Primary Care Counseling for Obesity, Nutrition,

and Physical Activity2013

Eileen L. Seeholzer, M.D., MS Associate Prof. - Case Western University School of Medicine

Dir. Weight Management and MetroHealthy Wellness Programs

Dept. of Medicine and Center for Healthcare Research and Policy

MetroHealth Medical Center

Objectives

To describe the evidence for and tools to provide effective office counseling for: Obesity Nutrition Physical Activity

Scope of the problem in the U.S.1999-2010 data

Prevalence of adult obesity is 36% Overweight and obesity prevalence is 69% Overweight + obesity prevalence is 77-80% for non-

Hispanic blacks, Hispanics, and Mexican-Americans Obesity rates highest in lowest socioeconomic levels

and in women who self-identify a part of an ethnic minority -rates of obesity 50% in some groups

Obesity prevalence in children and adolescents is 16.9%

1. Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, 1999-2010. JAMA 2012;307(5):491-497. 2. Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of obesity and trends in body mass index among US children and adolescents, 1999-2010. JAMA 2012;307(5):483-490.

Obesity Risk Higher if:

Female, black (women), Hispanic or and native American Maternal smoking or diabetes Lower socioeconomic status Sedentary lifestyle Higher fast-food intake Increased time-spent watching TV Pregnancy (2-3kg if age 18-30) – ? more in black women Sleep deprivation (<7 hours nightly, shift work, untreated

sleep apnea) Smoking cessation – average 4-5kg Medications Injury/condition impairing ambulation/use of lower

extremities

Obesity is a chronic disease

There are many definitions of  "chronic condition", some more expansive than others. We characterize it as any condition that requires ongoing adjustments by the affected person and interactions with the health care system. © 2006-2011 Improving Chronic Illness Care

Obesity is often not reversible: Adipose tissue hyperplasia

At normal BMI ranges usually very little visceral fat is present– largely subcutaneous

With weight gain the adipocytes increase in size and then in number – both hypertrophy and hyperplasia.

Hyperplasia may not be reversible

Fat cell hyperplasia can be different depending on individual characteristics and the degree of weight gain. With more weight gain at least some hyperplasia occurs

Bray, George. Medications for Obesity: Mechanisms and Applications. Clin Chest Med 30 (2009) 525–538

Obesity Treatment Pyramid

DietDiet Physical ActivityPhysical Activity

Lifestyle ModificationLifestyle Modification

PharmacotherapyPharmacotherapy

SurgerySurgery

NAASO Slide Library

Impact of Weight Loss on Risk Factors

~5%Weight Loss

5%-10%Weight Loss

HbA1c

Blood Pressure

Total Cholesterol

HDL Cholesterol

Triglycerides

1. Wing RR et al. Arch Intern Med. 1987;147:1749-1753; 2. Mertens IL, Van Gaal LF. Obes Res. 2000;8:270-

278; 3. Blackburn G. Obes Res. 1995;3 (Suppl 2):211S-216S; 4. Ditschunheit HH et al. Eur J Clin Nutr.

2002;56:264-270.NAASO Slide Library

1

2

3

3

1

2

3

3

4

Defining Lifestyle Treatment Non-drug treatment in which an individual opts

to engage and persist in regular activities to prevent, improve, or control a medical condition.

For obesity treatments may include activities affecting: Dietary patterns and content Activity level Sleep quantity and quality Other behavioral habits

Eating and Activity Assessment and counseling are necessary medical care

Physicians are required to let a patient know the most effective preventive and treatment tools for chronic disease

A person’s activity and diet are two of their most important medications

Patients want our help to discern where their efforts are best spent

Obesity prevention/treatment, healthy diet and physical activity reduce the risk of or prevent many conditions:

