Obesity: Apovian CM

Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J, Guven S, Anonymous00032, Anonymous00033, Anonymous00034. · No affiliation provided · Obesity (Silver Spring). · Pubmed #19319140 No free full text.

Abstract: American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist health-care professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. · No affiliation provided · Surg Obes Relat Dis. · Pubmed #18848315 No free full text.

Abstract: American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice are systematically developed statements to assist healthcare professionals in medical decision making for specific clinical conditions. Most of the content herein is based on literature reviews. In areas of uncertainty, professional judgment was applied. These guidelines are a working document that reflects the state of the field at the time of publication. Because rapid changes in this area are expected, periodic revisions are inevitable. We encourage medical professionals to use this information in conjunction with their best clinical judgment. The presented recommendations may not be appropriate in all situations. Any decision by practitioners to apply these guidelines must be made in light of local resources and individual patient circumstances. The American Society for Parenteral & Enteral Nutrition fully endorses sections of these guidelines that address the metabolic and nutritional management of the bariatric surgical patient.

Mechanick JI, Kushner RF, Sugerman HJ, Gonzalez-Campoy JM, Collazo-Clavell ML, Guven S, Spitz AF, Apovian CM, Livingston EH, Brolin R, Sarwer DB, Anderson WA, Dixon J. · No affiliation provided · Endocr Pract. · Pubmed #18723418 No free full text.

This publication has no abstract.

Villareal DT, Apovian CM, Kushner RF, Klein S, Anonymous00076, Anonymous00077. · Division of Geriatrics and Nutritional Sciences, Center for Human Nutrition, Washington University School of Medicine, St. Louis, MO 63110, USA. · Obes Res. · Pubmed #16339115 No free full text.

Abstract: Obesity causes serious medical complications and impairs quality of life. Moreover, in older persons, obesity can exacerbate the age-related decline in physical function and lead to frailty. However, appropriate treatment for obesity in older persons is controversial because of the reduction in relative health risks associated with increasing body mass index and the concern that weight loss could have potential harmful effects in the older population. This joint position statement from the American Society for Nutrition and NAASO, The Obesity Society reviews the clinical issues related to obesity in older persons and provides health professionals with appropriate weight-management guidelines for obese older patients. The current data show that weight-loss therapy improves physical function, quality of life, and the medical complications associated with obesity in older persons. Therefore, weight-loss therapy that minimizes muscle and bone losses is recommended for older persons who are obese and who have functional impairments or medical complications that can benefit from weight loss.

Villareal DT, Apovian CM, Kushner RF, Klein S, Anonymous00250, Anonymous00251. · Division of Geriatrics and Nutritional Sciences and Center for Human Nutrition, Washington University School of Medicine, St Louis, MO 63110, USA. · Am J Clin Nutr. · Pubmed #16280421 links to  free full text

Abstract: Obesity causes serious medical complications and impairs quality of life. Moreover, in older persons, obesity can exacerbate the age-related decline in physical function and lead to frailty. However, appropriate treatment for obesity in older persons is controversial because of the reduction in relative health risks associated with increasing body mass index and the concern that weight loss could have potential harmful effects in the older population. This joint position statement from the American Society for Nutrition and the NAASO, The Obesity Society reviews the clinical issues related to obesity in older persons and provides health professionals with appropriate weight-management guidelines for obese older patients. The current data show that weight-loss therapy improves physical function, quality of life, and the medical complications associated with obesity in older persons. Therefore, weight-loss therapy that minimizes muscle and bone losses is recommended for older persons who are obese and who have functional impairments or medical complications that can benefit from weight loss.

Apovian CM. · No affiliation provided · JAMA. · Pubmed #15328331 No free full text.

This publication has no abstract.

