Fatima Cody Stanford

Long-Term Effects of Changes in Cardiorespiratory Fitness and Body Mass Index on All-Cause and Cardiovascular Disease Mortality in Men The Aerobics Center Longitudinal Study

Background— The combined associations of changes in cardiorespiratory fitness and body mass index (BMI) with mortality remain controversial and uncertain. Methods and Results— We examined the independent and combined associations of changes in fitness and BMI with all-cause and cardiovascular disease (CVD) mortality in 14 345 men (mean age 44 years) with at least 2 medical examinations. Fitness, in metabolic equivalents (METs), was estimated from a maximal treadmill test. BMI was calculated using measured weight and height. Changes in fitness and BMI between the baseline and last examinations over 6.3 years were classified into loss, stable, or gain groups. During 11.4 years of follow-up after the last examination, 914 all-cause and 300 CVD deaths occurred. The hazard ratios (95% confidence intervals) of all-cause and CVD mortality were 0.70 (0.59–0.83) and 0.73 (0.54–0.98) for stable fitness, and 0.61 (0.51–0.73) and 0.58 (0.42–0.80) for fitness gain, respectively, compared with fitness loss in multivariable analyses including BMI change. Every 1-MET improvement was associated with 15% and 19% lower risk of all-cause and CVD mortality, respectively. BMI change was not associated with all-cause or CVD mortality after adjusting for possible confounders and fitness change. In the combined analyses, men who lost fitness had higher all-cause and CVD mortality risks regardless of BMI change. Conclusions— Maintaining or improving fitness is associated with a lower risk of all-cause and CVD mortality in men. Preventing age-associated fitness loss is important for longevity regardless of BMI change.

Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA

Objective Evidence suggests that the level of physical activity of physicians can be correlated directly with physician counselling patterns about this behaviour. Our objective was to determine if medical students, resident and fellow physicians and attending physicians meet the physical activity guidelines set forth by the US Department of Health and Human Services. Methods A representative cross-sectional web-based survey was conducted in June 2009–January 2010 throughout the USA (N=1949). Using the short form of the International Physical Activity Questionnaire, the authors gathered demographical data and information related to physical activity, the level of training, the number of work hours per week, body mass index (BMI), confidence about counselling about physical activity and frequency with which the physical activity is encouraged to his/her patients. Results Based on the 1949 respondents, attending physicians (84.8%) and medical students (84%) were more likely than resident (73.2%) and fellow physicians (67.9%) to meet physical activity guidelines. Conclusion Physicians and medical students engage in more physical activity and tend to have a lower BMI than the general population. Resident and fellow physicians engage in less physical activity than attending physicians and medical students.

Factors that Influence Physicians’ and Medical Students’ Confidence in Counseling Patients About Physical Activity

AbstractLess than half of US adults and two-thirds of US high school students do not meet current US guidelines for physical activity. We examined which factors promoted physicians’ and medical students’ confidence in counseling patients about physical activity. We established an online exercise survey targeting attending physicians, resident and fellow physicians, and medical students to determine their current level of physical activity and confidence in counseling patients about physical activity. We compared their personal level of physical activity with the 2008 Physical Activity Guidelines of the US Department of Health and Human Services (USDHHS). We administered a survey in 2009 and 2010 that used the short form of the International Physical Activity Questionnaire. A total of 1,949 individuals responded to the survey, of whom 1,751 (i.e., 566 attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students) were included in this analysis. After adjusting for their BMI, the odds that physicians and medical students who met USDHHS guidelines for vigorous activity would express confidence in their ability to provide exercise counseling were more than twice that of physicians who did not meet these guidelines. Individuals who were overweight were less likely to be confident than those with normal BMI, after adjusting for whether they met the vigorous exercise guidelines. Physicians with obesity were even less likely to express confidence in regards to exercise counseling. We conclude that physicians and medical students who had a normal BMI and met vigorous USDHHS guidelines were more likely to feel confident about counseling their patients about physical activity. Our findings suggest that graduate medical school education should focus on health promotion in their students, as this will likely lead to improved health behaviors in their students’ patient populations.

The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study

BACKGROUND Patients who undergo bariatric surgery often have inadequate weight loss or weight regain. OBJECTIVES We sought to discern the utility of weight loss pharmacotherapy as an adjunct to bariatric surgery in patients with inadequate weight loss or weight regain. SETTING Two academic medical centers. METHODS We completed a retrospective study to identify patients who had undergone bariatric surgery in the form of a Roux-en-Y gastric bypass (RYGB) or a sleeve gastrectomy from 2000-2014. From this cohort, we identified patients who were placed on weight loss pharmacotherapy postoperatively for inadequate weight loss or weight regain. We extracted key demographic data, medical history, and examined weight loss in response to surgery and after the initiation of weight loss pharmacotherapy. RESULTS A total of 319 patients (RYGB = 258; sleeve gastrectomy = 61) met inclusion criteria for analysis. More than half (54%; n = 172) of all study patients lost≥5% (7.2 to 195.2 lbs) of their total weight with medications after surgery. There were several high responders with 30.3% of patients (n = 96) and 15% (n = 49) losing≥10% (16.7 to 195.2 lbs) and≥15% (25 to 195.2 lbs) of their total weight, respectively, Topiramate was the only medication that demonstrated a statistically significant response for weight loss with patients being twice as likely to lose at least 10% of their weight when placed on this medication (odds ratio = 1.9; P = .018). Regardless of the postoperative body mass index, patients who underwent RYGB were significantly more likely to lose≥5% of their total weight with the aid of weight loss medications. CONCLUSIONS Weight loss pharmacotherapy serves as a useful adjunct to bariatric surgery in patients with inadequate weight loss or weight regain.

