemic hypoglycemia in the bariatric surgery population.
Additionally, the researchers wanted to see how patients who presented with symptoms suspicious for the syndrome were evaluated and to understand the efficacy of treatments.
Patients who had a diagnosis of type 1 diabetes mellitus and those who were on insulin or sulfonylureas were excluded from the retrospective chart review.
Of the 60 patients evaluated in the endocrinology clinic for symptoms suspicious for hyperinsulinemic hypoglycemia, 51 (85%) were female, and 14 had a diagnosis of diabetes before surgery. Mean patient age at surgery was 43 years.
These symptomatic patients had a mean presurgical body mass index (BMI) of 42.8 kg/m2 (range, 38.6-49.3 kg/m2). Their mean time to maximal weight loss was 1.3 years after surgery, with symptoms beginning at 1.4 years after surgery. Patients lost a mean 37.4% of their body mass to reach a mean nadir BMI of 26.2.
Overall, about two-thirds of the surgeries performed were RYGB. Of patients with hypoglycemic symptoms, 73.3% had an RYGB. Revision of gastric bypass was the next most common surgery, at 21.8% overall; these patients constituted 15% of the hypoglycemic symptom group.
Of the patients with symptoms, 80% noted symptoms only after eating, with half of patients describing symptoms coming on 1-3 hours after eating. A little over a third of the patients didn’t describe the exact timing of symptoms.
Just 20 patients had a complete hypoglycemia work up bundle documented in their medical record, said Dr. Cortes. This consisted of measures of serum glucose, insulin, and C-peptide levels. Of the 20 patients, 5 met Whipple’s Triad criteria, and 4 of these patients received a diagnosis of hyperinsulinemic hypoglycemia.
Two patients had a 72-hour fast, and neither of them met diagnostic criteria. Seventeen patients had a mixed meal tolerance test, with one individual meeting diagnostic criteria for and receiving a diagnosis of hypoinsulinemic hyperglycemia.
Of the five patients meeting diagnostic criteria (0.20% of surgical population), all had received RYGB, and two had previous weight loss procedures, said Dr. Cortes. For four of the patients, the surgical indication was weight loss; the other patient had an indication of gastroesophageal reflux disease (GERD).
“Dietary interventions are the most effective treatment” for post–bariatric surgery hyperinsulinemic hypoglycemia in the Mayo Clinic experience, said Dr. Cortes.
Turning to the investigators’ examination of treatment recommendations for the 60 patients who reported hypoglycemic symptoms, most (95%) received an initial recommendation to manage symptoms by diet changes.
Most patients (77%) had at least one follow-up visit, with over half of these patients (61%) reporting improvement in symptoms, and seven patients (16%) reporting resolution. Twelve patients (27%) either remained the same or had not had a recurrence of symptoms.
Medication was prescribed for 12 patients; of them, 8 received the alpha glucosidase inhibitor acarbose and 7 responded, according to the record review. No one reported worsening of symptoms on acarbose.
Other individual patients were prescribed octreotide alone, or octreotide, pasireotide, or diazoxide in combination with acarbose, with variable results.
Dr. Cortes reported no conflicts of interest and no external sources of funding.
SOURCE: Cortes T et al. Obesity Week 2018, Abstract T-OR-2015.
based on a decade’s worth of experience from the Mayo Clinic, Rochester, Minn.
Of 2,386 patients who had bariatric surgery at Mayo, 60 (2.6%) had a postsurgical diagnosis code associated with hypoglycemia in their medical record. However, just five of them (0.25%) had documentation meeting the criteria for Whipple’s Triad, which consists of low blood glucose levels, symptoms associated with the low glucose levels, and symptom resolution when glucose levels are corrected, Tiffany Cortes, MD, reported in an oral presentation at Obesity Week, which is presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery .
“Postbariatric hypoglycemia is an infrequent occurrence among patients who present with suspicious symptoms,” said Dr. Cortes, an endocrinology fellow at the clinic.
Post–bariatric surgery hypoglycemia is characterized by neuroglycopenia with a documented plasma glucose of less than 54 mg/dL with symptom resolution after a rise in glucose levels; neuroglycopenia that occurs 1-3 hours after a meal; and symptom onset more than 6 months after bariatric surgery, said Dr. Cortes.
Previous work had found that the overall prevalence of post–bariatric surgery hyperinsulinemic hypoglycemia ranged from 17%-34%, with severe symptoms seen in fewer than 1% of surgery recipients.
