Erik Hemmingsson

Effect of a very low energy diet on moderate and severe obstructive sleep apnoea in obese men: a randomised controlled trial.

Objective To assess the effect of weight loss induced by a very low energy diet on moderate and severe obstructive sleep apnoea in obese men. Design Single centre, two arm, parallel, randomised, controlled, open label trial. Blocked randomisation procedure used for treatment allocation. Setting Outpatient obesity clinic in a university hospital in Stockholm, Sweden. Participants 63 obese men (body mass index 30-40, age 30-65 years) with moderate to severe obstructive sleep apnoea (apnoea-hypopnoea index (AHI) ≥15), treated with continuous positive airway pressure. Interventions The intervention group received a liquid very low energy diet (2.3 MJ/day) for seven weeks to promote weight loss, followed by two weeks of gradual introduction of normal food, reaching 6.3 MJ/day at week 9. The control group adhered to their usual diet during the nine weeks of follow-up. Main outcome measure AHI, the major disease severity index for obstructive sleep apnoea. Data from all randomised patients were included in an intention to treat analysis (baseline carried forward for missing data). Results Of the 63 eligible patients, 30 were randomised to intervention and 33 to control. Two patients in the control group were dissatisfied with allocation and immediately discontinued. All other patients completed the trial. Both groups had a mean AHI of 37 events/h (SD 15) at baseline. At week 9, the intervention group’s mean body weight was 20 kg (95% confidence interval 18 to 21) lower than that of the control group, while its mean AHI was 23 events/h (15 to 30) lower. In the intervention group, five of 30 (17%) were disease free after the energy restricted diet (AHI <5), with 15 of 30 (50%) having mild disease (AHI 5-14.9), whereas the AHI of all patients in the control group except one remained at 15 or higher. In a subgroup analysis of the intervention group, baseline AHI significantly modified the effectiveness of treatment, with a greater improvement in AHI in patients with severe obstructive sleep apnoea (AHI >30) at baseline compared with those with moderate (AHI 15-30) sleep apnoea (AHI −38 v −12, P<0.001), despite similar weight loss (−19.2 v −18.2 kg, P=0.55). Conclusion Treatment with a low energy diet improved obstructive sleep apnoea in obese men, with the greatest effect in patients with severe disease. Long term treatment studies are needed to validate weight loss as a primary treatment strategy for obstructive sleep apnoea. Trial registration Current Controlled Trials ISRCTN70090382.

Effects of anti-obesity drugs, diet, and exercise on weight-loss maintenance after a very-low-calorie diet or low-calorie diet: a systematic review and meta-analysis of randomized controlled trials

Background: Weight-loss maintenance remains a major challenge in obesity treatment. Objective: The objective was to evaluate the effects of anti-obesity drugs, diet, or exercise on weight-loss maintenance after an initial very-low-calorie diet (VLCD)/low-calorie diet (LCD) period (<1000 kcal/d). Design: We conducted a systematic review by using MEDLINE, the Cochrane Controlled Trial Register, and EMBASE from January 1981 to February 2013. We included randomized controlled trials that evaluated weight-loss maintenance strategies after a VLCD/LCD period. Two authors performed independent data extraction by using a predefined data template. All pooled analyses were based on random-effects models. Results: Twenty studies with a total of 27 intervention arms and 3017 participants were included with the following treatment categories: anti-obesity drugs (3 arms; n = 658), meal replacements (4 arms; n = 322), high-protein diets (6 arms; n = 865), dietary supplements (6 arms; n = 261), other diets (3 arms; n = 564), and exercise (5 arms; n = 347). During the VLCD/LCD period, the pooled mean weight change was −12.3 kg (median duration: 8 wk; range 3–16 wk). Compared with controls, anti-obesity drugs improved weight-loss maintenance by 3.5 kg [95% CI: 1.5, 5.5 kg; median duration: 18 mo (12–36 mo)], meal replacements by 3.9 kg [95% CI: 2.8, 5.0 kg; median duration: 12 mo (10–26 mo)], and high-protein diets by 1.5 kg [95% CI: 0.8, 2.1 kg; median duration: 5 mo (3–12 mo)]. Exercise [0.8 kg; 95% CI: −1.2, 2.8 kg; median duration: 10 mo (6–12 mo)] and dietary supplements [0.0 kg; 95% CI: −1.4, 1.4 kg; median duration: 3 mo (3–14 mo)] did not significantly improve weight-loss maintenance compared with control. Conclusion: Anti-obesity drugs, meal replacements, and high-protein diets were associated with improved weight-loss maintenance after a VLCD/LCD period, whereas no significant improvements were seen for dietary supplements and exercise.

