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From the ACP Diabetes Care Guide
This tool will help calculate patient body mass index (BMI).
Provide counseling for pregnant women concerning gestational factors that can increase the risk of pregnancy and of unhealthy weight and outcomes in their offspring.
Provide counseling and preventive strategies for children who are at risk for weight gain.
Provide counseling and preventive strategies for adults who are at risk for weight gain.
Advise patients to reduce BMI and central adiposity to decrease health risks and improve quality of life, especially in patients with BMI ≥30 kg/m2.
Consider behavioral therapy with diet and exercise in overweight patients who need or want to lose weight.
Consider surgical treatment for very obese patients in whom other measures have failed.
Consider drug therapy for patients with a BMI ≥30 kg/m2, or ≥27 kg/m2 with comorbidities such as hypertension, diabetes, or dyslipidemia.
Recognize that OTC herbal preparations sold for weight loss have limited efficacy and safety data.
Provide realistic weight loss goals.
Recommend techniques to help patients adhere to lifestyle changes.
Counsel patients on adherence to drug therapy.
Provide advice on reducing weight gain when stopping smoking.
This guideline is based on the evidence report and accompanying background papers developed by the Southern California Evidence-Based Practice Center. The American College of Physicians nominated this topic to the Agency for Healthcare Research and Quality Evidence-Based Practice Center program as part of a concerted effort to complement the guidelines of the U.S. Preventive Services Task Force. The College recommends that all clinicians refer to the Task Force recommendations as part of an overall strategy for managing overweight and obesity, which should always include appropriate diet and exercise for all patients who are overweight or obese. The intent of this guideline is to provide recommendations based on a review of the evidence on pharmacologic and surgical treatments of obesity. The target audience is all clinicians caring for obese patients, defined as a body mass index of 30 kg/m2 or greater. This guideline is not intended to be used by commercial weight loss centers or for direct-to-consumer marketing by manufacturers and does not apply to patients with body mass indices below 30 kg/m2.
*This paper, written by Vincenza Snow, MD; Patricia Barry, MD, MPH; Nick Fitterman, MD; Amir Qaseem, MD, PhD, MHA; and Kevin Weiss, MD, MPH, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Kevin Weiss, MD, MPH (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Douglas K. Owens, MD; and Katherine D. Sherif, MD. Approved by the ACP Board of Regents in October 2004.
From the ACP Diabetes Care Guide
Medical Nutrition Therapy
- The Plate Method
- Healthy Food Choices
- Basic Carbohydrate Counting
- Advanced Carbohydrate Counting
- Helping Patients Succeed with Meal Planning
Physical Activity
- Lifetime Physical Activity Model
- 10,000 Steps
- Planned Aerobic Exercise Programs
- Anaerobic Exercise Programs
- Helping Patients Succeed with Exercise Plans
- What are some guidelines I can give patients to help them exercise safely?
- How should I tell my patients to manage hypoglycemia during exercise?
- What should I ask my patients at each visit to assess how they are doing with regard to physical activity?
- Can I provide tips to help patients stay more faithful to their exercise plans?
NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).
From the ACP Diabetes Care Guide
Obesity significantly increases the risk of developing type 2 diabetes, and the health consequences of obesity are more severe among patients with diabetes. In particular, central obesity is independently associated with insulin resistance and increased cardiovascular risk.
Topics in this chapter include:
- Classification of Obesity
- Helping Your Patients Lose Weight (Dietary Interventions, Pharmacologic Approaches, Surgical Approaches)
NOTE: You may order free copies of the complete ACP Diabetes Care Guide (book and CD-ROM).
SPECIAL NOTE: Page 75 has been revised.
ACP Summer Session was a two-day CME event that covered key topics and management strategies in the areas of cardiology, diabetes, pulmonary diseases, and neurological diseases. ACP Summer Session was held in Orlando, Florida on August 7-8, 2009 and in San Francisco, California on August 14-15, 2009. The following audio recordings with synchronized slides and course handouts are from the Orlando meeting and are available free to ACP members.
Login required (use ACP Online username/password)
Learn methods of approach in the management of obesity and hypertension in diabetic patients.
