Endothelial activation markers and their key regulators after restrictive bariatric surgery

Objective: Increased plasma levels of endothelial activation markers in obese subjects reflect the positive association between cardiovascular diseases and obesity. The pro‐inflammatory state associated with obesity is thought to play a major role in endothelial cell activation in severely obese individuals. Previous studies demonstrated that long‐term weight loss after bariatric surgery is accompanied by a decreased proinflammatory state. However, little is known about the long‐term effects of bariatric surgery on endothelial cell activation. Research Methods and Procedures: Plasma levels of soluble intercellular adhesion molecule‐1 (sICAM‐1), soluble endothelial selectin (sE‐selectin), and soluble vascular cell adhesion molecule‐1 (sVCAM‐1), all markers of endothelial cell activation, and of their regulators adiponectin and resistin were measured at different time‐points postoperatively in 26 consecutive patients who underwent restrictive surgery, with a follow‐up of 2 years. Results: During the first 6 months after bariatric surgery, sE‐selectin levels decreased. Despite substantial weight loss, sICAM‐1 and sVCAM‐1 plasma levels did not decrease significantly. After 24 months, sICAM‐1 levels were significantly decreased, whereas sE‐selectin levels were further decreased. However, sVCAM‐1 levels remained elevated. Adiponectin levels did not change significantly during the first 6 months after bariatric surgery, whereas resistin levels increased. After 24 months, adiponectin levels were similar to normal‐weight controls, but resistin levels remained high. Discussion: Reductions in plasma levels of different markers of endothelial activation after bariatric surgery show different temporal patterns, suggesting that distinct mechanisms are involved in their regulation. Although not all endothelial activation markers normalize after bariatric surgery, our findings suggest that bariatric surgery can reduce endothelial activation in the long term.     

Improved Arteriole‐to‐Venule Ratio of Retinal Vessels Resulting From Bariatric Surgery

Obesity causes increased morbidity and mortality from metabolic and cardiovascular disease (CVD). We investigated the effect of bariatric surgery on endothelial dysfunction (ED) in retinal vessels as a marker of metabolic and cardiovascular risk in patients with obesity WHO III. Thirty consecutive patients (19/11, w/m) were evaluated by anthropometry, lipid profile, and oral glucose tolerance test before and after bariatric surgery (Mannheim Obesity Study (MOS); NCT 00770276). Risk stratification was performed by the presence of metabolic syndrome (MetS) according to ATP‐III (adult treatment panel‐III). Subclinical atherosclerosis was assessed by measurement of intima‐media thickness (IMT). Flicker light response of retinal vessels was used as measures of ED. We measured their arteriole‐to‐venule ratio (AVR) for evaluation of vascular pathology. After a median of 9 months following bariatric surgery, mean weight loss was 39.4 kg (37.3%). Remission of impaired glucose metabolism was achieved in 53.3% of affected patients. Dyslipidemia improved significantly (triglycerides ?61.3 mg/dl, P < 0.0001, total cholesterol ?28.2 mg/dl, P = 0.002, and low‐density lipoprotein cholesterol were reduced ?24.5 mg/dl, P = 0.008). This resulted in a significant reduction of patients classified for MetS (27 vs. 9, P < 0.0001). Adiponectin increased by 2.08 µg/l (P = 0.032) and high sensitivity C‐reactive protein (hs‐CRP) and soluble intercellular cell adhesion molecule (sICAM) decreased (?7.3 mg/l, P < 0.0001 and ?146.4 ng/ml, P = 0.0006). AVR improved significantly (+0.04, P < 0.0001), but neither Flicker light response nor IMT changed significantly. Retinal AVR is ameliorated after bariatric intervention. As an increased AVR results from either or both widening retinal arteriolar caliber and narrowing retinal venular caliber, an improvement in small vessel profile is evident 9 months after bariatric surgery.     

