Association of Weight Trajectory With Severe Obesity: A Case-Control Study.

Background: Early childhood weight trajectory is associated with future risk for obesity. However, little is known about the association of birth weight and weight trajectories before age 5.5 years with severe adult obesity. Methods: This study used a nested case-control design of 785 matched sets of cases and controls matched 1:1 on age and gender from a 1976 to 1982 birth cohort in Olmsted County, Minnesota. Cases with severe adult obesity were defined as individuals with a BMI ≥40 kg/m2 after 18 years of age. There were 737 matched sets of cases and controls for the trajectory analysis. Weight and height data from birth through 5.5 years were abstracted from the medical records, and weight-for-age percentiles were obtained from the CDC growth charts. Results: A two-cluster weight-for-age trajectory solution was identified as optimal, with cluster 1 having higher weight-for-age before age 5.5 years. While there was no association between birth weight and severe adult obesity, the odds of being in cluster 1, which includes children with higher weight-for-age percentiles, was significantly increased for cases compared with controls [odds ratio (OR) 1.99, 95% confidence interval (CI) 1.60-2.47]. The association between cluster membership and case-control status persisted after adjusting for maternal age and education (adjusted OR 2.08, 95% CI 1.66-2.61). Conclusions: Our data suggest that early childhood weight-for-age trajectories are associated with severe obesity status in adult life. Our results add to growing evidence that it is critical to prevent excess early childhood weight gain.

Translation of a family-based behavioral intervention for adolescent obesity using the RE-AIM framework and common steps from adaptation frameworks.

Interventions for adolescent weight management that are ready to use in clinical settings are needed to address the obesity epidemic and improve the health and wellbeing of affected adolescents. This report describes the systematic process our team followed to adapt an evidence-based intervention (EBI) for adolescent weight management from its randomized control trial protocol to a package for delivery in a group-based telehealth format within a medical center. The EBI adaptation was clinician initiated, prompted by identified practice needs, and involved collaboration of the clinical team with the EBI developer. The process was guided by the Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework and followed key steps for adapting EBIs to new contexts. RE-AIM-aligned adaptations included telehealth delivery and broader inclusion criteria, separate clinical and research evaluation batteries, adaptations to fit the clinical practice, practical fidelity checklists to guide and record session delivery, and continuous quality improvement processes aimed to facilitate program longevity and family engagement. The process culminated in a package of adapted intervention materials deemed by stakeholders as appropriate to the practice and congruent with the EBI model. This report provides a much-needed practical demonstration of the translation of an EBI for adolescent weight management from research protocol to group telehealth delivery in a medical center. Key lessons include the value of clinician-researcher collaboration, the breadth of resources needed to adapt EBIs for real-world delivery, and the importance of considering delivery context in implementation and evaluation decisions, including defining inclusion criteria, staffing, and outcomes assessments.

Approximately one in five adolescents in the USA have or are at significant risk for health problems associated with higher weight, such as type 2 diabetes and high cholesterol. Health behavior scientists have developed promising programs to support adolescents in establishing and maintaining eating and activity habits for healthy weight management. However, such programs are not widely available. To increase access to effective interventions, science-developed programs for this age group need to be translated to ready-to-use packages suitable to real-world settings such as health care centers. This paper describes the systematic process our team followed to translate an adolescent weight management program from its research study form to an intervention package for delivery in a group-based telehealth format within a medical center. We describe the changes made to the intervention resulting from this process. We also present our plans for evaluating the performance of the adapted intervention. Key lessons from this work include the value of clinician-researcher collaboration, the breadth of resources needed to adapt science-developed interventions for real-world delivery, and the importance of considering delivery context when planning how to run and evaluate the program, including defining inclusion criteria, staffing, and outcomes assessments.

Association of Perinatal Factors With Severe Obesity and Dyslipidemia in Adulthood.

