Changes in telomere length 3-5 years after gastric bypass surgery.

Increased inflammation and oxidative stress associated with obesity can accelerate aging. Telomere length (TL) has the capacity to serve as an aging indicator at the cellular level. Obesity has a known association with shorter TL. This study evaluated TL of immune cells in a population of obese individuals who underwent gastric bypass surgery. Pre- and post-operative DNA samples were available for 50 subjects who had gastric bypass surgery. DNA was analyzed via quantitative polymerase chain reaction to determine TL. Changes in TL were evaluated by comparing TL at baseline to TL at 3-5 years post gastric bypass surgery. Sixty percent of the individuals in the study observed an increase in TL. Significant lengthening was observed for those with the shortest baseline TL (P=0.0011), but not for those with intermediate baseline TL (P=0.411) or longest baseline TL (P=0.207). Change in TL was negatively correlated with age and triglycerides but not correlated with weight loss induced by bariatric surgery. This study confirms that TL lengthening is observed post bariatric surgery and is the first to detect TL lengthening 3-5 years after surgery.

Gene expression profiling in subcutaneous, visceral and epigastric adipose tissues of patients with extreme obesity.

OBJECTIVE: The goal of the present study was to identify differences in gene expression between SAT, VAT and EAT depots in Class III severely obese individuals. DESIGN: Human subcutaneous (SAT) and visceral (VAT) adipose tissues exhibit differential gene expression profiles. There is little information, however, about the other proximal white adipose tissue, epigastric (EAT), in terms of its function and contribution to metabolism. SUBJECTS AND METHODS: Using RNA from adipose biospecimens obtained from Class III severely obese patients undergoing open Roux-en-Y gastric bypass surgery, we compared gene expression profiles between SAT, VAT and EAT, using microarrays validated by real-time quantitative PCR. RESULTS: The three depots were found to share 1907 genes. VAT had the greatest number of genes (66) expressed exclusively in this depot, followed by SAT (23), and then EAT (14). Moreover, VAT shared more genes with EAT (65) than with SAT (38). Further analyses using ratios of SAT/EAT, VAT/EAT and SAT/VAT identified specific as well as overlapping networks and pathways of genes representing dermatological diseases, inflammation, cell cycle and growth, cancer and development. Targeted analysis of genes, having a role in adipose tissue development and function, revealed that Peroxisome proliferator-activated receptor Gamma Coactivator 1-alpha (PGC1-α) that regulates the precursor of the hormone Irisin (FNCD5) were abundantly expressed in all three fat depots, along with fibroblast growth factors (FGF) FGF1, FGF7 and FGF10, whereas, FGF19 and FGF21 were undetectable. CONCLUSIONS: These data indicate that EAT has more in common with VAT, suggesting similar metabolic potential. The human epigastric adipose depot could have a significant functional role in metabolic diseases and should be further investigated.

Evaluation of multi-frequency bioelectrical impedance analysis for the assessment of body composition in individuals with obesity.

OBJECTIVE: The purpose of this study was to compare body composition measurements estimated by multi-frequency bioelectrical impedance analysis (MF-BIA) with air displacement plethysmography (ADP) in individuals with obesity. METHODS: Bariatric patients were recruited from Geisinger's Center for Nutrition and Weight Management Clinic in Danville, Pennsylvania. Sixty-two participants (age = 52.4 ± 9.3 years; body mass index = 38.9 ± 8.0 kg m-2) reported for a same-day testing visit. Body composition was measured using a common MF-BIA analyzer (InBody 720, Biospace Co., Beverly Hills, CA) and ADP. RESULTS: Strong relationships were observed between MF-BIA and ADP methods (r = 0.88-0.96, P < 0.001). There were no differences between MF-BIA and ADP measures of per cent body fat, fat mass or fat-free mass for the total sample or when examined by gender. CONCLUSIONS: The InBody 720 MF-BIA analyzer produced body composition measurements that were similar to ADP supporting the use of this technology in the obese population.

Electronically captured, patient-reported physical function: an important vital sign in obesity medicine.