Cost of In-Patient Care over 7 Years among Surgically and Conventionally Treated Obese Patients

Objective: Bariatric surgery improves cardiovascular risk factors and quality of life, but few studies have directly addressed the relation between obesity treatment and hospitalization costs. This prospective controlled study compares in-patient care between surgically and conventionally treated obese patients. Research Methods and Procedures: A total of 962 surgically and conventionally treated obese patients from the intervention study, Swedish Obese Subjects, were followed for 6 years. Changes in days of hospitalization and hospitalization costs were analyzed. Information on hospitalizations for each subject were obtained from the Swedish Hospital Discharge Register. Results: After 6 years, weight change was −16.7% in the surgical group and +0.9% in the control group (p < 0.0001). The cumulated hospital stay over 6 years was 23.4 days in the surgical group and 6.9 days in the control group (p < 0.0001). The average hospital cost for the surgical intervention was US$4300. Incremental costs that could be attributable to obesity surgery averaged US$1200 per year. After exclusion of hospitalizations for the surgical intervention and conditions common after bariatric surgery, there were no significant differences between the groups in number of hospital days or hospitalization costs. Discussion: Our experience from bariatric surgery indicates that average weight reductions of 16% will not reduce hospitalization costs over 6 years. Costs of bariatric surgery are limited and seem to be motivated given the marked improvements of cardiovascular risk factors, cardiac structure, and function and health-related quality of life.     

Characteristics of Patients Undergoing Bariatric Surgery in Canada

Objective: The increasing prevalence of obesity has led to an increased use of bariatric surgery in the treatment of severely obese individuals. The characteristics of patients undergoing bariatric procedures outside of clinical studies and on a national level have not previously been reported. Research Methods and Procedures: Acute‐care hospital discharge data from the Canadian Institute for Health Information were analyzed to determine the demographic and clinical features and in‐hospital mortality rates of individuals undergoing bariatric surgery in Canada. Data from individuals undergoing surgery in fiscal year 2002/2003 were compared with data from 1993/1994. Results: Over 1100 bariatric surgeries were performed in Canada in 2002/2003, with the vast majority being performed in middle‐aged women. Ten percent of patients had hypertension or diabetes, and only 1% or fewer had dyslipidemia or cardiovascular or cerebrovascular disease. Compared with 1993/1994, patients undergoing surgery in 2002/2003 were older, more likely to have diabetes or hypertension, and had shorter hospital stays. In‐hospital mortality rates were <1% in both years. Discussion: In the last decade, there has been a small increase in the average age and the number of patients with concomitant cardiovascular risk factors who are undergoing bariatric procedures in Canada. However, the vast majority of surgeries are being performed in middle‐aged women with little cardiovascular comorbidity, and this is likely contributing to very low in‐hospital death rates. Such individuals likely represent a highly selected sample of severely obese patients within Canada.     

Plasma visfatin concentrations in severely obese subjects are increased after intestinal bypass

Objective: Visfatin has shown to be increased in obesity and in type 2 diabetes. The aim of this study was to determine the change in plasma visfatin in severely obese (SO) persons after weight loss following bariatric surgery in relation to glucose concentration. Research Methods and Procedures: Visfatin and leptin were studied in 53 SO persons (BMI, 54.4 ± 6.8 kg/m²) before and 7 months after bariatric surgery and in 28 healthy persons (BMI, 26.8 ± 3.8 kg/m²). All of the patients underwent bariatric surgery with biliopancreatic diversion or gastric bypass. Results: The pre‐surgery levels of visfatin in the SO group were greater than in the control group (55.9 ± 39.9 vs. 42.9 ± 16.6 ng/mL, p = 0.024). This increase was significant in the SO group with impaired fasting glucose (63.4 ± 36.6 ng/mL) and diabetes (60.0 ± 46.0 ng/mL). SO patients with normal fasting glucose had similar levels of visfatin to the controls. Seven months after surgery, visfatin levels were significantly increased (84.8 ± 32.8 ng/mL, p < 0.001). This increase was independent of the pre‐surgical glucose levels. The type of bariatric surgery had no influence on visfatin levels. Post‐surgical visfatin was significantly correlated with the post‐surgery plasma concentrations of leptin (r = 0.39, p = 0.014). Discussion: Plasma levels of visfatin in the SO group were increased but only when accompanied by high glucose levels, even in the range of impaired fasting glucose. Bariatric surgery causes an increase in visfatin, which is correlated mainly with the changes produced in the leptin concentration.     

Psychosocial and Behavioral Aspects of Bariatric Surgery

Bariatric surgery has become an increasingly popular treatment option for individuals with extreme obesity (defined as a BMI ≥ 40 kg/m²) or those with less severe obesity accompanied by significant comorbidities. Sustained postoperative weight loss and improvements in obesity‐related health problems make bariatric surgery the most effective treatment for this population. Nevertheless, most experts agree that psychosocial and behavioral factors contribute to successful postoperative outcomes. This paper reviews the literature on the preoperative psychosocial status, eating behaviors, and quality of life of patients who seek bariatric surgery. In addition, the paper examines studies that investigated changes in these factors postoperatively. The review concludes with an agenda for future research in this area.     

