Addressing uncertainty about the role of structured lifestyle modification for metabolic surgery patients.

There is good evidence that structured lifestyle modification programmes improve health in patients with metabolic and cardiovascular disorders, but there is no specific evidence that they improve outcomes in patients undergoing metabolic or obesity surgery. Despite expert consensus guidelines stating this fact, some healthcare systems still compel patients to participate in a structured lifestyle modification programme prior to metabolic or obesity surgery. There is a well-established need for individualised multidisciplinary dietetic and physical activity care for metabolic and obesity surgery patients, and the benefits of intentional weight loss prior to surgery are well proven, but these are distinct from potentially harmful requirements for patients to undertake compulsory structured lifestyle programmes of fixed duration, frequency and intensity, which may delay surgery and reinforce obesity stigma. A critical step in rejuvenating metabolic surgery is to reframe patient participation in structured lifestyle modification programmes as an opportunity for education and empowerment, not as an indicator of motivation or suitability for metabolic surgery. Large, well-designed and adequately powered clinical trials are needed to address uncertainties in the evidence base for these programmes. Given genuine equipoise, they will need to determine whether "surgery plus lifestyle" is superior to "surgery plus placebo". Moreover, they will need to determine the cost-effectiveness of these programmes and identify some of the factors giving rise to the substantial heterogeneity in responses to structured lifestyle modification.

Factors associated with weight loss and health gains in a structured lifestyle modification programme for adults with severe obesity: a prospective cohort study.

Background: Individual responses to behavioural weight loss interventions can vary significantly, and a better understanding of the factors associated with successful treatment might help to target interventions for those who will benefit the most. We sought to identify demographic and clinical characteristics that predicted intervention "success" (defined as ≥5% weight loss) and other health gains in patients with severe obesity attending a ten-week structured lifestyle modification programme. Methods: We conducted a prospective cohort study of all 1122 patients (751 (66.9%) female, mean age 47.3 ± 11.9 years, mean body mass index (BMI) 46.7 ± 7.8 kgm-2) referred from our hospital-based obesity clinic, who started the structured lifestyle programme between 2012-2019. We compared routine clinical measures such as weight, fitness, blood pressure, lipids and HbA1c at baseline and follow-up. We also used validated questionnaires to quantify anxiety, depression and health-related quality of life. Results: Of 1122 patients who started, 877 (78.2%) completed the programme and attended for follow up. Of these, 12.8% lost ≥5% body weight. The amount of weight lost was a strong and consistent predictor of improvements in metabolic, cardiovascular, and mental health, even after adjusting for age, sex, programme attendance and baseline fitness. Older age, male sex, being physically active and having lower anxiety and depression scores at baseline predicted greater weight loss. Younger age, depression and longer wait time to start the intervention were associated with drop-out. Conclusions: In adults with severe obesity completing a structured lifestyle modification programme, older age and good mental health were associated with programme completion and attaining ≥5% weight loss. The magnitude of weight lost was a strong predictor of improvements in cardiovascular, metabolic and mental health associated with programme completion.

Philosophically, is obesity really a disease?

The question of whether obesity should be regarded as a disease remains controversial. One source of controversy can be addressed by distinguishing between two ways in which the word "obesity" is used. In medicine, the word "obesity" now typically refers to some or all of a set of interrelated dysfunctions of metabolism, adipose tissue, and dietary intake regulation. In other contexts, such as government-funded public education programs, the word "obesity" refers to a body mass index (BMI) category taken to indicate excess body fat. The result is that when medical experts say, "Obesity is a disease," the majority of outside medicine inevitably takes this to mean "being fat is a disease." In order to address this ambiguity, we apply key philosophical accounts of disease to the two different senses of "obesity." We draw two major conclusions: First, although obesity as understood in clinical medicine meets the criteria to be considered a disease, obesity as defined by BMI does not. Second, adequately addressing this disease requires us to distinguish it clearly and unambiguously from high BMI. Making this distinction would help both the public and policymakers to better understand the disease of obesity, facilitating advances in both prevention and treatment.

Descriptive Analysis of International Bariatric Surgery Tourism Services.