Bariatric surgery, especially Roux-en-Y gastric bypass (RYGB), may result in wide postprandial blood glucose excursions, with a spike occurring about 30 minutes after eating. For symptomatic individuals, this postprandial glucose peak will prompt an insulin surge followed by a rapid and steep decline in serum glucose.
Looking at Mayo Clinic medical records from mid-2008 to the end of 2017, Dr. Cortes and her colleagues wanted to determine the prevalence of hyperinsulinemic hypoglycemia in the bariatric surgery population.
Additionally, the researchers wanted to see how patients who presented with symptoms suspicious for the syndrome were evaluated and to understand the efficacy of treatments.
Patients who had a diagnosis of type 1 diabetes mellitus and those who were on insulin or sulfonylureas were excluded from the retrospective chart review.
Of the 60 patients evaluated in the endocrinology clinic for symptoms suspicious for hyperinsulinemic hypoglycemia, 51 (85%) were female, and 14 had a diagnosis of diabetes before surgery. Mean patient age at surgery was 43 years.
These symptomatic patients had a mean presurgical body mass index (BMI) of 42.8 kg/m2 (range, 38.6-49.3 kg/m2). Their mean time to maximal weight loss was 1.3 years after surgery, with symptoms beginning at 1.4 years after surgery. Patients lost a mean 37.4% of their body mass to reach a mean nadir BMI of 26.2.
Overall, about two-thirds of the surgeries performed were RYGB. Of patients with hypoglycemic symptoms, 73.3% had an RYGB. Revision of gastric bypass was the next most common surgery, at 21.8% overall; these patients constituted 15% of the hypoglycemic symptom group.
Of the patients with symptoms, 80% noted symptoms only after eating, with half of patients describing symptoms coming on 1-3 hours after eating. A little over a third of the patients didn’t describe the exact timing of symptoms.
Just 20 patients had a complete hypoglycemia work up bundle documented in their medical record, said Dr. Cortes. This consisted of measures of serum glucose, insulin, and C-peptide levels. Of the 20 patients, 5 met Whipple’s Triad criteria, and 4 of these patients received a diagnosis of hyperinsulinemic hypoglycemia.
Two patients had a 72-hour fast, and neither of them met diagnostic criteria. Seventeen patients had a mixed meal tolerance test, with one individual meeting diagnostic criteria for and receiving a diagnosis of hypoinsulinemic hyperglycemia.
Of the five patients meeting diagnostic criteria (0.20% of surgical population), all had received RYGB, and two had previous weight loss procedures, said Dr. Cortes. For four of the patients, the surgical indication was weight loss; the other patient had an indication of gastroesophageal reflux disease (GERD).
“Dietary interventions are the most effective treatment” for post–bariatric surgery hyperinsulinemic hypoglycemia in the Mayo Clinic experience, said Dr. Cortes.
Turning to the investigators’ examination of treatment recommendations for the 60 patients who reported hypoglycemic symptoms, most (95%) received an initial recommendation to manage symptoms by diet changes.
Most patients (77%) had at least one follow-up visit, with over half of these patients (61%) reporting improvement in symptoms, and seven patients (16%) reporting resolution. Twelve patients (27%) either remained the same or had not had a recurrence of symptoms.
Medication was prescribed for 12 patients; of them, 8 received the alpha glucosidase inhibitor acarbose and 7 responded, according to the record review. No one reported worsening of symptoms on acarbose.
Other individual patients were prescribed octreotide alone, or octreotide, pasireotide, or diazoxide in combination with acarbose, with variable results.
Dr. Cortes reported no conflicts of interest and no external sources of funding.
SOURCE: Cortes T et al. Obesity Week 2018, Abstract T-OR-2015.
REPORTING FROM OBESITY WEEK 2018
Key clinical point: Less than 1% of bariatric surgery patients had hyperinsulinemic hypoglycemia.
Major finding: When strict diagnostic criteria were used, 0.20% received the diagnosis.
Study details: Single-center retrospective chart review of 2,386 patients receiving bariatric surgery.
Disclosures: Dr. Cortes reported no outside sources of funding and no conflicts of interest.
Source: Cortes T et al. Obesity Week 2018, Abstract T-OR-2015.
Obesity linked to 10% of childhood asthma
Around one-quarter of new asthma cases in children with obesity may be attributable to their obesity, according to research published in Pediatrics.