Bariatric Surgery Patients’ Views of Their Physicians’ Weight‐Related Attitudes and Practices

Objective: A prior study found that nearly 80% of bariatric surgery patients felt that they were treated disrespectfully by members of the medical profession. This study assessed patient‐physician interactions in a group of bariatric surgery patients and in a group of less obese patients who sought weight loss by other means. Research Methods and Procedures: A total of 105 bariatric surgery candidates (mean BMI, 54.8 kg/m²) and 214 applicants to a randomized controlled trial of the effects of behavior modification and sibutramine (mean BMI, 37.8 kg/m²) completed a questionnaire that assessed patient‐physician interactions concerning weight. Results: Only 13% of bariatric surgery patients reported that they were usually or always treated disrespectfully by members of the medical profession, a percentage substantially lower than that found in the previous study. Surprisingly, surgery patients were significantly more satisfied than nonsurgery patients with the care they received for their obesity. Surgery patients also reported significantly more interactions with physicians concerning obesity and weight loss compared with nonsurgery patients. A substantial percentage of both groups, however, reported that their physician did not discuss weight control with them. Discussion: These and other findings suggest that doctor‐patient interactions concerning weight may have improved in the past decade; however, there is still much room for improvement. Increased efforts are needed to help physicians discuss, assess, and potentially treat obesity in primary care practice.     

Cardiovascular risk reduction over time in patients with diabetes or pre-diabetes undergoing bariatric surgery: data from a single-center retrospective observational study

Background

Bariatric surgery is effective in remission of obesity comorbidities. This study was aimed at comparing CVD risk between morbidly obese patients with type 2 diabetes and pre-diabetes before and after bariatric surgery as well as assessing comorbidities.

Methods

This is a retrospective observational study with 105 patients with type 2 diabetes (DMbaseline) and prediabetes (preDMbaseline) who underwent Roux-en-Y gastric bypass. Data were collected preoperative and then at 3,6,12,18,24,36,48, and 60?months after surgery. Anthropometric, cardiovascular and glycemic parameters were assessed. CVD risk was calculated using the Framingham Risk Score.

Results

Prior to surgery, 48 patients had type 2 diabetes, while 57 had pre-diabetes. Mean age was 48 (9.2) and mean BMI was 52 (7.4). 26.1% of patients had a high CVD risk. CVD risk decreased in patients with type 2 diabetes and prediabetes at month 12 after surgery compared to the baseline risk (p?<?0.001). BMI, body fat percentage, fasting plasma glucose, HbA1c, c-peptide, HOMA-IR, LDL-c, systolic blood pressure, and diastolic blood pressure decreased during the first year after surgery. From the 12th month until the 60th, they showed a flat trend, or a very mild increase in some cases. 3.2% of patients maintained high CVD risk at 60?months. Type 2 diabetes remission was 92%. No patient of the preDMbaseline group developed type 2 diabetes.

Conclusion

Bariatric surgery reduces CVD risk in type 2 diabetes and pre-diabetes. Given that patients with type 2 diabetes benefit the most, more studies are necessary to consider pre-diabetes as a criterion for metabolic surgery in patients with BMI?≥?35?kg/m².

     

Family Physicians' Practices and Attitudes Regarding Care of Extremely Obese Patients