Learn preventive strategies to combat this problem in different areas of the world.
Learn about the prevalence and epidemiology of diabetes and obesity globally.
This session answers the following questions:
- What dietary approach really work?
- Pharmacology treatment in the obese type 2 diabetic
- Bariatric surgery: Who to treat and what to do after?
This session answers the following questions:
- What are the commonly available, advertised diets that our patients are trying?
- How do these diets work, and how much do they cost?
- Are there contraindications or risks associated with any of the diets?
- Which diets accomplish what outcomes?
- Are any commercial weight loss programs better or worse than others?
The American College of Physicians currently considers patients with a body mass index (BMI) >30 as obese, and those with a BMI between 25 and 29.9 as overweight.
The recently published Dietary Guidelines for Americans 2005 recommend at least 60 minutes per day of moderate activity for the prevention of weight gain and up to 90 minutes per day of moderate activity for weight reduction.
Physical activity and fitness reduce morbidity and mortality for coronary artery disease, hypertension, obesity, diabetes, and osteoporosis.
Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.
In one of the longest-term randomized trials of its kind, researchers compared the effects of a Mediterranean-style diet versus a typical low-fat diet for diabetes management. The trial was designed to assess the effectiveness, durability, and safety of the two diets on the need for diabetes medications in overweight patients with newly-diagnosed type 2 diabetes. Researchers randomly assigned 215 patients to follow either a low carbohydrate, Mediterranean-style diet or a low-fat diet for four years. Nutritionists and dietitians counseled both groups in monthly sessions for the first year and bimonthly sessions for the next three years. After four years, 44 percent of patients in the Mediterranean-style diet group required antihyperglycemic drug therapy compared to 70 percent in the low-fat diet group. Patients in the Mediterranean diet group also experienced greater weight loss and an improvement in some coronary risk factors.
Background:
Low-carbohydrate diets remain popular despite a paucity of scientific evidence on their effectiveness.
Objective:
To compare the effects of a low-carbohydrate, ketogenic diet program with those of a low-fat, low-cholesterol, reduced-calorie diet.
Design:
Randomized, controlled trial.
Setting:
Outpatient research clinic.
Participants:
120 overweight, hyperlipidemic volunteers from the community.
Intervention:
Low-carbohydrate diet (initially, <20 g of carbohydrate daily) plus nutritional supplementation, exercise recommendation, and group meetings, or low-fat diet (<30% energy from fat, <300 mg of cholesterol daily, and deficit of 500 to 1000 kcal/d) plus exercise recommendation and group meetings.
Measurements:
Body weight, body composition, fasting serum lipid levels, and tolerability.
Results:
A greater proportion of the low-carbohydrate diet group than the low-fat diet group completed the study (76% vs. 57%; P = 0.02). At 24 weeks, weight loss was greater in the low-carbohydrate diet group than in the low-fat diet group (mean change, -12.9% vs. -6.7%; P < 0.001). Patients in both groups lost substantially more fat mass (change, -9.4 kg with the low-carbohydrate diet vs. -4.8 kg with the low-fat diet) than fat-free mass (change, -3.3 kg vs. -2.4 kg, respectively). Compared with recipients of the low-fat diet, recipients of the low-carbohydrate diet had greater decreases in serum triglyceride levels (change, -0.84 mmol/L vs. -0.31 mmol/L [-74.2 mg/dL vs. -27.9 mg/dL]; P = 0.004) and greater increases in high-density lipoprotein cholesterol levels (0.14 mmol/L vs. -0.04 mmol/L [5.5 mg/dL vs. -1.6 mg/dL]; P < 0.001). Changes in low-density lipoprotein cholesterol level did not differ statistically (0.04 mmol/L [1.6 mg/dL] with the low-carbohydrate diet and -0.19 mmol/L [-7.4 mg/dL] with the low-fat diet; P = 0.2). Minor adverse effects were more frequent in the low-carbohydrate diet group.
Limitations:
We could not definitively distinguish effects of the low-carbohydrate diet and those of the nutritional supplements provided only to that group. In addition, participants were healthy and were followed for only 24 weeks. These factors limit the generalizability of the study results.