Blackburn GL, Hutter MM, Harvey AM, Apovian CM, Boulton HR, Cummings S, Fallon JA, Greenberg I, Jiser ME, Jones DB, Jones SB, Kaplan LM, Kelly JJ, Kruger RS, Lautz DB, Lenders CM, Lonigro R, Luce H, McNamara A, Mulligan AT, Paasche-Orlow MK, Perna FM, Pratt JS, Riley SM, Robinson MK, Romanelli JR, Saltzman E, Schumann R, Shikora SA, Snow RL, Sogg S, Sullivan MA, Tarnoff M, Thompson CC, Wee CC, Ridley N, Auerbach J, Hu FB, Kirle L, Buckley RB, Annas CL. · Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA. · Obesity (Silver Spring). · Pubmed #19396063 No free full text.

Abstract: Rapid shifts in the demographics and techniques of weight loss surgery (WLS) have led to new issues, new data, new concerns, and new challenges. In 2004, this journal published comprehensive evidence-based guidelines on WLS. In this issue, we've updated those guidelines to assure patient safety in this fast-changing field. WLS involves a uniquely vulnerable population in need of specialized resources and ongoing multidisciplinary care. Timely best-practice updates are required to identify new risks, develop strategies to address them, and optimize treatment. Findings in these reports are based on a comprehensive review of the most current literature on WLS; they directly link patient safety to methods for setting evidence-based guidelines developed from peer-reviewed scientific publications. Among other outcomes, these reports show that WLS reduces chronic disease risk factors, improves health, and confers a survival benefit on those who undergo it. The literature also shows that laparoscopy has displaced open surgery as the predominant approach; that government agencies and insurers only reimburse procedures performed at accredited WLS centers; that best practice care requires close collaboration between members of a multidisciplinary team; and that new and existing facilities require wide-ranging changes to accommodate growing numbers of severely obese patients. More than 100 specialists from across the state of Massachusetts and across the many disciplines involved in WLS came together to develop these new standards. We expect them to have far-reaching effects of the development of health care policy and the practice of WLS.

Ness-Abramof R, Apovian CM. · Endocrine Unit, Meir Hospital, Kfar Saba, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel. · Nutr Clin Pract. · Pubmed #18682591 No free full text.

Abstract: The obesity epidemic is a major public health problem worldwide. Adult obesity is associated with increased morbidity and mortality. Measurement of abdominal obesity is strongly associated with increased cardiometabolic risk, cardiovascular events, and mortality. Although waist circumference is a crude measurement, it correlates with obesity and visceral fat amount, and is a surrogate marker for insulin resistance. A normal waist circumference differs for specific ethnic groups due to different cardiometabolic risk. For example, Asians have increased cardiometabolic risk at lower body mass indexes and with lower waist circumferences than other populations. One criterion for the diagnosis of the metabolic syndrome, according to different study groups, includes measurement of abdominal obesity (waist circumference or waist-to-hip ratio) because visceral adipose tissue is a key component of the syndrome. The waist circumference measurement is a simple tool that should be widely implemented in clinical practice to improve cardiometabolic risk stratification.

Berghöfer A, Pischon T, Reinhold T, Apovian CM, Sharma AM, Willich SN. · Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Center, Berlin, Germany. · BMC Public Health. · Pubmed #18533989 links to  free full text

Abstract: BACKGROUND: Obesity has been recognised as an important contributing factor in the development of various diseases, but comparative data on this condition are limited. We therefore aimed to identify and discuss current epidemiological data on the prevalence of obesity in European countries. METHODS: We identified relevant published studies by means of a MEDLINE search (1990-2008) supplemented by information obtained from regulatory agencies. We only included surveys that used direct measures of weight and height and were representative of each country's overall population. RESULTS: In Europe, the prevalence of obesity (body mass index > or = 30 kg/m2) in men ranged from 4.0% to 28.3% and in women from 6.2% to 36.5%. We observed considerable geographic variation, with prevalence rates in Central, Eastern, and Southern Europe being higher than those in Western and Northern Europe. CONCLUSION: In Europe, obesity has reached epidemic proportions. The data presented in our review emphasise the need for effective therapeutic and preventive strategies.