Despite the growing epidemic of extreme obesity in the United States, weight management is not adequately addressed in primary care. This study assessed family physicians' practices and attitudes regarding care of extremely obese patients and factors associated with them. A cross‐sectional, self‐administered survey was mailed to 500 family physicians in New Jersey (NJ) during March–May 2008. Measures included knowledge, weight management approaches, attitudes toward managing obesity, challenges with examinations, availability of supplies, and strategies to improve care. Response rate was 53% (N = 255). Bariatric surgery and weight loss medications were infrequently recommended, particularly in physicians with higher volume of extremely obese patients (odds ratio (OR) 0.38; 95% confidence interval (CI) 0.23, 0.62 and OR 0.51; 95% CI 0.31, 0.85 for surgery and medications, respectively). Higher knowledge was associated with increased frequency of recommendations of weight loss medications (P < 0.0001) and bariatric surgery (P < 0.0001). There was a high prevalence of negative attitudes, particularly in younger physicians and those with lower patient volume. Increased knowledge of weight‐loss diets was associated with less dislike in discussing weight loss (P < 0.0001), less frustration (P = 0.0001), less belief that treatment is often ineffective (P < 0.0001), and less pessimism about patient success (P = 0.0002). Many providers encountered challenges performing examinations on extremely obese patients. More education of primary care physicians, particularly on bariatric surgery, specific examination techniques, and availability of community resources for obese persons is needed. Further research is needed to determine if interventions to increase knowledge of physicians will lead to less negative attitudes toward weight loss and extremely obese patients.     

Safety and efficacy of laparoscopic adjustable gastric banding in the elderly

Objective: Bariatric surgery is not usually recommended in the elderly. The aim of this study is to evaluate the safety and efficacy of laparoscopic adjustable gastric banding (LAGB) in older patients registered in the database of the Italian Group for Lap‐Band Gruppo Italiano Lap‐Band (GILB). Methods and Procedures: GILB is a centralized database which collects operative and follow‐up data from 26 Italian surgical centers who utilize the Lap‐Band System as a restrictive procedure. Patients ≥60 years were selected from the database of the GILB and analyzed according to co‐morbidities, conversion, peri‐operative complications, and weight loss. Results: Of 5,290 patients, 216 (4.1%; 184F/32M) were ≥60 years old at surgery (mean age 64.1 ± 4.0 years; range 60–83). Baseline BMI was similar in both sets of patients i.e., ≥60 and <60 years of age (44.2 ± 7.6 kg/m² vs. 44.9 ± 7.4 kg/m²). Patients ≥60 years of age were more frequently affected by co‐morbidities than patients <60 years of age. Two cases of operative mortality were observed in patients <60 years old (0.04%) and one in patients ≥60 years old (0.46%). The proportion of patients requiring revision surgery was comparable as well. Weight loss was significantly lower in elderly patients. Despite their lower weight loss, patients ≥60 years of age experienced a significant improvement of obesity‐related co‐morbidities (they showed improvement 1 year after surgery in 100% of cases of diabetes or sleep apnoea, 67.1% of cases of hypertension, and 34.9% of cases of osteoarthritis). Discussion: LAGB may be performed safely in patients ≥60 years old. Weight loss in older patients seems unsatisfactory if compared to younger subjects. However, the majority of elderly patients show an improvement in obesity‐related co‐morbidities.     

Obesity and Cardiovascular Disease Risk Factors in Firefighters: A Prospective Cohort Study

Objective: Obesity, despite being a significant determinant of fitness for duty, is reaching epidemic levels in the workplace. Firefighters’ fitness is important to their health and to public safety. Research Methods and Procedures: We examined the distribution of BMI and its association with major cardiovascular disease (CVD) risk factors in Massachusetts firefighters who underwent baseline (1996) and annual medical examinations through a statewide medical surveillance program over 5 years of follow‐up. We also evaluated firefighters’ weight change over time. Results: The mean BMI among 332 firefighters increased from 29 at baseline to 30 at the follow‐up examination (2001), and the prevalence of obesity increased from 35% to 40%, respectively (p < 0.0001). In addition, the proportion of firefighters with extreme obesity increased 4‐fold at follow‐up (from 0.6% to 2.4%, p < 0.0001). Obese firefighters were more likely to have hypertension (p = 0.03) and low high‐density lipoprotein‐cholesterol (p = 0.01) at follow‐up. Firefighters with extreme obesity had an average of 2.1 CVD risk factors (excluding obesity) in contrast to 1.5 CVD risk factors for normal‐weight firefighters (p = 0.02). Finally, on average, normal‐weight firefighters gained 1.1 pounds, whereas firefighters with BMI ≥ 35 gained 1.9 pounds per year of active duty over 5 years of follow‐up. Discussion: Obesity is a major concern among firefighters and shows worsening trends over time. Periodic medical evaluations coupled with exercise and dietary guidelines are needed to address this problem, which threatens firefighters’ health and may jeopardize public safety.     