BACKGROUND: Perinatal factors including gestational age, birthweight, size for gestational age, delivery route, maternal parity, maternal age, maternal education, socioeconomic status, race, and sex, are associated with the future risk of obesity and co-morbid conditions. This study evaluated the relationship of birthweight for gestational age and perinatal factors with severe obesity and dyslipidemia in adulthood. METHODS: We conducted a population-based, retrospective birth cohort study of infants born to residents of Olmsted County, MN between 1976 and 1982. Outcomes were assessed after age 18 years until October 2020, including severe obesity (BMI ≥ 40 kg/m2) and dyslipidemia (total cholesterol ≥200 mg/dL, non-high density lipoprotein [non-HDL] cholesterol ≥145 mg/dL or HDL cholesterol <40 mg/dL). We obtained mother's age, education level, and parity as well as newborn sex, race, type of delivery, single/multiple birth, gestational age, and birthweight from birth certificate data. Individual-level socioeconomic status (SES) of the household at birth was determined with the HOUSES index. RESULTS: Of 10 938 birth cohort subjects, 7394 had clinic visits after age 18 years and were included, with 2630 having severe obesity (n = 798) or dyslipidemia (n = 2357) as adults. In multivariable models, female sex, singleton birth, less maternal education, and lower SES defined by HOUSES were independently associated with an increased risk of severe obesity in adulthood. Non-white race, singleton birth, and lower birthweight were independently associated with adult dyslipidemia. Birthweight for gestational age was not associated with severe obesity or dyslipidemia. CONCLUSION: Perinatal factors were associated with both severe obesity and dyslipidemia in adulthood. Lower SES at birth was predictive of severe obesity in adulthood, highlighting the opportunity to investigate modifiable perinatal social determinants to reduce the risk of severe obesity.

Weight Loss and Serum Lipids in Overweight and Obese Adults: A Systematic Review and Meta-Analysis.

BACKGROUND: Excess adipose tissue is associated with an abnormal lipid profile that may improve with weight reduction. In this meta-analysis, we aimed to estimate the magnitude of change in lipid parameters associated with weight loss in adults who are overweight or obese. METHODS: We searched MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus from 2013 to September, 2018. We included randomized controlled trials (RCTs) that evaluated interventions to treat adult obesity (lifestyle, pharmacologic and surgical) with follow-up of 6 months or more. RESULTS: We included 73 RCTs with moderate-to-low risk of bias, enrolling 32 496 patients (mean age, 48.1 years; weight, 101.6 kg; and body mass index [BMI], 36.3 kg/m2). Lifestyle interventions (diet, exercise, or both), pharmacotherapy, and bariatric surgery were associated with reduced triglyceride (TG) and low-density lipoprotein cholesterol (LDL-C) concentrations and increased high-density lipoprotein cholesterol (HDL-C) at 6 and 12 months. The following data are for changes in lipid parameters after 12 months of the intervention with 95% CI. Following lifestyle interventions, per 1 kg of weight lost, TGs were reduced by -4.0 mg/dL (95% CI, -5.24 to -2.77 mg/dL), LDL-C was reduced by -1.28 mg/dL (95% CI, -2.19 to -0.37 mg/dL), and HDL-C increased by 0.46 mg/dL (95% CI, 0.20 to 0.71 mg/dL). Following pharmacologic interventions, per 1 kg of weight lost, TGs were reduced by -1.25 mg/dL (95% CI, -2.94 to 0.43 mg/dL), LDL-C was reduced by -1.67 mg/dL (95% CI, -2.28 to -1.06 mg/dL), and HDL-C increased by 0.37 mg/dL (95% CI, 0.23 to 0.52 mg/dL). Following bariatric surgery, per 1 kg of weight lost, TGs were reduced by -2.47 mg/dL (95% CI, -3.14 to -1.80 mg/dL), LDL-C was reduced by -0.33 mg/dL (95% CI, -0.77 to 0.10 mg/dL), and HDL-C increased by 0.42 mg/dL (95% CI, 0.37 to 0.47 mg/dL). Low-carbohydrate diets resulted in reductions in TGs and increases in HDL-C, whereas low-fat diets resulted in reductions in TGs and LDL-C and increases in HDL-C. Results were consistent across malabsorptive and restrictive surgery. CONCLUSIONS: Weight loss in adults is associated with statistically significant changes in serum lipids. The reported magnitude of improvement can help in setting expectations, inform shared decision making, and facilitate counseling.