Cummings S, Apovian CM, Khaodhiar L. · MGH Weight Center, Massachusetts General Hospital, Boston, MA 02114, USA. · J Am Diet Assoc. · Pubmed #18358255 No free full text.

Abstract: Obesity is associated with an increased risk of developing insulin resistance and type 2 diabetes. Development of type 2 diabetes can be delayed or sometimes prevented from manifestation in individuals with obesity that are able to lose weight. Weight loss can be achieved either medically with behavioral therapies that combine diet and exercise treatment or with behavioral therapies combined with weight-loss medications or weight-loss surgery. There is strong evidence of an amelioration or resolution of type 2 diabetes in patients undergoing gastric bypass surgery. A recently published retrospective cohort study indicated that long-term total mortality from diabetes, heart disease, and cancer after gastric bypass surgery was substantially reduced. In this review, we summarize the evidence of surgical interventions in the treatment of type 2 diabetes.

Khaodhiar L, Apovian CM. · Department of Medicine, Boston University School of Medicine, Massachusetts 02118, USA. · Manag Care Interface. · Pubmed #17626588 No free full text.

Abstract: The prevalence of obesity and overweight is rising among adults and children. Ample evidence indicates that weight loss, even if moderate, can improve health status and lessen the incidence of obesity-related disease. A variety of treatments are available to deal with the condition. However, no matter what therapy is chosen, the patient must be aware that success may depend on adherence and follow-up with a health care practitioner.

Ness-Abramof R, Apovian CM. · Endocrine Unit, Sapir Medical Center, Kfar Saba, Israel. · Endocrine. · Pubmed #16622287 No free full text.

Abstract: The obesity epidemic is best explained by global lifestyle alterations favoring weight gain in a susceptible population. The consumption of calorically dense foods, increased portion sizes, and a decrease in workplace and leisure physical activity most likely accounts for the increase in overweight and obesity worldwide. The cornerstone of overweight and obesity therapy is dietary intervention, but unfortunately most patients eventually regain the weight lost through diet alone. The search for a macronutrient composition that may enhance and help maintain weight loss has brought an abundance of fad diets into the lay literature. According to the available data, weight loss and maintenance of weight loss are dictated by total caloric intake, and not by macronutrient composition. There is epidemiologic data linking sugar-sweetened beverages to adult and childhood obesity, and an inverse relationship between dairy intake and overweight and obesity has also been observed. More research is needed to elucidate mechanisms explaining these relationships. Further research should focus on permanent lifestyle changes that may reverse this growing epidemic. This review will focus on current practices for the dietary management of obesity and to promote weight maintenance.

Ness-Abramof R, Apovian CM. · Endocrine Unit, Sapir Medical Center, Tel Aviv University, Tel Aviv, Israel. · Drugs Today (Barc). · Pubmed #16234878 No free full text.

Abstract: Drug-induced weight gain is a serious side effect of many commonly used drugs leading to noncompliance with therapy and to exacerbation of comorbid conditions related to obesity. Improved glycemic control achieved by insulin, insulin secretagogues or thiazolidinedione therapy is generally accompanied by weight gain. It is a problematic side effect of therapy due to the known deleterious effect of weight gain on glucose control, increased blood pressure and worsening lipid profile. Weight gain may be lessened or prevented by adherence to diet and exercise or combination therapy with metformin. Weight gain is also common in psychotropic therapy. The atypical antipsychotic drugs (clozapine, olanzepine, risperidone and quetiapine) are known to cause marked weight gain. Antidepressants such as amitriptyline, mirtazapine and some serotonin reuptake inhibitors (SSRIs) also may promote appreciable weight gain that cannot be explained solely by improvement in depressive symptoms. The same phenomenon is observed with mood stabilizers such as lithium, valproic acid and carbamazepine. Antiepileptic drugs (AEDs) that promote weight gain include valproate, carbamazepine and gabapentin. Lamotrigine is an AED that is weight-neutral, while topiramate and zonisamide may induce weight loss.