Longer term effects of very low energy diet on obstructive sleep apnoea in cohort derived from randomised controlled trial: prospective observational follow-up study

Objective To determine whether initial improvements in obstructive sleep apnoea after a very low energy diet were maintained after one year in patients with moderate to severe obstructive sleep apnoea. Design Single centre, prospective observational follow-up study. Setting Outpatient obesity clinic in a university hospital in Stockholm, Sweden. Participants 63 men aged 30-65 with body mass index (BMI) 30-40 and moderate to severe obstructive sleep apnoea defined as an apnoea-hypopnoea index ≥15 (events/hour), all treated with continuous positive airway pressure. Intervention A one year weight loss programme, consisting of an initial very low energy diet for nine weeks (seven weeks of 2.3 MJ/day and two weeks of gradual introduction of normal food) followed by a weight loss maintenance programme. Main outcome measure Apnoea-hypopnoea index, the main index for severity of obstructive sleep apnoea. Data from all patients were analysed (baseline carried forward for missing data). Results Of 63 eligible patients, 58 completed the very low energy diet period and started the weight maintenance programme and 44 completed the full programme; 49 had complete measurements at one year. At baseline the mean apnoea-hypopnoea index was 36 events/hour. After the very low energy diet period, apnoea-hypopnoea index was improved by −21 events/hour (95% confidence interval −17 to −25) and weight by −18 kg (−16 to −19; both P<0.001). After one year the apnoea-hypopnoea index had improved by −17 events/hour (−13 to −21) and body weight by −12 kg (−10 to −14) compared with baseline (both P<0.001). Patients with severe obstructive sleep apnoea at baseline had greater improvements in apnoea-hypopnoea index (−25 events/hour) compared with patients with moderate disease (−7 events/hour, P<0.001). At one year, 30/63 (48%, 95% confidence interval 35% to 60%) no longer required continuous positive airway pressure and 6/63 (10%, 2% to 17%) had total remission of obstructive sleep apnoea (apnoea-hypopnoea index <5 events/hour). There was a dose-response association between weight loss and apnoea-hypopnoea index at follow-up (β=0.50 events/kg, 0.11 to 0.88; P=0.013). Conclusion Initial improvements in obstructive sleep apnoea after treatment with a very low energy diet can be maintained after one year in obese men with moderate to severe disease. Those who lose the most weight or have severe sleep apnoea at baseline benefit most. Trial registration Current Controlled Trials 70090382.

Bioelectrical Impedance Underestimates Total and Truncal Fatness in Abdominally Obese Women

Objective: To compare estimates of total and truncal fatness from eight‐electrode bioelectrical impedance analysis equipment (BIA8) with those from DXA in centrally obese women. The secondary aim was to examine BMI and waist circumference (WC) as proxy measures for percentage total body fat (%TBF) and truncal body fat percentage (tr%BF).