Ketogenic Diet: an Endocrinologist Perspective.

PURPOSE OF REVIEW: Obesity and its related comorbidities make up a large part of healthcare expenditures. Despite a wide array of options for treatment of obesity, rates of sustained weight loss continue to be low, leading patients to seek alternative treatment options. Although the first medically utilized ketogenic diet was described nearly 100 years ago, it has made a resurgence as a treatment option for obesity. Despite increased popularity in the lay public and increased use of ketogenic dietary strategies for metabolic therapy, we are still beginning to unravel the metabolic impact of long-term dietary ketosis. RECENT FINDINGS: There are a number of recent trials that have highlighted the short- and long-term benefits of ketogenic diet on weight, glycemic control, and other endocrine functions including reproductive hormones. This review is a summary of available data on the effectiveness and durability of the ketogenic diet when compared to conventional interventions. Ketogenic dietary strategies may play a role in short-term improvement of important metabolic parameters with potential for long-term benefit. However, response may vary due to inter-individual ability to maintain long-term carbohydrate restriction.

Identifying Opportunities for Advancing Weight Management in Primary Care.

Objective: Much has been written about the patients' perspective concerning weight management in health care. The purpose of this survey study was to assess perspectives of primary care providers (PCPs) and nurses toward patient weight management and identify possible areas of growth. Patients and Methods: We emailed a weight management-focused survey to 674 eligible participants (437 [64.8%] nurses and 237 [35.2%] PCPs) located in 5 outpatient primary care clinics. The survey focused on opportunities, practices, knowledge, confidence, attitudes, and beliefs. A total of 219 surveys were returned (137 [62.6%] from nurses and 82 [34.4%] from PCPs). Results: Among 219 responders, 85.8% were female and 93.6% were white non-Hispanic. In this study, PCPs and nurses believed obesity to be a major health problem. While PCPs felt more equipped than nurses to address weight management (P < .001) and reported receiving more training than nurses (50.0% vs 17.6%, respectively), both felt the need for more training on obesity (73.8% and 79.4%, respectively). Although, PCPs also spent more patient contact time providing weight management services versus nurses (P < .001), the opportunity/practices score was lower for PCPs than nurses (-0.35 ± 0.44 vs -0.17 ± 0.41, P < .001) with PCPs more likely to say they lacked the time to discuss weight and they worried it would cause a poor patient-PCP relationship. The knowledge/confidence score also differed significantly between the groups, with nurses feeling less equipped to deal with weight management issues than PCPs (-0.42 ± 0.43 vs -0.03 ± 0.55, P < .001). Neither group seemed very confident, with those in the PCP group only answering with an average score of neutral. Conclusion: By asking nurses and PCP general questions about experiences, attitudes, knowledge, and opinions concerning weight management in clinical care, this survey has identified areas for growth in obesity management. Both PCPs and nurses would benefit from additional educational training on weight management.

Accuracy of Accelerometers for Measuring Physical Activity and Levels of Sedentary Behavior in Children: A Systematic Review.

