Arthur Frank

The electrocardiogram in obesity: Statistical analysis of 1,029 patients

The electrocardiogram in 1,029 obese subjects was correlated with the severity of obesity and with age, sex and blood pressure. The heart rate, PR interval, QRS duration, QTc interval and voltage (R + S or Q wave in leads I, II and III) increased, and the QRS vector shifted to the left with increasing obesity. These changes were independent of age, sex and blood pressure. Bradycardia was present in 19% of the patients, but tachycardia in only 0.5%. ST and T wave abnormalities were present in 11%, correlating better with increasing age and blood pressure than with severity of obesity. Conduction abnormalities were infrequent. Low voltage was present in only 3.9% of the patients and QTc prolongation was present in 28.3%. The heart rate and QRS voltage increase with increasing obesity. Conduction is slowed, and the QRS vector shifts toward the left as percent overweight increases. These changes must be considered when evaluating both baseline electrocardiographic studies in obese patients and the changes seen during weight reduction.

Implantable gastric stimulation for the treatment of clinically severe obesity: results of the SHAPE trial.

BACKGROUND To compare implantable gastric stimulation therapy with a standard diet and behavioral therapy regimen in a group of carefully selected class 2 and 3 obese subjects by evaluating the difference in the percentage of excess weight loss (EWL) between the control and treatment groups. The primary endpoint was the percentage of EWL from baseline to 12 months after randomization. Implantable gastric stimulation has been proposed as a first-line treatment for severely obese patients; however, previous investigations have reported inconclusive results. METHODS A total of 190 subjects were enrolled in this prospective, randomized, placebo-controlled, double-blind, multicenter study. All patients underwent implantation with the implantable gastric stimulator and were randomized to 1 of 2 treatment groups: the control group (stimulation off) or treatment group (stimulation on). The patients were evaluated on a monthly basis. All individuals who enrolled in this study agreed to consume a diet with a 500-kcal/d deficit and to participate in monthly support group meetings. RESULTS The procedure resulted in no deaths and a low complication rate. The primary endpoint of a difference in weight loss between the treatment and control groups was not met. The control group lost 11.7% +/- 16.9% of excess weight and the treatment group lost 11.8% +/- 17.6% (P = .717) according to an intent-to-treat analysis. CONCLUSION Implantable gastric stimulation as a surgical option for the treatment of morbid obesity is a less complex procedure than current bariatric operations. However, the results of the present study do not support its application. Additional research is indicated to understand the physiology and potential benefits of this therapy.

Specificity of Screening Tests for Cushing’s Syndrome in an Overweight and Obese Population

CONTEXT Recent reports suggest a higher prevalence (1-5%) of Cushings syndrome in certain patient populations with features of the disorder (e.g., diabetes), but the prevalence in the overweight and obese population is not known. OBJECTIVE The aim of the study was to evaluate the diagnostic performance of screening tests for Cushings syndrome in overweight and obese subjects with at least two other features of the disorder. DESIGN AND SETTING We conducted a cross-sectional prospective study. SUBJECTS AND METHODS A total of 369 subjects (73% female) completed two or three tests: a 24-h urine cortisol, and/or late-night salivary cortisol, and/or 1 mg dexamethasone suppression test (DST). If any result was abnormal [based on laboratory reference range or cortisol after DST > or = 1.8 microg/dl (50 nmol/liter)], tests were repeated and/or a dexamethasone-CRH test was performed. Subjects with abnormal DST results and a low dexamethasone level were asked to repeat the test with 2 mg of dexamethasone. RESULTS In addition to obesity, subjects had a mean of five to six features of Cushings syndrome. None was found to have Cushings syndrome. Test specificities to exclude Cushings syndrome for subjects who completed three tests were: urine cortisol, 96% [95% confidence interval (CI), 93-98%]; DST, 90% (95% CI, 87-93%); salivary cortisol, 84% by RIA (95% CI, 79-89%) and 92% by liquid chromatography-tandem mass spectrometry (95% CI, 88-95%). The combined specificity (both tests normal) for all combinations of two tests was 84 to 90%, with overlapping CIs. CONCLUSION These data do not support widespread screening of overweight and obese subjects for Cushings syndrome; test results for such patients may be falsely abnormal.

