Multi-Organ System Metabolic Stress and Sex-Divergent Vascular Associations.

Introduction: Women experience excess cardiovascular risk compared to men in the setting of similar metabolic disease burden. This consistent finding could be related to sex differences in the vascular response to various forms of metabolic stress. In this study we examine the association of both systemic and organ-specific metabolic stress with vascular health in women and men. Methods: We conducted an observational study of 4,299 adult participants (52% women, aged 59±13 years) of the National Health and Nutrition Examination Survey (NHANES) 2017-2018 cohort and 110,225 adult outpatients (55% women, aged 64±16 years) of the Cedars-Sinai Medical Center (CSMC) 2019 cohort. We used natural splines to examine the association of systemic and organ-specific measures of metabolic stress including body mass index (BMI), hemoglobin A1c (HbA1c), hepatic FIB-4 score, and CKD-EPI estimated glomerular filtration rate (eGFR) on systolic blood pressure (SBP). Piecewise linear models were generated using normal value thresholds (BMI <25 kg/m 2 , HbA1c <5.7%, FIB-4 <1.3, and eGFR ≥90 ml/min), which approximated observed spline breakpoints. The primary outcome was increase in SBP (relative to a sex-specific physiologic baseline SBP) in association with increase in level of each metabolic measure. Results: Women compared to men demonstrated larger magnitudes and an earlier onset of increase in SBP per increment increase across all metabolic stress measures. The slope of SBP increase per increment of each metabolic measure was greater for women than men particularly for metabolic measures within the normal range, with slope differences of 1.71 mmHg per kg/m2 of BMI, 9.61 mmHg per %HbA1c, 6.45 mmHg per FIB-4 unit, and 0.37 mmHg per ml/min decrement of eGFR in the NHANES cohort (P difference <0.05 for all). Overall results were consistent in the CSMC cohort. Conclusions: Women exhibited greater vascular sensitivity in the setting of multiple types of metabolic stress, particularly in periods representing the transition from metabolic health to disease. These findings underscore the importance of involving early metabolic health interventions as part of efforts to mitigate vascular risks in both women and men.

Qualitative evaluation of artificial intelligence-generated weight management diet plans.

Importance: The transformative potential of artificial intelligence (AI), particularly via large language models, is increasingly being manifested in healthcare. Dietary interventions are foundational to weight management efforts, but whether AI techniques are presently capable of generating clinically applicable diet plans has not been evaluated. Objective: Our study sought to evaluate the potential of personalized AI-generated weight-loss diet plans for clinical applications by employing a survey-based assessment conducted by experts in the fields of obesity medicine and clinical nutrition. Design setting and participants: We utilized ChatGPT (4.0) to create weight-loss diet plans and selected two control diet plans from tertiary medical centers for comparison. Dietitians, physicians, and nurse practitioners specializing in obesity medicine or nutrition were invited to provide feedback on the AI-generated plans. Each plan was assessed blindly based on its effectiveness, balanced-ness, comprehensiveness, flexibility, and applicability. Personalized plans for hypothetical patients with specific health conditions were also evaluated. Main outcomes and measures: The primary outcomes measured included the indistinguishability of the AI diet plan from human-created plans, and the potential of personalized AI-generated diet plans for real-world clinical applications. Results: Of 95 participants, 67 completed the survey and were included in the final analysis. No significant differences were found among the three weight-loss diet plans in any evaluation category. Among the 14 experts who believed that they could identify the AI plan, only five did so correctly. In an evaluation involving 57 experts, the AI-generated personalized weight-loss diet plan was assessed, with scores above neutral for all evaluation variables. Several limitations, of the AI-generated plans were highlighted, including conflicting dietary considerations, lack of affordability, and insufficient specificity in recommendations, such as exact portion sizes. These limitations suggest that refining inputs could enhance the quality and applicability of AI-generated diet plans. Conclusion: Despite certain limitations, our study highlights the potential of AI-generated diet plans for clinical applications. AI-generated dietary plans were frequently indistinguishable from diet plans widely used at major tertiary medical centers. Although further refinement and prospective studies are needed, these findings illustrate the potential of AI in advancing personalized weight-centric care.

The Effects of Obesity on Health Care Delivery.

The rates of obesity continue to rise among adults and children in the United States; hence, it is natural that obesity is reshaping health care delivery. This is seen in numerous ways, including physiologic, physical, social, and economic impacts. This article reviews a broad range of topics, from the effects of increased adiposity on drug pharmacokinetics and pharmacodynamics to the changes health care environments are making to accommodate patients with obesity. The significant social impacts of weight bias are reviewed, as are the economic consequences of the obesity epidemic. Finally, a patient case that demonstrates the effects of obesity on health care delivery is examined.