Conclusions:
Compared with a low-fat diet, a low-carbohydrate diet program had better participant retention and greater weight loss. During active weight loss, serum triglyceride levels decreased more and high-density lipoprotein cholesterol level increased more with the low-carbohydrate diet than with the low-fat diet.
A new study of published literature that reported the effect of dietary counseling for weight loss finds that, on average, dietary counseling has resulted in weight loss of approximately 6 percent of initial body weight (approximately 10-15 pounds) after one year, compared with people not involved in formal weight loss programs.
Approximately half the weight loss remained at three years, but almost none of the weight loss remained at five years. The study, "Meta-analysis: Effect of Dietary Counseling for Weight Loss," appears in the July 3, 2007, issue of Annals of Internal Medicine.
Researchers measured weight loss in 376 obese patients taking a daily dose of sibutramine to determine which method of delivering support for a lifestyle modification program would produce the most weight loss. Patients were randomly assigned to high-frequency face-to-face counseling, low-frequency face-to-face counseling, high-frequency telephone counseling, high-frequency e-mail counseling, or no dietician contact. After six months, the patients assigned to high-frequency telephone contact with a dietitian lost the same amount of weight as those assigned to high-frequency face-to-face counseling. Researchers conclude that telephone counseling could be a viable and cost-effective way for primary care physicians to help their obese patients lose more weight. Results appear in the Feb. 17 issue of Annals of Internal Medicine.
How does someone decide whether to have a salad or ice cream with lunch? How do cancer patients choose between different courses of chemotherapy? While these questions vary greatly in their difficulty and significance, the key to understanding how people answer them lies in a still-developing field called behavioral economics.
"Behavioral economics brings together psychology and economics to better understand how people make decisions," said Kevin Volpp, ACP Member, assistant professor of medicine and health care systems at the University of Pennsylvania School of Medicine and the Wharton School in Philadelphia. The field grew out of some economists' recent realization that, contrary to traditional economic theory, people do not always make rational decisions or choose the course of action that is in their long-term interests.
Gastric band surgery results in significantly more remission of type 2 diabetes than conventional therapy, according to the first randomized trial to compare the two treatments. It was also the first study to document the results of surgery in diabetics with BMIs of less than 35, the usual threshold for recommending bariatric surgery.
The authors of the study were guarded in their recommendations, and although they concluded that the study provided strong evidence for surgically induced weight loss for treatment of obese patients with diabetes, they also cautioned that the results need to be confirmed in a larger, more diverse population over a longer term.
SAN FRANCISCO - Diabetes and testosterone studies topped the news at ENDO 08, the Endocrine Society's 90th annual meeting held last week. Among the research of interest to internists:
- Women with type 2 diabetes and heart disease get less intensive medical treatment for, and have poorer control of, these two conditions than men. In a study of nearly 45,000 diabetics, the comorbid women were 44% more likely than the comorbid men to have high LDL, but 15% less likely to get lipid-lowering medication. The women were also 19% more likely to have uncontrolled hypertension, and 15% more likely to have poor long-term control of their blood glucose levels. The findings may explain why death from heart disease has decreased among diabetic men in the past 25 years, but hasn't decreased for diabetic women, the study's lead author said.
- For obese and overweight men with type 2 diabetes, moderate fitness levels lowered the risk of all-cause death by 40%-50% during an average follow-up of seven years. By measuring peak metabolic rate during a standard treadmill exercise tolerance test, researchers classified fitness levels as low, moderate or high. Moderate fitness reduced death risk by 40% in healthy-weight and overweight men, and 52% in obese men, while high fitness level reduced death risk by 60% in healthy-weight men, and 65% in overweight men. The results suggest all diabetics, regardless of weight, should achieve and maintain at least a moderate fitness level, a study co-author said.
The ADA has issued their 2008 Comprehensive Guidelines for Diabetes Care
Question
In obese patients, is bariatric surgery for management of type 2 diabetes cost-effective at 2 years?