Hypertension Diabetes mellitus type 2 Dyslipidemia Obstructive sleep apnea GERD Asthma Degenerative disease of weight-bearing joints Cardiovascular, cerebral, and peripheral vascular disease Breast, colorectal, and endometrial cancer Depression and anxiety Infertility and sexual dysfunction

and several cancers

Increased Risks in Pregnancy associated with Obesity Gestational Diabetes Hypertension Disordered breathing/Obstructive Sleep Apnea Cesarean section rate (RR1.5-1.8) Congenital heart defects (OR 1.4-2.0) Spina Bifida (OR 3.5) Omphalocele (OR 3.3) Increased levels of leptin, crp and tnf-alpha

Obesity treatment: Healthier eating and active living for life

The goal is to reduce fat mass and preserve or increase lean mass and fitness Diet changes drive weight loss Exercise preserves weight loss and lean

mass Pregnancy, menopause, injury, aging, and

sedentary life are particular times adipose tissue increase is likely

Rationale for Providers to Guide Lifestyle Treatment for Obesity

Patients who improve dietary, activity, and other behavioral recommendations have: better health outcomes, better social outcomes, and reduced mortality

Non-Pharmacologic Treatments

Weight loss goals of 5-15% considered achievable and sustainable,

and improve health

Components of Basic Program Diet Recommendations Exercise Recommendations Behavior Therapy Monitoring and/or follow-up life-long

All 4 components needed!

Results from Non-pharmacologic Programs Patients overwhelmingly regain the

weight if there is no long-term plan

Behavior therapy and exercise key to weight loss maintenance

High intensity interventions most effective

-18-16-14-12-10

-8-6-4-20

Long-term Weight Loss is Improved with Long-term Maintenance Therapy

Wei

ght L

oss

(%)

Perri et al. J Consult Clin Psychol 1988;56:529. NAASO Slide Library

0 1 2 3 4 5 6 7 8 9 10 11 12

Time (mo)

13 14 15 16 17

PP <0.05 <0.05

No maintenance txNo maintenance tx

Maintenance txMaintenance tx

Diet andDiet andbehaviorbehaviormodificationmodificationtherapytherapy

Look AHEAD

Unick JL, Beavers D, Bond DS et al. The Long-term Effectiveness of a Lifestyle Intervention in Severely Obese Individuals. Am J Med 2013;126(3):236-242.

Commercial Programs

Limited studies show: They can work, are often expensive, none

proven superior. More improvements in lipid profile and

fasting sugar results known in low carbohydrate diets, the new Weight Watchers, and Mediterranean diets

1. Rock CL, Flatt SW, Sherwood NE, Karanja N, Pakiz B, Thomson CA. Effect of a free prepared meal and incentivized weight loss program on weight loss and weight loss maintenance in obese and overweight women: a randomized controlled trial. JAMA 2010;304(16):1803-1810

2. Jolly K, Daley A, Adab P et al. A randomised controlled trial to compare a range of commercial or primary care led weight reduction programmes with a minimal intervention control for weight loss in obesity: the Lighten Up trial. BMC Public Health 2010;10:439.

3. Cobiac L, Vos T, Veerman L. Cost-effectiveness of Weight Watchers and the Lighten Up to a Healthy Lifestyle program. Aust N Z J Public Health 2010;34(3):240-247.

4. Brown T, Avenell A, Edmunds LD et al. Systematic review of long-term lifestyle interventions to prevent weight gain and morbidity in adults. Obes Rev 2009;10(6):627-638.

5. Morgan LM, Griffin BA, Millward DJ et al. Comparison of the effects of four commercially available weight-loss programmes on lipid-based cardiovascular risk factors. Public Health Nutr 2009;12(6):799-807.

Panel B shows the change in weight for each of the dietary Groups during the weight-maintenance intervention, adjusted for body-mass index at randomization, Weight loss during the low- calorie-diet phase, sex, family Type (single-parent family, two-parent family with one parentas participant, or two-parent family with both parentsas participants), center, and age at screening, on the basis of an intention-to-treat mixed-model analysis.

The changes in body weight from randomization to week 26 among participants who completed the interventionare also shown (boxes). HGI denotes high glycemic index, HP high protein, LGI

low glycemic index, and LP low protein.

