Prevalence and impact of obesity in people with haemophilia: Review of literature and expert discussion around implementing weight management guidelines.

Obesity affects more than 35% of Americans, increasing the risk of more than 200 comorbid conditions, impaired quality of life and premature mortality. This review aimed to summarize literature published over the past 15 years regarding the prevalence and impact of obesity in people with haemophilia (PWH) and to discuss implementing general guidelines for weight management in the context of the haemophilia comprehensive care team. Although few studies have assessed the effects of obesity on haemophilia-specific outcomes, existing evidence indicates an important impact of weight status on lower extremity joint range of motion and functional disability, with potentially important effects on overall quality of life. Data regarding bleeding tendency in PWH with coexisting obesity are largely inconclusive; however, some individuals may experience reduced joint bleeds following moderate weight loss. Additionally, conventional weight-based dosing of factor replacement therapy leads to increased treatment costs for PWH with obesity or overweight, suggesting pharmacoeconomic benefits of weight loss. Evidence-based recommendations for weight loss include behavioural strategies to reduce caloric intake and increase physical activity, pharmacotherapy and surgical therapy in appropriate patients. Unique considerations in PWH include bleed-related risks with physical activity; thus, healthcare professionals should advise patients on types and intensities of, and approaches to, physical activity, how to adjust treatment to accommodate exercise and how to manage potential activity-related bleeding. Increasing awareness of these issues may improve identification of PWH with coexisting obesity and referral to appropriate specialists, with potentially wide-ranging benefits in overall health and well-being.

One Health Solutions to Obesity in People and Their Pets.

Despite the high prevalence of overweight and obesity in the human and companion animal populations, and the global trends for increasing numbers of affected people and pets, there are few successful interventions that are proven to combat this complex multifactorial problem. One key strategy involves effective communication between human and veterinary healthcare professionals with patients and clients about obesity. In human healthcare, the focus of communication should be on physical activity as part of overall health and wellbeing, rather than assessment of the body mass index; clinical examination of patients should record levels of physical activity as a key 'vital sign' as part of their assessment. Successful weight loss programmes for companion animals also involves strategic communication with the entire healthcare team leading clients through the 'stages of change'. There is great potential in employing a 'One Health' framework to provide novel solutions for the prevention and treatment of this condition in people and their pets. Comparative clinical research into the biology of obesity and its comorbidities in dogs and cats is likely to lead to knowledge relevant to the equivalent human conditions. The advantages of companion animal clinical research over traditional rodent models include the outbred genetic background and relatively long lifespan of pets and the fact that they share the human domestic environment. The human-companion animal bond can be leveraged to create successful programmes that promote physical activity in people and their pets with obesity. Dog walking is a proven motivator for human physical activity, with health benefits to both the owner and the dog. Realizing the potential of a One Health approach will require the efforts and leadership of a committed group of like-minded individuals representing a range of scientific and medical disciplines. Interested parties will need the means and opportunities to communicate and to collaborate, including having the resources and funding for research. One Health proponents must have a role in forming public policy related to the prevention and management of overweight and obesity.

A proposed clinical staging system for obesity.

Current classifications of obesity based on body mass index, waist circumference and other anthropometric measures, although useful for population studies, have important limitations when applied to individuals in clinical practice. Thus, these measures do not provide information on presence or extent of comorbidities or functional limitations that would guide decision making in individuals. In this paper we review historical and current classification systems for obesity and propose a new simple clinical and functional staging system that allows clinicians to describe the morbidity and functional limitations associated with excess weight. It is anticipated that this system, when used together with the present anthropometric classification, will provide a simple framework to aid decision making in clinical practice.

Effect of histaminergic manipulation on weight in obese adults: a randomized placebo controlled trial.