Development of Obesity Competencies for Medical Education: A Report from the Obesity Medicine Education Collaborative.

OBJECTIVE: Obesity Medicine Education Collaborative (OMEC) was formed to develop obesity-focused competencies and benchmarks that can be used by undergraduate and graduate medical education program directors. This article describes the developmental process used to create the competencies. METHODS: Fifteen professional organizations with an interest in obesity collaborated to form OMEC. Using the six Core Competencies of the Accreditation Council for Graduate Medical Education as domains and as a guiding framework, a total of 36 group members collaborated by in-person meetings, email exchange, and conference calls. An iterative process was used by each working subgroup to develop the competencies and assessment benchmarks. The initial work was subsequently externally reviewed by 19 professional organizations. RESULTS: Thirty-two competencies were developed across the six domains. Each competency contains five descriptive measurement benchmarks for evaluator rating. CONCLUSIONS: This set of OMEC obesity-focused competencies is the first evaluation tool developed to be used within undergraduate and graduate medical training programs for both formative and summative assessments. Routine and more robust assessment is expected to increase the competence of health care providers to assess, prevent, and treat obesity. In addition to dissemination, the competencies and benchmarks will need to undergo evaluation for further validity and practicality.

Development and outcomes of an immersive obesity summit workshop for medical resident and fellow education.

Physicians need better training to manage patients with obesity. Our study capitalized on the intimate nature of an extracurricular obesity workshop, creating an interactive educational programme. We assessed the short- and long-term impact of the workshop on trainees' knowledge, competence and confidence in caring for patients with obesity in an outpatient setting. This is a cross-sectional study, involving regionally diverse mix of resident and fellow physicians. A live 2.5-day continuing medical education summit was held 11 to 13 March 2016. Obesity-related topics were reviewed using state-of-the art pedagogical techniques. Pre-/post-levels of knowledge, competence and clinical practice strategies were analysed. Sixty-three candidates interested in additional obesity medicine training were nominated by US residency and fellowship programme directors and selected to attend the summit. On average, learners experienced a 110% relative increase in knowledge and competence. The overall effect size was 0.95, with participants being ~54% more knowledgeable about the management of patients with obesity. All participants self-reported that this activity increased their knowledge about the subject matter, improving their performance in caring for patients when asked about their practice in a follow-up survey 6 months following the workshop. This immersive summit promoted robust gains in knowledge and confidence, ultimately translating to reported practice improvements at the individual and health system levels. Future research is warranted on the sustainability of gained skills.

Weight Recidivism After Roux-en-Y Gastric Bypass Surgery: An 11-Year Experience in a Multiethnic Medical Center.

OBJECTIVE: Weight recidivism following Roux-en-Y gastric bypass (RYGB) is common and is associated with recurrence of comorbidities. Studies with long-term follow-up of recidivism quantified by weight regain (WR) are lacking. A retrospective review of all RYGB at our center from 2004 to 2015 was performed to examine the effects of race and type 2 diabetes on WR following RYGB. METHODS: Multivariable linear mixed models were used for the effects of time and race on weight, WR relative to nadir weight (WR/nadir), and WR relative to maximal weight loss, and Cox regressions were used for low, moderate, and high WR/nadir. RESULTS: A total of 1,395 participants were identified. The sample was limited to African American (AA), Caucasian American (CA), and Hispanic American (HA) participants. The effects of time (P < 0.0001), race (P < 0.0001), and race × time interaction (P = 0.0008) on weight trajectory were significant. AA had significantly more WR than CA (P < 0.01). AA and HA had a higher hazard ratio for having low, moderate, and rapid WR/nadir. CONCLUSIONS: Racial disparities after RYGB include WR and particularly affect AA. Understanding the etiologic factors that contribute to these disparities is important to optimize the long-term clinical outcomes of bariatric surgery.

Updates on obesity pharmacotherapy.