Apovian CM, Baker C, Ludwig DS, Hoppin AG, Hsu G, Lenders C, Pratt JS, Forse RA, O'brien A, Tarnoff M. · Department of Medicine, Surgery, and Pediatrics, and Section of Endocrinology, Diabetes and Nutrition, Boston University Medical Center, 88 East Newton Street, Robinson Building, Suite 4400, Boston, MA 02118, USA. · Obes Res. · Pubmed #15800284 No free full text.

Abstract: OBJECTIVE: To establish evidence-based guidelines for best practices in pediatric/adolescent weight loss surgery (WLS). RESEARCH METHODS AND PROCEDURES: We carried out a systematic search of English-language literature in MEDLINE on WLS performed on children and adolescents. Key words were used to narrow the field for a selective review of abstracts. Data were extracted, and evidence categories were assigned according to a grading system based on established evidence-based models. Eight pertinent case series, published between 1980 and 2004, were identified and reviewed. These data were supplemented with expert opinions and literature on WLS in adults. RESULTS: Recommendations focused on patient safety, reduction of medical errors, systems improvements, credentialing, and future research. We developed evidence-based criteria for eligibility, assessment, treatment, and follow-up; recommended surgical procedures based on the best available evidence; and established minimum guideline requirements for data collection. DISCUSSION: Lack of adequate data and gaps in knowledge were cited as important reasons for caution. Physiological status, comprehensive screening of patients and their families, and required education and counseling were identified as key factors in assessing eligibility for surgery. Data collection and peer review were also identified as important issues in the delivery of best practice care.

Saltzman E, Anderson W, Apovian CM, Boulton H, Chamberlain A, Cullum-Dugan D, Cummings S, Hatchigian E, Hodges B, Keroack CR, Pettus M, Thomason P, Veglia L, Young LS. · Jean Mayer U.S. Department of Agriculture Human Nutrition Research Center on Aging at Tufts University, 711 Washington Street, Boston, MA 02111, USA. · Obes Res. · Pubmed #15800279 No free full text.

Abstract: OBJECTIVE: To provide evidence-based guidelines for patient selection and to recommend the medical and nutritional aspects of multidisciplinary care required to minimize perioperative and postoperative risks in patients with severe obesity who undergo weight loss surgery (WLS). RESEARCH METHODS AND PROCEDURES: Members of the Multidisciplinary Care Task Group conducted searches of MEDLINE and PubMed for articles related to WLS in general and medical and nutritional care in particular. Pertinent abstracts and literature were reviewed for references. Multiple searches were carried out for various aspects of multidisciplinary care published between 1980 and 2004. A total of 3000 abstracts were identified; 242 were reviewed in detail. RESULTS: We recommended multidisciplinary screening of WLS patients to ensure appropriate selection; preoperative assessment for cardiovascular, pulmonary, gastrointestinal, endocrine, and other obesity-related diseases associated with increased risk for complications or mortality; preoperative weight loss and cessation of smoking; perioperative prophylaxis for deep vein thrombosis and pulmonary embolism (PE); preoperative and postoperative education and counseling by a registered dietitian; and a well-defined postsurgical diet progression. DISCUSSION: Obesity-related diseases are often undiagnosed before WLS, putting patients at increased risk for complications and/or early mortality. Multidisciplinary assessment and care to minimize short- and long-term risks include: comprehensive medical screening; appropriate pre-, peri-, and postoperative preparation; collaboration with multiple patient care disciplines (e.g., anesthesiology, pulmonary medicine, cardiology, and psychology); and long-term nutrition education/counseling.

