Edward Saltzman

Nonsurgical factors that influence the outcome of bariatric surgery: a review.

Objective Severe obesity (ie, at least 100% overweight or body mass index >or=to40 kg/m2) is associated with significant morbidity and increased mortality. It is apparently becoming more common in this country. Conventional weight-loss treatments are usually ineffective for severe obesity and bariatric surgery is recommended as a treatment option. However, longitudinal data on the long-term outcome of bariatric surgery are sparse. Available data indicate that the outcome of bariatric surgery, although usually favorable in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. The objective of this study is to present a review of the outcome of bariatric surgery in three areas: weight loss and improvement in health status, changes in eating behavior, and psychosocial adjustment. The study will also review how eating behavior, energy metabolism, and psychosocial functioning may affect the outcome of bariatric surgery. Suggestions for additional research in these areas are made. Method Literature review. Results On average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty. In about 30% of patients, weight regain occurs at 18 months to 2 years after surgery. Binge eating behavior, which is common among the morbidly obese, may recur after surgery and is associated with weight regain. Energy metabolism may affect the outcome of bariatric surgery, but it has not been systematically studied in this population. Presurgery psychosocial functioning does not seem to affect the outcome of surgery, and psychosocial outcome is generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and suicide. Conclusions Factors leading to poor outcome of bariatric surgery, such as binge eating and lowered energy metabolism, should be studied to improve patient selection and outcome. Long-term outcome data on psychosocial functioning are lacking. Longitudinal studies to examine the long-term outcome of bariatric surgery and the prognostic indicators are needed.

Binge eating disorder in extreme obesity.

OBJECTIVE: To determine whether extremely obese binge eating disorder (BED) subjects (BED defined by the Eating Disorder Examination) differ from their extremely obese non-BED counterparts in terms of their eating disturbances, psychiatric morbidity and health status.DESIGN: Prospective clinical comparison of BED and non-BED subjects undergoing gastric bypass surgery (GBP).SUBJECTS: Thirty seven extremely obese (defined as BMI ≥40 kg/m2) subjects (31 women, six men), aged 22–58 y.MEASUREMENTS: Eating Disorder Examination 12th Edition (EDE), Three Factor Eating Questionnaire (TFEQ), Structured Clinical Interview for the Diagnostic and Statistical Manual-IV (SCID-IV), Short-Form Health Status Survey (SF-36), and 24 h Feeding Paradigm.RESULTS: Twenty-five percent of subjects were classified as BED (11% met full and 14% partial BED criteria) and 75% of subjects were classified as non-BED. BED (full and partial) subjects had higher eating disturbance in terms of eating concern and shape concern (as found by the EDE), higher disinhibition (as found by the TFEQ), and they consumed more liquid meal during the 24 h feeding paradigm. No difference was found in psychiatric morbidity between BED and non-BED in terms of DSM-IV Axis I diagnosis. The health status scores of both BED and non-BED subjects were significantly lower than US norms on all subscales of the SF-36, particularly the BED group.CONCLUSION: Our findings support the validity of the category of BED within a population of extremely obese individuals before undergoing GBP. BED subjects differed from their non-BED counterparts in that they had a greater disturbance in eating attitudes and behavior, a poorer physical and mental health status, and a suggestion of impaired hunger/satiety control. However, in this population of extremely obese subjects, the stability of BED warrants further study.

Morbid obesity is an independent determinant of death among surgical critically ill patients.

Objective:To determine whether extreme obesity (morbid obesity; body mass index ≥40 kg/m2) is an independent risk factor for death among critically ill patients; this objective is most salient in the subset of patients who sustain a prolonged intensive care unit stay during which the burdens of care imposed by obesity and its consequences would become most apparent. Design:Cohort analysis of data from the Project Impact database used to catalog admissions and outcomes to a surgical intensive care unit, with predetermined end point analyses of outcomes. Setting:Surgical intensive care unit serving Tufts-New England Medical Center, a tertiary care and university medical center in Boston. Patients:All critically ill surgical patients admitted to the Tufts-New England Medical Center surgical intensive care unit from January 1998 to March 2001. Interventions:Intensive care unit and hospital mortality and lengths of stay were compared with body mass index subclassified into five groups: underweight, normal weight, overweight, obese, and extremely obese. Data were examined for all admissions during the study period and for a predetermined subgroup with a prolonged intensive care unit stay (≥4 days). Measurements and Main Results:The prevalence of obesity in the surgical intensive care unit was 26.7%; extreme obesity was observed in 6.8%. In the full cohort of patients (n = 1373), median length of stay was short (2 days) and there were no differences in mortality in patients among any of the body mass index classes. In the subgroup of prolonged stay patients (n = 406), intensive care unit and hospital mortality rates were significantly increased in extremely obese patients compared with all other patients (intensive care unit, 33.3% vs. 12.3%, p = .009; hospital, 33.3% vs. 16%, p = .045). Multivariate analysis showed that extreme obesity was an independent predictor of death in surgical critically ill patients with prolonged intensive care unit stay after controlling for age, gender, and severity of illness. The odds of death increased 7.4 times in patients with morbid obesity. Conclusions:Morbid obesity (body mass index ≥40 kg/m2) is an independent risk factor for death in surgical patients with catastrophic illness requiring prolonged intensive care. The prevalence of obesity is growing, both in the intensive care unit and in the general population. The increased risk of complications and death in this population mandates that we adapt customized processes of care to specifically address this unique and very challenging subset of patients.