Beneficial effects of individualized physical activity on prescription on body composition and cardiometabolic risk factors: results from a randomized controlled trial

Background Insufficient physical activity (PA), overweight and abdominal obesity are increasing global public health problems. Design Randomized controlled 6-month intervention study. Methods One hundred and one 68-year-old individuals (57% female) with low PA, overweight (BMI 25-40 kg/m2) and abdominal obesity (waist circumference >88 cm in women and > 102 cm in men), were randomized to PA on prescription (PAP) or a minimal intervention. PA measured by several methods, anthropometric parameters, body composition and cardiometabolic risk factors were measured at baseline and after intervention. Results Favourable changes in anthropometrics, body composition, S-glucose, glycosolated haemoglobin (HbA1c), blood lipids and apolipoproteins were seen in the PAP group. In the control group, however, some positive changes were also noted. Bodyweight, neck circumference, fat mass, S-cholesterol and HbA1c decreased significantly more in the PAP group. Conclusion Individualized PAP improves body composition and cardiometabolic risk factors in sedentary older overweight individuals. PAP might be useful in clinical practice to counteract the epidemic of sedentary lifestyle and concomitant cardiometabolic disorders. Eur J Cardiovasc Prev Rehabil 16:80-84

Is the association between physical activity and body mass index obesity dependent

Background:Most studies indicate an inverse relationship between physical activity (PA) and body mass index (BMI). However, the impact of obesity on this relationship is unclear.Objective:To scrutinize the BMI/PA relationship by analysing multiple categories of PA from a sample with a wide BMI range.Design:PA was measured with accelerometry for 7 consecutive days during free-living conditions in 85 severely obese outpatients (mean BMI 42.7 kg/m2 (s.d. 6.1); age 43.0 year (12.6)) and 193 control subjects (24.0 kg/m2 (3.5); 41.6 year (13.0)). Six categories of PA were calculated from the accelerometer data (min/day of sedentary time, min/day of light PA, min/day of moderate PA, min/day of vigorous PA, activity counts/day and steps/day). Participants were stratified in obese and non-obese subgroups (BMI=30 kg/m2 as cutoff). Associations between BMI and PA were examined in the total sample, and in subgroups. The impact of sex and age on the BMI/PA association was tested.Results:In the total sample, the association between BMI and PA was significant in all PA categories except for time spent sedentary (P=0.68). However, in subgroup analyses, the association between BMI and PA in non-obese was only significant for activity counts/day (r=−0.16, P<0.05) and vigorous intensity PA (r=−0.15, P=0.05). After adjustment for age, vigorous PA remained significantly associated with BMI in the non-obese (r=−0.17, P<0.05). In obese individuals, significant associations between BMI and PA were found for all six PA categories (age adjusted), sedentary time (r=0.26, P=0.05), light PA (r=−0.30, P<0.01), moderate PA (r=−0.35, P<0.01), vigorous PA (r=−0.39, P<0.001), activity counts/day (r=−0.50, P<0.001) and steps/day (r=−0.54, P<0.001).Conclusion:The association between PA and BMI was weak in non-obese individuals. In contrast, BMI was highly significantly associated with PA in obese individuals. Longitudinal studies are needed to tease out the direction of association between PA and BMI across BMI categories, as the cross-sectional associations seem to be dependent on obesity status.

A new model of the role of psychological and emotional distress in promoting obesity: conceptual review with implications for treatment and prevention.

The lack of significant treatment and prevention progress highlights the need for a more expanded strategy. Given the robust association between socioeconomic factors and obesity, combined with new insights into how socioeconomic disadvantage affects both behaviour and biology, a new causal model is proposed. The model posits that psychological and emotional distress is a fundamental link between socioeconomic disadvantage and weight gain. At particular risk are children growing up in a disharmonious family environment, mainly caused by parental socioeconomic disadvantage, where they are exposed to parental frustrations, relationship discord, a lack of support and cohesion, negative belief systems, unmet emotional needs and general insecurity. Without adequate resilience, such experiences increase the risk of psychological and emotional distress, including low self‐esteem and self‐worth, negative emotions, negative self‐belief, powerlessness, depression, anxiety, insecurity and a heightened sensitivity to stress. These inner disturbances eventually cause a psycho‐emotional overload, triggering a cascade of weight gain‐inducing effects including maladaptive coping strategies such as eating to suppress negative emotions, chronic stress, appetite up‐regulation, low‐grade inflammation and possibly reduced basal metabolism. Over time, this causes obesity, circular causality and further weight gain. Tackling these proposed root causes of weight gain could potentially improve both treatment and prevention outcomes.