Increased exercise capacity after surgically induced weight loss in morbid obesity

Objective: To investigate the effects of surgically induced weight loss on exercise capacity in patients with morbid obesity (MO). Research Methods and Procedures: A prospective 1‐year follow‐up study was carried out, with patients being their own controls. A symptom‐limited cardiopulmonary exercise stress test was performed in 31 MO patients (BMI > 40 kg/m²) before and 1 year after undergoing bariatric surgery. Results: At 1 year after surgery, weight was reduced from 146 ± 33 to 95 ± 19 kg (p < 0.001), and BMI went from 51 ± 4 to 33 ± 6 kg/m² (p < 0.001). After weight loss, obese patients performed each workload with lower oxygen consumption, heart rate, systolic arterial pressure, and ventilatory volume (p < 0.001). This reduced energy expenditure allowed them to increase the duration of their effort test from 13.8 ± 3.8 to 21 ± 4.2 minutes (p < 0.001). Upon finishing the exercise, MO patients before surgery were able to reach only 83% of their age‐predicted maximal heart rate, and their respiratory exchange ratio was 0.87 ± 0.06. After weight loss, those values were 90% and 1 ± 0.08, respectively (p < 0.01). When we compared the peak O₂ pulse corrected by fat free mass before and after surgery, no significant differences between the groups were found. Discussion: After surgically induced weight loss, MO patients markedly improved their exercise capacity. This is due to the fact that they were able to perform the external work with lower energy expenditure and also to increase cardiovascular stress, optimizing the use of cardiac reserve. There were no differences in cardiac function before and after surgery.     

Impact of surgically induced weight loss on cardiovascular autonomic function: one-year follow-up

Objective: To determine the impact of surgically induced weight loss on cardiovascular autonomic function in subjects with severe obesity and examine whether the effect was comparable for persons with and without diabetes. Research Methods and Procedures: Twenty‐six severely obese individuals (BMI = 48 ± 7 kg/m²) underwent bariatric surgery (laparoscopic Roux‐en‐Y gastric bypass, n = 21; laparoscopic adjustable gastric banding, n = 5). Cardiovascular autonomic function (heart rate variation during deep breathing and the Valsalva maneuver) was assessed before and 6 and 12 months after surgery. Results: Twelve months after bariatric surgery, there was a 28% decrease in BMI. There was an increase in all parasympathetic indices of autonomic function (all assessment modalities, p < 0.05) with weight loss. The amount of improvement from baseline for all measures of autonomic function did not differ for those with or without diabetes. Discussion: Surgically induced weight loss 12 months after surgery has a favorable effect on cardiovascular autonomic function in severely obese individuals with and without diabetes.     

Circulating trimethylamine N‐oxide and the risk of cardiovascular diseases: a systematic review and meta‐analysis of 11 prospective cohort studies

Circulating trimethylamine N‐oxide (TMAO), a canonical metabolite from gut flora, has been related to the risk of cardiovascular disorders. However, the association between circulating TMAO and the risk of cardiovascular events has not been quantitatively evaluated. We performed a systematic review and meta‐analysis of all available cohort studies regarding the association between baseline circulating TMAO and subsequent cardiovascular events. Embase and PubMed databases were searched for relevant cohort studies. The overall hazard ratios for the developing of cardiovascular events (CVEs) and mortality were extracted. Heterogeneity among the included studies was evaluated with Cochran's Q Test and I² statistics. A random‐effect model or a fixed‐effect model was applied depending on the heterogeneity. Subgroup analysis and meta‐regression were used to evaluate the source of heterogeneity. Among the 11 eligible studies, three reported both CVE and mortality outcome, one reported only CVEs and the other seven provided mortality data only. Higher circulating TMAO was associated with a 23% higher risk of CVEs (HR = 1.23, 95% CI: 1.07–1.42, I² = 31.4%) and a 55% higher risk of all‐cause mortality (HR = 1.55, 95% CI: 1.19–2.02, I² = 80.8%). Notably, the latter association may be blunted by potential publication bias, although sensitivity analysis by omitting one study at a time did not significantly change the results. Further subgroup analysis and meta‐regression did not support that the location of the study, follow‐up duration, publication year, population characteristics or the samples of TMAO affect the results significantly. Higher circulating TMAO may independently predict the risk of subsequent cardiovascular events and mortality.     