Ness-Abramof R, Nabriski D, Apovian CM. · Endocrine Unit, Sapir Medical Center, Kfar Saba, Israel. · Isr Med Assoc J. · Pubmed #15609891 links to  free full text

Abstract: The prevalence of obesity worldwide has risen sharply during the last four decades. The etiology of obesity is complex and includes a host of genetic influences in addition to the overconsumption of energy coupled with a sedentary lifestyle. Obesity is known to cause or exacerbate many co-morbid conditions such as diabetes, hypertension, dyslipidemia, coronary heart disease, stroke, certain cancers, arthritis and obstructive sleep apnea. Modest weight losses of 5-10% of actual weight are related to significant improvements in co-morbid conditions, but unfortunately the rate of recidivism with short-term therapy for obesity is high. The recent recognition of obesity as a chronic disease that should be treated with long-term programs and possibly with polypharmacy, and the alarming increase in its prevalence, have prompted extensive research and the development of new pharmacotherapy.

Panzer C, Apovian CM. · Boston University School of Medicine, Boston Medical Center, Section of Endocrinology: Nutrition and Weight Management Center, 88 East Newton Street, Suite D-614, Boston, MA 02118, USA. · Curr Cardiol Rep. · Pubmed #15485609 No free full text.

Abstract: Poor diet and physical inactivity, the two major contributors to the development of overweight and obesity, have recently been identified as the second most common actual cause of death in the United States. With the increasing awareness of the strong link between obesity and chronic disease, in particular cardiovascular disease, a myriad of diets have surfaced and many of them claim weight loss depends more on the macronutrient composition of the diet than the number of calories consumed. Long-term outcome data, particularly cardiovascular outcome data, on these diets are sparse. This article summarizes previous and recent reports of popular and aggressive diets, such as low-carbohydrate diets, low-fat diets, and very low-calorie diets, addressing their effects on weight loss and focusing on their effects on lipids and lipoproteins.

Apovian CM. · Program for Weight Management, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass. 02184, USA. · J Am Osteopath Assoc. · Pubmed #10624371 No free full text.

Abstract: The statistics are staggering: 59.4% of men, 50.7% of women, and 54.9% of the total population are overweight. Consequently, heightened efforts are being directed to control this epidemic. Clinicians have shown a renewed interest in the use of appetite suppressants and other antiobesity agents concomitantly with conventional treatment of diet education, exercise training, and lifestyle modification. This article reviews appetite suppressants both from a historical perspective and currently, and then presents a rationale for the continued use of antiobesity agents in the management of obesity.

Early JL, Apovian CM, Aronne LJ, Fernstrom MH, Frank A, Greenway FL, Heber D, Kushner RF, Cwik KM, Walch JK, Hewkin AC, Blakesley V. · Department of Preventive Medicine and Public Health, University of Kansas School of Medicine, 1010 N. Kansas Rd., Wichita, KS 67214-3199, USA. · Obesity (Silver Spring). · Pubmed #17557984 No free full text.

Abstract: OBJECTIVE: Our objective was to assess the efficacy and safety of sibutramine with a low-calorie diet (LCD) and commercial meal-replacement product in achieving weight loss and weight-loss maintenance in obese patients. RESEARCH METHODS AND PROCEDURES: Eight U.S. centers recruited 148 obese patients for a 3-month comprehensive weight-loss therapy (Phase I) comprising daily sibutramine 10 mg + LCD (two Slim-Fast meal-replacement shakes, one low-calorie meal; total kcal/d = 1200-1500). Patients (N = 113) who lost > or =5% of initial body weight during Phase I were randomized for a 9-month period (Phase II) to daily sibutramine 15 mg + LCD (one meal-replacement shake; two low-calorie meals: total kcal/d approximately 1200-1500) or daily placebo + three low-calorie meals (total kcal/d approximately 1200-1500). Both phases included behavior modification. Efficacy was assessed by body weight change during each phase and by the number of patients at endpoint maintaining > or =80% of the weight they had lost by the end of Phase I. Other outcomes included changes in cardiovascular and metabolic risk factors, adverse events, and vital signs. RESULTS: Mean body weight change during Phase I was -8.3 kg (p < 0.001). Patients randomized to sibutramine in Phase II had an additional -2.5 kg mean weight loss vs. a 2.8-kg increase in the placebo group (p < 0.001). More sibutramine patients maintained > or =80% of their Phase I weight loss at the end of Phase II (85.5% vs. placebo 36.7%, p < 0.001). Most adverse events were mild or moderate in severity, and all serious adverse events were unrelated to sibutramine. DISCUSSION: Sibutramine plus LCD with meal replacements and behavior modification is a safe and effective strategy for achieving and sustaining weight loss in obese patients.

