Judith S. Stern

Obesity and Cardiovascular Disease: Pathophysiology, Evaluation, and Effect of Weight Loss

Obesity is becoming a global epidemic in both children and adults. It is associated with numerous comorbidities such as cardiovascular diseases (CVD), type 2 diabetes, hypertension, certain cancers, and sleep apnea/sleep-disordered breathing. In fact, obesity is an independent risk factor for CVD, and CVD risks have also been documented in obese children. Obesity is associated with an increased risk of morbidity and mortality as well as reduced life expectancy. Health service use and medical costs associated with obesity and related diseases have risen dramatically and are expected to continue to rise. Besides an altered metabolic profile, a variety of adaptations/alterations in cardiac structure and function occur in the individual as adipose tissue accumulates in excess amounts, even in the absence of comorbidities. Hence, obesity may affect the heart through its influence on known risk factors such as dyslipidemia, hypertension, glucose intolerance, inflammatory markers, obstructive sleep apnea/hypoventilation, and the prothrombotic state, in addition to as-yet-unrecognized mechanisms. On the whole, overweight and obesity predispose to or are associated with numerous cardiac complications such as coronary heart disease, heart failure, and sudden death because of their impact on the cardiovascular system. The pathophysiology of these entities that are linked to obesity will be discussed. However, the cardiovascular clinical evaluation of obese patients may be limited because of the morphology of the individual. In this statement, we review the available evidence of the impact of obesity on CVD with emphasis on the evaluation of cardiac structure and function in obese patients and the effect of weight loss on the cardiovascular system.

Obesity and Cardiovascular Disease Pathophysiology, Evaluation, and Effect of Weight Loss

Obesity is becoming a global epidemic in both children and adults, and it is associated with numerous co-morbidities such as cardiovascular diseases (CVD), type 2 diabetes, hypertension, certain cancers, and sleep apnea/sleep-disordered breathing. In fact, is an independent risk factor for CVD and CVD risks have been also documented in obese children, and is associated with reduced life expectancy. A variety of adaptations/alterations in cardiac structure and function occur in the individual as adipose tissue accumulates in excess amount. As a whole, overweight/obesity predispose or is associated with numerous cardiac complications such as coronary heart disease, heart failure, and sudden death through its impact on the cardiovascular system.

Dietary Changes Favorably Affect Bone Remodeling in Older Adults

OBJECTIVE To determine whether dietary counseling to increase milk intake could produce useful changes in the calcium economy and what, if any, other nutrition-related changes might be produced. DESIGN Randomized, open trial. SUBJECTS/SETTING Two hundred four healthy men and women, aged 55 to 85 years, who habitually consumed fewer than 1.5 servings of dairy foods per day. Six academic health centers in the United States. INTERVENTION Subjects were instructed to consume 3 servings per day of nonfat milk or 1% milk as a part of their daily diets, or to maintain their usual diets, for a 12-week intervention period, which followed 4 weeks of baseline observations. MAIN OUTCOME MEASURES Energy and nutrient intake assessed from milk intake logs and 3-day food records; serum calciotrophic hormone levels at baseline and at 8 and 12 weeks; urinary excretion of calcium and N-telopeptide at 12 weeks. STATISTICAL ANALYSES Repeated-measures analysis of variance. RESULTS In the milk-supplemented group, calcium intake increased by 729 +/- 45 mg/day (mean +/- standard error), serum parathyroid hormone level decreased by approximately 9%, and urinary excretion of N-telopeptide, a bone resorption marker, decreased by 13%. Urine calcium excretion increased in milk-supplemented subjects by 21 +/- 7.6 mg/day (mean +/- standard error), less than half the amount predicted to be absorbed from the increment in calcium intake. All of these changes were significantly different from baseline values in the milk group and from the corresponding changes in the control group. Bone-specific alkaline phosphatase level (a bone formation marker) fell by approximately 9% in both groups. Serum level of insulin-like growth factor-1 (IGF-1) rose by 10% in the milk group (P < .001), and the level of insulin-like growth factor binding protein-4 (IGFBP-4) fell slightly (1.9%) in the milk group and rose significantly (7.9%) in the control group (P < .05). APPLICATIONS/CONCLUSIONS The changes observed in the calcium economy through consumption of food sources of calcium are similar in kind and extent to those reported previously for calcium supplement tablets. The increase in IGF-1 level and the decrease in IBFBP-4 level are new observations that are beneficial for bone health. Important improvements in skeletal metabolism can feasibly occur in older adults by consumption of food sources of calcium. Dietitians can be confident that food works, and that desired calcium intakes can be achieved using food sources.