Objectives: This systematic review evaluated the accuracy of triaxial and omnidirectional accelerometers for measuring physical activity and sedentary behavior in children. Design: Systematic review of the literature. Methods: We comprehensively searched several databases for studies published from January 1996 through June 2018 that reported diagnostic accuracy measures in children and adolescents (age 3-18 years) and compared accelerometers with energy expenditure using indirect calorimetry. Results: We included 11 studies that enrolled 570 participants. All studies used indirect calorimetry as the reference standard. Across the studies, median sensitivity ranged from 46% to 96% and median specificity ranged from 71% to 96%. Median area under the curve ranged from 69% to 98%. Conclusions: Accuracy measures were greatest when detecting sedentary behavior and lowest when detecting light physical activity. Accuracy was higher when the accelerometer was placed on the hip compared with the wrist. The current evidence suggests that triaxial and omnidirectional accelerometers are accurate in measuring sedentary behavior and physical activity levels in children.

On-the-farm cardiovascular risk screening among migrant agricultural workers in Southeast Minnesota: a pilot prospective study.

INTRODUCTION: Accessibility to healthcare services is a major concern facing migrant agricultural workers (MAWs) in the USA. We aimed to test the feasibility of implementing cardiovascular risk screening at farm sites. METHODS: This was a pilot prospective cohort study providing on-site monthly screenings of cardiovascular risk factors. We estimated the prevalence of cardiovascular risk factors and evaluated the success of this approach via modified validated satisfaction surveys. RESULTS: We enrolled 38 MAWs and diagnosed 18 cases of pre-diabetes, diabetes, hypertension and hyperlipidaemia in 15 subjects (39.4%). Mean scores of workers' satisfaction were high (≥4) on a 5-point scale except 'Time spent with provider'. Over 80% of workers were likely to use this model if it was permanently available on the farm. Only 8.7% of workers were able to follow up after referral to a clinic. CONCLUSIONS: Cardiovascular risk factors are highly prevalent in MAWs. On-the-farm screening is a feasible and satisfactory model of healthcare delivery; however, other barriers continue to hinder MAWs from receiving follow-up care. TRIAL REGISTRATION NUMBER: NCT02418637.

Treatment Effect in Earlier Trials of Patients With Chronic Medical Conditions: A Meta-Epidemiologic Study.

OBJECTIVE: To determine whether the early trials in chronic medical conditions demonstrate an effect size that is larger than that in subsequent trials. METHODS: We identified randomized controlled trials (RCTs) evaluating a drug or device in patients with chronic medical conditions through meta-analyses (MAs) published between January 1, 2007, and June 23, 2015, in the 10 general medical journals with highest impact factor. We estimated the prevalence of having the largest effect size or heterogeneity in the first 2 published trials. We evaluated the association of the exaggerated early effect with several a priori hypothesized explanatory variables. RESULTS: We included 70 MAs that had included a total of 930 trials (average of 13 [range, 5-48] RCTs per MA) with average follow-up of 24 (range, 1-168) months. The prevalence of the exaggerated early effect (ie, proportion of MAs with largest effect or heterogeneity in the first 2 trials) was 37%. These early trials had an effect size that was on average 2.67 times larger than the overall pooled effect size (ratio of relative effects, 2.67; 95% CI, 2.12-3.37). The presence of exaggerated effect was not significantly associated with trial size; number of events; length of follow-up; intervention duration; number of study sites; inpatient versus outpatient setting; funding source; stopping a trial early; adequacy of random sequence generation, allocation concealment, or blinding; loss to follow-up or the test for publication bias. CONCLUSION: Trials evaluating treatments of chronic medical conditions published early in the chain of evidence commonly demonstrate an exaggerated treatment effect compared with subsequent trials. At the present time, this phenomenon remains unpredictable. Considering the increasing morbidity and mortality of chronic medical conditions, decision makers should act on early evidence with caution.

The Association of Weight Loss and Cardiometabolic Outcomes in Obese Children: Systematic Review and Meta-regression.