Conclusion
In obese patients, bariatric surgery was cost-effective at 2 years compared with conventional therapy alone for management of type 2 diabetes.
Question
In obese patients, is bariatric surgery for management of type 2 diabetes cost-effective over the patient’s lifetime?
Conclusion
In obese patients, bariatric surgery for management of type 2 diabetes was estimated to be more effective and less costly than conventional therapy alone over the patient’s lifetime.
Question
In patients with screen-detected type 2 diabetes, does an intensive, multifactorial primary care treatment strategy reduce cardiovascular (CV) risk factors more than routine care?
Conclusion
In patients with screen-detected type 2 diabetes, an intensive, multifactorial, primary care treatment strategy reduced cardiovascular risk factors more than routine care.
Question
Does the combination of a lifestyle intervention (LSI) and metformin reduce antipsychotic-induced weight gain more than either intervention alone in schizophrenia?
Conclusion
In patients with schizophrenia, metformin plus a lifestyle intervention was better than placebo or either intervention alone for antipsychotic-associated weight gain.
Question
Does laparoscopic adjustable gastric banding (LAGB) improve glycemic control more than conventional therapy (CT) alone in obese patients with recently diagnosed type 2 diabetes?
Conclusion
Laparoscopic adjustable gastric banding improved glycemic control more than conventional therapy alone in obese patients with recently diagnosed type 2 diabetes.
Question
In overweight or obese adults who have recently lost weight, do weight-loss maintenance interventions reduce weight regain?
Conclusions
In overweight or obese adults who had recently lost weight, a personal-contact weight-loss maintenance intervention reduced weight regain more than a self-directed control condition. An Internet intervention provided early but transient benefit.
Question
In adults, do statins prevent stroke and reduce mortality?
Conclusion
Statins prevent all strokes and reduce all-cause mortality.
Question
In older men, do measures of adiposity and muscle mass predict mortality?
Conclusion
In older men, the combination of midarm muscle circumference and waist circumference best predicted mortality.
Question
In older adults, do measures of adiposity and cardiorespiratory fitness predict mortality?
Conclusion
In older adults, body mass index and cardiorespiratory fitness were predictors of mortality.
Question
In middle-aged women, what is the association between body mass index (BMI) and cancer incidence and mortality?
Conclusions
In middle-aged women, increasing body mass index was associated with increasing risk for cancer incidence and mortality overall. High body mass index increased risk for some types of cancer but reduced risk for other types.
Question
In overweight or obese persons, what is the long-term efficacy of antiobesity drugs (AODs) for reducing weight and improving health status?
Conclusion
Orlistat, sibutramine, and rimonabant reduce weight and improve some health measures in overweight and obese persons.
Question
In obese patients with type 2 diabetes mellitus, is a portion-control (PC) plate effective for weight loss?
Conclusion
A portion-control plate was effective for weight loss and decreased use of hypoglycemic medication in obese patients with type 2 diabetes mellitus.
Question
Which measures of adiposity in middle-aged adults best predict mortality?
Conclusions
The highest levels of all measures of adiposity predicted increased mortality for men. For women, measures of central adiposity were better predictors of mortality than measures of overall adiposity.
Question
In obese patients with knee osteoarthritis (OA), does weight loss reduce pain and improve functional disability?
Conclusion
Moderate weight loss improves functional disability but does not reduce pain in obese patients with knee osteoarthritis.
Question
In women 65 years of age, what is the association between measures of body composition and mortality?
Conclusions
In women 65 years of age, those with the highest values for measures of body composition did not have increased risk for mortality compared with women with the lowest values. Women in the intermediate ranges (e.g., BMI 23.4 to 29.8 kg/m2) had reduced mortality compared with the leanest women.
Question
In patients with mild-to-moderate obesity, is laparoscopic gastric band (LGB) surgery more effective than a nonsurgical diet and lifestyle intervention for promoting weight loss?
Conclusion
In patients with mild-to-moderate obesity, laparoscopic gastric band surgery was more effective than a nonsurgical diet and lifestyle intervention for weight loss and improvement of the metabolic syndrome and in quality of life.