OBJECTIVE: To determine the magnitude and determinants of weight loss in humans exposed to betahistine, a centrally acting histamine-1 (H-1) agonist and partial histamine-3 (H-3) antagonist. DESIGN: A multicenter randomized, placebo-controlled dose-ranging weight loss trial with a 12-week treatment period. SUBJECTS: Two hundred and eighty-one obese but otherwise healthy participants. MEASUREMENTS: Weight and obesity-related comorbidities at baseline and at the end of the intervention. RESULTS: Betahistine, at the doses tested, did not induce significant weight loss. With the exception of headache, no difference in adverse effect profile was noted between placebo and treatment groups. Subgroup analysis revealed that age below 50 years, ethnicity (non-Hispanics) and gender (women) were the strongest predictors of weight loss in this population. When these three factors were combined together, the betahistine 48 mg group (n=23) lost -4.24+/-3.87 kg, whereas the placebo group (n=25) lost -1.65+/-2.96 kg during this time period (P=0.005). CONCLUSION: Betahistine, at the doses tested, induced significant weight loss with minimal adverse events only in women below 50 years.

Development of a measure of attitude toward nutrition in patient care.

BACKGROUND: Development of reliable measures of medical student and resident attitudes about nutrition in patient care is needed before the effects of educational interventions or clinical experience can be gauged. This report describes the systematic development of a measure of attitude toward nutrition in patient care. It presents evidence about scale reliability and the absence of response bias that endorses the trustworthiness of data from the measure. METHODS: An eight-step attitude scale development procedure was used to create the Nutrition In Patient care Survey (NIPS). Data from five samples of first- and second-year medical students and first-year medical residents were subjected to factor analysis (PA2, varimax rotation), reliability analyses, and statistical analyses to test for demographic bias in the attitude data. RESULTS: A 45-item attitude measure was developed that contains five subscales derived from the factor analysis: (1) nutrition in routine care (NRC, 8 items); (2) clinical behavior (CB, 20 items); (3) physician-patient relationship (PPR, 8 items); (4) patient behavior/motivation (PBM, 3 items); and (5) physician efficacy (PE, 6 items). Each subscale yields reliable data in terms of internal consistency (alpha coefficients) and stability (test-retest reliability). Medical student and resident demographic variables have negligible influence on attitude scores. DISCUSSION: The NIPS subscales yield reliable data that can be used to assess outcomes in evaluation research on educational or clinical interventions or to predict patient care practices. Systematic attitude scale development increases the likelihood that the resulting measures will produce useful, trustworthy data.

Obesity and quality of life.

The focus of this review is the impact of obesity and weight loss on quality of life. A focus on quality of life broadens the scope of treatment efficacy beyond weight loss and provides a patient-centered perspective. The concept of quality of life is defined, and both general and obesity-specific measures are reviewed. It is clear that obesity confers negative consequences on both the physical and psychosocial aspects of quality of life, especially among the severely obese. The effects of weight loss appear to be favorable, although few studies have examined non-surgical interventions. Future studies would be enhanced by assessing a variety of approaches to weight loss by using both general and obesity-specific measures of quality of life and conducting follow-up studies to assess the effects of weight regain on quality of life.

Evaluation of the obese patient. Practical considerations.

The evaluation process for obesity uses the same framework of a history, physical examination and interpretation of selected laboratory and diagnostic tests that are used for other chronic care patient encounters. What makes this evaluation process different is knowing how to take an obesity focused history, what to examine, and which tests to order. An assessment of risk status is then determined based on the National Heart, Lung, and Blood Institute Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. Other important aspects of the evaluation process include determining the patient's goals, expectations, and motivation for weight loss along with support systems and/or barriers to behavior change.

Single- and multifrequency models for bioelectrical impedance analysis of body water compartments.

The 1994 National Institutes of Health Technology Conference on bioelectrical impedance analysis (BIA) did not support the use of BIA under conditions that alter the normal relationship between the extracellular (ECW) and intracellular water (ICW) compartments. To extend applications of BIA to these populations, we investigated the accuracy and precision of seven previously published BIA models for the measurement of change in body water compartmentalization among individuals infused with lactated Ringer solution or administered a diuretic agent. Results were compared with dilution by using deuterium oxide and bromide combined with short-term changes of body weight. BIA, with use of proximal, tetrapolar electrodes, was measured from 5 to 500 kHz, including 50 kHz. Single-frequency, 50-kHz models did not accurately predict change in total body water, but the 50-kHz parallel model did accurately measure changes in ICW. The only model that accurately predicted change in ECW, ICW, and total body water was the 0/infinity-kHz parallel (Cole-Cole) multifrequency model. Use of the Hanai correction for mixing was less accurate. We conclude that the multifrequency Cole-Cole model is superior under conditions in which body water compartmentalization is altered from the normal state.