OBJECTIVES: Impaired physical function (i.e., inability to walk 200 feet, climb a flight of stairs or perform activities of daily living) predicts poor clinical outcomes and adversely impacts medical and surgical weight management. However, routine assessment physical function is seldom performed clinically. The PROMIS Physical Function Short Form 20a (SF-20a) is a validated questionnaire for assessing patient reported physical function, which includes published T-score percentiles adjusted for gender, age and education. However, the effect that increasing levels of obesity has on these percentiles is unclear. We hypothesized that physical function would decline with increasing level of obesity independent of gender, age, education and comorbidity. MATERIALS AND METHODS: This study included 1,627 consecutive weight management patients [(mean ± SEM), 44.7 ± 0.3 years and 45.1 ± 0.2 kg/m2] that completed the PROMIS SF-20a during their initial consultation. We evaluated the association between obesity level and PROMIS T-score percentiles using multiple linear regression adjusting for gender, age, education and Charlson Comorbidity Index (CCI). RESULTS: Multiple linear regression T-score percentiles were lower in obesity class 2 (-12.4%tile, p < 0.0001), class 3 (-17.0%tile, p < 0.0001) and super obesity (-25.1%tile, p < 0.0001) compared to class 1 obesity. CONCLUSION: In patients referred for weight management, patient reported physical function was progressively lower in a dose-dependent fashion with increasing levels of obesity, independent of gender, age, education and CCI.

Surgical options for the severely obese patient.

Surgical options for severe obesity are becoming an increasingly common method of treatment, the consequence of the historically high rates of recidivism with conventional medical treatment, the availability of modified, less drastic surgical procedures, and long-term efficacy statistics. This article reviews the indications and contraindications to bariatric surgery and reviews common surgical procedures and their efficacy.

Future trends in weight management.

Although advances have been made in the treatment of obese and overweight patients, no "magic bullet" yet exists. Future targets for pharmacotherapy include the OB protein leptin, neuropeptide, beta 3-adrenergic receptors, uncoupling proteins 2 and 3, and protein kinase A. Cholecystokinin, bombesin, and glucogen-like peptide-1, receptors for gastrointestinal hormones, offer potential future pharmacologic agents that enhance energy expenditure, and they have proven promising for the development of appetite-suppressant pharmacotherapy. Receptor agonists for each of these proteins have been shown to be useful as appetite suppressants and reducing meal size. This article discusses various research modalities currently under consideration. Despite rapid strides toward an ideal antiobesity agent, the role of diet, exercise, and behavior modification must be considered the cornerstone for any potential future pharmacotherapy.

Advances in the understanding and treatment of obesity.

The epidemic of obesity in the United States has major consequences for society. Healthcare providers need to have an appreciation for obesity's complexity and related multiple comorbid medical problems. This article reviews the epidemiology, definitions, and assessment of obesity with emphasis on its clinical consequences. In addition, current techniques in evaluating and treating the obese patient are also described.

Lactose intolerance.

Lactose intolerance affects more than 50 million Americans. It is one of the most common gastrointestinal disorders seen by primary care physicians. When this disorder is properly diagnosed, the patient is easily treated with education and dietary modifications. Lactose intolerance is commonly misdiagnosed because of its overlapping symptoms of diarrhea and abdominal bloating. This article reviews the etiology, diagnosis, and treatment of lactose intolerance.

Acute pancreatitis.

Acute pancreatitis is a relatively common disease with an incidence of 30 per 100,000 persons per year. In the United States, more than 80% of the cases are related to biliary stones or alcohol use. It is a potentially fatal disease with an overall mortality of 5% to 10%. When first seen, patients have an acute abdomen. It is imperative that the diagnosis be established rapidly with a thorough history, physical examination, and appropriate laboratory and imaging studies. Prompt determination of patients who need referral for intensive care or consultation is crucial. There is no specific treatment for most patients with acute pancreatitis. Supportive care includes intravenous administration of fluids, parenterally administered analgesia, nutritional support, and prevention and treatment of complications.

Enteral and parenteral nutrition support.

The use of enteral and parenteral nutrition support may be warranted when patients are unable to ingest adequate calories or protein (or both). This review provides an overview of the indications, access, administration, management, and complications of these modes of therapy.

Overview and treatment of diverticular disease.