Background: Excess body weight in children is associated with multiple immediate and long-term medical comorbidities. We aimed to identify the degree of reduction in excess body weight associated with cardiometabolic changes (lipid panel, liver function tests, systolic blood pressure (SBP), diastolic blood pressure, glycosylated hemoglobin, and fasting blood glucose) in overweight and obese children. Methods: We conducted a comprehensive search of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through February 12, 2015. We included randomized controlled trials and cohort studies that evaluated interventions to treat pediatric obesity (medication, surgery, lifestyle, and community-based interventions) with ≥ a 6-month follow-up. We used a random effects meta-regression approach to assess the association between body mass index (BMI)/weight and cardiometabolic changes. Results: We included 42 studies (37 randomized controlled trials and five cohorts) enrolling 3807 children (mean age, 12.2 years; weight, 74.7 kg; and BMI, 31.7 kg/m2). Studies had overall moderate to low risk of bias. A 1-mm Hg decrease in SBP was significantly associated with a decrease of 0.16 kg/m2 (P = .04) in BMI. A 1-mg/dL increase in HDL was significantly associated with a 0.74-kg decrease in weight (P = .02). A 1-mg/dL decrease in triglycerides was significantly associated with a 0.1-kg decrease in weight (P = .03). The remaining associations were not statistically significant. Conclusions: Weight reduction in children is associated with significant changes in several cardiometabolic outcomes, particularly HDL, SBP, and triglycerides. The magnitude of improvement may help in setting expectations and may inform shared decision-making and counseling.

Treatment of Pediatric Obesity: An Umbrella Systematic Review.

Objective: Multiple interventions are available to reduce excess body weight in children. We appraised the quality of evidence supporting each intervention and assessed the effectiveness on different obesity-related outcomes. Methods: We conducted a systematic search for systematic reviews of randomized controlled trials evaluating pediatric obesity interventions applied for ≥6 months. We assessed the quality of evidence for each intervention using GRADE (Grading of Recommendation, Assessment, Development, and Evaluation) approach. Results: From 16 systematic reviews, we identified 133 eligible randomized controlled trials. Physical activity interventions reduced systolic blood pressure and fasting glucose (low to moderate quality of evidence). Dietary interventions with low-carbohydrate diets had a similar effect to low-fat diets in terms of body mass index (BMI) reduction (moderate quality of evidence). Educational interventions reduced waist circumference, BMI, and diastolic blood pressure (low quality of evidence). Pharmacological interventions reduced BMI (metformin, sibutramine, orlistat) and waist circumference (sibutramine, orlistat) and increased high-density lipoprotein cholesterol (sibutramine) but also raised systolic and diastolic blood pressure (sibutramine). Surgical interventions (laparoscopic adjustable gastric banding, Roux-en-Y gastric bypass, sleeve gastrectomy) resulted in the largest BMI reduction (moderate quality of evidence). Combined interventions consisting of dietary modification, physical activity, behavioral therapy, and education significantly reduced systolic and diastolic blood pressure, BMI, and triglycerides. Combined parent-child interventions and parent-only interventions had similar effects on BMI (low quality of evidence). Conclusions: Several childhood obesity interventions are effective in improving metabolic and anthropometric measures. A comprehensive multicomponent intervention, however, appears to have the best overall outcomes.

The Association of Weight Loss and Cardiometabolic Outcomes in Obese Children: Systematic Review and Meta-regression.

BACKGROUND: Excess body weight in children is associated with multiple immediate and long-term medical comorbidities. We aimed to identify the degree of reduction in excess body weight associated with cardiometabolic changes (lipid panel, liver function tests, systolic blood pressure (SBP), diastolic blood pressure, glycosylated hemoglobin, and fasting blood glucose) in overweight and obese children. METHODS: We conducted a comprehensive search of MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Scopus through February 12, 2015. We included randomized controlled trials and cohort studies that evaluated interventions to treat pediatric obesity (medication, surgery, lifestyle, and community-based interventions) with ≥ a 6-month follow-up. We used a random effects meta-regression approach to assess the association between body mass index (BMI)/weight and cardiometabolic changes. RESULTS: We included 42 studies (37 randomized controlled trials and five cohorts) enrolling 3807 children (mean age, 12.2 years; weight, 74.7 kg; and BMI, 31.7 kg/m2). Studies had overall moderate to low risk of bias. A 1-mm Hg decrease in SBP was significantly associated with a decrease of 0.16 kg/m2 (P = .04) in BMI. A 1-mg/dL increase in HDL was significantly associated with a 0.74-kg decrease in weight (P = .02). A 1-mg/dL decrease in triglycerides was significantly associated with a 0.1-kg decrease in weight (P = .03). The remaining associations were not statistically significant. CONCLUSIONS: Weight reduction in children is associated with significant changes in several cardiometabolic outcomes, particularly HDL, SBP, and triglycerides. The magnitude of improvement may help in setting expectations and may inform shared decision-making and counseling.

