Frank L. Greenway

Comparison of Weight-Loss Diets with Different Compositions of Fat, Protein, and Carbohydrates

BACKGROUNDnThe possible advantage for weight loss of a diet that emphasizes protein, fat, or carbohydrates has not been established, and there are few studies that extend beyond 1 year.nnnMETHODSnWe randomly assigned 811 overweight adults to one of four diets; the targeted percentages of energy derived from fat, protein, and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35%. The diets consisted of similar foods and met guidelines for cardiovascular health. The participants were offered group and individual instructional sessions for 2 years. The primary outcome was the change in body weight after 2 years in two-by-two factorial comparisons of low fat versus high fat and average protein versus high protein and in the comparison of highest and lowest carbohydrate content.nnnRESULTSnAt 6 months, participants assigned to each diet had lost an average of 6 kg, which represented 7% of their initial weight; they began to regain weight after 12 months. By 2 years, weight loss remained similar in those who were assigned to a diet with 15% protein and those assigned to a diet with 25% protein (3.0 and 3.6 kg, respectively); in those assigned to a diet with 20% fat and those assigned to a diet with 40% fat (3.3 kg for both groups); and in those assigned to a diet with 65% carbohydrates and those assigned to a diet with 35% carbohydrates (2.9 and 3.4 kg, respectively) (P>0.20 for all comparisons). Among the 80% of participants who completed the trial, the average weight loss was 4 kg; 14 to 15% of the participants had a reduction of at least 10% of their initial body weight. Satiety, hunger, satisfaction with the diet, and attendance at group sessions were similar for all diets; attendance was strongly associated with weight loss (0.2 kg per session attended). The diets improved lipid-related risk factors and fasting insulin levels.nnnCONCLUSIONSnReduced-calorie diets result in clinically meaningful weight loss regardless of which macronutrients they emphasize. (ClinicalTrials.gov number, NCT00072995.)

A Randomized, Controlled Trial of 3.0 mg of Liraglutide in Weight Management

BACKGROUNDnObesity is a chronic disease with serious health consequences, but weight loss is difficult to maintain through lifestyle intervention alone. Liraglutide, a glucagon-like peptide-1 analogue, has been shown to have potential benefit for weight management at a once-daily dose of 3.0 mg, injected subcutaneously.nnnMETHODSnWe conducted a 56-week, double-blind trial involving 3731 patients who did not have type 2 diabetes and who had a body-mass index (BMI; the weight in kilograms divided by the square of the height in meters) of at least 30 or a BMI of at least 27 if they had treated or untreated dyslipidemia or hypertension. We randomly assigned patients in a 2:1 ratio to receive once-daily subcutaneous injections of liraglutide at a dose of 3.0 mg (2487 patients) or placebo (1244 patients); both groups received counseling on lifestyle modification. The coprimary end points were the change in body weight and the proportions of patients losing at least 5% and more than 10% of their initial body weight.nnnRESULTSnAt baseline, the mean (±SD) age of the patients was 45.1±12.0 years, the mean weight was 106.2±21.4 kg, and the mean BMI was 38.3±6.4; a total of 78.5% of the patients were women and 61.2% had prediabetes. At week 56, patients in the liraglutide group had lost a mean of 8.4±7.3 kg of body weight, and those in the placebo group had lost a mean of 2.8±6.5 kg (a difference of -5.6 kg; 95% confidence interval, -6.0 to -5.1; P<0.001, with last-observation-carried-forward imputation). A total of 63.2% of the patients in the liraglutide group as compared with 27.1% in the placebo group lost at least 5% of their body weight (P<0.001), and 33.1% and 10.6%, respectively, lost more than 10% of their body weight (P<0.001). The most frequently reported adverse events with liraglutide were mild or moderate nausea and diarrhea. Serious events occurred in 6.2% of the patients in the liraglutide group and in 5.0% of the patients in the placebo group.nnnCONCLUSIONSnIn this study, 3.0 mg of liraglutide, as an adjunct to diet and exercise, was associated with reduced body weight and improved metabolic control. (Funded by Novo Nordisk; SCALE Obesity and Prediabetes NN8022-1839 ClinicalTrials.gov number, NCT01272219.).