Diverticular disease is a common medical problem seen in Western society. Outpatient management with close observation is appropriate for the majority of patients. Established criteria for hospitalization and treatment of diverticulitis can help to reduce medical costs and length of stay. Minimally invasive techniques such as computed tomography-guided drainage of diverticular abscess can expedite medical and surgical treatment.

Relative validity of the Geisinger Rural Aging Study food frequency questionnaire.

OBJECTIVE: To determine the relative validity of a population specific food frequency questionnaire (FFQ) and evaluate the effectiveness of the instrument for assessing nutritional risk in older adults. DESIGN: A cross-over design with participants completing two different dietary assessment instruments in random order. SETTING: The Geisinger Rural Aging Study (GRAS), a longitudinal study of over 20,000 adults living in the central, northern and eastern counties of Pennsylvania. PARTICIPANTS: A subset of GRAS consisting of 245 older adults (60% women) ranging in age from 70 to 95 years. MEASUREMENTS: Energy and nutrient intakes were assessed from two instruments: a population specific food frequency questionnaire (FFQ) and four 24-hour dietary recalls conducted over a two week period. RESULTS: Pearson correlation coefficients between the FFQ and dietary recalls for most nutrients were 0.5 or higher which suggests that the FFQ provided relatively valid estimates of macro and micronutrient intakes examined. Bland-Altman plots were generated to examine the agreement between instruments. Data are shown for energy, folate and zinc with close agreement at lower intakes indicative of risk for folate and zinc. Sensitivity results also showed that the FFQ was able to correctly classify individuals adequately at risk for most nutrients examined. CONCLUSION: This population specific FFQ appears to be a valid instrument for use in in evaluating risk for many nutrients that are of particular concern in older adults residing throughout many predominately rural counties in Pennsylvania.

Pharmacological management of obesity: an Endocrine Society clinical practice guideline

OBJECTIVE: To formulate clinical practice guidelines for the pharmacological management of obesity. PARTICIPANTS: An Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer. This guideline was co-sponsored by the European Society of Endocrinology and The Obesity Society. EVIDENCE: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe the strength of recommendations and the quality of evidence. CONSENSUS PROCESS: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of the Endocrine Society, the European Society of Endocrinology, and The Obesity Society reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize some of the supporting evidence. CONCLUSIONS: Weight loss is a pathway to health improvement for patients with obesity-associated risk factors and comorbidities. Medications approved for chronic weight management can be useful adjuncts to lifestyle change for patients who have been unsuccessful with diet and exercise alone. Many medications commonly prescribed for diabetes, depression, and other chronic diseases have weight effects, either to promote weight gain or produce weight loss. Knowledgeable prescribing of medications, choosing whenever possible those with favorable weight profiles, can aid in the prevention and management of obesity and thus improve health.(AU)

Nutrition and enterocutaneous fistulas.

Enterocutaneous fistulas (ECFs) are a complex topic in terms of classification. ECF-related morbidity and mortality can be high due to fluid loss and electrolyte imbalance, sepsis, and malnutrition. Most prognostic factors influencing the outcome of ECF are now well-known. ECF treatment is complex; and, based on various situations, it can be surgical or conservative/ medical. Depending on fistula site and nutritional status, clinicians have to decide whether total parenteral or enteral nutrition should be established. In cases where total parenteral nutrition alone for 7 days has failed to influence the high output fistulas, overall data support the use of adjuvant drug, somatostatin, or its synthetic analogue, octreotide. Somatostatin 250 microg/d and octreotide 300-600 microg/d have been tried along with total parenteral nutrition to decrease the healing time of ECFs and to reduce the number of complications.

Leptin: pathogenesis and treatment of morbid obesity.

Leptin is a hormone produced primarily by the adipocytes. It works through different receptors and seems to provide information to the hypothalamus about the energy status of the body. Although leptin appears to exert its anti-obesity effect through its central action, the full spectrum of its action is yet to be determined. Most obese subjects in studies have high serum levels of leptin, suggesting that the major problem is leptin resistance rather than leptin deficiency. Consequently, these patients may not respond to exogenous leptin. Recent trials have indicated, however, that leptin may have therapeutic potential in leptin-deficient as well as leptin-resistant states.