Changes of serum leptin and endocrine and metabolic parameters after 7 days of energy restriction in men and women

Circulating leptin decreases during fasting in rodents and humans; however, the mechanism of the decrease is unknown. The aim of this study was to examine the relationship between decrements of serum leptin concentrations and changes of hormonal (insulin and cortisol) and metabolic (glucose, ketones, and fatty acids) parameters involved in the metabolic adaptation to energy restriction in normal-weight humans. Because there are marked gender differences in circulating leptin, both men and women were studied. The body mass index (BMI), percent body fat (% body fat), and serum leptin, insulin, cortisol, glucose, beta-hydroxybutyrate,(BOHB), and nonesterified fatty acids (NEFA) were determined in 11 men and 13 women (age, 20 to 41 years; BMI, 21.2 to 26.8 kg/m2) before and during 7 days of energy restriction (-68% +/- 1% of daily energy requirements). Weight loss averaged about 4% in both men and women. Leptin in men was 3.7 +/- 0.5 and decreased to 2.1 +/- 0.4 ng/mL (percent change [%delta], -36% +/- 6.0%, P < .0005) during restriction. Concurrently, insulin decreased from 7.2 +/- 0.6 to 1.8 +/- 0.3 microU/mL (%delta, -74% +/- 4%, P < .0001). In contrast, leptin was higher in women before (16.2 +/- 1.9 ng/mL) and after (6.0 +/- 0.8 ng/mL) restriction and decreased more than in men (%delta, -61% +/- 4%, P < .02 v men), whereas the decrease of insulin in women was less than in men: 10.1 +/- 1.9 to 6.1 +/- 1.0 microU/mL (%delta, -31% +/- 9%, P < .0025; P < .0005 v men), perhaps because glucose decreased less in women than in men. Overall, the changes of leptin during fasting were independently correlated with the changes of glucose (r = .53, P < .007), NEFA (r = .53, P < .01), and BOHB (r = .65, P < .001). In addition, the change of leptin correlated with a combined index of the parameters that reflect decreased glucose availability and increased lipolysis ([deltaglucose + deltainsulin + deltaNEFA]/3, r = .73, P < .0001) or a combined index of parameters that would be expected to limit glucose uptake by adipocytes ([deltaglucose + deltainsulin + deltacortisol]/3, r = .48, P < .02). We conclude that there are significant differences between men and women in the responses of leptin and insulin to energy restriction. Furthermore, decreases of circulating leptin during negative energy balance are related to changes of endocrine and metabolic parameters, suggesting that leptin secretion may be regulated by alterations of adipocyte glucose and lipid metabolism, ie, decreased glucose uptake and metabolism and increased lipolysis.

Marked and rapid decreases of circulating leptin in streptozotocin diabetic rats : reversal by insulin