Prevalence of risk factors for metabolic syndrome in adolescents: National Health and Nutrition Examination Survey (NHANES), 2001-2006.

OBJECTIVEnTo investigate the prevalence of distinct combinations of components of the metabolic syndrome among adolescents.nnnDESIGNnA complex, multistage, stratified geographic area design for collecting representative data from the noninstitutionalized US population.nnnSETTINGnThe NHANES, an ongoing surveillance of the nations health conducted by the Centers for Disease Control and Prevention.nnnPARTICIPANTSnTwo thousand four hundred fifty-six Hispanic, white, and black adolescents aged 12 to 19 years observed in the 2001-2002, 2003-2004, and 2005-2006 NHANES data releases.nnnMAIN OUTCOME MEASURESnMetabolic syndrome was defined as having 3 or more disorders in the following measurements: waist circumference, blood pressure, fasting triglycerides, high-density lipoprotein serum cholesterol, and glucose.nnnRESULTSnAbout half of the participants had at least 1 disordered measurement, with an overall metabolic syndrome prevalence of 8.6% (95% confidence interval, 6.5%-10.6%). Prevalence was higher in males (10.8%) than females (6.1%), and in Hispanic (11.2%) and white (8.9%) individuals than in black individuals (4.0%). In black females, there was a high prevalence of a large waist circumference (23.3%), but no component of metabolic syndrome dominated its diagnosis in black adolescents of either sex. A large waist circumference and high fasting triglyceride and low high-density lipoprotein serum cholesterol concentrations were salient factors in Hispanic and white adolescents of both sexes; high glucose concentrations were prominent among Hispanic and white males.nnnCONCLUSIONnThe low prevalence of metabolic syndrome in black adolescents, in parallel with uniformly low prevalence of all 5 risk factors among those with metabolic syndrome, portend ethnic disparities in the time table for early onset of cardiometabolic disorders.

Effects of naltrexone sustained-release/bupropion sustained-release combination therapy on body weight and glycemic parameters in overweight and obese patients with type 2 diabetes.

OBJECTIVE To assess the efficacy and safety of 32 mg naltrexone sustained-release (SR)/360 mg bupropion SR (NB) in overweight/obese individuals with type 2 diabetes with or without background oral antidiabetes drugs. RESEARCH DESIGN AND METHODS This was a 56-week, double-blind, placebo-controlled study in which 505 patients received standardized lifestyle intervention and were randomized 2:1 to NB or placebo. Coprimary end points were percent weight change and achievement of ≥5% weight loss. Secondary end points included achievement of HbA1c <7% (53 mmol/mol), achievement of weight loss ≥10%, and change in HbA1c, waist circumference, fasting blood glucose, and lipids. RESULTS In the modified intent-to-treat population (54% female, 80% Caucasian, and mean age 54 years, weight 106 kg, BMI 37 kg/m2, and HbA1c 8.0% [64 mmol/mol]), NB resulted in significantly greater weight reduction (−5.0 vs. −1.8%; P < 0.001) and proportion of patients achieving ≥5% weight loss (44.5 vs. 18.9%, P < 0.001) compared with placebo. NB also resulted in significantly greater HbA1c reduction (−0.6 vs. −0.1% [6.6 vs. 1.1 mmol/mol]; P < 0.001), percent of patients achieving HbA1c <7% (53 mmol/mol) (44.1 vs. 26.3%; P < 0.001), and improvement in triglycerides and HDL cholesterol compared with placebo. NB was associated with higher incidence of nausea (42.3 vs. 7.1%), constipation (17.7 vs. 7.1%), and vomiting (18.3 vs. 3.6%). No difference was observed between groups in the incidence of depression, suicidal ideation, or hypoglycemia. CONCLUSIONS NB therapy in overweight/obese patients with type 2 diabetes induced weight loss, which was associated with improvements in glycemic control and select cardiovascular risk factors and was generally well tolerated with a safety profile similar to that in patients without diabetes.