Larsen TM, Dalskov SM, van BM, et al. Diets with high or low protein content and glycemic index for weight-loss maintenance. N.Engl.J.Med. 2010 Nov 25;363(22):2102-13

Eat a lower-calorie diet

Women Calorie guide (Kcal)

Shorter, post-menopausal, less active 1000-1200

Average height, moderately active 1200-1400

Younger, taller, moderately to very active women

1400-1800

Men Men

Shorter, less active 1400-1600

Average height, moderately active 1800-2000

Younger, taller, moderately to very active 2000-2200

Healthy plate

Prudent Dietary Recommendations for addressing obesity and cardiovascular risk factors

• Low SFA (<7%), TFA (<1%), dietary cholesterol (<200mg)• Rich in PUFA• ample fiber 30g/day – soluble fiber emphasis• nuts as able 1 oz a day and other soy and legumes• lean dairy• 5-7 servings of fruits and vegetables daily• limit sugary beverages• limit refined foods• rich in whole grains• Energy balanced to prevent weight gain• Avoid high salt food – over 450mg/serving and <2000mg/day• For many, a low calorie diet that is low in fat and refined

carbohydrates is best for long-term adherence

Van HL, McCoin M, Kris-Etherton PM et al. The evidence for dietary prevention and treatment of cardiovascular disease. J Am Diet Assoc 2008;108(2):287-33

Dietary Recommendations

Low-calorie diet better than very-low calorie diet for maintaining weight loss

Meal replacements (e.g. South Beach, Atkins, Slimfast or Glucerna) often helpful in improving success with dietary caloric adherence – best if >12g-14g protein, >5gm fiber, <7grams sugar

Portion-controlled servings also useful for weight loss adherence

Diet Recommendations

Can be achieved with plans – do not need to count- few people can count accurately

Planning, routinizing, and tracking support success

Encourage use of low or no-cost supports for both ideas and tracking like: myfitnesspal.com and sparkpeople.com

Bray, George. Medications for Obesity: Mechanisms and Applications. Clin Chest Med 30 (2009) 525–538

What modifies the REE over time?

Aerobic exercise from 40-60 minutes can raise REE the following day for 19-24 hours

Caffeine mildly raises REE Resistance work over time will increase

lean mass and raise REE for that weight Calorie restriction lowers REE Weight loss of 10-20% reduces REE –

(lasts at least 3-5 years)

Effect of exercise on body composition and energy expenditure

Moderate to vigorous aerobic activity of 35 minutes or more increases RMR the following day

Regular resistance exercise slows or prevents the loss of lean mass, preserving a higher RMR and insulin sensitivity

All activity has calorie output

Activity as a single intervention

Buchner DM. Physical activity and prevention of cardiovascular disease in older adults. Clin Geriatr Med 2009;25(4):661-75, viii.

What exercise is Recommended?

CDC/ACSM -1993: 30 min. of moderate activity most/all days of the week (also endorsed by ACOG 2012 for pregnant women with no contraindications)

AHA – 2003: 30-60 min. of activity 4-6x weekly and resistance training 2-3 x weekly

IOM - 2003: 60 minutes of physical activity daily

USPSTF – 2012: avoid inactivity; be physically active > 150 minutes/week; include muscle-strengthening activities twice weekly or more (endorsed by AAFP)

General Exercise Goal Recommendations

Aerobic Activity: 30-60 minutes of moderate to vigorous activity most days of the week (e.g. brisk walking, stationary bike, swimming)

Strengthening/Resistance 3 days a week

When do I prescribe Exercise? Research shows effective counseling

can be done in about 5 minutes Research shows patients who are

counseled to exercise by physicians have higher activity levels in the year following the counseling

Calfas, K. J.; Long, B. J.et.al. A controlled trial of physician counseling to promote the adoption of physical activity. Prev Med. 1996 May-1996 Jun 30; 25(3):225-33.

Long, B. J.; Calfas, K. J, et.al. A multisite field test of the acceptability of physical activity counseling in primary care: project PACE. Am J Prev Med. 1996 Mar-1996 Apr 30; 12(2):73-81.