Dietary Determinants of Energy Intake and Weight Regulation in Healthy Adults

Until recently, the percentage of energy from dietary fat has been considered a primary determinant of body fatness. This review covers recent studies from our laboratory that challenge this notion. High and low fat diets matched for energy density, palatability and fiber resulted in similar mean voluntary energy intakes over 9 d; analysis of the individual foods in these diets showed that energy density and palatability were significant determinants of energy intake, independent of fat content. Path analysis further revealed that the influence of energy density on energy intake was in part direct, and in part indirect and mediated by palatability. In another study, dietary variety within food groups was shown to be an important predictor of body fatness, and the direction of the association depended on which food groups provided the variety, i.e., the variety of sweets, snacks, condiments, entrees and carbohydrates consumed was positively associated with body fatness, whereas the variety of vegetables was negatively associated. Last, a study of restaurant food and body fatness showed that the frequency of consumption of restaurant food was positively associated with body fatness, independent of education level, smoking status, alcohol intake and physical activity. Restaurant meals tend to be high in fat and low in fiber, and thus energy dense. Restaurants also typically serve a variety of palatable foods in large portions. The increasing variety of high energy foods available and the increasing proportion of household income spent on foods consumed away from home may help explain the U.S. national rising prevalence of obesity.

Hibiscus Sabdariffa L. Tea (Tisane) Lowers Blood Pressure in Prehypertensive and Mildly Hypertensive Adults

In vitro studies show Hibiscus sabdariffa L., an ingredient found in many herbal tea blends and other beverages, has antioxidant properties, and, in animal models, extracts of its calyces have demonstrated hypocholesterolemic and antihypertensive properties. Our objective in this study was to examine the antihypertensive effects of H. sabdariffa tisane (hibiscus tea) consumption in humans. A randomized, double-blind, placebo-controlled clinical trial was conducted in 65 pre- and mildly hypertensive adults, age 30-70 y, not taking blood pressure (BP)-lowering medications, with either 3 240-mL servings/d of brewed hibiscus tea or placebo beverage for 6 wk. A standardized method was used to measure BP at baseline and weekly intervals. At 6 wk, hibiscus tea lowered systolic BP (SBP) compared with placebo (-7.2 +/- 11.4 vs. -1.3 +/- 10.0 mm Hg; P = 0.030). Diastolic BP was also lower, although this change did not differ from placebo (-3.1 +/- 7.0 vs. -0.5 +/- 7.5 mm Hg; P = 0.160). The change in mean arterial pressure was of borderline significance compared with placebo (-4.5 +/- 7.7 vs. -0.8 +/- 7.4 mm Hg; P = 0.054). Participants with higher SBP at baseline showed a greater response to hibiscus treatment (r = -0.421 for SBP change; P = 0.010). No effects were observed with regard to age, gender, or dietary supplement use. These results suggest daily consumption of hibiscus tea, in an amount readily incorporated into the diet, lowers BP in pre- and mildly hypertensive adults and may prove an effective component of the dietary changes recommended for people with these conditions.

Effect of vitamin K supplementation on insulin resistance in older men and women

OBJECTIVE—Vitamin K has a potentially beneficial role in insulin resistance, but evidence is limited in humans. We tested the hypothesis that vitamin K supplementation for 36 months will improve insulin resistance in older men and women. RESEARCH DESIGN AND METHODS—This was an ancillary study of a 36-month, randomized, double-blind, controlled trial designed to assess the impact of supplementation with 500 μg/day phylloquinone on bone loss. Study participants were older nondiabetic men and women (n = 355; aged 60–80 years; 60% women). The primary outcome of this study was insulin resistance as measured by homeostasis model assessment (HOMA-IR) at 36 months. Fasting plasma insulin and glucose were examined as the secondary outcomes. RESULTS—The effect of 36-month vitamin K supplementation on HOMA-IR differed by sex (sex × treatment interaction P = 0.02). HOMA-IR was statistically significantly lower at the 36-month visit among men in the supplement group versus the men in the control group (P = 0.01) after adjustment for baseline HOMA-IR, BMI, and body weight change. There were no statistically significant differences in outcome measures between intervention groups in women. CONCLUSIONS—Vitamin K supplementation for 36 months at doses attainable in the diet may reduce progression of insulin resistance in older men.