Laparoscopic Sleeve Gastrectomy, 529 Cases Without a Leak: Short-Term Results and Technical Considerations

BackgroundLaparoscopic sleeve gastrectomy (LSG) is gaining acceptance among bariatric surgeons as a viable option for treating morbidly obese patients. We describe results of a single surgeon’s experience with LSG in a community practice revealing a low complication rate and describing the surgical technique.MethodsLSG was performed in 529 consecutive patients from December 2006 to March 2010. A technique is described where all operations were performed with attention to avoiding strictures at the incisura angularis and stapling close to the esophagus at the angle of His. No operations performed used buttressing material or over-sewing of the staple line. A retrospective chart review and e-mail survey was conducted to determine the occurrence of complications and weight loss.ResultsFollow-up data was collected on 490 of the 529 (92.6%) patients at 6xa0weeks. A total complication rate of 3.2% and a 1.7% 30-day readmission rate were observed. No leaks occurred in any of the 529 patients, and one death (0.19%) was observed. The most common complications were nausea and vomiting with dehydration and venous thrombosis. The percentages of excess weight loss were 42.36, 65.92, 66.11, and 64.42 with a follow-up of 71%, 68%, 63%, and 49% at 6xa0months, 1xa0year, 2, and 3xa0years, respectively.ConclusionThe LSG can be performed in a community practice with a low complication rate. Surgeons performing LSG should strive to minimize the risk of creating strictures at the incisura angularis and stapling near the esophagus at the angle of His.

Prehypertension in disease-free adults: a marker for an adverse cardiometabolic risk profile

Cardiovascular disease (CVD) is the leading cause of death worldwide. Understandably, cardiometabolic risk assessment is an integral component of every adult health evaluation. Customary assessment measures are, however, inadequate: as two-thirds of sudden cardiac deaths occur in clinically healthy individuals. Novel indicators favoring early recognition of adverse cardiometabolic risk in disease-free adults are clearly needed. Clinically healthy disease-free adults with prehypertension (PreHTN: BP120–139/80–89u2009mmu2009Hg) have an adverse cardiometabolic risk profile. A statistical analysis of disease-free adult NHANES participants was conducted from 1999 to 2006. Overall prevalence of PreHTN in disease-free adults was 36.3%. Prevalence was higher in men (P<0.001) increasing with age up to 70 years (P<0.001). Prevalence correlated strongly with indicators of adverse cardiometabolic risk profile: it was higher with increasing body mass index (BMI) and waist circumference (WC) (P<0.001 for both). Means were significantly higher for BMI, WC, glucose, insulin, hemoglobin A1c, homeostasis model assessment, pulse pressure, C-reactive protein, total cholesterol and triglycerides in subjects with PreHTN (vs. desirable BP: P<0.05 for all). Prevalence of two or more unfavorable risk factors (other than high BP) was 30% higher in disease-free adults with PreHTN vs. desirable BP (prevalence ratio: 1.30; 95% CI: 1.22, 1.39). Detection of PreHTN (a precursor for subsequent HTN), during annual health maintenance in disease-free adults, (especially with one or more of the recognized CVD risk correlates), could become an early marker of adverse cardiometabolic risk profile. Clinical care designed to prevent progression from PreHTN to HTN (JNC 7 recommendation) may attenuate risk.

Whole Grains and Pulses: A Comparison of the Nutritional and Health Benefits

Nutrition plays an important role in the prevention and management of disease. Whole grain cereals contain a host of nutrients and bioactive substances that have health-promoting effects. Epidemiological evidence shows a consistent inverse association between whole grain intake and the risk of chronic disease. Despite a concerted effort by scientists, educators, and policy makers to promote the consumption of whole grains, it remains dismally short of the recommended intakes. Pulses (dried beans and peas) differ from whole grains in their structural and physicochemical properties and have varying amounts of fiber, resistant starch, vitamins, minerals, and other bioactive components; nevertheless, these food groups complement each other. Observational as well as intervention trials show that pulse consumption has beneficial effects on the prevention and management of chronic disease. The nutritional and phytochemical components of pulses coupled with those of whole grains suggest a potential synergistic effect that could provide significant health benefits.