Replication of the Range of Native Anterior Cruciate Ligament Fiber Length Change Behavior Achieved by Different Grafts Measurement Using Computer-Assisted Navigation

Background The native anterior cruciate ligament (ACL) does not behave as a simple bundle of fibers with constant tension but as a continuum of ligament fibers with differential length change during knee flexion/extension. Computer-assisted navigation can be used to assess length change in different fibers within the native ACL and to evaluate how different reconstruction grafts replicate the range of native ligament fiber length change behavior. Hypothesis Anterior cruciate ligament reconstruction graft size and configuration (single- vs double-bundle) are deciding factors as to how much of the native ACL fiber length change behavior is replicated. Study Design Controlled laboratory study. Methods The fiber length change behavior of the entire native ACL was assessed by measuring the length change pattern of representative anteromedial (AM) and posterolateral (PL) bundle fibers (1 at the center and 4 at the periphery of each bundle). The tibial and femoral ACL attachment areas in 5 fresh-frozen cadaveric knees were digitized, and the length change of each representative fiber was recorded during knee flexion/extension using an image-free, optical navigation system. Subsequently, single-bundle ACL reconstructions of different diameters (6, 9, and 12 mm) positioned at the center of the overall native femoral and tibial attachment sites were modeled to assess how much of the range of ligament fiber length change of the native ligament was captured. This was compared with a double-bundle graft using 6-mm-diameter AM and PL grafts positioned at the centers of the femoral and tibial attachment sites of each separate bundle. Results The 6-, 9-, and 12-mm single-bundle grafts simulated 32%, 51%, and 66% of the ligament fiber length change behavior of the native ACL, respectively. The length change patterns in these grafts were similar to the central fibers of the native ACL: the PL fibers of the AM bundle and AM fibers of the PL bundle. However, even a 12-mm graft did not represent the most AM and PL native fibers. The 6-mm AM and PL bundle grafts (equivalent in cross-sectional area to a 9-mm single-bundle graft) simulated 71% of the native ACL and better captured the extremes of the range of native ligament fiber length change. Conclusion Increasing single-bundle graft size appears to capture more of the range of native ACL fiber length change. However, for a similar graft cross-sectional area, a 2-bundle graft simulates the length change behavior of the native ligament more precisely and thus may better emulate the synergistic actions of anisometric and isometric fibers of the native ligament in restraining knee laxity throughout the range of flexion. Clinical Relevance The range of native ACL fiber length change behavior is better replicated by larger diameter grafts but may be best reproduced by double-bundle reconstruction.

Native Anterior Cruciate Ligament Obliquity versus Anterior Cruciate Ligament Graft Obliquity: An Observational Study Using Navigated Measurements

Background The goal of anterior cruciate ligament reconstruction is to attain a graft that closely resembles the native anterior cruciate ligament anatomy. By reconstructing the original anatomy, one hopes to eliminate issues related to graft elongation, impingement, and excessive tension while achieving ideal knee kinematics. Hypothesis Clinical grafts placed using the transtibial technique will differ in the sagittal and coronal planes when compared with obliquity of the anatomic anterior cruciate ligament. Study Design Controlled laboratory study/case series; Level of evidence, 4. Methods With the assistance of computer navigation, our study compared the anterior cruciate ligament orientation of 5 cadaver knees with 12 clinical anterior cruciate ligament—reconstructed knees using the transtibial technique. Results Clinical graft obliquity differed from the anatomic anterior cruciate ligament in all flexion angles 0°, 30°, 60°, and 90°. In the sagittal plane, the clinical graft obliquity differed from the anatomic anterior cruciate ligament by 13.6°, 12.7°, 16.7°, and 17°, respectively. In the coronal plane, the clinical graft obliquity differed from the anatomic anterior cruciate ligament by 4.9°, 7.6°, 8.9°, and 12.7°, respectively. Paired t tests demonstrated that the difference between the clinical and anatomic anterior cruciate ligament was significant (P < .05), except in the coronal plane at 0° of flexion. In spite of this, all patients demonstrated a negative pivot shift and Lachman at the conclusion of their reconstructions and at 6-month follow-up. Conclusion The sagittal and coronal plane obliquity of well-functioning grafts placed using the transtibial technique were more vertical than anatomic fibers. Clinical Relevance Graft obliquity, in both the coronal and sagittal plane, may be an important means to target appropriate anterior cruciate ligament graft position and can be monitored using surgical navigation systems.

