Jøran Hjelmesæth

Obstructive Sleep Apnea after Weight Loss: A Clinical Trial Comparing Gastric Bypass and Intensive Lifestyle Intervention

INTRODUCTIONnFew studies have compared the effect of surgical and conservative weight loss strategies on obstructive sleep apnea (OSA). We hypothesized that Roux-en-Y gastric bypass (RYGB) would be more effective than intensive lifestyle intervention (ILI) at reducing the prevalence and severity of OSA (apnea-hypopnea-index [AHI] ≥ 5 events/hour).nnnMETHODSnA total of 133 morbidly obese subjects (93 females) were treated with either a 1-year ILI-program (n = 59) or RYGB (n = 74) and underwent repeated sleep recordings with a portable somnograph (Embletta).nnnRESULTSnParticipants had a mean (SD) age of 44.7(10.8) years, BMI 45.1(5.7) kg/m(2), and AHI 17.1(21.4) events/hour. Eighty-four patients (63%) had OSA. The average weight loss was 8% in the ILI-group and 30% in the RYGB-group (p < 0.001). The mean (95%CI) AHI reduced in both treatment groups, although significantly more in the RYGB-group (AHI change -6.0 [ILI] vs -13.1 [RYGB]), between group difference 7.2 (1.3, 13.0), p = 0.017. Twenty-nine RYGB-patients (66%) had remission of OSA, compared to 16 ILI-patients (40%), p = 0.028. At follow-up, after adjusting for age, gender, and baseline AHI, the RYGB-patients had significantly lower adjusted odds for OSA than the ILI-patients-OR (95% CI) 0.33 (0.14, 0.81), p = 0.015. After further adjustment for BMI change, treatment group difference was no longer statistically significant-OR (95% CI) 1.31 (0.32, 5.35), p = 0.709.nnnCONCLUSIONnOur study demonstrates that RYGB was more effective than ILI at reducing the prevalence and severity of OSA. However, our analysis also suggests that weight loss, rather than the surgical procedure per se, explains the beneficial effects.

Health related quality of life after gastric bypass or intensive lifestyle intervention: a controlled clinical study

BackgroundThere is little robust evidence relating to changes in health related quality of life (HRQL) in morbidly obese patients following a multidisciplinary non-surgical weight loss program or laparoscopic Roux-en-Y Gastric Bypass (RYGB). The aim of the present study was to describe and compare changes in five dimensions of HRQL in morbidly obese subjects. In addition, we wanted to assess the clinical relevance of the changes in HRQL between and within these two groups after one year. We hypothesized that RYGB would be associated with larger improvements in HRQL than a part residential intensive lifestyle-intervention program (ILI) with morbidly obese subjects.MethodsA total of 139 morbidly obese patients chose treatment with RYGB (n=76) or ILI (n=63). The ILI comprised four stays (seven weeks) at a specialized rehabilitation center over one year. The daily schedule was divided between physical activity, psychosocially-oriented interventions, and motivational approaches. No special diet or weight-loss drugs were prescribed. The participants completed three HRQL-questionnaires before treatment and 1 year thereafter. Both linear regression and ANCOVA were used to analyze differences between weight loss and treatment for five dimensions of HRQL (physical, mental, emotional, symptoms and symptom distress) controlling for baseline HRQL, age, age of onset of obesity, BMI, and physical activity. Clinical relevance was assessed by effect size (ES) where ES<.49 was considered small, between .50-.79 as moderate, and ES>.80 as large.ResultsThe adjusted between group mean difference (95% CI) was 8.6 (4.6,12.6) points (ES=.83) for the physical dimension, 5.4 (1.5–9.3) points (ES=.50) for the mental dimension, 25.2 (15.0–35.4) points (ES=1.06) for the emotional dimension, 8.7 (1.8–15.4) points (ES=.37) for the measured symptom distress, and 2.5 for (.6,4.5) fewer symptoms (ES=.56), all in favor of RYGB. Within-group changes in HRQOL in the RYGB group were large for all dimensions of HRQL. Within the ILI group, changes in the emotional dimension, symptom reduction and symptom distress were moderate. Linear regression analyses of weight loss on HRQL change showed a standardized beta-coefficient of –.430 (p<.001) on the physical dimension, –.288 (p=.004) on the mental dimension, –.432 (p<.001) on the emotional dimension, .287 (p=.008) on number of symptoms, and .274 (p=.009) on reduction of symptom pressure.ConclusionsMorbidly obese participants undergoing RYGB and ILI had improved HRQL after 1 year. The weaker response of ILI on HRQL, compared to RYGB, may be explained by the difference in weight loss following the two treatments.Trial registrationClinical Trials.gov number NCT00273104

