Transcript Update In Obesity Assessment and Treatment

Primary Care Counseling for
Obesity, Nutrition,
and Physical Activity
2013
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
Surgery
Pharmacotherapy
Lifestyle Modification
Diet
Physical Activity
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Impact of Weight Loss on Risk Factors
~5%
Weight Loss
1
HbA1c
Blood Pressure
Total Cholesterol
HDL Cholesterol
5%-10%
Weight Loss
1
2
2
3
3
3
3
4
Triglycerides
1. Wing RR et al. Arch Intern Med. 1987;147:1749-1753; 2. Mertens IL, Van Gaal LF. Obes Res. 2000;8:270278; 3. Blackburn G. Obes Res. 1995;3 (Suppl 2):211S-216S; 4. Ditschunheit HH et al. Eur J Clin Nutr.
2002;56:264-270.
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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:
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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:

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


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
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
Weight Loss (%)
Long-term Weight Loss is Improved with
Long-term Maintenance Therapy
0
-2
-4
-6
-8
-10
-12
-14
-16
-18
No maintenance tx
Maintenance tx
Diet and
behavior
modification
therapy
0 1 2
3 4
P <0.05
5 6 7
8 9 10 11 12 13 14 15 16 17
Time (mo)
Perri et al. J Consult Clin Psychol 1988;56:529.
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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.
2.
3.
4.
5.
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
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.
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.
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.
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 weightmaintenance intervention,
adjusted for body-mass index
at randomization, Weight loss
during the low- calorie-diet
phase, sex, family Type
(single-parent family, twoparent family with one parent
as participant, or two-parent
family with both parents
as participants), center, and
age at screening, on the basis
of an intention-to-treat mixedmodel analysis.
The changes in body weight
from randomization to week 26
among participants who
completed the intervention
are 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 1924 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 musclestrengthening 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):11021.
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
 Motivation: Patient is ready to make long-term
changes in activity AND diet to lead to a lower weight
 Stress level: Patient is free of major life crises
 Psychiatric issues:
Patient does not have untreated or under treated
depression, substance abuse, bulimia nervosa
 Medical issues: Patient medical problems are stable
 Time availability: Patient can devote 15-30 min/d to
weight control for next 26 weeks
YES
Patient Ready?
Initiate weight loss
therapy
NO
Prevent weight gain and
explore barriers to weight
reduction
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
Low calorie diet
Regular physical
activity
Monitoring
weight loss
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


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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
External factors
Brain
Central Signals
Stimulate
Inhibit
NPY
Orexin-A
AGRP dynorphin
galanin
α-MSH
CART
CRH/UCN NE
GLP-I
5-HT
Peripheral signals
Glucose

CCK, GLP-1,
Apo-A-IV
Vagal afferents
Peripheral organs
Gastrointestinal
tract
Food
Intake
Insulin
+

+
Ghrelin
Emotions
Food characteristics
Lifestyle behaviors
Environmental cues
Leptin
Adipose
tissue
Cortisol
Adrenal glands
NAASO Slide Library
Drugs Approved by FDA for
Treating Obesity
•
•
•
•
Orlistat (Xenical)
Lorcaserin (Belviq)
Phentermine-topiramate (Qsymia)
Phentermine (Adipex-P,
Suprenza). (short-term only)
Key Knowledge about obesity that
change treatment approach
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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
changes treatment approach
 It is not just calories – protein, fiber, fat composition,



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


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 mattersWhile 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?
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 Guide
can be found at:
NHLBI web site:
www.nhlbi.nih.gov
The Obesity
Society web site:
www.obesity.org
Obesity-Related Resources
Professional Associations
The Obesity Society
www.obesity.org
American Academy of Family Physicians (AAFP)
www.aafp.org
American College of Sports Medicine (ACSM)
www.acsm.org
American Diabetes Association (ADA)
www.diabetes.org
American Dietetic Association (ADA)
www.eatright.org
American Gastroenterological Association (AGA)
www.gastro.org
American Heart Association (AOA)
www.americanheart.org
American Obesity Association (AOA)
www.obesity.org
American Society for Bariatric Surgery (ASBS)
www.asbs.org
Obesity-Related Resources
Government Organizations
Centers for Disease Control (CDC):
Obesity and Overweight
www.cdc.gov/nccdphp/dnpa/obesity/
index.htm
Centers for Disease Control (CDC):
Prevalence data and growth charts
www.cdc.gov/nchs/nhanes.htm
National Institutes of Health (NIH)
www.nih.gov
National Institutes of Diabetes &
www.niddk.nih.gov/health/nutrit/win.htm
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
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
Effect of Continuous and Intermittent
Phentermine Therapy on Body Weight
(Short-term only approved)
0
Weight Loss (lbs)
-4
Continuous
Dummy
-8
-12
-16
-20
Continuous
Phentermine
-24
Alternate Phentermine
and Dummy
-28
-32
0
4
8
12 16 20 24
Time (weeks)
Munro JF et al. Brit Med J 1:352, 1968
28
32
36
NAASO Slide Library
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
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.
Orlistat Prevents Fat Digestion and Absorption
by Binding to Gastrointestinal Lipases
Intestinal Lumen
Orlistat
Mucosal Cell
TG
FA
MG
Bile Acids
Micelle
TG=triglyceride; MG=monoglyceride; FA=fatty acid. NAASO Slide Libary
Effect of Long-term Orlistat
Therapy on Body Weight
Change in Weight (kg)
0
-3
-4.1 kg
Placebo
-6
-6.9 kg
-9
Orlistat
P<0.001 vs placebo
-12
0
52
104
Weeks
Torgenson et al. Diabetes Care 2004;27:155
156
NAASO Slide Library
208
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)
*All subjects had type 2 diabetes
WMD=weighted mean difference
Padwal et al. Int J Obes 2003;27:1437
-10
-5
0
Favours
Treatment
5
Favours
Control
10
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/stimulators
Antagonists/inhibitors
Adiponectin
Acetyl CoA carboxylase Agouti-related
2αMSH/MC4R
protein 11βHSD1
Central CPT1
CRH receptor
DP-IV
Endocannabinoid receptor
(rimonabant/SR141716A)
Fatty acid synthase (cerulenin; C75)
 Galanin
GIP
Ghrelin
Histamine receptor
MCH
NPY
Orexin A and B
Suppressor of cytokine signaling-3
Tyrosine phosphatase IB
Apolipoprotein A-IV
Brain-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 mimetics
Leptin; leptin receptor Oxyntomodulin
PYY
Phosphatidylinositol 3-kinase
Somatostatin
β3, serotonin, norepinephrine, dopamine
receptors
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
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:
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.