How much physical activity is needed to minimize weight gain in previously obese women?

Exercise is frequently identified as a predictor of weight maintenance after elective weight loss in retrospective studies of treatments for obesity. We conducted a prospective study to test whether physical activity measured soon after weight loss predicted weight maintenance and to determine how much physical activity was required to optimize maintenance. Thirty-two women [mean (+/- SD) age, 38 +/- 7 y; body mass index (in kg/m2), 24 +/- 3] were recruited through local advertising within 3 mo of reaching their target for weight loss (23 +/- 9 kg). Total energy expenditure (TEE) was measured by the doubly labeled water method. Postabsorptive resting metabolic rate (RMR) and postprandial RMR [expressed as thermic effect of a meal (TEM)] were measured by respiratory gas exchange. Women in the physically active group (ratio of TEE to RMR = 1.89 +/- 0.08) gained 2.5 +/- 3.1 kg during the 12 mo after reaching their target for weight loss, moderately active women (TEE:RMR = 1.64 +/- 0.05) gained 9.9 +/- 10.5 kg, and sedentary women (TEE:RMR = 1.44 +/- 0.08) gained 7.0 +/- 5.9 kg (P < 0.01). Retrospective analyses of weight regain as a function of energy expended in physical activity indicated a threshold for weight maintenance of 47 kJ x kg body wt(-1) x d(-1). This corresponds to an average of 80 min/d of moderate activity or 35 min/d of vigorous activity added to a sedentary lifestyle.

Clinical characteristics influencing bioelectrical impedance analysis measurements.

Standardization of measurement conditions is essential for obtaining accurate, precise, and reproducible bioelectrical impedance analysis (BIA) data. Errors due to lack of measurement control are propagated in subsequent calculations of body composition and contribute to differences in predictive equations among investigators. Various individual and environmental factors have been shown to influence BIA. We review the factors that have been identified from the literature as being conditions requiring standardization both for healthy subjects and for those in a medical setting.

Use of bioelectrical impedance analysis measurements in the clinical management of patients undergoing dialysis.

The use of bioelectrical impedance analysis (BIA) in patients with end-stage renal disease who are receiving dialysis provides researchers with two important applications: 1) a biological model in which the underlying assumptions of BIA can be tested, and 2) if valid, a tool that can be used to improve the clinical management of patients receiving dialysis. We review the rationale of and purpose for using BIA in the dialysis population, the physiologic changes that occur during dialysis that influence BIA measurements, and last, conclusions reached from the current scientific literature.

Effect of skin temperature on multifrequency bioelectrical impedance analysis.

This study assessed the effects of changes in skin temperature on multifrequency bioimpedance analysis (MF-BIA) and on the prediction of body water compartments. Skin temperature (baseline 29.3 +/- 2.1 degrees C) of six healthy adults was raised over 50 min to 35.8 +/- 0.6 degrees C, followed by cooling for 20 min to 26.9 +/- 1.3 degrees C, by using an external heating and cooling blanket. MF-BIA was measured at both distal (conventional) and proximal electrode placements. Both distal and proximal impedance varied inversely with a change in skin temperature across all frequencies (5-500 kHz). The change in proximal impedance per degree centigrade change in skin surface temperature was approximately 60% of distal impedance. The change in measured impedance at 50 kHz erroneously increased predicted total body water (TBW) by 2.6 +/- 0.9 liters (P < 0.001) and underpredicted fat mass by 3.3 +/- 1.3 kg (P < 0.0001). Computer modeling of the MF-BIA data indicated changes in predicted water compartments with temperature modifications; however, the ratio of extracellular water (ECW) to TBW did not significantly change (P < 0.4). This change in impedance was not due to a change in the movement of water of the ECW compartment and thus probably represents a change in cutaneous impedance of the skin. Controlled ambient and skin temperatures should be included in the standardization of BIA measurements. The error in predicted TBW is < 1% within an ambient temperature range of 22.3 to 27.7 degrees C (72.1-81.9 degrees F).