Effectiveness of a Cognitive Behavioral Therapy for Dysfunctional Eating among Patients Admitted for Bariatric Surgery: A Randomized Controlled Trial

Objective. To examine whether cognitive behavioral therapy (CBT) alleviates dysfunctional eating (DE) patterns and symptoms of anxiety and depression in morbidly obese patients planned for bariatric surgery. Design and Methods. A total of 98 (68 females) patients with a mean (SD) age of 43 (10) years and BMI 43.5 (4.9)u2009kg/m2 were randomly assigned to a CBT-group or a control group receiving usual care (i.e., nutritional support and education). The CBT-group received ten weekly intervention sessions. DE, anxiety, and depression were assessed by the TFEQ R-21 and HADS, respectively. Results. Compared with controls, the CBT-patients showed significantly less DE, affective symptoms, and a larger weight loss at follow-up. The effect sizes were large (DE-cognitive restraint, g = −.92, P ≤ .001; DE-uncontrolled eating, g = −.90, P ≤ .001), moderate (HADS-depression, g = −.73, P ≤ .001; DE-emotional eating, g = −.67, P ≤ .001; HADS-anxiety, g = −.62, P = .003), and low (BMI, g = −.24, P = .004). Conclusion. This study supports the use of CBT in helping patients preparing for bariatric surgery to reduce DE and to improve mental health. This clinical trial is registered with NCT01403558.

Arterial stiffness, lifestyle intervention and a low‐calorie diet in morbidly obese patients—A nonrandomized clinical trial

Arterial stiffness is an independent predictor of cardiovascular morbidity and mortality. This study aimed to compare the 7‐week effect of a low‐calorie diet (LCD) and an intensive lifestyle intervention program (ILI) on arterial stiffness in morbidly obese individuals.

Dietary changes in obese patients undergoing gastric bypass or lifestyle intervention: a clinical trial.

We compared changes in the dietary patterns of morbidly obese patients undergoing either laparoscopic gastric bypass surgery or a comprehensive lifestyle intervention programme. The present 1-year non-randomised controlled trial included fifty-four patients in the lifestyle group and seventy-two in the surgery group. Dietary intake was assessed by a validated FFQ. ANCOVA was used to adjust for between-group differences in sex, age, baseline BMI and baseline values of the dependent variables. Intakes of food groups and nutrients did not differ significantly between the intervention groups at baseline. At 1-year follow-up, the lifestyle group had a significantly higher daily intake of fruits and vegetables (561 (sd 198) v. 441 (sd 213) g, P= 0·002), whole grains (63 (sd 24) v. 49 (sd 16) g, P< 0·001) and fibre (28 (sd 6) v. 22 (sd 6) g, P< 0·001) than the surgery group and a lower percentage of total energy intake of saturated fat (12 (sd 3) v. 14 (sd 3) %, P< 0·001). The intake of red meat declined significantly within both groups, vegetables and fish intake were reduced significantly in the surgery group and added sugar was reduced significantly in the lifestyle group. The lifestyle patients improved their dietary patterns significantly (compared with the surgery group), increasing their intake of vegetables, whole grains and fibre and reducing their percentage intake of saturated fat (ANCOVA, all P< 0·001). In conclusion, lifestyle intervention was associated with more favourable dietary 1-year changes than gastric bypass surgery in morbidly obese patients, as measured by intake of vegetables, whole grains, fibre and saturated fat.