Single nucleotide polymorphisms at the adiponectin locus and risk of coronary heart disease in men and women

Objective: The objective was to examine the association of 5 common single nucleotide polymorphisms (SNPs) at the adiponectin locus with risk of coronary heart disease (CHD) in men and women. Methods and Procedures: We genotyped five common SNPs in the adiponectin gene (rs266729, ?11365C>G; rs822395, ?4034A>C; rs822396, ?3964A>G; rs2241766, +45T>G; and rs1501299, +276G>T) in men (Health Professionals Follow‐up Study) and women (Nurses’ Health Study) in a nested case control setting. Among participants free of cardiovascular disease at baseline, 266 men and 249 women developed non‐fatal myocardial infarction or fatal CHD during 6 and 8 years of follow‐up, respectively. In addition, 564 men had coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty. Using risk set sampling, controls were selected 2:1 matched on age, smoking, and date of blood draw. Results: The ?4034CC genotype was related to an increased risk of non‐fatal myocardial infarction or fatal CHD compared with the AA genotype [relative risk (RR), men, 1.69; 95% confidence interval (CI), 0.99 to 2.89; women, 2.04; 95% CI, 1.20 to 3.49); however, this genotype was not related to risk of coronary artery bypass graft surgery or percutaneous transluminal coronary angioplasty or to plasma adiponectin levels. Other SNPs or haplotypes defined by the 5 SNPs were not consistently related to risk of CHD in men and women or to plasma adiponectin levels. Discussion: Our study does not support the hypothesis that these 5 common SNPs in the adiponectin gene play an important role in the development of CHD among men and women, although we cannot exclude an association between the ?4034CC genotype and risk of CHD.     

Long-Term Effect of Bariatric Surgery on Liver Enzymes in the Swedish Obese Subjects (SOS) Study

Background and Aim

Obesity is associated with elevated serum transaminase levels and non-alcoholic fatty liver disease and weight loss is a recommended therapeutic strategy. Bariatric surgery is effective in obtaining and maintaining weight loss. Aim of the present study was to examine the long-term effects of bariatric surgery on transaminase levels in obese individuals.

Methods

The Swedish Obese Subjects (SOS) study is a prospective controlled intervention study designed to compare the long-term effects of bariatric surgery and usual care in obese subjects. A total of 3,570 obese participants with no excess of alcohol consumption at baseline (1,795 and 1,775 in the control and surgery group, respectively) were included in the analyses. Changes in transaminase levels during follow-up were compared in the surgery and control groups.

Results

Compared to usual care, bariatric surgery was associated with lower serum ALT and AST levels at 2- and 10- year follow up. The reduction in ALT levels was proportional to the degree of weight loss. Both the incidence of and the remission from high transaminase levels were more favorable in the surgery group compared to the control group. Similarly, the prevalence of ALT/AST ratio <1 was lower in the surgery compared to the control group at both 2- and 10-year follow up.

Conclusions

Bariatric surgery results in a sustained reduction in transaminase levels and a long-term benefit in obese individuals.     

The geographic distribution of obesity in the US and the potential regional differences in misreporting of obesity

Objective: State‐level estimates of obesity based on self‐reported height and weight suggest a geographic pattern of greater obesity in the Southeastern US; however, the reliability of the ranking among these estimates assumes errors in self‐reporting of height and weight are unrelated to geographic region. Design and Methods: Regional and state‐level prevalence of obesity (body mass index ≥ 30 kg m^?2) for non‐Hispanic black and white participants aged 45 and over were estimated from multiple sources: ( 1 ) self‐reported from the behavioral risk factor surveillance system (BRFSS 2003‐2006) (n = 677,425), ( 2 ) self‐reported and direct measures from the National Health and Nutrition Examination Study (NHANES 2003‐2008) (n = 6,615 and 6,138, respectively), and ( 3 ) direct measures from the REasons for Geographic and Racial Differences in Stroke (REGARDS 2003‐2007) study (n = 30,239). Results: Data from BRFSS suggest that the highest prevalence of obesity is in the East South Central Census division; however, direct measures suggest higher prevalence in the West North Central and East North Central Census divisions. The regions relative ranking of obesity prevalence differs substantially between self‐reported and directly measured height and weight. Conclusions: Geographic patterns in the prevalence of obesity based on self‐reported height and weight may be misleading, and have implications for current policy proposals.     