Jason E. Lang, MD, MPH, of Duke University, Durham, N.C., and his coauthors used the PEDSnet clinical data research network to conduct a retrospective cohort study of 507,496 children aged 2-17 years from 2009-2015, comparing the incidence of asthma in overweight and obese children to the incidence in healthy weight children.
The overall rate of new diagnoses of asthma was 2.4 per 1,000 patient years among normal-weight children and 3.2 per 1,000 patient years among obese children.
After adjustment for factors such as age, ethnicity, insurance status, sex, allergic rhinitis, food allergy, and proton pump inhibitor use, overweight children had a 17% higher risk of incident asthma, and obese children had a 26% higher risk of asthma, compared with children of normal weight. The relative risk of spirometry-confirmed asthma was 29% higher in obese children compared with normal-weight children, and the association between obesity and asthma persisted even when a second asthma encounter was required for the diagnosis.
Overall, the authors estimated that 23%-25% of clinically diagnosed asthma in children with obesity could be specifically attributed to obesity, and that in the overall population of children 10% of asthma was attributable to obesity.
“Currently, there are few known preventable risk factors that can be used to reduce childhood asthma,” wrote Dr. Lang and his coauthors. “With these data, it is suggested that reducing the onset of obesity in childhood would significantly reduce the public health burden of asthma in children.”
They noted that with current estimates of U.S. pediatric asthma prevalence being around 6-8 million cases, obesity could therefore account for up to 1 million of these cases.
The study was funded by the Patient-Centered Outcomes Research Institute, the Nemours Children’s Hospital and Nemours Children’s Health System. One author declared advisory board positions and consultancies with the pharmaceutical industry. The remaining researchers said they had no conflicts of interest.
SOURCE: Lang J et al. Pediatrics. 2018 Dec;142(6):e20182119.
While there has long been recognition of an association between childhood obesity and childhood asthma, the incidence of pediatric obesity–related asthma has not been well known. This study therefore addresses that gap in knowledge, and does so among children with a range of racial and ethnic backgrounds and while addressing potential confounders such as comorbidities and sociodemographic variables.
The findings show how significant a contribution obesity makes to the burden of childhood asthma, and also points to the potential increase in childhood asthma incidence that may arise with the increase in childhood obesity.
However, the good news is that this offers what may be the first modifiable risk factor for childhood asthma, which presents an opportunity for primary prevention of this common childhood condition.
Deepa Rastogi, MBBS, MS, is from the department of pediatrics at the Albert Einstein College of Medicine, New York. These comments are taken from an editorial (Pediatrics. 2018 Dec;142(6):e20182979.). No conflicts of interest were declared.
While there has long been recognition of an association between childhood obesity and childhood asthma, the incidence of pediatric obesity–related asthma has not been well known. This study therefore addresses that gap in knowledge, and does so among children with a range of racial and ethnic backgrounds and while addressing potential confounders such as comorbidities and sociodemographic variables.
The findings show how significant a contribution obesity makes to the burden of childhood asthma, and also points to the potential increase in childhood asthma incidence that may arise with the increase in childhood obesity.
However, the good news is that this offers what may be the first modifiable risk factor for childhood asthma, which presents an opportunity for primary prevention of this common childhood condition.
Deepa Rastogi, MBBS, MS, is from the department of pediatrics at the Albert Einstein College of Medicine, New York. These comments are taken from an editorial (Pediatrics. 2018 Dec;142(6):e20182979.). No conflicts of interest were declared.
While there has long been recognition of an association between childhood obesity and childhood asthma, the incidence of pediatric obesity–related asthma has not been well known. This study therefore addresses that gap in knowledge, and does so among children with a range of racial and ethnic backgrounds and while addressing potential confounders such as comorbidities and sociodemographic variables.
The findings show how significant a contribution obesity makes to the burden of childhood asthma, and also points to the potential increase in childhood asthma incidence that may arise with the increase in childhood obesity.
However, the good news is that this offers what may be the first modifiable risk factor for childhood asthma, which presents an opportunity for primary prevention of this common childhood condition.
Deepa Rastogi, MBBS, MS, is from the department of pediatrics at the Albert Einstein College of Medicine, New York. These comments are taken from an editorial (Pediatrics. 2018 Dec;142(6):e20182979.). No conflicts of interest were declared.