Lewis, B. S. and Lynch, W. D. The effect of physician advice on exercise behavior. Prev Med. 1993 Jan; 22(1):110-21.

Where does a patient begin Reducing TV time is a free way for a patient to reduce

sedentary activity and possibly reduce calories

Activities should include safe, weather independent, and cost neutral options

Activities should be chosen in part on patients personal preference

Scheduling time or making daily weekly goals help patients maintain routines (step/day or minute/week goals)

Small bouts at work / home

Assessing Weight Loss Readiness MotivationMotivation:: Patient is ready to make long-term Patient is ready to make long-term

changes in activity AND diet to lead to a lower weightchanges in activity AND diet to lead to a lower weight

Stress level:Stress level: Patient is f Patient is free of major life crisesree of major life crises

Psychiatric issues:Patient does not have untreated or under treated depression, substance abuse, bulimia nervosa

Medical issuesMedical issues:: Patient medical problems are stable Patient medical problems are stable

Time availability:Time availability: Patient can devote 15-30 min/d to Patient can devote 15-30 min/d to weight control for next 26 weeksweight control for next 26 weeks

Patient Ready?Patient Ready?Patient Ready?Patient Ready?

Prevent weight gain and Prevent weight gain and explore barriers to weight explore barriers to weight

reductionreduction

Initiate weight loss Initiate weight loss therapytherapy

YESYES NONO

Clinical Guidelines on the Identification, Evaluation and Treatment of overweight and Obesity in Adults, NIH – NHLBI 1998

Assess values and motivators

The effort of lifestyle change is great Motivations vary Persistence is linked to how connected a

person is to his or her motivator Values like responsibility, self-concern,

and honesty may be key to making and adapting plans

Four Components of Successful Weight Loss

Weight loss goal

Monitoring weight loss

Regular physical activity

Low calorie diet

Build in Monitoring - Success and persistence linked to keeping records or high structure

Journal Reflect on data Daily to weekly weights Goal setting

Lifestyle management: Processes to be tended and amended

Sustainable Choices fit Values Plans to reduce barriers Preferences – convenience, type Resources – time, money, place Finances Ability

Lifestyle management: Connect patients to local resources

Refer to programs – nutritionists, Weight management clinic, behaviorists, appropriate commercial diets, self-help groups, local recreation centers, local produce programs

Encourage investigation and experimentation

Encourage persistence, flexibility, and hope

Document the plan

Type of goal: dietary, activity, other Tools to achieve: stuff, time, people,

places, skills, knowledge Date for start Resources needed: people, places

things Anticipated barriers Strategies Assess and redesign

How do I follow-up with clients/patients?

Research shows that appointments 1-2 times a month for at least 16 weeks are most effective in establishing behavior changes. Long-term frequent follow-up needed for maintenance.

Follow-up can be in person, group visit, on-line or by phone

Pick your counseling tool

Solution-focused brief therapy 5 As Motivational interviewing Personal improvement (systems approach) Diet and activity prescriptions

Make your approach: Non-judgmental Patient-centered Focused Documentation friendly

Regulation of Food Intake

BrainBrain

NPYAGRPgalanin

Orexin-Adynorphin

StimulateStimulateα-MSHCRH/UCNGLP-I

CARTNE5-HT

InhibitInhibit

Central SignalsCentral Signals

Glucose

CCK, GLP-1,Apo-A-IVVagal afferents

Insulin

Ghrelin

Leptin

Cortisol

Peripheral signalsPeripheral signals PeripheralPeripheral organsorgans

+

+

Gastrointestinaltract

Adiposetissue

FoodIntake

Adrenal glands

External factorsEmotionsFood characteristicsLifestyle behaviorsEnvironmental cues

NAASO Slide Library

Drugs Approved by FDA for Treating Obesity

• Orlistat (Xenical)• Lorcaserin (Belviq) • Phentermine-topiramate (Qsymia)• Phentermine (Adipex-P,

Suprenza). (short-term only)