Inadequate access to public bariatric surgical services has favoured the growth of bariatric tourism. This study analysed data extracted from bariatric surgical centres that care for patients travelling from abroad. The research highlights apparent deficits in accreditation, communication, perioperative care, and travel health advice. An international registry of accredited bariatric tourism providers and patient education may be indicated.

Multidimensional pain profiling in people living with obesity and attending weight management services: a protocol for a longitudinal cohort study.

INTRODUCTION: Pain is prevalent in people living with overweight and obesity. Obesity is associated with increased self-reported pain intensity and pain-related disability, reductions in physical functioning and poorer psychological well-being. People living with obesity tend to respond less well to pain treatments or management compared with people living without obesity. Mechanisms linking obesity and pain are complex and may include contributions from and interactions between physiological, behavioural, psychological, sociocultural, biomechanical and genetic factors. Our aim is to study the multidimensional pain profiles of people living with obesity, over time, in an attempt to better understand the relationship between obesity and pain. METHODS AND ANALYSIS: This longitudinal observational cohort study will recruit (n=216) people living with obesity and who are newly attending three weight management services in Ireland. Participants will complete questionnaires that assess their multidimensional biopsychosocial pain experience at baseline and at 3, 6, 12 and 18 months post-recruitment. Quantitative analyses will characterise the multidimensional pain experiences and trajectories of the cohort as a whole and in defined subgroups. ETHICS AND DISSEMINATION: The study protocol has been approved by the Ethics and Medical Research Committee of St Vincent's Healthcare Group, Dublin, Ireland (reference no: RS21-059) and the University College Dublin Human Research Ethics Committee (reference no: LS-E-22-41-Hinwood-Smart). Findings will be disseminated through peer-reviewed journals, conference presentations, public and patient advocacy groups, and social media. STUDY REGISTRATION: Open Science Framework Registration DOI: https://doi.org/10.17605/OSF.IO/QCWUE.

Higher Waist Hip Ratio Genetic Risk Score Is Associated with Reduced Weight Loss in Patients with Severe Obesity Completing a Meal Replacement Programme.

Background: A better understanding of the influence of genetic factors on the response to lifestyle interventions in people with obesity may allow the development of more personalised, effective and efficient therapeutic strategies. We sought to determine the influence of six obesity-related genetic risk scores on the magnitude of weight lost by patients with severe obesity who completed a dietary intervention. Methods: In this single-centre prospective cohort study, participants with severe and complicated obesity who completed a 24-week, milk-based meal replacement programme were genotyped to detect the frequency of common risk alleles for obesity and type 2 diabetes-related traits. Genetic risk scores (GRS) for six of these traits were derived. Participants with a potentially deleterious monogenic gene variant were excluded from the analysis. Results: In 93 patients completing the programme who were not carrying a known obesity-related gene mutation, 35.5% had diabetes, 53.8% were female, mean age was 51.4 ± 11 years, mean body mass index was 51.5 ± 8.7 and mean total weight loss percent at 24 weeks was 16 ± 6.3%. The waist-hip ratio (WHR) GRS was inversely associated with percentage total weight loss at 24 weeks (adjusted ß for one standard deviation increase in WHR GRS -11.6 [-23.0, -0.3], p = 0.045), and patients in the lowest tertile of WHR GRS lost more weight. Conclusions: Patients with severe and complicated obesity with a genetic predisposition to central fat accumulation had less weight loss in a 24-week milk-based meal replacement programme, but there was no evidence for influence from the five other obesity-related genetic risk scores on the response to dietary restriction.

Yeast ß-Glucan Improves Insulin Sensitivity and Hepatic Lipid Metabolism in Mice Humanized with Obese Type 2 Diabetic Gut Microbiota.

SCOPE: Gut microbiota alterations are associated with obesity and type 2 diabetes. Yeast ß-glucans are potential modulators of the innate immune-metabolic response, by impacting glucose, lipid, and cholesterol homeostasis. The study examines whether yeast ß-glucan interacts differentially with either an obese healthy or obese diabetic gut microbiome, to impact metabolic health through hepatic effects under high-fat dietary challenge. METHODS AND RESULTS: Male C57BL/6J mice are pre-inoculated with gut microbiota from obese healthy (OBH) or obese type 2 diabetic (OBD) subjects, in conjunction with a high-fat diet (HFD) with/without yeast ß-glucan. OBD microbiome colonization adversely impacts metabolic health compared to OBH microbiome engraftment. OBD mice are more insulin resistant and display hepatic lipotoxicity compared to weight matched OBH mice. Yeast ß-glucan supplementation resolves this adverse metabolic phenotype, coincident with increasing the abundance of health-related bacterial taxa. Hepatic proteomics demonstrates that OBD microbiome transplantation increases HFD-induced hepatic mitochondrial dysfunction, disrupts oxidative phosphorylation, and reduces protein synthesis, which are partly reverted by yeast ß-glucan supplementation. CONCLUSIONS: Hepatic metabolism is adversely affected by OBD microbiome colonization with high-fat feeding, but partially resolved by yeast ß-glucan. More targeted dietary interventions that encompass the interactions between diet, gut microbiota, and host metabolism may have greater treatment efficacy.

Design of a Planner-Based Intervention to Facilitate Diet Behaviour Change in Type 2 Diabetes.

Diet behaviour is influenced by the interplay of the physical and social environment as well as macro-level and individual factors. In this study, we focus on diet behaviour at an individual level and describe the design of a behaviour change artefact to support diet behaviour change in persons with type 2 diabetes. This artefact was designed using a human-centred design methodology and the Behaviour Change Wheel framework. The designed artefact sought to support diet behaviour change through the addition of healthy foods and the reduction or removal of unhealthy foods over a 12-week period. These targeted behaviours were supported by the enabling behaviours of water consumption and mindfulness practice. The artefact created was a behaviour change planner in calendar format, that incorporated behaviour change techniques and which focused on changing diet behaviour gradually over the 12-week period. The behaviour change planner forms part of a behaviour change intervention which also includes a preparatory workbook exercise and one-to-one action planning sessions and can be customised for each participant.

Improved Quality of Life, Fitness, Mental Health and Cardiovascular Risk Factors with a Publicly Funded Bariatric Lifestyle Intervention for Adults with Severe Obesity: A Prospective Cohort Study.

BACKGROUND: Lifestyle modification is the cornerstone of management for patients with severe and complicated obesity, but the effects of structured lifestyle programmes on quality of life, anxiety and depression scores and cardiovascular risk factors are not well-described. We sought to describe changes in self-reported quality of life and mental health-related outcomes as well as cardiovascular risk factors in patients completing a 10-week multidisciplinary lifestyle-modification programme. METHODS: We conducted a prospective cohort study of all patients referred from our bariatric service who completed the programme between 2013 and 2019. In addition to weight, body mass index (BMI), blood pressure, HbA1c, lipid profile and functional capacity, we quantified health-related quality of life using the Dartmouth COOP Questionnaire and the European Quality of Life Questionnaire Visual Analogue Scale (EQVAS) and mental health using the Hospital Anxiety and Depression Scale (HADS). RESULTS: Of 1122 patients who started the programme, 877 (78.2%) completed it and were included in per protocol analyses. Mean age was 47.3 ± 11.9 years, 66.9% were female, 34.8% were in full- or part-time employment and 69.4% were entitled to state-provided medical care. BMI decreased from 47.0 ± 7.8 to 46.2 ± 7.8 kg m-2 and weight decreased from 131.6 ± 25.5 to 129.5 ± 25.4 kg (both p < 0.001). There were significant reductions in anxiety and depression scores and improvements in all Dartmouth COOP domains. The EQVAS score increased from 52 ± 22 to 63 ± 19 (p < 0.001). Small but statistically significant reductions in LDL cholesterol, systolic blood pressure and HBA1c were also observed. CONCLUSIONS: Adults with severe and complicated obesity completing a specialised bariatric lifestyle-modification programme showed significant improvements in self-reported mental health and quality of life, in addition to reductions in cardiovascular risk factors.

Making weight: acute muscle weakness and hypokalaemia exacerbated by thyrotoxicosis factitia in a bodybuilder.

SUMMARY: A 32-year-old Caucasian male presented to the emergency department with a one-day history of acute severe bilateral lower limb weakness, three days after competing in a bodybuilding competition. He consumed large quantities of carbohydrate-rich foods following the competition. His past medical history was significant for anxiety, and family history was non-contributory. Examination was normal except for reduced power and hyporeflexia in both legs, despite his muscular physique. He was noted to have severe hypokalaemia (K+= 1.9 mmol/L). His thyroid function tests were consistent with thyrotoxicosis. He reported taking thyroxine and several other agents to facilitate muscle mass generation before the bodybuilding competition. His presentation was reminiscent of thyrotoxic periodic paralysis, albeit uncommon with Caucasian ethnicity. He also had transient hyperglycaemia at presentation with concomitant hyperinsulinaemia, which could be attributed to the carbohydrate load and may have exacerbated his hypokalaemia through a transcellular shift. Urine toxicology screen subsequently ruled out the use of diuretics but confirmed the presence of a long-acting beta agonist (clenbuterol) which, along with other substances, may have aggravated the hypokalaemia further. After 12 h of i.v. replacement, the potassium level normalised and leg weakness resolved. The patient agreed to stop taking thyroxine and beta agonists and was well during the clinic visit at one month follow-up. This case highlights the potential for thyrotoxicosis factitia to exacerbate hypokalaemia and muscle weakness from other causes in bodybuilders presenting with acute severe weakness, irrespective of ethnicity. LEARNING POINTS: In patients presenting with muscle weakness and hypokalaemia, early consideration of thyrotoxicosis is essential, even in the absence of a past history of thyroid disease or specific symptoms of thyrotoxicosis, in order to allow prompt initiation of appropriate treatment and to prevent recurrence. Bodybuilders may constitute a uniquely 'at-risk' group for thyrotoxic periodic paralysis secondary to thyrotoxicosis factitia, especially where there is concomitant use of beta-adrenergic agonists, even in the absence of diuretic use. Although rare and usually described in patients of Asian or Polynesian ethnicity, this case highlights that thyrotoxic periodic paralysis secondary to thyrotoxicosis factitia can also occur in patients with Caucasian ethnicity. We speculate that consuming large quantities of carbohydrates may induce hyperinsulinaemia, which could theoretically contribute to worse hypokalaemia, though mechanistic studies would be needed to explore this further.

Identifying Barriers and Facilitators to Diet and Physical Activity Behaviour Change in Type 2 Diabetes Using a Design Probe Methodology.

Treatment of Type 2 Diabetes (T2D) typically involves pharmacological methods and adjunct behavioural modifications, focused on changing diet and physical activity (PA) behaviours. Changing diet and physical activity behaviours is complex and any behavioural intervention in T2D, to be successful, must use an appropriate suite of behaviour change techniques (BCTs). In this study, we sought to understand the perceived barriers and facilitators to diet and PA behaviour change in persons with T2D, with a view to creating artefacts to facilitate the required behaviour changes. The Design Probe was chosen as the most appropriate design research instrument to capture the required data, as it enabled participants to reflect and self-document, over an extended period of time, on their daily lived experiences and, following this reflection, to identify their barriers and facilitators to diet and PA behaviour change. Design Probes were sent to 21 participants and 13 were fully completed. A reflective thematic analysis was carried out on the data, which identified themes of food environment, mental health, work schedule, planning, social support, cravings, economic circumstances and energy associated with diet behaviour. Similar themes were identified for PA as well as themes of physical health, weather, motivation and the physical environment.

Burden of chronic kidney disease and rapid decline in renal function among adults attending a hospital-based diabetes center in Northern Europe.

INTRODUCTION: This study aimed to determine the prevalence of diabetic kidney disease (DKD) and rapid renal function decline and to identify indices associated with this decline among adults attending a diabetes center in Northern Europe. RESEARCH DESIGN AND METHODS: This is a retrospective cohort study of 4606 patients who attended a diabetes center in Ireland between June 2012 and December 2016. Definition/staging of chronic kidney disease used the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 classification based on data from the most recently attended appointment. Relevant longitudinal trends and variabilities were derived from serial records prior to index visit. Rapid renal function decline was defined based on per cent and absolute rates of estimated glomerular filtration rate (eGFR) change. Multiple linear regression was used to explore the relationships between explanatory variables and per cent eGFR change. RESULTS: 42.0% (total), 23.4% (type 1 diabetes), 47.9% (type 2 diabetes) and 32.6% (other diabetes) had DKD. Rapid decline based on per cent change was more frequent in type 2 than in type 1 diabetes (32.8% vs 14.0%, p<0.001). Indices independently associated with rapid eGFR decline included older age, greater number of antihypertensives, higher log-normalized urine albumin to creatinine ratio (LNuACR), serum alkaline phosphatase, thyroid stimulating hormone, variability in systolic blood pressure and variability in LNuACR, lower glycated hemoglobin, high-density lipoprotein cholesterol and diastolic blood pressure, and lack of ACE inhibitor/angiotensin receptor blocker prescription. CONCLUSIONS: DKD (using the KDIGO 2012 classification) and rapid eGFR decline were highly prevalent among adults attending a hospital-based diabetes clinic in a predominantly Caucasian Northern European country. The burden was greater for adults with type 2 diabetes. Expected as well as potentially novel clinical predictors were identified.

Long-Term Changes in Weight in Patients With Severe and Complicated Obesity After Completion of a Milk-Based Meal Replacement Programme.

Introduction: Even with very significant short term weight loss with intensive dietary restriction, subsequent weight regain remains a challenge for most patients. We sought to assess long-term weight change in patients with obesity following completion of a 24-week milk-based meal replacement programme. Methods: We conducted a retrospective cohort study of bariatric patients who completed our milk-based meal replacement programme. This programme started with an 8-week weight loss phase, followed by weight stabilization (8 weeks) and weight maintenance (8 weeks) phases, after which patients were followed up in the bariatric outpatient clinics. A paired sample t-test was used to compare mean differences in weight at the start and the end of the programme and at follow-up. Linear regression was used to identify predictors of weight regain. Results: In total, 78 patients had long term follow-up data at a mean of 34.4 ± 19.8 months after the start of the milk diet and were included in this analysis. Mean body mass index at baseline was 50.5 ± 7.6 kg m-2, 41 (52.6%) were female and the mean age was 51.6 ± 12.0 (range 18.0-71.5) years. Weight decreased from144 ± 26 kg at the start of the milk diet to 121.2 ± 24 kg at completion (P < 0.001), with a non-significant trend upwards in the 1st and 2nd years of follow-up to 129.0 ± 27.7 (P = 0.07 compared to nadir) and 123.4 ± 29.0kg (P = 0.17), respectively. Although regains in the 3rd and 4th follow-up years were substantial to 131.0 ± 22.3 (P < 0.001), and 139.8 ± 35.4 kg (P < 0.001), there was still a moderate net weight loss of 4.7 [9.5, 0.21] and 7.0 [13.9, 0.26] kg (both P = 0.04) between the start and the 3rd and 4th follow-up years, respectively. The amount of weight regain was inversely associated with weight loss at completion of the programme, age, and directly associated with the duration of follow up in months (ß = 1.2 [0.46, 1.9] P = 0.002). Conclusion: In patients with severe obesity who completed a milk-based meal replacement programme and lost a large amount of weight, over 4 years of follow-up there was very substantial weight regain. Greater initial weight loss and older age were associated with less subsequent weight regain.

How are frames generated? Insights from the industry lobby against the sugar tax in Ireland.