Question
Is being obese or overweight associated with an increased risk for end-stage renal disease (ESRD)?
Conclusion
Being overweight or obese was associated with an increased risk for end-stage renal disease in community-dwelling men and women.
Question
In persons with impaired glucose tolerance, does an intensive lifestyle intervention (ILS) or treatment with metformin plus standard lifestyle recommendations prevent onset or promote resolution of the metabolic syndrome?
Conclusions
In persons with impaired glucose tolerance, an intensive lifestyle intervention or treatment with metformin plus standard lifestyle recommendations was more effective than standard lifestyle recommendations alone for preventing or delaying onset of the metabolic syndrome. Also, the intensive lifestyle intervention was more effective than metformin for preventing the metabolic syndrome.
Question
What is the evidence that pharmacologic therapies can prevent type 2 diabetes mellitus?
Conclusion
In patients with type 2 diabetes mellitus, some oral hypoglycemic agents and antiobesity drugs reduce the incidence of diabetes, but the findings are inconsistent and many studies have low patient follow-up or show high drug-related gastrointestinal adverse effects.
Question
How effective and safe are pharmacologic therapies in the treatment of obesity?
Conclusion
On average, sibutramine, phentermine, orlistat, diethylpropion, bupropion, topiramate, and fluoxetine led to 1 to 7 kg of weight loss by 6 months in obese adults with body mass index 27 kg/m2.
Question
How effective and safe are surgical treatments for obesity?
Conclusion
Evidence, mostly from observational studies, suggests that surgical treatment of obesity is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with body mass index 40 kg/m2.
Question
What is the efficacy of major commercial or organized self-help weight loss programs that provide structured in-person or online counseling?
Conclusions
1 of 5 randomized controlled trials showed that a nonmedical commercial weight loss program (Weight Watchers) was modestly effective in achieving long-term weight loss. Little evidence supports the efficacy of commercial and self-help weight loss programs.
Question
In obese patients with type 2 diabetes mellitus, is a registered dietitian–led case management (RDCM) intervention more effective than usual care (UC) for improving health indicators?
Conclusion
In obese patients with type 2 diabetes mellitus, a registered dietitian–led case management intervention was better than usual care for reducing weight, waist circumference, use of prescription medications, and improved health-related quality of life.
Question
In patients with type 2 diabetes mellitus, what is the efficacy of pharmacotherapy for weight loss?
Conclusion
In patients with type 2 diabetes mellitus, fluoxetine, orlistat, and sibutramine modestly reduce weight and fluoxetine and orlistat improve blood sugar control.
Question
What is the effectiveness of antiobesity medications in trials with 1-year follow-up?
Conclusion
Orlistat and sibutramine are modestly effective for weight loss at 1 year.
Background:
Each year millions of Americans enroll in commercial and self-help weight loss programs. Health care providers and their obese patients know little about these programs because of the absence of systematic reviews.
Purpose:
To describe the components, costs, and efficacy of the major commercial and organized self-help weight loss programs in the United States that provide structured in-person or online counseling.
Data Sources:
Review of company Web sites, telephone discussion with company representatives, and search of the MEDLINE database.
Study Selection:
Randomized trials at least 12 weeks in duration that enrolled only adults and assessed interventions as they are usually provided to the public, or case series that met these criteria, stated the number of enrollees, and included a follow-up evaluation that lasted 1 year or longer.
Data Extraction:
Data were extracted on study design, attrition, weight loss, duration of follow-up, and maintenance of weight loss.
Data Synthesis:
We found studies of eDiets.com, Health Management Resources, Take Off Pounds Sensibly, OPTIFAST, and Weight Watchers. Of 3 randomized, controlled trials of Weight Watchers, the largest reported a loss of 3.2% of initial weight at 2 years. One randomized trial and several case series of medically supervised very-low-calorie diet programs found that patients who completed treatment lost approximately 15% to 25% of initial weight. These programs were associated with high costs, high attrition rates, and a high probability of regaining 50% or more of lost weight in 1 to 2 years. Commercial interventions available over the Internet and organized self-help programs produced minimal weight loss.