Apovian CM, Cummings S, Anderson W, Borud L, Boyer K, Day K, Hatchigian E, Hodges B, Patti ME, Pettus M, Perna F, Rooks D, Saltzman E, Skoropowski J, Tantillo MB, Thomason P. · Department of Endocrinology, Diabetes, and Nutrition, Boston University Medical Center, Boston, Massachusetts, USA. · Obesity (Silver Spring). · Pubmed #19396065 No free full text.

Abstract: The objective of this study is to update evidence-based best practice guidelines for multidisciplinary care of weight loss surgery (WLS) patients. We performed systematic search of English-language literature on WLS, patient selection, and medical, multidisciplinary, and nutritional care published between April 2004 and May 2007 in MEDLINE and the Cochrane Library. Key words were used to narrow the search for a selective review of abstracts, retrieval of full articles, and grading of evidence according to systems used in established evidence-based models. A total of 150 papers were retrieved from the literature search and 112 were reviewed in detail. We made evidence-based best practice recommendations from the most recent literature on multidisciplinary care of WLS patients. New recommendations were developed in the areas of patient selection, medical evaluation, and treatment. Regular updates of evidence-based recommendations for best practices in multidisciplinary care are required to address changes in patient demographics and levels of obesity. Key factors in patient safety include comprehensive preoperative medical evaluation, patient education, appropriate perioperative care, and long-term follow-up.

Moore TJ, Alsabeeh N, Apovian CM, Murphy MC, Coffman GA, Cullum-Dugan D, Jenkins M, Cabral H. · Boston University Medical Center, Boston, MA 02118, USA. · J Med Internet Res. · Pubmed #19073541 links to  free full text

Abstract: BACKGROUND: The dietary habits of Americans are creating serious health concerns, including obesity, hypertension, diabetes, cardiovascular disease, and even some types of cancer. While considerable attention has been focused on calorie reduction and weight loss, approaches are needed that will not only help the population reduce calorie intake but also consume the type of healthy, well-balanced diet that would prevent this array of medical complications. OBJECTIVE: To design an Internet-based nutrition education program and to explore its effect on weight, blood pressure, and eating habits after 12 months of participation. METHODS: We designed the DASH for Health program to provide weekly articles about healthy nutrition via the Internet. Dietary advice was based on the DASH diet (Dietary Approaches to Stop Hypertension). The program was offered as a free benefit to the employees of EMC Corporation, and 2834 employees and spouses enrolled. Enrollees voluntarily entered information about themselves on the website (food intake), and we used these self-entered data to determine if the program had any effect. Analyses were based upon the change in weight, blood pressure, and food intake between the baseline period (before the DASH program began) and the 12th month. To be included in an outcome, a subject had to have provided both a baseline and 12th-month entry. RESULTS: After 12 months, 735 of 2834 original enrollees (26%) were still actively using the program. For subjects who were overweight/obese (body mass index > 25; n = 151), weight change at 12 months was -4.2 lbs (95% CI: -2.2, -6.2; P < .001). For subjects with hypertension or prehypertension at baseline (n = 62), systolic blood pressure fell 6.8 mmHg at 12 months (CI: -2.6, -11.0; P < .001; n = 62). Diastolic pressure fell 2.1 mmHg (P = .16). Based upon self-entered food surveys, enrollees (n = 181) at 12 months were eating significantly more fruits, more vegetables, and fewer grain products. They also reduced consumption of carbonated beverages. Enrollees who had visited the website more often tended to have greater blood pressure and weight loss effect, suggesting that use of the DASH for Health program was at least partially responsible for the benefits we observed. CONCLUSIONS: We have found that continued use of a nutrition education program delivered totally via the Internet, with no person-to-person contact with health professionals, is associated with significant weight loss, blood pressure lowering, and dietary improvements after 12 months. Effective programs like DASH for Health, delivered via the Internet, can provide benefit to large numbers of subjects at low cost and may help address the nutritional public health crisis.