Obesity is not fair Other diseases promote obesity and impede its treatment How much and how well we sleep matters It really is unfair for women – pregnancy, motherhood,

and menopause provide additional challenges and opportunities

Obesity is not always reversible, and its control with treatment is variable

Average activity levels currently lead to decreased lean mass quantity and quality. This decrease has profound implications for obesity and chronic disease prevention and treatment

Exercise cannot over-come high calorie-dense foods for many people

Key Knowledge about obesity that change treatment approach

It is not just calories – protein, fiber, fat composition, sugar, and other factors affect: satiety and satiation, blood pressure, lipids, insulin sensitivity

Some foods make you hungry When we eat matters The goal is to teach people basic concepts to assess,

adjust and adapt as change is relentless Healthcare providers have more impact when they are

engaged, not perfect, in making healthy lifestyle choices The environment matters- While everyone does not get “sick” in high risk

environments, fewer can stay well, get better, improve optimally

We all work harder to make good choices in less healthy environments – do we really want to work that hard?

Key Knowledge about obesity that changes treatment approach

Conclusion

Obesity is a chronic disease influenced by multiple endocrine pathways that influence eating behaviors and activity levels

Neuroendocrine substances that are made in the brain, the gastrointestinal system, and the adipose tissue are just being elucidated.

Obesity treatment requires behavioral treatment and may require pharmacologic and sometimes invasive treatment to produce optimal disease control

Obesity Treatment Guidelines

The Practical GuideThe Practical Guidecan be found at:can be found at:

NHLBI web site:www.nhlbi.nih.gov

The Obesity Society web site:www.obesity.org

Obesity-Related ResourcesProfessional Associations

The Obesity Society

American Academy of Family Physicians (AAFP)

American College of Sports Medicine (ACSM)

American Diabetes Association (ADA)

American Dietetic Association (ADA)

American Gastroenterological Association (AGA)

American Heart Association (AOA)

American Obesity Association (AOA)

American Society for Bariatric Surgery (ASBS)

www.obesity.org

www.aafp.org

www.acsm.org

www.diabetes.org

www.eatright.org

www.gastro.org

www.americanheart.org

www.obesity.org

www.asbs.org

Centers for Disease Control (CDC): Obesity and Overweight

Centers for Disease Control (CDC): Prevalence data and growth charts

National Institutes of Health (NIH)

National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK) Weight-Control Information Network (WIN)

National Institutes of Diabetes & Digestive & Kidney Diseases (NIDDK) Weight Loss and Control

National Library of Medicine, MEDLINE Plus

Obesity-Related ResourcesGovernment Organizations

www.cdc.gov/nccdphp/dnpa/obesity/ index.htm

www.cdc.gov/nchs/nhanes.htm

www.nih.gov

www.niddk.nih.gov/health/nutrit/win.htm

www.niddk.nih.gov/health/nutrit/nutrit. htm

www.nlm.nih.gov/medlineplus/obesity.html

Weight friendly medications NOT approved for Obesity treatment

Anti-epileptics Topiramate Zonisamide

Incretins Exenatide Liraglutide Pramlintide and other amylin analogues

-32

-28

-24

-20

-16

-12

-8

-4

0

Effect of Continuous and Intermittent Phentermine Therapy on Body Weight(Short-term only approved)

0

Time (weeks)

8 24 28

Munro JF et al. Brit Med J 1:352, 1968 NAASO Slide Library

Wei

ght L

oss

(lbs)

364 12 16 20 32

Alternate Phentermine and Dummy

ContinuousPhentermine

Continuous Dummy

Allison DB, Gadde KM, Garvey WT et al. Controlled-Release Phentermine/Topiramate in Severely Obese Adults: A Randomized Controlled Trial (EQUIP). Obesity (Silver Spring) 2012;20(2):330-342.

Allison DB, Gadde KM, Garvey WT et al. Controlled-Release Phentermine/Topiramate in Severely Obese Adults: A Randomized Controlled Trial (EQUIP). Obesity (Silver Spring) 2012;20(2):330-342.