Limitations:
Because many studies did not control for high attrition rates, the reported results are probably a best-case scenario.
Conclusions:
With the exception of 1 trial of Weight Watchers, the evidence to support the use of the major commercial and self-help weight loss programs is suboptimal. Controlled trials are needed to assess the efficacy and cost-effectiveness of these interventions.
This guideline is based on the evidence report and accompanying background papers developed by the Southern California Evidence-Based Practice Center. The American College of Physicians nominated this topic to the Agency for Healthcare Research and Quality Evidence-Based Practice Center program as part of a concerted effort to complement the guidelines of the U.S. Preventive Services Task Force. The College recommends that all clinicians refer to the Task Force recommendations as part of an overall strategy for managing overweight and obesity, which should always include appropriate diet and exercise for all patients who are overweight or obese. The intent of this guideline is to provide recommendations based on a review of the evidence on pharmacologic and surgical treatments of obesity. The target audience is all clinicians caring for obese patients, defined as a body mass index of 30 kg/m2 or greater. This guideline is not intended to be used by commercial weight loss centers or for direct-to-consumer marketing by manufacturers and does not apply to patients with body mass indices below 30 kg/m2.
*This paper, written by Vincenza Snow, MD; Patricia Barry, MD, MPH; Nick Fitterman, MD; Amir Qaseem, MD, PhD, MHA; and Kevin Weiss, MD, MPH, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Kevin Weiss, MD, MPH (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Douglas K. Owens, MD; and Katherine D. Sherif, MD. Approved by the ACP Board of Regents in October 2004.
Background:
In response to the increase in obesity, pharmacologic treatments for weight loss have become more numerous and more commonly used.
Purpose:
To assess the efficacy and safety of weight loss medications approved by the U.S. Food and Drug Administration and other medications that have been used for weight loss.
Data Sources:
Electronic databases, experts in the field, and unpublished information.
Study Selection:
Up-to-date meta-analyses of sibutramine, phentermine, and diethylpropion were identified. The authors assessed in detail 50 studies of orlistat, 13 studies of fluoxetine, 5 studies of bupropion, 9 studies of topiramate, and 1 study each of sertraline and zonisamide. Meta-analysis was performed for all medications except sertraline, zonisamide, and fluoxetine, which are summarized narratively.
Data Extraction:
The authors abstracted information about study design, intervention, co-interventions, population, outcomes, and methodologic quality, as well as weight loss and adverse events from controlled trials of medication.
Data Synthesis:
All pooled weight loss values are reported relative to placebo. A meta-analysis of sibutramine reported a mean difference in weight loss of 4.45 kg (95% CI, 3.62 to 5.29 kg) at 12 months. In the meta-analysis of orlistat, the estimate of the mean weight loss for orlistat-treated patients was 2.89 kg (CI, 2.27 to 3.51 kg) at 12 months. A recent meta-analysis of phentermine and diethylpropion reported pooled mean differences in weight loss at 6 months of 3.6 kg (CI, 0.6 to 6.0 kg) for phentermine-treated patients and 3.0 kg (CI, −1.6 to 11.5 kg) for diethylpropion-treated patients. Weight loss in fluoxetine studies ranged from 14.5 kg of weight lost to 0.4 kg of weight gained at 12 or more months. For bupropion, 2.77 kg (CI, 1.1 to 4.5 kg) of weight was lost at 6 to 12 months. Weight loss due to topiramate at 6 months was 6.5% (CI, 4.8% to 8.3%) of pretreatment weight. With one exception, long-term studies of health outcomes were lacking. Significant side effects that varied by drug were reported.
Limitations:
Publication bias may exist despite a comprehensive search and despite the lack of statistical evidence for the existence of bias. Evidence of heterogeneity was observed for all meta-analyses.
Conclusions:
Sibutramine, orlistat, phentermine, probably diethylpropion, bupropion, probably fluoxetine, and topiramate promote modest weight loss when given along with recommendations for diet. Sibutramine and orlistat are the 2 most-studied drugs.
Background:
Controversy exists regarding the effectiveness of surgery for weight loss and the resulting improvement in health-related outcomes.