Obesity is a chronic, relapsing disease that necessitates a multidisciplinary approach to management. Behavioral changes are the foundation to management, but adjunctive therapy is often warranted, including pharmacologic therapies and/or bariatric surgery. Until recently, treatment options included only short-term therapy (≤12 weeks), and paths beyond that schedule were challenging, as knowledge of the biology of obesity was lacking. With increased recognition of obesity as a chronic, complex medical disease, newer agents have been approved as long-term therapy, and the cornerstone of treatment is chronic behavior and lifestyle change. In the last decade, the Food and Drug Administration (FDA) has approved several new weight loss medications for the chronic management of obesity. In this review paper, we provide the latest updates on obesity pharmacotherapy. The main areas we will cover include (1) pharmacological management of obesity, (2) a review of FDA-approved weight loss medications, (3) comanagement of obesity and its metabolic sequelae (type 2 diabetes mellitus, hypertension, and dyslipidemia), and (4) obesity-centric prescribing for mental illness, neurological disorders, and contraceptive planning.

Pharmacological management of obesity.

Current management of obesity includes three main arms: behavioral modification, pharmacologic therapy, and bariatric surgery. Decades prior, the only pharmacological agents available to treat obesity were approved only for short-term use (≤12 weeks) by the Food and Drug Administration (FDA). However, in the last several years, the FDA has approved several medications for longer term treatment of obesity. This highlights the important progression that we, as a society, better appreciate now the chronicity and complexity of obesity as a disease. Also, availability of more medication options gives healthcare providers more possibilities to consider in the management of obesity. Medications for obesity can be simply categorized as FDA approved short-term use (diethylproprion, phendimetrazine, benzphetamine, and phentermine) and long-term use (orlistat, phentermine/topiramate ER, lorcaserin, naltrexone/bupropion ER and liraglutide). Additionally, type 2 diabetes (T2DM) is commonly seen in patients with obesity and necessitates consideration of pharmacological options that do not hinder patients' weight loss. Finally, weight-centric prescribing is also an important component to pharmacological management of obesity. It warrants that healthcare providers thoroughly review their patients' medication lists to determine if any of these agents could be contributing to weight gain.

Intranasal dexmedetomidine: an effective sedative agent for electroencephalogram and auditory brain response testing.

OBJECTIVE: Dexmedetomidine is an α2 agonist with sedative, anxiolytic, and analgesic properties. The intranasal (IN) route avoids the pain of intravenous (i.v.) catheter placement but limited literature exists on the use of IN dexmedetomidine. This study examines the effectiveness and safety of IN dexmedetomidine for sedation of patients undergoing electroencephalogram (EEG) and auditory brain response (ABR) testing. STUDY DESIGN: This was a review of all outpatients sedated with IN dexmedetomidine for EEG or ABR between October 1, 2012 and October 1, 2014. An initial dose of 2.5-3 µg · kg(-1) IN dexmedetomidine was given with a repeat dose of 1-1.5 µg · kg(-1) IN if needed 30 min later. Prospectively entered patient information was extracted from a quality assurance database and additional information gathered via retrospective chart review. RESULTS: Intranasal dexmedetomidine was used in 169 patients (EEG = 117, ABR = 52). First-dose success rates were 90.4% for ABR and 87.2% for EEG. Total success rates (with one or two doses of IN dexmedetomidine) were 100% for ABR and 99.1% for EEG. The median time to onset of sleep was 25 min (IQR, 20-32 min). The median duration of sedation was 107 min (IQR, 90-131 min). Adverse events included: 18 patients (10.7%) with hypotension which resolved without intervention, six patients with oxygen desaturation <90%, two of whom received supplemental oxygen, and one patient with an underlying upper airway abnormality who was treated with continuous positive airway pressure. CONCLUSIONS: IN dexmedetomidine is an effective and noninvasive method of sedating children for EEG and ABR.

Understanding barriers to cervical cancer screening among Hispanic women.

OBJECTIVE: We investigated issues affecting Papanicolaou smear screening access, health services utilization, acculturation, social networking, and media venues most conducive to acquiring health information among Hispanics. STUDY DESIGN: Self-identified Hispanics were surveyed. Participants were stratified based on age, time living in the United States, and Papanicolaou screening frequency. RESULTS: Of 318 participants, Hispanics aged 30 years or older and living in the United States less than 5 years prefer speaking Spanish. Women with 5 or more lifetime Papanicolaou smears were 1.610 times more likely to have lived in the United States 5 or more years, 1.706 times more likely to speak a second language, and 1.712 times less likely to need a translator during their health care encounter. CONCLUSION: Age and years living in the United States may be independent risk factors for participation in Papanicolaou screening programs. Social difficulties inherent to acculturation inform health behavior and translate to health disparity among Hispanics. Our results may help design federally funded and community-level programs.