Adiposity among children in Norway by urbanity and maternal education: a nationally representative study

BackgroundInternational research has demonstrated that rural residency is a risk factor for childhood adiposity. The main aim of this study was to investigate the urban-rural gradient in overweight and obesity and whether the association differed by maternal education.MethodsHeight, weight and waist circumference (WC) were measured in a nationally representative sample of 3166 Norwegian eight-year-olds in 2010. Anthropometric measures were stratified by area of residence (urbanity) and maternal education. Risk estimates for overweight (including obesity) and waist-to-height ratio ≥0.5 were calculated by log-binomial regression.ResultsMean BMI and WC and risk estimates of overweight (including obesity) and waist-to-height ratio ≥0.5 were associated with both urbanity and maternal education. These associations were robust after mutual adjustment for each other. Furthermore, there was an indication of interaction between urbanity and maternal education, as trends of mean BMI and WC increased from urban to rural residence among children of low-educated mothers (pu2009=u20090.01 for both BMI and WC), whereas corresponding trends for children from higher educational background were non-significant (pu2009>u20090.30). However, formal tests of the interaction term urbanity by maternal education were non-significant (p-value for interaction was 0.29 for BMI and 0.31 for WC).ConclusionsIn this nationally representative study, children living rurally and children of low-educated mothers had higher mean BMI and waist circumference than children living in more urban areas and children of higher educated mothers.

Parental marital status and childhood overweight and obesity in Norway: a nationally representative cross-sectional study

Objective Sociodemographic changes in Norway and other western industrialised countries, including family structure and an increasing proportion of cohabiting and divorced parents, might affect the prevalence of childhood overweight and obesity issues. We aimed to examine whether parental marital status was associated with general and abdominal obesity among children. We also sought to explore whether the associations differed by gender. Design Cross-sectional. Setting 127 primary schools across Norway. Participant 3166 third graders (mean age 8.3u2005years) participating in the nationally representative Norwegian Child Growth Study in 2010. Measurements Height, weight and waist circumference were objectively measured. The main outcome measures were general overweight (including obesity; body mass index ≥25u2005kg/m2) using International Obesity Task Force (IOTF) cut-offs and abdominal obesity (waist-to-height ratio ≥0.5) by gender and parental marital status. Prevalence ratios, adjusted for possible confounders, were calculated by log-binomial regression. Results General overweight (including obesity) was 1.54 (95% CI 1.21 to 1.95) times more prevalent among children of divorced parents compared with children of married parents, and the corresponding prevalence ratio for abdominal obesity was 1.89 (95% CI 1.35 to 2.65). Formal tests of the interaction term parental marital status by gender were not statistically significant. However, in gender-specific analyses the association between parental marital status and adiposity measures was only statistically significant in boys (p=0.04 for general overweight (including obesity) and p=0.01 for abdominal obesity). The estimates were robust against adjustment for maternal education, family country background and current area of residence. Conclusions General and abdominal obesities were more prevalent among children of divorced parents. This study provides valuable information by focusing on societal changes in order to identify vulnerable groups.

Association of Bariatric Surgery vs Medical Obesity Treatment With Long-term Medical Complications and Obesity-Related Comorbidities

Importance The association of bariatric surgery and specialized medical obesity treatment with beneficial and detrimental outcomes remains uncertain. Objective To compare changes in obesity-related comorbidities in patients with severe obesity (body mass index ≥40 or ≥35 and at least 1 comorbidity) undergoing bariatric surgery or specialized medical treatment. Design, Setting, and Participants Cohort study with baseline data of exposures from November 2005 through July 2010 and follow-up data from 2006 until death or through December 2015 at a tertiary care outpatient center, Vestfold Hospital Trust, Norway. Consecutive treatment-seeking adult patients (nu2009=u20092109) with severe obesity assessed (221 patients excluded and 1888 patients included). Exposures Bariatric surgery (nu2009=u2009932, 92% gastric bypass) or specialized medical treatment (nu2009=u2009956) including individual or group-based lifestyle intervention programs. Main Outcomes and Measures Primary outcomes included remission and new onset of hypertension based on drugs dispensed according to the Norwegian Prescription Database. Prespecified secondary outcomes included changes in comorbidities. Adverse events included complications retrieved from the Norwegian Patient Registry and a local laboratory database. Results Among 1888 patients included in the study, the mean (SD) age was 43.5 (12.3) years (1249 women [66%]; mean [SD] baseline BMI, 44.2 [6.1]; 100% completed follow-up at a median of 6.5 years [range, 0.2-10.1]). Surgically treated patients had a greater likelihood of remission and lesser likelihood for new onset of hypertension (remission: absolute risk [AR], 31.9% vs 12.4%); risk difference [RD], 19.5% [95% CI, 15.8%-23.2%], relative risk [RR], 2.1 [95% CI, 2.0-2.2]; new onset: AR, 3.5% vs 12.2%, RD, 8.7% [95% CI, 6.7%-10.7%], RR, 0.4 [95% CI, 0.3-0.5]; greater likelihood of diabetes remission: AR, 57.5% vs 14.8%; RD, 42.7% [95% CI, 35.8%-49.7%], RR, 3.9 [95% CI, 2.8-5.4]; greater risk of new-onset depression: AR, 8.9% vs 6.5%; RD, 2.4% [95% CI, 1.3%-3.5%], RR, 1.5 [95% CI, 1.4-1.7]; and treatment with opioids: AR, 19.4% vs 15.8%, RD, 3.6% [95% CI, 2.3%-4.9%], RR, 1.3 [95% CI, 1.2-1.4]). Surgical patients had a greater risk for undergoing at least 1 additional gastrointestinal surgical procedure (AR, 31.3% vs 15.5%; RD, 15.8% [95% CI, 13.1%-18.5%]; RR, 2.0 [95% CI, 1.7-2.4]). The proportion of patients with low ferritin levels was significantly greater in the surgical group (26% vs 12%, Pu2009<u2009.001). Conclusions and Relevance Among patients with severe obesity followed up for a median of 6.5 years, bariatric surgery compared with medical treatment was associated with a clinically important increased risk for complications, as well as lower risks of obesity-related comorbidities. The risk for complications should be considered in the decision-making process.