Lower Total Adipocyte Number but No Evidence for Small Adipocyte Depletion in Patients With Type 2 Diabetes

OBJECTIVE We hypothesized that, compared with obese subjects, patients with type 2 diabetes have a lower total adipocyte number with fewer small adipocytes. RESEARCH DESIGN AND METHODS Abdominal subcutaneous adipose tissue was obtained from lean and obese subjects with or without type 2 diabetes matched for BMI. Adipocyte size was measured by osmium fixation and sizing/counting in a Coulter counter. Adipocyte size and number subdistributions (small, medium, large, and very large) were determined. RESULTS Compared with obese subjects, type 2 diabetic patients had larger mean adipocyte size and 67% bigger very large adipocytes; the total adipocyte number was lower, but the fraction of small adipocytes was increased by 27%. CONCLUSIONS Total adipocyte cellularity is lower in type 2 diabetic subjects than in obese subjects. We found no evidence for depletion of small adipocytes in patients with type 2 diabetes. This suggests the presence of a defect in early maturation of adipocytes in patients with type 2 diabetes.

Efficacy of Low-Level Laser Therapy for Body Contouring and Spot Fat Reduction

BackgroundLow-level laser therapy (LLLT) is commonly used in medical applications, but scientific studies of its efficacy and the mechanism by which it causes loss of fat from fat cells for body contouring are lacking. This study examined the effectiveness and mechanism by which 635–680xa0nm LLLT acts as a non-invasive body contouring intervention method.MethodsForty healthy men and women ages 18–65xa0years with a BMI <30xa0kg/m2 were randomized 1:1 to laser or control treatment. Subjects waistlines were treated 30xa0min twice a week for 4xa0weeks. Standardized waist circumference measurements and photographs were taken before and after treatments 1, 3, and 8. Subjects were asked not to change their diet or exercise habits. In vitro assays were conducted to determine cell lysis, glycerol, and triglyceride release.ResultsData were analyzed for those with body weight fluctuations within 1.5xa0kg during 4xa0weeks of the study. Each treatment gave a 0.4–0.5xa0cm loss in waist girth. Cumulative girth loss after 4xa0weeks was −2.15xa0cm (−0.78xa0±xa02.82 vs. 1.35xa0±xa02.64xa0cm for the control group, pxa0<xa00.05). A blinded evaluation of standardized pictures showed statistically significant cosmetic improvement after 4xa0weeks of laser treatment. In vitro studies suggested that laser treatment increases fat loss from adipocytes by release of triglycerides, without inducing lipolysis or cell lysis.ConclusionsLLLT achieved safe and significant girth loss sustained over repeated treatments and cumulative over 4xa0weeks of eight treatments. The girth loss from the waist gave clinically and statistically significant cosmetic improvement.

Early Resolution of Type 2 Diabetes Seen After Roux-en-Y Gastric Bypass and Vertical Sleeve Gastrectomy

BACKGROUNDnType 2 diabetes (T2D) accounts for the majority of diagnosed cases of diabetes in adults in the United States. Many of these individuals are also morbidly obese and choose to undergo bariatric surgery to lose weight and gain glycemic control. The Roux-en-Y gastric bypass (RYGB) has been shown to resolve diabetes before substantial weight loss occurs. Several studies suggest that the vertical sleeve gastrectomy (VSG), a newer bariatric operation, may result in comparable weight loss and rapid diabetes control.nnnMETHODSnWe conducted a retrospective chart review of 262 patients diagnosed with diabetes who underwent either the RYGB or the VSG between 2002 and 2010. Medication usage before and after surgery was recorded. Patients who discontinued all medications postoperatively were considered resolved of T2D, and those who reduced the number of medications were considered as showing improvement in their T2D. Peri- and postoperative complications were also recorded for each operation.nnnRESULTSnAt 8 weeks postoperatively, follow-up data were available for 38 RYGB patients and 71 VSG patients. Approximately 79% of RYGB patients and 83% of VSG patients remained off their diabetes medication. VSG patients experienced a significantly lower incidence of major and minor complications both peri- and postoperatively compared with RYGB patients.nnnCONCLUSIONSnBoth operations appear to equally resolve T2D in an obese, adult population; however, the incidence of both major and minor complications is much lower in the VSG patient group. Therefore, the VSG should also be considered as a treatment option for obese individuals with T2D.