Evidence for regulation of circulating leptin by insulin is conflicting. Diabetes was induced in rats with streptozotocin (STZ; 40 mg ⋅ kg-1 ⋅ day-1× 2 days) to examine the effect of insulin-deficient diabetes and insulin treatment on circulating leptin. After 12 wk, plasma leptin concentrations in untreated rats were all <0.4 ng/ml versus 4.9 ± 0.9 ng/ml in control animals ( P < 0.005). In rats treated with subcutaneous insulin implants for 12 wk, which reduced hyperglycemia by ∼50%, plasma leptin was 2.1 ± 0.6 ng/ml, whereas leptin concentrations were 6.0 ± 1.6 ng/ml in insulin-implanted rats receiving supplemental injections of insulin for 4 days to normalize plasma glucose ( P< 0.005 vs. STZ untreated). In a second experiment, plasma leptin was monitored at biweekly intervals during 12 wk of diabetes. In rats treated with insulin implants, plasma leptin concentrations were inversely proportional to glycemia ( r= -0.64; P < 0.0001) and unrelated to body weight ( P = 0.40). In a third experiment, plasma leptin concentrations were examined very early after the induction of diabetes. Within 24 h after STZ injection, plasma insulin decreased from 480 ± 30 to 130 ± 10 pM ( P < 0.0001), plasma glucose increased from 7.0 ± 0.2 to 24.8 ± 0.5 mM, and plasma leptin decreased from 3.2 ± 0.2 to 1.2 ± 0.1 ng/ml (Δ = -63 ± 3%, P < 0.0001). In a subset of diabetic rats treated with insulin for 2 days, glucose decreased to 11.7 ± 3.9 mM and leptin increased from 0.5 ± 0.1 to 2.9 ± 0.6 ng/ml ( P< 0.01) without an effect on epididymal fat weight. The change of leptin was correlated with the degree of glucose lowering ( r = 0.75, P < 0.05). Thus insulin-deficient diabetes produces rapid and sustained decreases of leptin that are not solely dependent on weight loss, whereas insulin treatment reverses the hypoleptinemia. We hypothesize that decreased glucose transport into adipose tissue may contribute to decreased leptin production in insulin-deficient diabetes.Evidence for regulation of circulating leptin by insulin is conflicting. Diabetes was induced in rats with streptozotocin (STZ; 40 mg.kg(-1).day(-1) x 2 days) to examine the effect of insulin-deficient diabetes and insulin treatment on circulating leptin. After 12 wk, plasma leptin concentrations in untreated rats were all < 0.4 ng/ml versus 4.9 +/- 0.9 ng/ml in control animals (P < 0.005). In rats treated with subcutaneous insulin implants for 12 wk, which reduced hyperglycemia by approximately 50%, plasma leptin was 2.1 +/- 0.6 ng/ml, whereas leptin concentrations were 6.0 +/- 1.6 ng/ml in insulin-implanted rats receiving supplemental injections of insulin for 4 days to normalize plasma glucose (P < 0.005 vs. STZ untreated). In a second experiment, plasma leptin was monitored at biweekly intervals during 12 wk of diabetes. In rats treated with insulin implants, plasma leptin concentrations were inversely proportional to glycemia (r = -0.64; P < 0.0001) and unrelated to body weight (P = 0.40). In a third experiment, plasma leptin concentrations were examined very early after the induction of diabetes. Within 24 h after STZ injection, plasma insulin decreased from 480 +/- 30 to 130 +/- 10 pM (P < 0.0001), plasma glucose increased from 7.0 +/- 0.2 to 24.8 +/- 0.5 mM, and plasma leptin decreased from 3.2 +/- 0.2 to 1.2 +/- 0.1 ng/ml (delta = -63 +/- 3%, P < 0.0001). In a subset of diabetic rats treated with insulin for 2 days, glucose decreased to 11.7 +/- 3.9 mM and leptin increased from 0.5 +/- 0.1 to 2.9 +/- 0.6 ng/ml (P < 0.01) without an effect on epididymal fat weight. The change of leptin was correlated with the degree of glucose lowering (r = 0.75, P < 0.05). Thus insulin-deficient diabetes produces rapid and sustained decreases of leptin that are not solely dependent on weight loss, whereas insulin treatment reverses the hypoleptinemia. We hypothesize that decreased glucose transport into adipose tissue may contribute to decreased leptin production in insulin-deficient diabetes.

Evaluating a 'non-diet' wellness intervention for improvement of metabolic fitness, psychological well-being and eating and activity behaviors

Context: Current public health policy recommends weight loss for obese individuals, and encourages energy-restricted diets. Others advocate an alternative, ‘non-diet’ approach which emphasizes eating in response to physiological cues (eg hunger and satiety) and enhancing body acceptance.Objective: To evaluate the effects of a ‘health-centered’ non-diet wellness program, and to compare this program to a traditional ‘weight loss-centered’ diet program.Design: Six-month, randomized clinical trial.Setting: Free-living, general community.Participants: Obese, Caucasian, female, chronic dieters, ages 30–45 y (n=78).Interventions: Six months of weekly group intervention in a non-diet wellness program or a traditional diet program, followed by 6 months of monthly after-care group support.Outcome Measures: Anthropometry (weight, body mass index); metabolic fitness (blood pressure, blood lipids); energy expenditure; eating behavior (restraint, eating disorder pathology); psychology (self-esteem, depression, body image); attrition and attendance; and participant evaluations of treatment helpfulness. Measures obtained at baseline, 3 months, 6 months and 1 y.Results (1 y after program initiation): Cognitive restraint increased in the diet group and decreased in the non-diet group. Both groups demonstrated significant improvement in many metabolic fitness, psychological and eating behavior variables. There was high attrition in the diet group (41%), compared to 8% in the non-diet group. Weight significantly decreased in the diet group (5.9±6.3 kg) while there was no significant change in the non-diet group (−0.1±4.8 kg).Conclusions: Over a 1 y period, a diet approach results in weight loss for those who complete the intervention, while a non-diet approach does not. However, a non-diet approach can produce similar improvements in metabolic fitness, psychology and eating behavior, while at the same time effectively minimizing the attrition common in diet programs.

Insulin resistance and pancreatic insulin release in the genetically obese Zucker rat.