Controlled-Release Phentermine/Topiramate in Severely Obese Adults

Allison DB, Gadde KM, Garvey WT et al. Controlled-Release Phentermine/Topiramate in Severely Obese Adults: A Randomized Controlled Trial (EQUIP). Obesity (Silver Spring) 2012;20(2):330-342.

Controlled-Release Phentermine/Topiramate in Severely Obese Adults

Orlistat Prevents Fat Digestion and Absorption by Binding to Gastrointestinal Lipases

TG=triglyceride; MG=monoglyceride; FA=fatty acid. NAASO Slide Libary

Mucosal CellMucosal CellIntestinal LumenIntestinal Lumen

OrlistatOrlistat TGTG

LIPASELIPASE

LIPASELIPASE

LIPASELIPASE

Bile AcidsBile AcidsMicelleMicelle

MGMGFAFA

-12

-9

-6

-3

0

Effect of Long-term Orlistat Therapy on Body Weight

0Weeks

52

Torgenson et al. Diabetes Care 2004;27:155 NAASO Slide Library

Cha

nge

in W

eigh

t (kg

)

104 156 208

P<0.001 vs placebo

-4.1 kg

-6.9 kg

Placebo

Orlistat

Meta-analysis of RCTs Evaluating Effect of Orlistat Therapy on Weight Loss at 1-Year

Study or Sub-category

WMD (random)95% CI

Hollander 1998*

Sjostrom 1998

Davidson 1999

Finer 2000

Heuptman 2000

Lindgarde 2000

Rossner 2000

Bakris 2002

Broom 2002

Kelley 2002*

Miles 2002*

Total (95% CI)

Padwal et al. Int J Obes 2003;27:1437

*All subjects had type 2 diabetesWMD=weighted mean difference

FavoursTreatment

FavoursControl

-10 -5 0 105

Food and the Incretins:Glucagon-like-peptide (GLP-1)

Site of Synthesis: secreted of the L- cells distal small intestine, Also made in the NTS, hypothalamus and amygdala

Site(s) of action: Inhibits NPY neurons and stimulates the POMC system, PYY decreases ghrelin levels, activates neurons in the area postrema of the PVN

Factors affecting production: secreted in response to rapid passage of food to hindgut with contact with chyme

Major known effects: increases insulin secretion and increases insulin sensitivity. It leads to decreased food ingestion and weight.

GLP-1 receptor agonists (i.e. exenatide, liraglutide) Mechanism: long-acting synthetic peptide that

is a GLP-1 receptor agonist Currently twice daily or daily subcutaneous dosing Weekly dosing in release

Side effects: Most common is nausea Hypoglycemia as discussed prior Weight loss ?increase in INR in patients on coumadin Local reaction/allergy ?rare pancreatitis

TABLE 1 -- Potential targets for new obesity treatments

Agonists/stimulatorsAdiponectin 2αMSH/MC4R Apolipoprotein A-IVBrain-derived neurotrophic factor/TrkB receptor CCK/CCK-A receptor CNTF/axokine Cocaine- and amphetaimine-regulated transcript GLP-1/exendin-4 Human GH fragment (AOD9604) Insulin mimeticsLeptin; leptin receptor OxyntomodulinPYYPhosphatidylinositol 3-kinase Somatostatin β3, serotonin, norepinephrine, dopamine receptors

Antagonists/inhibitorsAcetyl CoA carboxylase Agouti-related protein 11βHSD1Central CPT1CRH receptorDP-IVEndocannabinoid receptor (rimonabant/SR141716A)Fatty acid synthase (cerulenin; C75) Galanin GIPGhrelinHistamine receptorMCHNPYOrexin A and BSuppressor of cytokine signaling-3Tyrosine phosphatase IB

Korner J - J Clin Endocrinol Metab - 01-JUN-2004; 89(6): 2616-21

Brethauer, Stacy A. Sleeve Gastrectomy. Surgical Clinics of North America; Volume 91, Issue 6 (December 2011).  

Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.