Purpose:
To perform a meta-analysis of effectiveness and adverse events associated with surgical treatment of obesity.
Data Sources:
MEDLINE, EMBASE, Cochrane Controlled Trials Register, and systematic reviews.
Study Selection:
Randomized, controlled trials; observational studies; and case series reporting on surgical treatment of obesity.
Data Extraction:
Information about study design, procedure, population, comorbid conditions, and adverse events.
Data Synthesis:
The authors assessed 147 studies. Of these, 89 contributed to the weight loss analysis, 134 contributed to the mortality analysis, and 128 contributed to the complications analysis. The authors identified 1 large, matched cohort analysis that reported greater weight loss with surgery than with medical treatment in individuals with an average body mass index (BMI) of 40 kg/m2 or greater. Surgery resulted in a weight loss of 20 to 30 kg, which was maintained for up to 10 years and was accompanied by improvements in some comorbid conditions. For BMIs of 35 to 39 kg/m2, data from case series strongly support superiority of surgery but cannot be considered conclusive. Gastric bypass procedures result in more weight loss than gastroplasty. Bariatric procedures in current use (gastric bypass, laparoscopic adjustable gastric band, vertical banded gastroplasty, and biliopancreatic diversion and switch) have been performed with an overall mortality rate of less than 1%. Adverse events occur in about 20% of cases. A laparoscopic approach results in fewer wound complications than an open approach.
Limitations:
Only a few controlled trials were available for analysis. Heterogeneity was seen among studies, and publication bias is possible.
Conclusions:
Surgery is more effective than nonsurgical treatment for weight loss and control of some comorbid conditions in patients with a BMI of 40 kg/m2 or greater. More data are needed to determine the efficacy of surgery relative to nonsurgical therapy for less severely obese people. Procedures differ in efficacy and incidence of complications.
Background:
The association of body mass index and gastroesophageal reflux disease (GERD), including its complications (esophagitis, Barrett esophagus, and esophageal adenocarcinoma), is unclear.
Purpose:
To conduct a systematic review and meta-analysis to estimate the magnitude and determinants of an association between obesity and GERD symptoms, erosive esophagitis, Barrett esophagus, and adenocarcinoma of the esophagus and of the gastric cardia.
Data Sources:
MEDLINE search between 1966 and October 2004 for published full studies.
Study Selection:
Studies that provided risk estimates and met criteria on defining exposure and reporting outcomes and sample size.
Data Extraction:
Two investigators independently performed standardized search and data abstraction. Unadjusted and adjusted odds ratios for individual outcomes were obtained or calculated for each study and were pooled by using a random-effects model.
Data Synthesis:
Nine studies examined the association of body mass index (BMI) with GERD symptoms. Six of these studies found statistically significant associations. Six of 7 studies found significant associations of BMI with erosive esophagitis, 6 of 7 found significant associations with esophageal adenocarcinoma, and 4 of 6 found significant associations with gastric cardia adenocarcinoma. In data from 8 studies, there was a trend toward a dose–response relationship with an increase in the pooled adjusted odds ratios for GERD symptoms of 1.43 (95% CI, 1.158 to 1.774) for BMI of 25 kg/m2 to 30 kg/m2 and 1.94 (CI, 1.468 to 2.566) for BMI greater than 30 kg/m2. Similarly, the pooled adjusted odds ratios for esophageal adenocarcinoma for BMI of 25 kg/m2 to 30 kg/m2 and BMI greater than 30 kg/m2 were 1.52 (CI, 1.147 to 2.009) and 2.78 (CI, 1.850 to 4.164), respectively.
Limitations:
Heterogeneity in the findings was present, although it was mostly in the magnitude of statistically significant positive associations. No studies in this review examined the association between Barrett esophagus and obesity.
Conclusion:
Obesity is associated with a statistically significant increase in the risk for GERD symptoms, erosive esophagitis, and esophageal adenocarcinoma. The risk for these disorders seems to progressively increase with increasing weight.