Economic Impact of the Clinical Benefits of Bariatric Surgery in Diabetes Patients With BMI ≥35 kg/m2

The medical costs for a type 2 diabetes patient are two to four times greater than the costs for a patient without diabetes. Bariatric surgery is the most effective weight‐loss therapy and has marked therapeutic effects on diabetes. We estimate the economic effect of the clinical benefits of bariatric surgery for diabetes patients with BMI ≥35 kg/m². Using an administrative claims database of privately insured patients covering 8.5 million lives 1999–2007, we identify obese patients with diabetes, aged 18–65 years, who were treated with bariatric surgery identified using Healthcare Common Procedure Coding System codes. These patients were matched with nonsurgery control patients on demographic factors, comorbidities, and health‐care costs. The overall return on investment (RoI) associated with bariatric surgery was calculated using multivariate analysis. Surgery and control patients were compared postindex with respect to diagnostic claims for diabetes, diabetes medication claims, and adjusted diabetes medication and supply costs. Surgery costs were fully recovered after 26 months for laparoscopic surgery. At month 6, 28% of surgery patients had a diabetes diagnosis, compared to 74% of control patients (P < 0.001). Among preindex insulin users, insulin use dropped to 43% by month 3 for surgery patients, vs. 84% for controls (P < 0.001). By month 1, medication and supply costs were significantly lower for surgery patients (P < 0.001). The therapeutic benefits of bariatric surgery on diabetes translate into considerable economic benefits. These data suggest that surgical therapy is clinically more effective and ultimately less expensive than standard therapy for diabetes patients with BMI ≥35 kg/m².     

Familial Risk of Overweight and Obesity in the Canadian Population using the WHO/NIH Criteria

Objective: To determine the familial risk of overweight and obesity in Canada. Research Methods and Procedures: The sample was comprised of 15,245 participants from 6377 families of the Canada Fitness Survey. The risk of overweight and obesity among spouses and first‐degree relatives of individuals classified as underweight, normal weight, pre‐obese, or obese (Class I and II) according to the WHO/NIH guidelines for body mass index (BMI) was determined using standardized risk ratios. Results: Spouses and first‐degree relatives of underweight individuals have a lower risk of overweight and obesity than the general population. On the other hand, the risk of Class I and Class II obesity (BMI 35 to 39.9 kg/m²) in relatives of Class I obese (BMI 30 to 34.9 kg/m²) individuals was 1.84 (95% CI: 1.27, 2.37) and 1.97 (95% CI: 0.67, 3.25), respectively, in spouses, and 1.44 (95% CI:1.10, 1.78) and 2.05 (95% CI: 1.37, 2.73), respectively in first‐degree relatives. Further, the risk of Class II obesity in spouses and first‐degree relatives of Class II obese individuals was 2.59 (95% CI: ?0.91, 6.09) and 7.07 (95% CI: 1.48, 12.66) times the general population risk, respectively. Discussion: There is significant familial risk of overweight and obesity in the Canadian population using the BMI as an indicator. Comparison of risks among spouses and first‐degree relatives suggests that genetic factors may play a role in obesity at more extreme levels (Class II obese) more so than in moderate obesity.     

Clinical practice guidelines for the perioperative nutritional,metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by american association of clinical endocrinologists,The obesity society,and american society for metabolic & bariatric surgery*

Abstract:

The development of these updated guidelines was commissioned by the AACE, TOS, and ASMBS Board of Directors and adheres to the AACE 2010 protocol for standardized production of clinical practice guidelines (CPG). Each recommendation was re‐evaluated and updated based on the evidence and subjective factors per protocol. Examples of expanded topics in this update include: the roles of sleeve gastrectomy, bariatric surgery in patients with type‐2 diabetes, bariatric surgery for patients with mild obesity, copper deficiency, informed consent, and behavioral issues. There are 74 recommendations (of which 56 are revised and 2 are new) in this 2013 update, compared with 164 original recommendations in 2008. There are 403 citations, of which 33 (8.2%) are EL 1, 131 (32.5%) are EL 2, 170 (42.2%) are EL 3, and 69 (17.1%) are EL 4. There is a relatively high proportion (40.4%) of strong (EL 1 and 2) studies, compared with only 16.5% in the 2008 AACE‐TOS‐ASMBS CPG. These updated guidelines reflect recent additions to the evidence base. Bariatric surgery remains a safe and effective intervention for select patients with obesity. A team approach to perioperative care is mandatory with special attention to nutritional and metabolic issues.