Around one-quarter of new asthma cases in children with obesity may be attributable to their obesity, according to research published in Pediatrics.
Jason E. Lang, MD, MPH, of Duke University, Durham, N.C., and his coauthors used the PEDSnet clinical data research network to conduct a retrospective cohort study of 507,496 children aged 2-17 years from 2009-2015, comparing the incidence of asthma in overweight and obese children to the incidence in healthy weight children.
The overall rate of new diagnoses of asthma was 2.4 per 1,000 patient years among normal-weight children and 3.2 per 1,000 patient years among obese children.
After adjustment for factors such as age, ethnicity, insurance status, sex, allergic rhinitis, food allergy, and proton pump inhibitor use, overweight children had a 17% higher risk of incident asthma, and obese children had a 26% higher risk of asthma, compared with children of normal weight. The relative risk of spirometry-confirmed asthma was 29% higher in obese children compared with normal-weight children, and the association between obesity and asthma persisted even when a second asthma encounter was required for the diagnosis.
Overall, the authors estimated that 23%-25% of clinically diagnosed asthma in children with obesity could be specifically attributed to obesity, and that in the overall population of children 10% of asthma was attributable to obesity.
“Currently, there are few known preventable risk factors that can be used to reduce childhood asthma,” wrote Dr. Lang and his coauthors. “With these data, it is suggested that reducing the onset of obesity in childhood would significantly reduce the public health burden of asthma in children.”
They noted that with current estimates of U.S. pediatric asthma prevalence being around 6-8 million cases, obesity could therefore account for up to 1 million of these cases.
The study was funded by the Patient-Centered Outcomes Research Institute, the Nemours Children’s Hospital and Nemours Children’s Health System. One author declared advisory board positions and consultancies with the pharmaceutical industry. The remaining researchers said they had no conflicts of interest.
SOURCE: Lang J et al. Pediatrics. 2018 Dec;142(6):e20182119.
Around one-quarter of new asthma cases in children with obesity may be attributable to their obesity, according to research published in Pediatrics.
Jason E. Lang, MD, MPH, of Duke University, Durham, N.C., and his coauthors used the PEDSnet clinical data research network to conduct a retrospective cohort study of 507,496 children aged 2-17 years from 2009-2015, comparing the incidence of asthma in overweight and obese children to the incidence in healthy weight children.
The overall rate of new diagnoses of asthma was 2.4 per 1,000 patient years among normal-weight children and 3.2 per 1,000 patient years among obese children.
After adjustment for factors such as age, ethnicity, insurance status, sex, allergic rhinitis, food allergy, and proton pump inhibitor use, overweight children had a 17% higher risk of incident asthma, and obese children had a 26% higher risk of asthma, compared with children of normal weight. The relative risk of spirometry-confirmed asthma was 29% higher in obese children compared with normal-weight children, and the association between obesity and asthma persisted even when a second asthma encounter was required for the diagnosis.
Overall, the authors estimated that 23%-25% of clinically diagnosed asthma in children with obesity could be specifically attributed to obesity, and that in the overall population of children 10% of asthma was attributable to obesity.
“Currently, there are few known preventable risk factors that can be used to reduce childhood asthma,” wrote Dr. Lang and his coauthors. “With these data, it is suggested that reducing the onset of obesity in childhood would significantly reduce the public health burden of asthma in children.”
They noted that with current estimates of U.S. pediatric asthma prevalence being around 6-8 million cases, obesity could therefore account for up to 1 million of these cases.
The study was funded by the Patient-Centered Outcomes Research Institute, the Nemours Children’s Hospital and Nemours Children’s Health System. One author declared advisory board positions and consultancies with the pharmaceutical industry. The remaining researchers said they had no conflicts of interest.
SOURCE: Lang J et al. Pediatrics. 2018 Dec;142(6):e20182119.
FROM PEDIATRICS
Key clinical point: Obesity may be responsible for around 10% of childhood asthma.
Major finding: Obesity in children is associated with a 26% higher risk of asthma compared with normal-weight children.
Study details: A retrospective cohort study of 507,496 children.
Disclosures: The study was funded by the Patient-Centered Outcomes Research Institute and the Nemours Children’s Hospital and Nemours Children’s Health System. One author declared advisory board positions and consultancies with the pharmaceutical industry.
Source: Lang J et al. Pediatrics. 2018 Dec;142(6):e20182119. doi: 10.1542/peds.2018- 2119