Body Mass Index Is Associated with Impaired Semen Characteristics and Reduced Levels of Anti-Müllerian Hormone across a Wide Weight Range

There is still controversy as to how body mass index (BMI) affects male reproduction. We investigated how BMI is associated with semen quality and reproductive hormones in 166 men, including 38 severely obese men. Standard semen analysis and sperm DNA integrity analysis were performed, and blood samples were analysed for reproductive hormones. Adjusted for age and time of abstinence, BMI was negatively associated with sperm concentration (B = -0.088, P = 0.009), total sperm count (B = -0.223, P = 0.001), progressive sperm motility (B = -0.675, P = 0.007), normal sperm morphology (B = -0.078, P = 0.001), and percentage of vital spermatozoa (B = -0.006, P = 0.027). A negative relationship was observed between BMI and total testosterone (B = -0.378, P < 0.001), sex hormone binding globulin (B = -0.572, P < 0.001), inhibin B (B = -3.120, P < 0.001) and anti-Müllerian hormone (AMH) (B = -0.009, P < 0.001). Our findings suggest that high BMI is negatively associated with semen characteristics and serum levels of AMH.

Validation of a portable monitor for the diagnosis of obstructive sleep apnea in morbidly obese patients.

STUDY OBJECTIVESnWe aimed to validate the diagnostic accuracy and night-to-night variability of a simple 3-channel (type IV monitor) portable sleep monitor, ApneaLink (AL), in a population of morbidly obese subjects.nnnDESIGNnCross-sectional validation and diagnostic accuracy study.nnnSETTINGnPublic tertiary care obesity center in Norway.nnnPARTICIPANTSnA total of 105 (67 females) treatment seeking morbidly obese subjects were included, mean (SD) age 44.3 (11.4) years and BMI 43.6 (5.6) kg/m2.nnnINTERVENTIONSnThe patients underwent two successive nights of recordings; the first night with the AL only, and the following night with both the reference instrument Embletta (E), a type III portable somnograph, and the AL.nnnMEASUREMENTS AND RESULTSnMain outcomes were diagnostic accuracy of AL as assessed by sensitivity, specificity and area under ROC curves, and level of agreement between AL and E. AL had high diagnostic accuracy at all levels of OSA, and the Bland-Altman plots showed good agreement between AL and E. The sensitivity and specificity of the instrument were 93% and 71% at the AHI cutoff 5 events/h, and 94% and 94% at the AHI cutoff 15, respectively. The night-to-night variability was low.nnnCONCLUSIONnOur results indicate that a simple 3-channel portable sleep monitor (ApneaLink) has a high diagnostic accuracy in diagnosing OSA in morbidly obese treatment seeking patients. Accordingly, this and similar instruments might help non-specialists to diagnose OSA in morbidly obese patients, and, importantly, help non-specialists to refer patients who need specific treatment to specialist without unnecessary delay.