Whole-Grain Intake and Cereal Fiber Are Associated with Lower Abdominal Adiposity in Older Adults

Foods high in dietary fiber may play an important role in regulating body weight. Few observational studies have examined the relationship between dietary fiber from different sources and body fat in older adults. Our objectives were to examine the associations among grain intake (whole and refined), dietary fiber and fiber sources, and body fat among older adults. We used data from 434 free-living adults (177 men and 257 women) aged between 60 and 80 y. Dietary intake was estimated from a 126-item semiquantitative FFQ. Percent body fat and percent trunk fat mass were measured by whole-body dual-energy X-ray absorptiometry. After adjustment for covariates, whole-grain intake was inversely associated with BMI [26.8 kg/m(2) (25.7-28.1) vs. 25.8 kg/m(2) (24.6-27.1), (95% CI); P-trend = 0.08], percent body fat [34.5% (32.7-36.3) vs. 32.1% (30.1-34.1); P-trend = 0.02], and percent trunk fat mass [43.0% (40.4-45.5) vs. 39.4% (36.7-42.1); P-trend = 0.02] in the lowest compared with the highest quartile category of whole-grain intake. Refined grain intake was not associated with any measure of body fat distribution. Cereal fiber was inversely associated with BMI [27.3 kg/m(2) (26.1-28.6) vs. 25.4 kg/m(2) (24.3-26.7); P-trend = 0.012], percent body fat [34.7% (32.8-36.6) vs. 31.5% (29.4-33.5); P-trend = 0.004], and percent trunk fat mass [42.8% (40.2-45.4) vs. 37.8% (35.0-40.6); P-trend = 0.001]. No significant association was observed between intakes of total fiber, vegetable or fruit fiber, and body composition measurements. Higher intakes of cereal fiber, particularly from whole-grain sources, are associated with lower total percent body fat and percent trunk fat mass in older adults.

Food cravings and energy regulation: the characteristics of craved foods and their relationship with eating behaviors and weight change during 6 months of dietary energy restriction

Objective:To examine characteristics of craved foods in relation to dietary energy restriction (ER) with high (HG) and low glycemic load (LG) diets.Design:Assessments of food cravings before and during a randomized controlled trial of HG and LG diets provided for 6 months.Subjects:Thirty-two healthy, overweight women aged 20–42 years.Measurements:Self-reported food cravings and dietary intake, body weight, weight history and measures of eating behaviors.Results:Foods craved at baseline were more than twice as high in energy density as the habitual diet (3.7±1.5 vs 1.7±0.3 kcal/g; P<0.001), and on average were lower in protein (P<0.001) and fiber (P<0.001) and higher in fat (P=0.002). There were no statistically significant changes in nutritional characteristics of craved foods after 6 months of ER. There was a significant relationship between reported portion size of craved food consumed at baseline and lifetime high body mass index (r=0.49, P=0.005). Additionally, there was a significant association between susceptibility to hunger and craving frequency at baseline, and there were significant relationships between hunger score, craving frequency, strength and percentage of time that cravings are given in to after 6 months of ER. In multiple regression models, subjects who lost a greater percentage of weight craved higher energy-dense foods at month 6 of ER, but also reported giving in to food cravings less frequently (adjusted R 2=0.31, P=0.009).Conclusion:High energy density and fat content, and low protein and fiber contents were identifying characteristics of craved foods. The relationships between craving variables and hunger score suggest that the relative influence of hunger susceptibility on cravings may be important before and especially after ER. Portion size of craved foods and frequency of giving in to food cravings appear to be important areas for focus in lifestyle modification programs for long-term weight loss.

The influence of dietary composition on energy intake and body weight

We review evidence regarding the influence of dietary fat, fiber, the glycemic index and sugar on energy intake and body weight. Although data from comprehensive long-term studies are lacking, published investigations suggest that the previous focus on lowering dietary fat as a means for promoting negative energy balance has led to an underestimation of the potential role of dietary composition in promoting reductions in energy intake and weight loss. More randomized clinical trials are needed to examine the relative utility of different putative dietary factors in the treatment of obesity.

Nutrient Deficiencies After Gastric Bypass Surgery

Bariatric surgery, and in particular, gastric bypass, is an increasingly utilized and successful approach for long-term treatment of obesity and amelioration of comorbidities. Nutrient deficiencies after surgery are common and have multiple causes. Preoperative factors include obesity, which appears to be associated with risk for several nutrient deficiencies, and preoperative weight loss. Postoperatively, reduced food intake, suboptimal dietary quality, altered digestion and absorption, and nonadherence with supplementation regimens contribute to risk of deficiency. The most common clinically relevant micronutrient deficiencies after gastric bypass include thiamine, vitamin B₁₂, vitamin D, iron, and copper. Reports of deficiencies of many other nutrients, some with severe clinical manifestations, are relatively sporadic. Diet and multivitamin use are unlikely to consistently prevent deficiency, thus supplementation with additional specific nutrients is often needed. Though optimal supplement regimens are not yet defined, most micronutrient deficiencies after gastric bypass currently can be prevented or treated by appropriate supplementation.