Summary Zucker obese rats are normoglycemic, hyperinsulinemic, and release more insulin from isolated pancreatic islets than do their nonobese controls. Basal glucose conversion to glycogen by muscle and to CO2 by isolated adipocytes is similar in Zucker obese and nonobese; insulin resistance is present in both tissues in the obese. There is a significant correlation between adipocyte response to insulin and pancreatic insulin release in obese and nonobese rats. The authors suggest a role for adipocytes in determining pancreatic function.

Hyperprolactinemia stimulates food intake in the female rat

Lactation in the rat is marked by extreme hyperphagia. The present study examined the possibility that elevated prolactin levels contribute to this increase. It also evaluated the effects of hyperprolactinemia on brown adipose tissue and carcass composition. Virgin Osborne-Mendel rats were made hyperprolactinemic via ectopic pituitary transplants (PIT, n = 9) or were sham-operated (SHAM, n = 8). Eight lactating rats (LACT) served as additional controls. Food intake, body weight and rectal temperature were recorded daily. Eleven days postsurgery (or 11-12 days postpartum), the rats were sacrificed, and brown fat (scapular, axillary, cervical and thoracic) was excised, weighed, and assayed for GDP binding, one indicator of thermogenic capacity. Carcasses were subjected to body composition analysis. Although prior to surgery, PIT and SHAM rats weighed the same, PIT rats gained significantly more weight during the experiment than did SHAMs. Percent body fat and food intake (both total intake and intake relative to metabolic body size) were significantly elevated in the PIT rats. GDP binding in both PIT and LACT rats was significantly less than in SHAMs. This was true whether GDP binding was expressed per mg mitochondrial protein or per total amount of mitochondrial protein recovered. These data confirm that brown fat thermogenic capacity is suppressed during lactation. They also demonstrate that elevations of serum prolactin, to levels that are well within physiological limits, are capable of stimulating food intake and white fat deposition in the female rat. It is presently unclear whether these results are a direct or an indirect effect of hyperprolactinemia.

Food intake, body composition and blood lipids following treadmill exercise in male and female rats

Body weight gain, food intake, body composition and blood lipids of male and female Osborne Mendel rats were compared on the same exercise treadmill program. To mimic their nocturnal habits, rats were exercised daily at the beginning of the 12 hour dark cycle and food intake was measured for both light and dark cycles. After a 10 day treadmill adaptation period, the duration of exercise was successively increased over a 12 day period until 60 min/day at 21.3 meters/min was reached. Relative to their respective controls, exercised male rats showed a reduction in body weight and light cycle food intake while female runners showed no change in body weight or food intake. Exercise resulted in a decrease in percent body fat in both males and females while only male runners increased percent protein. Both males and females reduced serum triglycerides while serum cholesterol was reduced only in the males. The short term exercise program produced highly significant changes in the males while the females were more resistant to the same exercise regimen.

Low bone mass in premenopausal chronic dieting obese women

Background: Obese premenopausal women are thought to be at low risk for osteoporosis due to increased body weight and effects of estrogen on weight-bearing bone.Objective: To examine the effect of restrained eating on obese women, we examined bone mineral density (BMD) and content (BMC) of the spine and femur in obese women who were restrained eaters, with emphasis on the relationship between BMC and determinants of bone mass, and current eating behaviors, dietary intake, physical activity, and indices of calcium regulation, bone metabolism, stress and inflammation.Design: A total of 78 obese, Caucasian, female, restrained eaters, ages 30–45 y, were enrolled in a weight lose program. Height, weight, bone turnover markers, serum parathyroid hormone (PTH), cortisol, c-reactive protein (CRP), dietary intake, eating behaviors, physical activity, and BMD and BMC were measured.Setting: This study was conducted at the University of California, in Davis, CA, USA.Results: In all, 31% of women had osteopenia or osteoporosis (OSTEO). In the OSTEO group, 87.5% of women had osteoporosis or osteopenia of the lumbar spine and 12.5% of the women had osteoporosis or osteopenia in femur. A significant positive correlation between BMC and energy expenditure (r=0.256), and a significant negative correlation between BMC and number of times on a weight loss diet (r=−0.250) and cognitive restraint (r=−0.239) were observed. No significant differences were observed between OSTEO women and nonosteoporotic women for current eating behaviors, dietary intake, physical activity habits, bone turnover, calcium regulation, stress, or inflammation.Conclusions: Obese restrained eaters are at risk for low bone mass. Prior dieting may be responsible. Chronic dieters should be encouraged to decrease their dietary restraint, develop healthy eating habits and increase physical activity.