Lenders CM, Wright JA, Apovian CM, Hess DT, Shukla RR, Adams WG, Lee K. · Department of Pediatrics, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA. · Obesity (Silver Spring). · Pubmed #19008870 No free full text.

Abstract: A BMI cutoff point at the 99th percentile for age and gender or at 40 kg/m(2) has been suggested for more aggressive treatment of adolescent obesity. The main objective of this study was to determine the proportion of adolescents eligible for weight loss surgery (WLS) based on various BMI cutoff points. Data was extracted from the electronic medical record database of an urban pediatric ambulatory care center over 4 years. National data were used to calculate BMI percentiles (Centers for Disease Control and Prevention (CDC), 2000). Eligibility for WLS was based on a BMI percentile criterion (>or=99th percentile) or the adult WLS cutoff point (>or=40 kg/m(2)). The sample consisted of 3,220 adolescents aged 12-17.9 years, of which 53% were female, 55% were of black race, and 17% of Hispanic ethnicity. Overall, 88 (3%) adolescents had a BMI >or=40 kg/m(2) and 236 (7%) had a BMI >or=99th percentile (P < 0.001). All adolescents with BMI >or=40 kg/m(2) had a BMI >or=99th percentile. A total of 159/2,007 (8%) of 12-14.9-year olds had a BMI >or=99th percentile compared with 77/1,213 (6%) 15-17.9-year olds (P = 0.10), whereas 43/2,007 (2%) of 12-14.9-year olds had a BMI >or=40 kg/m(2) compared with 45/1,213 (4%) 15-17.9-year olds (P = 0.003). In summary, a relatively large proportion of adolescents from a diverse urban population would qualify for WLS based on the percentile criterion. Fewer adolescents would be eligible based on the adult WLS criterion, and younger adolescents would be less likely to be eligible for WLS than older adolescents.

Apovian CM, Bigornia S, Mott M, Meyers MR, Ulloor J, Gagua M, McDonnell M, Hess D, Joseph L, Gokce N. · Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Mass., USA. · Arterioscler Thromb Vasc Biol. · Pubmed #18566296 No free full text.

Abstract: OBJECTIVE: Experimental studies suggest that adipose inflammation is etiologically linked to obesity-induced systemic disease. Our goal was to characterize the state of inflammation in human fat in relation to vascular function and metabolic parameters in obese individuals. METHODS AND RESULTS: We collected subcutaneous abdominal fat in 77 obese subjects (BMI >or=30 kg/m(2)) and quantified adipose macrophage population using targeted immunohistochemistry. Brachial artery vasodilator function was examined using high-resolution vascular ultrasound. In 50 subjects, an inflamed adipose phenotype characterized by tissue macrophage accumulation in crown-like structures was associated with systemic hyperinsulinemia and insulin resistance (HOMA-IR 5.5+/-4.5 versus 2.6+/-1.9, P=0.002) and impaired endothelium-dependent flow-mediated vasodilation (8.5+/-4.4% versus 10.8+/-3.8%, P<0.05), as compared to subjects with quiescent noninflamed adipose architecture (n=27). Macrophage retention in fat was linked to upregulated tissue CD68 and tumor necrosis factor (TNF)-alpha mRNA expression in addition to increased plasma hs-CRP. CONCLUSIONS: In a cohort of obese subjects, we demonstrate that proinflammatory changes in adipose tissue are associated with systemic arterial dysfunction and insulin resistance. These findings suggest that adipose inflammation may be linked to vascular injury and increased cardiovascular risk in obese subjects.