Effects of childhood abuse on adult obesity: a systematic review and meta-analysis

Controversy exists surrounding the role of childhood abuse in obesity development. This is a meta‐analysis of observational studies on the role of childhood abuse in adult obesity. Systematic searches of PubMed, PsycInfo, Medline and CINAHL resulted in 23 cohort studies (4 prospective, 19 retrospective) with n = 112,708 participants, containing four abuse types (physical, emotional, sexual, general). Four studies reported dose–response effects. A random effects model was used to quantify effect sizes, meta‐regression/subgroup analysis for identifying potential moderating variables and Eggers test for publication bias. Adults who reported childhood abuse were significantly more likely to be obese (odds ratio [OR]: 1.34, 95% confidence interval [CI]: 1.24–1.45, P < 0.001). All four types of abuse were significantly associated with adult obesity: physical (OR: 1.28, 95% CI: 1.13–1.46), emotional (OR: 1.36, 95% CI: 1.08–1.71), sexual (OR: 1.31, 95% CI: 1.13–1.53) and general abuse (OR: 1.45, 95% CI: 1.25–1.69). Severe abuse (OR: 1.50, 95% CI: 1.27–1.77) was significantly more associated with adult obesity (P = 0.043) compared with light/moderate abuse (OR: 1.13, 95% CI: 0.91–1.41). We found no significant effects of study design (prospective vs. retrospective, P = 0.07), age (P = 0.96) or gender (P = 0.92). Publication bias was evident (Eggers test P = 0.007), but effect sizes remained statistically significant in sensitivity analyses. Childhood abuse was clearly associated with being obese as an adult, including a positive dose–response association. This suggests that adverse life experiences during childhood plays a major role in obesity development, potentially by inducing mental and emotional perturbations, maladaptive coping responses, stress, inflammation and metabolic disturbances.

Weight loss and dropout during a commercial weight-loss program including a very-low-calorie diet, a low-calorie diet, or restricted normal food: observational cohort study

Background: The effectiveness of commercial weight-loss programs consisting of very-low-calorie diets (VLCDs) and low-calorie diets (LCDs) is unclear. Objective: The aim of the study was to quantify weight loss and dropout during a commercial weight-loss program in Sweden (Itrim; cost:

Trends in consumption of ultra-processed foods and obesity in Sweden between 1960 and 2010

1300/€1000; all participants paid their own fee). Design: This observational cohort study linked commercial weight-loss data with National Health Care Registers. Weight loss was induced with a 500-kcal liquid-formula VLCD [n = 3773; BMI (in kg/m2): 34 ± 5 (mean ± SD); 80% women; 45 ± 12 y of age (mean ± SD)], a 1200–1500-kcal formula and food-combination LCD (n = 4588; BMI: 30 ± 4; 86% women; 50 ± 11 y of age), and a 1500–1800-kcal/d restricted normal-food diet (n = 676; BMI: 29 ± 5; 81% women; 51 ± 12 y of age). Maintenance strategies included exercise and a calorie-restricted diet. Weight loss was analyzed by using an intention-to-treat analysis (baseline substitution). Results: After 1 y, mean (±SD) weight changes were −11.4 ± 9.1 kg with the VLCD (18% dropout), −6.8 ± 6.4 kg with the LCD (23% dropout), and −5.1 ± 5.9 kg with the restricted normal-food diet (26% dropout). In an adjusted analysis, the VLCD group lost 2.8 kg (95% CI: 2.5, 3.2) and 3.8 kg (95% CI: 3.2, 4.5) more than did the LCD and restricted normal-food groups, respectively. A high baseline BMI and rapid initial weight loss were both independently associated with greater 1-y weight loss (P < 0.001). Younger age and low initial weight loss predicted an increased dropout rate (P < 0.001). Treatment of depression (OR: 1.4; 95% CI: 1.1, 1.9) and psychosis (OR: 2.6; 95% CI: 1.1, 6.3) were associated with an increased dropout rate in the VLCD group. Conclusion: A commercial weight-loss program, particularly one using a VLCD, was effective at reducing body weight in self-selected, self-paying adults.