The influence of an individual's weight perception on the acceptance of bariatric surgery.

This study assessed the proportion of US adults with excess weight and obesity who consider bariatric surgery to be appropriate for themselves and how their own weight perception influences this consideration.

Comparing Outcomes of Two Types of Bariatric Surgery in an Adolescent Obese Population: Roux-en-Y Gastric Bypass vs. Sleeve Gastrectomy

Background Obesity is prevalent among adolescents and is associated with serious health consequences. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are bariatric procedures that cause significant weight loss in adults and are increasingly being performed in adolescents with morbid obesity. Data comparing outcomes of RYGB vs. SG in this age-group are scarce. This study aims to compare short-term (1–6 months) and longer-term (7–18 months) body mass index (BMI) and biochemical outcomes following RYGB and SG in adolescents/young adults. Methods A retrospective study using data extracted from medical records of patients 16–21 years who underwent RYGB or SG between 2012 and 2014 at a tertiary care academic medical center. Results Forty-six patients were included in this study: 24 underwent RYGB and 22 underwent SG. Groups did not differ for baseline age, sex, race, or BMI. BMI reductions were significant at 1–6 months and 7–18 months within groups (p < 0.0001), but did not differ by surgery type (p = 0.65 and 0.09, for 1–6 months and 7–18 months, respectively). Over 7–18 months, within-group improvement in low-density lipoprotein (LDL) (−24 ± 6 in RYGB, p = 0.003, vs. −7 ± 9 mg/dl in SG, p = 0.50) and non-high-density lipoprotein (non-HDL) cholesterol (−23 ± 8 in RYGB, p = 0.02, vs. −12 ± 7 in SG, p = 0.18) appeared to be of greater magnitude following RYGB. However, differences between groups did not reach statistical significance. When divided by non-alcoholic steatohepatitis stages (NASH), patients with Stage II–III NASH had greater reductions in alanine aminotransferase levels vs. those with Stage 0–I NASH (−45 ± 18 vs. −9 ± 3, p = 0.01) after 7–18 months. RYGB and SG groups did not differ for the magnitude of post-surgical changes in liver enzymes. Conclusion RYGB and SG did not differ for the magnitude of BMI reduction across groups, though changes trended higher following RYGB. Further prospective studies are needed to confirm these findings.

Comparison of Physical Activity Levels in Physicians and Medical Students with the General Adult Population of the United States

Abstract Objective: Physicians who are physically fit have a higher likelihood of counseling their patients about physical activity. We sought to determine if the amount of physical activity in physicians and medical students differs from the general adult population of the United States and if geographic differences in physical activity levels exist. Methods: A cross-sectional survey was distributed to physicians and medical students throughout the United States to determine their level of physical activity according to US Department of Health and Human Services (DHHS) 2008 guidelines; data were collected from participants from June 2009 through January 2010. Our data set was compared with physical activity data from the Centers for Disease Control and Prevention (CDC) and we used geographic regions defined by the US Census Bureau. Results: Our survey respondents contained 631 attending physicians, 159 fellow physicians, 897 resident physicians, and 262 medical students. Only 64.5% of the general US adult population meets DHHS guidelines for physical activity, but 78% of the survey participants fulfilled the guidelines. The percentage of US adults who do not engage in leisure-time physical activity is 25.4% compared with 5.8% of survey participants. Survey respondents in the southern region had the lowest physical activity levels and participants in the western region had the highest levels. Conclusion: Physicians and medical students engage in more physical activity than the general US adult population. Regional differences in the general populations physical activity also persisted in physicians and medical students. Therefore, physicians who complete less physical activity may be less likely to encourage patients to engage in physical activity in geographic areas where the adult population is less active.

The gap between expectations and reality of exercise-induced weight loss is associated with discouragement.

BACKGROUND Exercise interventions result in modest weight loss, yet exercise is frequently prescribed for weight loss. PURPOSE To identify individuals who become discouraged when exercise fails to achieve weight loss. METHODS Representative samples of U.S. adults were recruited using Google Consumer Surveys in August-October 2014. Respondents were asked about beliefs and potential discouragement regarding the role of exercise and weight loss. An analysis of variance was performed to predict individuals that become discouraged if exercise does not lead to weight loss. RESULTS The belief that exercise is a very effective way to lose weight was common (71% of respondents). Stronger belief that exercise is an effective way to lose weight (p<0.001) in individuals with higher weight status (p=0.04) positively predicted discouragement with exercise. Higher weight status combined with the belief that exercise reduces weight was a significant positive predictor of discouragement (p=0.01). CONCLUSIONS Individuals with higher weight status that believe that exercise is an effective way to lose weight are more likely to become discouraged when exercise does not lead to weight loss. Prescribing exercise for weight loss might contribute to discouragement. Future studies should evaluate ways to encourage exercise without promoting the belief that exercise will yield weight loss.