Mackey RH, Belle SH, Courcoulas AP et al. Distribution of 10-year and lifetime predicted risk for cardiovascular disease prior to surgery in the longitudinal assessment of bariatric surgery-2 study. Am J Cardiol 2012;110(8):1130-1137.

Bariatric Outcomes from SOS The Swedish Obese Subjects (SOS) study is an ongoing, nonrandomized, prospective,

controlled study in Sweden of 2010 obese participants who underwent bariatric surgery and 2037 contemporaneously matched obese controls between Surgery patients underwent gastric bypass (13.2%), banding (18.7%), or vertical banded gastroplasty (68.1%), and controls

MAIN OUTCOME : The primary end point of the SOS study (total mortality) There were 129 deaths in the control group and 101 deaths in the surgery group. The unadjusted overall hazard ratio was 0.76 in the surgery group (P=0.04), as compared with the control group, and the hazard ratio adjusted for sex, age, and risk factors was 0.71 (P=0.01). The most common causes of death were myocardial infarction (control group, 25 subjects; surgery group, 13 subjects) and cancer (control group, 47; surgery group, 29).

Bariatric surgery was associated with a reduced number of cardiovascular deaths (28 events among 2010 patients in the surgery group vs 49 events among 2037 patients in the control group; adjusted hazard ratio [HR], 0.47; 95% CI, 0.29-0.76; P = .002). The number of total first time (fatal or nonfatal) cardiovascular events was lower in the surgery group (199 events among 2010 patients) than in the control group (234 events among 2037 patients; adjusted HR, 0.67; 95% CI, 0.54-0.83; P < .001). average of 10.9 years of follow-up.

 1.Sjostrom L, Peltonen M, Jacobson P et al. Bariatric surgery and long-term cardiovascular events. JAMA 2012;307(1):56-65. 2.Sjostrom L, Narbro K, Sjostrom CD et al. Effects of bariatric surgery on mortality in Swedish obese subjects. N Engl J Med 2007;357(8):741-752

Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.

Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.

Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.

Heneghan HM, Meron-Eldar S, Brethauer SA, Schauer PR, Young JB. Effect of bariatric surgery on cardiovascular risk profile. Am J Cardiol 2011;108(10):1499-1507.

Brethauer, Stacy A. Sleeve Gastrectomy. Surgical Clinics of North America; Volume 91, Issue 6 (December 2011).  

Comparison of surgical and lifestyle intervention for obesity on DM and cardiovascular risk factors

Hofso D, Nordstrand N, Johnson LK et al. Obesity-related cardiovascular risk factors after weight loss: a clinical trial comparing gastric bypass surgery and intensive lifestyle intervention. Eur J Endocrinol 2010;163(5):735-745.

DESIGN: One-year controlled clinical trial

METHODS: Morbidly obese subjects (19-66 years, mean (s.d.) body mass index 45.1 kg/m(2) (5.6), 103 women) were treated with either Roux-en-Y gastric bypass surgery (n=80) or intensive lifestyle intervention at a rehabilitation centre (n=66). The dropout rate within both groups was 5%.

RESULTS: Among the 76 completers in the surgery group and the 63 completers in the lifestyle group, mean (s.d.) 1-year weight loss was 30% (8) and 8% (9) respectively. Beneficial effects on glucose metabolism, blood pressure, lipids and low-grade inflammation were observed in both groups. Remission rates of type 2 diabetes and hypertension were significantly higher in the surgery group than the lifestyle intervention group; 70 vs 33%, P=0.027, and 49 vs 23%, P=0.016. The improvements in glycaemic control and blood pressure were mediated by weight reduction. The surgery group experienced a significantly greater reduction in the prevalence of metabolic syndrome, albuminuria and electrocardiographic left ventricular hypertrophy than the lifestyle group. Gastrointestinal symptoms and symptomatic postprandial hypoglycaemia developed more frequently after gastric bypass surgery than after lifestyle intervention. There were no deaths.

CONCLUSIONS: Type 2 diabetes and obesity-related cardiovascular risk factors were improved after both treatment strategies. However, the improvements were greatest in those patients treated with gastric bypass surgery.Citation: