Personalizing obesity assessment and care planning in primary care: patient experience and outcomes in everyday life and health.

Obesity is a complex, chronic disease, frequently associated with multiple comorbidities. Its management is hampered by a lack of translation of evidence on chronicity and pathophysiology into clinical practice. Also, it is not well understood how to support effective provider-patient communication that adequately addresses patients' personal root causes and barriers and helps them feel capable to take action for their health. This study examined interpersonal processes during clinical consultations, their impacts, and outcomes with the aim to develop an approach to personalized obesity assessment and care planning. We used a qualitative, explorative design with 20 participants with obesity, sampling for maximum variation, to examine video-recorded consultations, patient interviews at three time points, provider interviews and patient journals. Analysis was grounded in a dialogic interactional perspective and found eight key processes that supported patients in making changes to improve health: compassion and listening; making sense of root causes and contextual factors in the patient's story; recognizing strengths; reframing misconceptions about obesity; focusing on whole-person health; action planning; fostering reflection and experimenting. Patient outcomes include activation, improved physical and psychological health. The proposed approach fosters emphatic care relationships and sensible care plans that support patients in making manageable changes to improve health.

Incidence of spinal disease and role of spinal radiotherapy in multiple myeloma.

Background: Spinal disease (spd) in multiple myeloma (mm) can be a major source of morbidity in newly diagnosed patients and long-term survivors. We retrospectively assessed the incidence of spinal disease in patients newly diagnosed with myeloma, its effect on survival, and the possible effect of spinal radiation therapy (rt). Methods: Patients diagnosed with mm between 2010 and 2014 were identified through the provincial cancer registry. Plain radiography, computed tomography, and magnetic resonance imaging were reviewed to detect and document the type of spd. Data related to rt and systemic therapy were collected. Kaplan-Meier and time-varying Cox regression models were used to describe overall survival. Results: Of 306 identified patients with newly diagnosed mm, 51% had spd, including 17% with lytic disease, 68% with compression fractures, and 15% with spinal cord compression. Of the patients with spd, 61% received spinal rt. Of those patients, 84% received spinal rt within 3 months after their diagnosis. Median dose was 20 Gy. Most patients (89.2%) received chemotherapy, and 22.5% underwent autologous stem-cell transplantation. Only 6 of the patients treated with spinal rt received re-irradiation to the same site. Overall survival was similar for patients with and without spd. On multivariate analysis, spinal rt had no effect on survival. Conclusions: In patients newly diagnosed with mm, spd is a common presentation. With current systemic therapy, the presence of spd had no adverse effect on overall survival. The effect of spinal rt on overall survival was nonsignificant.

Addressing weight bias and discrimination: moving beyond raising awareness to creating change.

Weight discrimination is the unjust treatment of individuals because of their weight. There have been very few interventions to address weight discrimination, due in part to the lack of consensus on key messages and strategies. The objective of the third Canadian Weight Bias Summit was to review current evidence and move towards consensus on key weight bias and obesity discrimination reduction messages and strategies. Using a modified brokered dialogue approach, participants, including researchers, health professionals, policy makers and people living with obesity, reviewed the evidence and moved towards consensus on key messages and strategies for future interventions. Participants agreed to these key messages: (1) Weight bias and obesity discrimination should not be tolerated in education, health care and public policy sectors; (2) obesity should be recognized and treated as a chronic disease in health care and policy sectors; and (3) in the education sector, weight and health need to be decoupled. Consensus on future strategies included (1) creating resources to support policy makers, (2) using personal narratives from people living with obesity to engage audiences and communicate anti-discrimination messages and (3) developing a better clinical definition for obesity. Messages and strategies should be implemented and evaluated using consistent theoretical frameworks and methodologies.

Geographic and socioeconomic factors affecting delivery of bariatric surgery across high- and low-utilization healthcare systems.

BACKGROUND: In countries with universal health coverage, the delivery of care should be driven by need. However, other factors, such as proximity to local facilities or neighbourhood socioeconomic status, may be more important. The objective of this study was to evaluate which geographic and socioeconomic factors affect the delivery of bariatric care in Canada. METHODS: This was a national retrospective cohort study of all adult patients undergoing bariatric surgery between April 2008 and March 2015 in Canada (excluding Quebec). The main outcome was neighbourhood rate of bariatric surgery per 1000 obese individuals (BMI over 30 kg/m2 ). Geographic cluster analysis and multilevel ordinal logistic regression were used to identify high-use clusters, and to evaluate the effect of geographic and socioeconomic factors on care delivery. RESULTS: Having a bariatric facility within the same public health unit as the neighbourhood was associated with a 6·6 times higher odds of being in a bariatric high-use cluster (odds ratio (OR) 6·60, 95 per cent c.i. 1·90 to 22·88; P = 0·003). This finding was consistent across provinces after adjusting for utilization rates. Neighbourhoods with higher obesity rates were also more likely to be within high-use clusters (OR per 5 per cent increase: 2·95, 1·54 to 5·66; P = 0·001), whereas neighbourhoods closer to bariatric centres were less likely to be (OR per 50 km: 0·91, 0·82 to 1·00; P = 0·048). CONCLUSION: In this study, across provincial healthcare systems with high and low utilization, the delivery of care was driven by the presence of local facilities and neighbourhood obesity rates. Increasing distance to bariatric centres substantially influenced care delivery.

High-grade glioma management and response assessment-recent advances and current challenges.

The management of high-grade gliomas (hggs) is complex and ever-evolving. The standard of care for the treatment of hggs consists of surgery, chemotherapy, and radiotherapy. However, treatment options are influenced by multiple factors such as patient age and performance status, extent of tumour resection, biomarker profile, and tumour histology and grade. Follow-up cranial magnetic resonance imaging (mri) to differentiate treatment response from treatment effect can be challenging and affects clinical decision-making. An assortment of advanced radiologic techniques-including perfusion imaging with dynamic susceptibility contrast mri, dynamic contrast-enhanced mri, diffusion-weighted imaging, proton spectroscopy, mri subtraction imaging, and amino acid radiotracer imaging-can now incorporate novel physiologic data, providing new methods to help characterize tumour progression, pseudoprogression, and pseudoresponse. In the present review, we provide an overview of current treatment options for hgg and summarize recent advances and challenges in imaging technology.

Obesity-related health status is a better predictor of pregnancy with fertility treatment than body mass index: a prospective study.

This study assessed whether an obesity-related health status instrument (Edmonton obesity scoring system - EOSS) or body mass index (BMI) better predicted pregnancy rates in overweight women undergoing fertility treatments. A prospective cohort study was conducted on patients with a BMI ≥ 25 kg m(-2) undergoing a fertility treatment cycle (ovulation induction, superovulation, or in vitro fertilization). Obesity-related health status including blood pressure, blood work, health history, and functional assessment were assessed. A total of 101 patients were included in the study with an average age of 36.3 ± 4.2 years and a mean BMI of 31.8 ± 5.2 kg m(-2) . EOSS was found to be statistically predictive of pregnancy rate/cycle (OR 0.51, 95% CI 0.27-0.94; P = 0.03), whereas BMI was not (OR 0.95, 95% CI 0.86-1.05). A similar trend was seen for clinical pregnancy rate/cycle started. However, the association between clinical pregnancy rates and EOSS or BMI did not reach statistical significance (OR 0.53, P = 0.06 and OR 0.98, P = 0.62 respectively). Our results demonstrated that EOSS better predicted pregnancy rates after fertility treatments than BMI. In fact, for every EOSS stage increased by one unit, the odds of pregnancy were approximately halved. A multi-centre study powered for live birth is warranted to establish effective pre-fertility management of overweight women.

Weight bias reduction in health professionals: a systematic review.

Innovative and coordinated strategies to address weight bias among health professionals are urgently needed. We conducted a systematic literature review of empirical peer-reviewed published studies to assess the impact of interventions designed to reduce weight bias in students or professionals in a health-related field. Combination sets of keywords based on three themes (1: weight bias/stigma; 2: obesity/overweight; 3: health professional) were searched within nine databases. Our search yielded 1447 individual records, of which 17 intervention studies satisfied the inclusion criteria. Most studies (n = 15) included medical, dietetic, health promotion, psychology and kinesiology students, while the minority included practicing health professionals (n = 2). Studies utilized various bias-reduction strategies. Many studies had methodological weaknesses, including short assessment periods, lack of randomization, lack of control group and small sample sizes. Although many studies reported changes in health professionals' beliefs and knowledge about obesity aetiology, evidence of effectiveness is poor, and long-term effects of intervention strategies on weight bias reduction remain unknown. The findings highlight the lack of experimental research to reduce weight bias among health professionals. Although changes in practice will likely require multiple strategies in various sectors, well-designed trials are needed to test the impact of interventions to decrease weight bias in healthcare settings.

Why do families enrol in paediatric weight management? A parental perspective of reasons and facilitators.

BACKGROUND: Few children with obesity who are referred for weight management end up enroled in treatment. Factors enabling enrolment are poorly understood. Our purpose was to explore reasons for and facilitators of enrolment in paediatric weight management from the parental perspective. METHODS: Semi-structured interviews were conducted with parents of 10- to 17-year-olds who were referred to one of four Canadian weight management clinics and enroled in treatment. Interviews were audio-recorded and transcribed verbatim. Manifest/inductive content analysis was used to analyse the data, which included the frequency with which parents referred to reasons for and facilitators of enrolment. RESULTS: In total, 65 parents were interviewed. Most had a child with a BMI ≥95th percentile (n = 59; 91%), were mothers (n = 55; 85%) and had completed some post-secondary education (n = 43; 66%). Reasons for enrolment were related to concerns about the child, recommended care and expected benefits. Most common reasons included weight concern, weight loss expectation, lifestyle improvement, health concern and need for external support. Facilitators concerned the referral initiator, treatment motivation and barrier control. Most common facilitators included the absence of major barriers, parental control over the decision to enrol, referring physicians stressing the need for specialized care and parents' ability to overcome enrolment challenges. CONCLUSIONS: Healthcare providers might optimize enrolment in paediatric weight management by being proactive in referring families, discussing the advantages of the recommended care to meet treatment expectations and providing support to overcome enrolment barriers.

Challenges in interdisciplinary weight management in primary care: lessons learned from the 5As Team study.

Increasingly, research is directed at advancing methods to address obesity management in primary care. In this paper we describe the role of interdisciplinary collaboration, or lack thereof, in patient weight management within 12 teams in a large primary care network in Alberta, Canada. Qualitative data for the present analysis were derived from the 5As Team (5AsT) trial, a mixed-method randomized control trial of a 6-month participatory, team-based educational intervention aimed at improving the quality and quantity of obesity management encounters in primary care practice. Participants (n = 29) included in this analysis are healthcare providers supporting chronic disease management in 12 family practice clinics randomized to the intervention arm of the 5AsT trial including mental healthcare workers (n = 7), registered dietitians (n = 7), registered nurses or nurse practitioners (n = 15). Participants were part of a 6-month intervention consisting of 12 biweekly learning sessions aimed at increasing provider knowledge and confidence in addressing patient weight management. Qualitative methods included interviews, structured field notes and logs. Four common themes of importance in the ability of healthcare providers to address weight with patients within an interdisciplinary care team emerged, (i) Availability; (ii) Referrals; (iii) Role perception and (iv) Messaging. However, we find that what was key to our participants was not that these issues be uniformly agreed upon by all team members, but rather that communication and clinic relationships support their continued negotiation. Our study shows that firm clinic relationships and deliberate communication strategies are the foundation of interdisciplinary care in weight management. Furthermore, there is a clear need for shared messaging concerning obesity and its treatment between members of interdisciplinary teams.

Missing an opportunity: the embedded nature of weight management in primary care.

The 5As Team study was designed to create, implement and evaluate a flexible intervention to improve the quality and quantity of weight management visits in primary care. The objective of this portion of the study was to explore how primary care providers incorporate weight management in their practice. 5AsT is a randomized controlled trial (RCT) on the implementation of a 6-month 5 As Team (5AsT) intervention designed to operationalize the 5As of obesity management in primary care. Data for the qualitative portion of the study presented here included semi-structured interviews with 29 multidisciplinary team providers and field notes of intervention sessions. Thematic analysis was undertaken. A key pattern that emerged from the data was that healthcare providers usually do not address obesity as a primary focus for a visit. Rather, obesity is embedded in a wide range of primary care encounters for other conditions. Implications were it can take extra time to discuss weight, it can be inappropriate to bring up weight as a topic, and treating risk factors and root causes of obesity have indirect benefits to patient weight management. Our findings have implications for obesity treatment approaches and tools that assume a discreet weight management visit. The embedded nature of obesity management in primary care can be harnessed to leverage multiple opportunities for asking and assessing root causes of obesity, and working longitudinally towards individual health goals.

5As Team obesity intervention in primary care: development and evaluation of shared decision-making weight management tools.

Despite several clinical practice guidelines, there remains a considerable gap in prevention and management of obesity in primary care. To address the need for changing provider behaviour, a randomized controlled trial with convergent mixed method evaluation, the 5As Team (5AsT) study, was conducted. As part of the 5AsT intervention, the 5AsT tool kit was developed. This paper describes the development process and evaluation of these tools. Tools were co-developed by the multidisciplinary research team and the 5AsT, which included registered nurses/nurse practitioners (n = 15), mental health workers (n = 7) and registered dieticians (n = 7), who were previously randomized to the 5AsT intervention group at a primary care network in Edmonton, Alberta, Canada. The 5AsT tool development occurred through a practice/implementation-oriented, need-based, iterative process during learning collaborative sessions of the 5AsT intervention. Feedback during tool development was received through field notes and final provider evaluation was carried out through anonymous questionnaires. Twelve tools were co-developed with 5AsT. All tools were evaluated as either 'most useful' or 'moderately useful' in primary care practice by the 5AsT. Four key findings during 5AsT tool development were the need for: tools that were adaptive, tools to facilitate interdisciplinary practice, tools to help patients understand realistic expectations for weight loss and shared decision-making tools for goal setting and relapse prevention. The 5AsT tools are primary care tools which extend the utility of the 5As of obesity management framework in clinical practice.

Clinical trial success rates of anti-obesity agents: the importance of combination therapies.

The objective of this study was to construct a clinical trial profile assessing the risk of drug failure among anti-obesity agents. Research was conducted by looking at anti-obesity therapies currently on the market or in clinical trials (phases I to III) conducted from 1998 to September 2014, with the exclusion of any drugs whose phase I trial was conducted prior to January 1998. This was completed primarily through a search on http://clinicaltrials.gov where a total of 51 drugs met the search criteria. The transition probabilities were then calculated based on various classifications and compared against industry standards. The transition probability of anti-obesity agents was 8.50% whereas the transition probability of industry standards was 10.40%. Combination therapies had four times the transition probability than monotherapies, 40% and 4.75%, respectively. Therefore, it was determined that 92% of drugs fail during clinical trial testing for this indication and combination therapy appears to improve clinical trial success rates to 10-fold.

Women with severe obesity and relatively low bone mineral density have increased fracture risk.

UNLABELLED: Among women with obesity, those with the lowest bone density have the highest fracture risk. The types of fractures include any fracture, fragility-type fractures (vertebra, hip, upper arm, forearm, and lower leg), hand and foot fractures, osteoporotic, and other fracture types. INTRODUCTION: Recent reports have contradicted the traditional view that obesity is protective against fracture. In this study, we have evaluated the relationship between fracture history and bone mineral density (BMD) in subjects with obesity. METHODS: Fracture risk was assessed in 400 obese women in relation to body mass index (BMI), BMD, and clinical and laboratory variables. RESULTS: Subjects (mean age, 43.8 years; SD, 11.1 years) had a mean BMI of 46.0 kg/m(2) (SD, 7.4 kg/m(2)). There were a total of 178 self-reported fractures in 87 individuals (21.8% of subjects); fragility-type fractures (hip, vertebra, proximal humerus, distal forearm, and ankle/lower leg) were present in 58 (14.5%). There were higher proportions of women in the lowest femoral neck BMD quintile who had any fracture history (41.3 vs. 17.2%, p < 0.0001), any fragility-type fractures (26.7 vs. 11.7%, p = 0.0009), hand and foot fractures (16.0 vs. 5.5%, p = 0.002), other fracture types (5.3 vs. 1.2%, p = 0.02), and osteoporotic fractures (8.0 vs. 1.2%, p < 0.0001) compared to the remaining population. The odds ratio for any fracture was 0.63 (95% CI, 0.49-0.89; p = 0.0003) per SD increase in BMD and was 4.3 (95% CI, 1.9-9.4; p = 0.003) in the lowest BMD quintile compared to the highest quintile. No clinical or biochemical predictors of fracture risk were identified apart from BMD. CONCLUSIONS: Women with obesity who have the lowest BMD values, despite these being almost normal, have an elevated risk of fracture compared to those with higher BMD.

Changes in body weight and pulse: outcome events in overweight and obese subjects with cardiovascular disease in the SCOUT trial.

BACKGROUND/OBJECTIVES: The Sibutramine Cardiovascular OUTcomes (SCOUT) trial showed a significantly increased relative risk of nonfatal cardiovascular events, but not mortality, in overweight and obese subjects receiving long-term sibutramine treatment with diet and exercise. We examined the relationship between early changes (both increases and decreases) in pulse rate, and the impact of these changes on subsequent cardiovascular outcome events in both the placebo and sibutramine groups. SUBJECTS/METHODS: 9804 males and females, aged ⩾55 years, with a body mass index of 27-45 kg m(-)(2) were included in this current subanalysis of the SCOUT trial. Subjects were required to have a history of cardiovascular disease and/or type 2 diabetes mellitus with at least one cardiovascular risk factor, to assess cardiovascular outcomes. The primary outcome event (POE) was a composite of nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death. Time-to-event analyses of the POE were performed using Cox regression models. RESULTS: During the initial 6-week sibutramine treatment period, the induced pulse rate increase was related to weight change (1.9±7.7 beats per minute (bpm) with weight increase; 1.4±7.3 bpm, 0-5 kg weight loss; 0.6±7.4 bpm, ⩾5 kg weight loss). Throughout the subsequent treatment period, those continuing on sibutramine showed a consistently higher mean pulse rate than the placebo group. There was no difference in POE rates with either an increase or decrease in pulse rate over the lead-in period, or during lead-in baseline to 12 months post randomization. There was also no relationship between pulse rate at lead-in baseline and subsequent cardiovascular events in subjects with or without a cardiac arrhythmia. CONCLUSION: Baseline pulse rate and changes in pulse rate may not be an important modifier nor a clinically useful predictor of outcome in an individual elderly cardiovascular obese subject exposed to weight management.

Effect of implementing the 5As of obesity management framework on provider-patient interactions in primary care.

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT: Obesity counselling in primary care is positively associated with self-reported behaviour change in patients with obesity. Obesity counselling is rare, and when it does occur, it is often of low quality because of poor training and/or competency of providers' obesity management, lack of time and economical disincentives, and negative attitude towards obesity and obesity management. 5As frameworks are routinely used for behaviour-change counselling and addiction management (e.g. smoking cessation), but few studies have examined its efficacy for weight management. WHAT THIS STUDY ADDS: This study presents pilot data from the implementation and evaluation of an obesity management tool (5As of Obesity Management developed by the Canadian Obesity Network) in a primary care setting. Results show that the tool facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care. Obesity remains poorly managed in primary care. The 5As of Obesity Management is a theory-driven, evidence-based minimal intervention designed to facilitate obesity counselling and management by primary care practitioners. This project tested the impact of implementing this tool in primary care clinics. Electronic self-administered surveys were completed by pre-screened obese subjects at the end of their appointments in four primary care clinics (over 25 healthcare providers [HCPs]). These measurements were performed before (baseline, n = 51) and 1 month after implementing the 5As of Obesity Management (post-intervention, n = 51). Intervention consisted of one online training session (90 min) and distribution of the 5As toolkit to HCPs of participating clinics. Subjects completing the survey before and after the intervention were comparable in terms of age, sex, body mass index, comorbidities, satisfaction and self-reported health status (P > 0.2). Implementing the 5As of Obesity Management resulted in a twofold increase in the initiation of obesity management (19 vs. 39%, P = 0.03), and caused a statistically significant increase in the perceived follow-up/coordination efforts (self-reported Patient Assessment of Chronic Illness Care components, 45 ± 22 vs. 67 ± 12 points, P = 0.002), as well as two components of the 5As framework: Assess (50 ± 29 vs. 66 ± 15 points, P = 0.03) and Assist (54 ± 26 vs. 72 ± 13 points, P = 0.01). Our results suggest that using the 5As of Obesity Management facilitates weight management in primary care by promoting physician-patient communications, medical assessments for obesity and plans for follow-up care.

Impact of rosiglitazone on body composition, hepatic fat, fatty acids, adipokines and glucose in persons with impaired fasting glucose or impaired glucose tolerance: a sub-study of the DREAM trial.

AIMS: Thiazolidinediones reduce ectopic fat, increase adiponectin and reduce inflammatory adipokines, fatty acids and glucose in people with Type 2 diabetes. We aimed to measure these effects in people with impaired fasting glucose and/or impaired glucose tolerance. METHODS: After approximately 3.5 years of exposure to rosiglitazone 8 mg (n = 88) or placebo (n = 102), 190 DREAM trial participants underwent abdominal computed tomography and dual-energy X-ray absorptiometry scans. Visceral and subcutaneous adipose tissue areas, estimated hepatic fat content, total fat and lean mass were calculated and changes in levels of fasting adipokines, free fatty acids, glucose and post-load glucose were assessed. RESULTS: Compared with the placebo, participants on rosiglitazone had no difference in lean mass, had 4.1 kg more body fat (P < 0.0001) and 31 cm(2) more subcutaneous abdominal adipose tissue area (P = 0.007). Only after adjusting for total fat, participants on rosiglitazone had 23 cm² less visceral adipose tissue area (P = 0.01) and an 0.08-unit higher liver:spleen attenuation ratio (i.e. less hepatic fat; P = 0.02) than those on the placebo. Adiponectin increased by 15.0 µg/ml with rosiglitazone and by 0.4 µg/ml with placebo (P < 0.0001). Rosiglitazone's effect on fat distribution was not independent of changes in adiponectin. Rosiglitazone's effects on fasting (-0.36 mmol/l; P = 0.0004) and 2-h post-load glucose (-1.21 mmol/l; P = 0.0008) were not affected by adjustment for fat distribution or changes in adiponectin or free fatty acids. CONCLUSIONS: In people with impaired fasting glucose/impaired glucose tolerance, rosiglitazone is associated with relatively less hepatic and visceral fat, increased subcutaneous fat and increased adiponectin levels. These effects do not appear to explain the glucose-lowering effect of rosiglitazone.

Changes in body weight and blood pressure: paradoxical outcome events in overweight and obese subjects with cardiovascular disease.

BACKGROUND/OBJECTIVES: The Sibutramine Cardiovascular OUTcomes (SCOUT) trial showed a significantly increased relative risk of nonfatal cardiovascular events, but not mortality, in overweight and obese subjects receiving long-term sibutramine treatment with diet and exercise. We examined the relationship between early changes (both increases and decreases) in body weight and blood pressure, and the impact of these changes on subsequent cardiovascular outcome events. SUBJECTS/METHODS: A total of 9804 male and female subjects, aged 55 years or older, with a body mass index of 27-45 kg m(-2) were included in this current subanalysis of the SCOUT trial. Subjects were required to have a history of cardiovascular disease and/or type 2 diabetes mellitus with at least one cardiovascular risk factor (hypertension, dyslipidemia, current smoking or diabetic nephropathy) to assess cardiovascular outcomes. Post hoc subgroup analyses of weight change (categories) and blood pressure were performed overall and by treatment group (6-week sibutramine followed by randomized placebo or continued sibutramine). The primary outcome event (POE) was a composite of nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death. Time-to-event analyses of the POE were performed using Cox regression models with factors for treatment, subgroups and interactions. RESULTS: During the initial 6-week sibutramine treatment period, systolic blood pressure decreased progressively with increasing weight loss in hypertensive subjects (-8.1±10.5 mm Hg with <5 kg weight loss to -10.8±11.0 mm Hg with ⩾5 kg weight loss). The highest POE incidence occurred mainly in groups with increases in both weight and blood pressure. However, with long-term sibutramine treatment, a markedly lower blood pressure tended to increase POEs. CONCLUSION: Modest weight loss and modest lower blood pressure each reduced the incidence of cardiovascular events, as expected. However, the combination of early marked weight loss and rapid blood pressure reduction seems to be harmful in this obese elderly cardiovascular diseased population.

Association of anemia with the risk of cardiovascular adverse events in overweight/obese patients.

OBJECTIVE: Anemia is associated with increased cardiovascular risks. Obesity may cause anemia in several ways, for example, by low-grade inflammation and relative iron deficit. The outcomes associated with anemia in overweight/obese patients at high cardiovascular risk are however not known. Therefore, we investigated the cardiovascular prognosis in overweight/obese subjects with anemia. METHODS: A total of 9,687 overweight/obese cardiovascular high-risk patients from the Sibutramine Cardiovascular OUTcomes trial were studied. Patients were stratified after baseline hemoglobin level and followed for the risks of primary event (comprising nonfatal myocardial infarction, nonfatal stroke, resuscitated cardiac arrest or cardiovascular death) and all-cause mortality. Risk estimates (hazard ratios (HR) with 95% confidence intervals (CI)) were calculated using Cox regression models. RESULTS: Anemia was unadjusted associated with increased risk for the primary event, HR 1.73 (CI 1.37-2.18) and HR 2.02 (CI 1.34-3.06) for patients with mild or moderate-to-severe anemia, respectively, compared with patients without anemia. Adjusted for several confounders, anemia remained of prognostic importance. Increased risk of the primary events appeared to be driven by risk of cardiovascular death, adjusted HR 1.82 (CI 1.33-2.51) for mild anemia and adjusted HR 1.65 (CI 0.90-3.04) for moderate-to-severe anemia, and all-cause mortality, adjusted HR 1.50 (CI 1.17-1.93) for mild and adjusted HR 1.61 (CI 1.04-2.51) for moderate-to-severe anemia. While adding serum creatinine to the models, the increased risk of mild anemia was still a significant predictor for mortality (cardiovascular and all-cause), whereas moderate-to-severe anemia was not. For the primary events, anemia was no longer of independent prognostic importance when including serum creatinine. CONCLUSION: Anemia is associated with an increased risk of long-term adverse cardiovascular events and deaths among overweight/obese cardiovascular high-risk patients. The increased risk appeared to be driven by the risk of cardiovascular death and all-cause mortality, and renal impairments seemed to have a role in the increased risk.