A survey of health care needs of physicians.

BACKGROUND: The healthcare needs of physician are not well studied. METHODS: We surveyed physicians attending a large primary care conference about their access and perceived barriers to receiving healthcare services. RESULTS: Response rate was 46 % (270/592). The majority were trained in family medicine. The age category of above 60 years was the most common (39 %) and 46 % were women. Important difficulty in accessing healthcare services was reported by 39 % of physicians and the majority (61 %) reported reverting to self-diagnosis and self-treatment. Female physicians reported more difficulties than male physicians (p < 0.001 for difficulty in securing access and p = 0.02 for self-diagnosis and treatment). The barriers cited were finding time for healthcare, concern about confidentiality, and lack of encouragement by employer. Respondents reported experiencing a career threatening illness themselves (20 %) or in a colleague (81 %). Forty-two percent experienced being concerned about a colleague being able to safely practice due to illness. Participants ranked substance abuse as the most common illnesses affecting a physician's ability to practice followed by psychiatric disorders, heart disease, neurological disorders and cancer. CONCLUSIONS: Physicians face important barriers to accessing healthcare services. Female physicians report worse access. The identified barriers are modifiable. This survey calls for efforts to improve physicians' health that require collaboration among physicians, employers and policymakers.

Creating a Patient-Centered Health Care Delivery System: A Systematic Review of Health Care Quality From the Patient Perspective.

Patient experience is one of key domains of value-based purchasing that can serve as a measure of quality and be used to improve the delivery of health services. The aims of this study are to explore patient perceptions of quality of health care and to understand how perceptions may differ by settings and condition. A systematic review of multiple databases was conducted for studies targeting patient perceptions of quality of care. Two reviewers screened and extracted data independently. Data synthesis was performed following a meta-narrative approach. A total of 36 studies were included that identified 10 quality dimensions perceived by patients: communication, access, shared decision making, provider knowledge and skills, physical environment, patient education, electronic medical record, pain control, discharge process, and preventive services. These dimensions can be used in planning and evaluating health care delivery. Future research should evaluate the effect of interventions targeting patient experience on patient outcomes.

Direct free fatty acid storage in different sized adipocytes from the same depot.

OBJECTIVE: Human adipocytes take up free fatty acids (FFA) directly from the circulation, even at times of high lipolytic activity. Whether these processes occurs simultaneously within the same cells or are partitioned between different cells, for example large and small cells, is unknown. METHODS: The direct FFA storage in subcutaneous fat in 13 adults were measured using a continuous infusion of [U-(13)C]palmitate and a bolus of [1-(14)C]palmitate followed 30 min later by abdominal and femoral adipose biopsies. The adipocytes were isolated by digestion procedures and separated into small, medium and large populations by differential floatation. RESULTS: Populations of adipocytes were isolated that were statistically and clinically (∼3 fold different) in size. Adipocyte lipid SA was not different between small, medium and large cells, therefore, FFA storage per unit lipid was not different. However, FFA storage rates were significantly (two to four times) greater per cell in large than small cells (P < 0.005). In summary, relative to lipid content, FFA storage rates are not different in large and small adipocytes, however, large cells have greater storage rates per cell. CONCLUSIONS: This suggests that the processes of FFA release and storage are taking place simultaneously in adipocytes.