There is a causal link between the consumption of ultra-processed foods and a range of non-communicable diseases (NCDs) such as obesity, type 2 diabetes and cancers. Despite this, no country in the world has reduced its obesity levels because the factors that drive obesity continue unchanged (Swinburn et al., 2019). One systemic driver is corporate influence on the public policy process. The world's largest food and beverage manufacturers engage public relations firms to create a narrative which speaks of corporate cooperation with public health policy, while simultaneously influencing policy making in ways that are favorable to industry. We sought to examine framing as a key strategy in the corporate political activity of food industry actors attempting to resist the introduction of a public health policy. Specifically, we analyzed industry submissions for an Irish government consultation for the proposed introduction of a sugar sweetened beverage (SSB) tax in 2018. We describe how a food product like sugar is framed positively by corporate actors who rely on it as their principal ingredient. Sugar is a good focus from a framing perspective because it is currently undergoing recalibration in the public's imagination - from a benign, nourishing treat in its heyday to a dangerous 'substance' that can contribute to premature mortality. Framing is already well established as a corporate political activity (CPA) to influence public policy (Shelton et al., 2017; Nixon et al., 2015; Darmon et al., 2008). Our research expands this understanding by uncovering four underlying mechanisms used to generate frames - dichotomizing, contesting, equating and cropping. Recognizing these mechanisms could help policy makers, public health professionals and business ethicists to deconstruct any given frame that becomes dominant in corporate discourse, such as 'personal responsibility', 'inadequate exercise', 'freedom' and so on. These mechanisms may also apply to other industries such as alcohol, fossil fuels and tobacco, where hazards from interference in public health strategies are a concern.

Effects of a Milk-Based Meal Replacement Program on Weight and Metabolic Characteristics in Adults with Severe Obesity.

OBJECTIVE: Low energy meal replacement regimens can induce short-term weight loss in patients with severe obesity, but usually require specially formulated dietary supplements. We sought to determine the effects of a milk-based meal replacement program on anthropometric and metabolic characteristics in adults with severe obesity. METHODS: We conducted a retrospective cohort study of patients attending our hospital-based bariatric medicine service who completed a 24-week program consisting of eight weeks of milk-based meal replacement followed by weight stabilisation and maintenance phases. Patients were seen fortnightly by the bariatric physician, nurse and dietitian. We assessed changes in anthropometric and metabolic outcomes in completers at 0, 8, 16 and 24 weeks. RESULTS: Of 105 program completers available for follow-up, 53.3% were female. Mean age was 51.1±11.2 years. Body weight decreased from 144.0±27.6 kg at baseline to 121.1±25.0 kg at 24 weeks (P<0.001), a mean total body weight loss of 15.9±6.0%, with a reduction in body mass index from 50.6±8.0 to 42.6±7.6 kg m-2 (P<0.001). In patients with diabetes, haemoglobin A1c decreased from 66.3±13.0 to 48.3±13.5 mmol/mol (P<0.001) and diabetes medication use decreased significantly. There were significant improvements also in lipid profiles and reductions in antihypertensive medication use. CONCLUSION: These preliminary findings suggest that completion of a 24-week milk-based meal replacement program has large effects on important outcomes in adults with severe obesity. However, attrition was high. Prospective assessment of the efficacy, safety, durability and cost-effectiveness of this intervention seems warranted.

Cross-sectional study of the association between skin tags and vascular risk factors in a bariatric clinic-based cohort of Irish adults with morbid obesity.

OBJECTIVE: Skin tags are associated with an insulin resistant phenotype but studies in White Europeans with morbid obesity are lacking. We sought to determine whether the presence of cervical or axillary skin tags was associated with increased cardiovascular risk in Irish adults with morbid obesity. We conducted a cross-sectional study of patients attending our Irish regional bariatric centre with a BMI ≥ 40 kg m-2 (or ≥ 35 kg m-2 with co-morbidities). We compared anthropometric and metabolic characteristics in those with versus without skin tags. RESULTS: Of 164 patients, 100 (31 male, 37 with type 2 diabetes, 36 on lipid lowering therapy, 41 on antihypertensive therapy) participated. Mean age was 53.7 ± 11.3 (range 31.1-80) years. Cervical or axillary tags were present in 85 patients. Those with tags had higher systolic blood pressure 138.0 ± 16.0 versus 125.1 ± 8.3 mmHg, p = 0.003) and HbA1c (46.5 ± 13.2 versus 36.8 ± 3.5 mmol/mol, p = 0.017). Tags were present in 94.6% of patients with diabetes, compared to 79.4% of those without diabetes (p = 0.039). Antihypertensive therapy was used by 45.8% of patients with skin tags compared to 13.3% without tags (p = 0.018). In bariatric clinic attenders skin tags were associated with higher SBP and HbA1c and a higher prevalence of diabetes and hypertension, consistent with increased vascular risk, but lipid profiles were similar.