Barriers to providing nutrition counseling by physicians: a survey of primary care practitioners.

BACKGROUND: Previous surveys have shown that there is a disparity between physicians' beliefs about the importance of diet and nutrition in health maintenance and disease prevention and the actual delivery of nutrition counseling. The primary objective of this study was to assess the current attitudes, practice behavior, and barriers to the delivery of nutrition counseling by primary care physicians. METHODS: A random-sample-mailed questionnaire was sent to 2,250 primary care physicians selected from the AMA masterfile from general practice, internal medicine, and pediatrics, representing self-employed, group, hospital, and HMO practices. Participants were stratified by age, gender, geographical region, and present employment. The main outcome measures were to determine time spent by physicians providing and percentage of patients receiving dietary counseling and to identify barriers to the delivery of nutrition counseling. RESULTS: A 49% response rate (n = 1,103) was obtained. Results are presented for the 1,030 physicians (70% private practice) with complete data. Over two-thirds of physicians provide dietary counseling to 40% or less of patients and spend 5 or fewer min discussing dietary changes. Despite this pattern, nearly three-quarters of respondents feel that dietary counseling is important and is the responsibility of the physician. Ranking of perceived barriers to delivery of dietary counseling were lack of time, patient noncompliance, inadequate teaching materials, lack of counseling, training, lack of knowledge, inadequate reimbursement, and low physician confidence. CONCLUSIONS: This survey suggests that multiple barriers exist that prevent the primary care practitioner from providing dietary counseling. A multifaceted approach will be needed to change physician counseling behavior.

Measurement of physical activity among black and white obese women.

Several recent self-reported surveys have suggested that African-American women may engage in less leisure-time physical activity (PA) than whites. Objective measurements of PA have not been performed, however. Therefore, the purpose of this study was to compare the components of energy expenditure, including PA, between black and white obese women. Using the doubly labeled water method, total daily energy expenditure (TDEE), basal metabolic rate (BMR), thermic effect of a meal (TEM), and PA were measured in 14 black and 15 white moderately obese women over 2 weeks. No statistically significant differences were seen between the 2 groups in BMR, TEM or TDEE. Mean PA was significantly (p = 0.05) lower among black women compared to whites when expressed as MJ. d-1 (3.49 vs. 4.30) or kJ.kg-1.d-1 (37.6 vs. 47.7). Our study supports the survey differences seen in PA among black and white women.

Exercise enhances dietary compliance during moderate energy restriction in obese women.

The effect of aerobic exercise on dietary compliance was assessed in 13 obese women (44 +/- 3% fat) during a 12-wk weight-reduction program (EX group). Seventeen obese women (45 +/- 5% fat) not engaged in aerobic exercise (NX group) served as control subjects. The reducing diets were designed to promote a weight loss of 1 kg/wk, with energy intakes individually prescribed (mean +/- SD: 4.9 +/- 0.6 MJ/d) to approximate 75% of each subject's measured basal metabolic rate. The EX group completed of three 45-min sessions/wk of supervised aerobic exercise at 65% of maximal oxygen consumption (VO2max). Daily energy intakes were calculated by summing changes in body stores, measured by total body water isotope dilution, and total daily energy expenditure, measured by doubly labeled water (DLW). Dietary compliance was assessed by comparing calculated intakes with prescribed intakes. Both the EX and NX groups reported consuming close to their prescribed daily intakes, with differences of -0.08 +/- 0.28 (EX group) and +0.03 +/- 0.57 (NX group) MJ/d, respectively. However, expenditure/balance data determined by the DLW method indicated that the EX subjects exhibited better dietary compliance than the NX subjects, with intakes exceeding those prescribed by only 0.7 +/- 1.5 compared with 2.3 +/- 1.6 MJ/d for the NX subjects (P = 0.01). Therefore, an additional benefit of aerobic exercise during energy restriction is enhanced dietary compliance, which has important implications for the treatment of moderate obesity.