Obesity is a major risk factor for heart disease. In the face of obesity's growing prevalence, it is important for physicians to be aware of emerging research of novel mechanisms through which adiposity adversely affects the heart. Conventional wisdom suggests that either hemodynamic (that is, increased cardiac output and hypertension) or metabolic (that is, dyslipidemic) derangements associated with obesity may predispose individuals to coronary artery disease and heart failure. The purpose of this review is to highlight a novel mechanism for heart disease in obesity whereby excessive lipid accumulation within the myocardium is directly cardiotoxic and causes left ventricular remodeling and dilated cardiomyopathy. Studies in animal models of obesity reveal that intracellular accumulation of triglyceride renders organs dysfunctional, which leads to several well-recognized clinical syndromes related to obesity (including type 2 diabetes). In these rodent models, excessive lipid accumulation in the myocardium causes left ventricular hypertrophy and nonischemic, dilated cardiomyopathy. Novel magnetic resonance spectroscopy techniques are now available to quantify intracellular lipid content in the myocardium and various other human tissues, which has made it possible to translate these studies into a clinical setting. By using this technology, we have recently begun to study the role of myocardial steatosis in the development of obesity-specific cardiomyopathy in humans. Recent studies in healthy individuals and patients with heart failure reveal that myocardial lipid content increases with the degree of adiposity and may contribute to the adverse structural and functional cardiac adaptations seen in obese persons. These studies parallel the observations in obese animals and provide evidence that myocardial lipid content may be a biomarker and putative therapeutic target for cardiac disease in obese patients.
Background:
Dietary and lifestyle modification efforts are the primary treatments for people who are obese or overweight. The effect of dietary counseling on long-term weight change is unclear.
Purpose:
To perform a meta-analysis of the effect of dietary counseling compared with usual care on body mass index (BMI) over time in adults.
Data Sources:
Early studies (1980 through 1997) from a previously published systematic review; MEDLINE and the Cochrane Central Register of Controlled Trials from 1997 through July 2006.
Study Selection:
English-language randomized, controlled trials (≥16 weeks in duration) in overweight adults that reported the effect of dietary counseling on weight. The authors included only weight loss studies with a dietary component.
Data Extraction:
Single reviewers performed full data extraction; at least 1 additional reviewer reviewed the data.
Data Synthesis:
Random-effects model meta-analyses of 46 trials of dietary counseling revealed a maximum net treatment effect of −1.9 (95% CI, −2.3 to −1.5) BMI units (approximately −6%) at 12 months. Meta-analysis of changes in weight over time (slopes) and meta-regression suggest a change of approximately −0.1 BMI unit per month from 3 to 12 months of active programs and a regain of approximately 0.02 to 0.03 BMI unit per month during subsequent maintenance phases. Different analyses suggested that calorie recommendations, frequency of support meetings, inclusion of exercise, and diabetes may be independent predictors of weight change.
Limitations:
The interventions, study samples, and weight changes were heterogeneous. Studies were generally of moderate to poor methodological quality. They had high rates of missing data and failed to explain these losses. The meta-analytic techniques could not fully account for these limitations.
Conclusions:
Compared with usual care, dietary counseling interventions produce modest weight losses that diminish over time. In future studies, minimizing loss to follow-up and determining which factors result in more effective weight loss should be emphasized.
Bariatric surgery leads to substantial and durable weight reduction. Nearly 30% of patients who undergo bariatric surgery have type 2 diabetes, and for many of them, diabetes resolves after surgery (84% to 98% for bypass procedures and 48% to 68% for restrictive procedures). Glycemic control improves in part because of caloric restriction but also because gut peptide secretion changes. Gut peptides, which mediate the enteroinsular axis, include the incretins glucagon-like peptide-1 and glucose-dependent insulinotropic peptide, as well as ghrelin and peptide YY. Bariatric surgery (particularly bypass procedures) alters secretion of these gut hormones, which results in enhanced insulin secretion and sensitivity. This review discusses the various bariatric procedures and how they alter the enteroinsular axis. Familiarity with these effects can help physicians decide among the different surgical procedures and avoid postoperative hypoglycemia.
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ACP Journal Club
Annals of Internal Medicine
ACP Internist
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