Barriers to Treatment

The treatment of obesity is unlike the medical management of any other disease. It is a chronic, alarmingly common, and incurable disease that is remarkably easy to diagnose with appalling associated disabilities. Nevertheless, for almost all overweight people, the traditional medical care system is irrelevant for the management of their problem (1); and its treatment, therefore, has traditionally followed a format outside the typical care patterns of other chronic diseases.

American College of Lifestyle Medicine Expert Panel Discussion The Treat the Cause Movement

Dr Rippe: The American Journal of Lifestyle Medicine (AJLM) is proud to play a role in bringing together these diverse experts in multiple areas of lifestyle medicine to discuss the “The Treat the Cause Movement.” Our goal at AJLM has always been to provide a platform for serious, evidence-based discussion on how issues related to lifestyle impact on both shortand long-term health and quality of life. We recognize that expertise in this area resides in many places and covers numerous bodies of literature. In our expert panel, we are delighted to have individuals with expertise in multiple areas related to lifestyle medicine. Let me briefly introduce our panelists. Each of them is a leading expert in his or her field with numerous accomplishments. I will only briefly highlight several of each of their qualifications: Rosanne Rust, MS, RDN, LDN is a registered, licensed nutritionist with over 25 years of experience in clinical and community nutrition, and currently works as a nutrition communications consultant. Dr Arthur Frank is a world-renowned expert in the field of weight management and obesity treatment. Dr Steven Blair is Professor in the Departments of Exercise Science and Epidemiology and Biostatistics at the Arnold School of Public Health, at the University of South Carolina and a widely quoted expert in the area of physical activity and exercise. Dr Wayne Dysinger is the Chair of the Department of Preventive Medicine and Director of the Family and Preventive (Lifestyle) Medicine Residency at Loma Linda University. He is also Medical Director of the Lifestyle Medicine Institute. Dr Michael Parkinson is the Senior Medical Director of Health and Productivity for the UPMC Health Plan and WorkPartners overseeing employer strategies to improve health and competitiveness. He is the former President of the American College of Preventive Medicine (ACPM).

Re: 'The Light Look at a Heavy Problem' cartoon series.

Dear Editors, There is a role for editorial cartoons in professional journals, and we recognize their purpose and value. Nevertheless, we are distressed by several pieces in the cartoon series ‘A Light Look at a Heavy Problem’, which has been featured in Obesity Reviews. People who have the disease of obesity endure much abuse and social prejudice. In many contexts, the public has found it acceptable to treat obese people with derision, and to dismiss the complexity of their disease and the seriousness of its implications. Indeed, obesity has been called ‘the last remaining socially acceptable form of prejudice’ (1). The cartoons tend to reinforce negative stereotypes of obese patients and imply that their illness is a result of sloth, gluttony, indifference, wilful misconduct or characterological flaw. It does not serve us well to participate in these inappropriate characterizations and myths of obese patients. Indeed, professionals who work with, or perform research on, obese patients have a particular need to avoid the common cultural patterns that diminish the dignity of our patients. The cartoons are not respectful of obese patients. They reinforce incorrect and demeaning social stereotypes, and they add to the prejudice that complicates the lives of our patients. It is our hope that the editorial board will reconsider the content contained in these cartoons.

Why Is It So Difficult to Lose Weight

Obesity is notoriously difficult to treat. Effective treatment has been encumbered by traditional assumptions about the cause of the disease. Obesity is typically considered a manifestation of the patient’s dietary misconduct, a simple lack of willpower, or the inability to modify dysfunctional eating habits. Abundant evidence suggests that eating behavior is much more complex than patient choice alone. Eating and the system of regulating eating and body weight are largely controlled by complex signals from multiple organ systems that monitor food intake, gastrointestinal function, and energy storage and send multiple messages to the brain. The brain coordinates the physiological messages and creates additional signals about eating, appetite, hunger, and satiety. Multiple survival, environmental, and genetic factors become part of a biological regulatory system that controls eating and body weight. The system appears to be unstable and often becomes dysfunctional, particularly in an environment of abundant food and calories. Despite the difficulty in modifying the regulatory system, opportunities for management of the disease do exist. Comprehensive lifestyle management can be useful, as can selective pharmacotherapy and bariatric surgery. Public policy changes will likely be helpful in changing community understanding of the disease and its management.