Vitseva OI, Tanriverdi K, Tchkonia TT, Kirkland JL, McDonnell ME, Apovian CM, Freedman J, Gokce N. · Whitaker Cardiovascular Institute, Evans Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA. · Obesity (Silver Spring). · Pubmed #18292749 No free full text.

Abstract: OBJECTIVE: Inflammatory activity in fat tissue has recently been implicated in mechanisms of insulin resistance and obesity-related metabolic dysfunction. Toll-like receptors (TLRs) play a key role in innate immune responses and recent studies implicate the TLR pathway in mechanisms of inflammation and atherosclerosis. The aim of this study was to examine differential TLR expression and function in human adipose tissue. METHODS AND PROCEDURES: We biopsied subcutaneous abdominal fat from 16 obese subjects (age 39+/-11 years, BMI 49+/-14 kg/m2) and characterized TLR expression using quantitative real-time PCR and confocal immunofluorescence imaging. In tissue culture, we stimulated isolated human adipocytes with Pam3CSK4 and lipopolysaccharide (LPS) (TLR2 and TLR4 agonists, respectively) and quantified TLR activity, interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) production, and nuclear factor-kappaB (NF-kappaB) p65 nuclear activation using real-time PCR, enzyme-linked immunosorbent assay (ELISA), and immunofluorescence. RESULTS: TLR1, 2, and 4 protein colocalized with adiponectin in human adipocytes with TLR4 exhibiting the highest immunohistochemical expression. Using real-time PCR, we confirmed higher level of gene expression for TLR4 as compared to other members of the TLR family (TLR1, 2, 7, 8) in human adipose depots (P<0.001). In tissue culture, adipocyte TLR2/TLR4 mRNA expression and protein increased significantly following Pam3CSK4 and LPS (P<0.001). TLR2/TLR4 stimulation was associated with NF-kappaB p65 nuclear translocation and proinflammatory cytokine production. DISCUSSION: The findings demonstrate that TLRs are inducible in adipose tissue and linked with downstream NF-kappaB activation and cytokine release. Adipose stores may play a dynamic role in the regulation of inflammation and innate immunity in human subjects via modulation of the TLR/NF-kappaB regulatory pathway.

Arkin JM, Alsdorf R, Bigornia S, Palmisano J, Beal R, Istfan N, Hess D, Apovian CM, Gokce N. · Evans Department of Medicine and Whitaker Cardiovascular Institute, Boston University School of Medicine, Boston, Massachusetts, USA. · Am J Cardiol. · Pubmed #18157973 links to  free full text

Abstract: Although excess fat mass is linked to increased cardiovascular risk, the relation between vascular phenotype and degree of obesity in high weight categories is unknown. We examined brachial artery vasomotor responses using ultrasound in 203 consecutive patients with severe obesity (mean age 44 +/- 11 years; body mass index [BMI] 46 +/- 9 kg/m(2), range 30 to 72; and body weight 128 +/- 29 kg, range 69 to 207). We studied a unique population in which 71% of subjects were characterized as morbidly obese (BMI > or =40 kg/m(2)), which included a 31% group of super-obese subjects (BMI > or =50 kg/m(2)). Brachial artery flow-mediated dilation (FMD) and nitroglycerin-mediated dilation were examined as measures of endothelium-dependent and -independent dilation, respectively, in relation to clinical, hemodynamic, and metabolic variables. Endothelial function was significantly impaired in the highest compared with the lowest tertile of body weight (FMD 6.5 +/- 4.6% vs 9.8 +/- 4.8%, p <0.001), whereas nitroglycerin-mediated dilation was similar in all groups. Univariate correlates of FMD were gender, weight, waist circumference, BMI, diastolic blood pressure, and creatinine. In multivariate analysis, weight was a strong independent significant predictor of FMD (beta = -0.23, p = 0.005) in addition to gender. Within an overweight population, cumulative weight burden remains strongly linked to progressive arterial dysfunction. In conclusion, these results suggest that cardiovascular risks intensify with higher degrees of obesity and underscore the importance of therapeutic weight loss interventions.