Scott Kahan

Association Between Glycosylated Hemoglobin and Intentional Weight Loss in Overweight and Obese Patients With Type 2 Diabetes Mellitus: A Retrospective Cohort Study.

Purpose The purpose of this study is to assess the relationship between magnitude of weight loss and improvement in percentage A1C (A1C%) among overweight and obese patients with type 2 diabetes mellitus (DM) undergoing weight reduction. Methods Case records of patients enrolled in 2 university-based weight management programs were reviewed. Patients were sampled if they had a diagnosis of DM and had at least 1 documented A1C% reduction from their baseline value. Weight loss treatment was individualized and consisted of a calorie-restricted diet, a behavior modification plan, and a plan for increasing physical activity. Patient weights were measured at bimonthly visits. A1C% was measured every 3 months. Results Seventy-two patients formed the study cohort. Mean baseline body mass index was 35.1 kg/m2, mean age was 52.6 years, and 59% were males. Mean starting A1C% was 8.6. Patients achieved significant mean weight loss (10.7 kg) at study exit. Weight loss of 6.5 kg (4.5% of baseline body weight), 12.2 kg (8.7%), and 15.9 kg (10.3%) was required to reduce A1C% by 0.5, 1, and 1.5, respectively, and it took a mean of 5.6, 8.7, and 10.1 months, respectively, to achieve this. After adjustment for antidiabetic medication intake, for every 10% weight loss, the predicted reduction in A1C% was 0.81. Conclusions Intentional weight loss of 10% can potentially decrease A1C% by 0.81 among patients with type 2 DM. This finding may be clinically useful in encouraging and counseling a patient attempting weight loss.

Intentional Weight Loss and Dose Reductions of Anti-Diabetic Medications – A Retrospective Cohort Study

BACKGROUND AND AIM Intentional weight loss, primarily by improving insulin resistance, is known to decrease the need for anti-diabetic medications. In this study, we assess the magnitude of weight loss that resulted in dose reductions or discontinuation of anti-diabetic medications in overweight or obese patients with type 2 diabetes (DM) undergoing weight loss treatment. METHODS Case records of 50 overweight or obese patients with DM who successfully decreased dosage or discontinued diabetes medications after losing weight via attendance at two University-based, outpatient weight management centers were analyzed. Follow-up visits, weight reduction interventions, and decisions for dose reductions or discontinuation of medications were individualized to patient needs by the treating physician. RESULTS Mean starting BMI was 35 kg/m(2), mean age 53.4 years, and 58% were male. All 50 used at least one anti-diabetic medication (30 metformin, 39 sulfonylureas, 31 insulin, 21 sitagliptin) to manage blood sugar. Mean duration of follow-up was 30.2 months. Mean weight loss was 10.8 ± 4.1 kgs (11.1% of initial body weight ± 4.7%). 22/50 patients (44%) discontinued anti-diabetes medications (14 sulfonylureas [36%], 7 insulin [23%], 4 sitagliptin [19%]). The mean percentage weight loss achieved at the point of successful discontinuation of medication was 11.2% ± 3.5% (14% for sulphonylureas, 11% for insulin, and 7.1% for sitagliptin). Mean percentage weight loss of 5.6% ± 2.8% (5.1% for sulphonylureas, 4.3% for insulin, and 7.1% for sitagliptin) was required for initial dose reduction. For every 5% weight loss, predicted dose reductions were sulphonylureas, 39%; insulin, 42%; and any anti-diabetic medications, 49%. CONCLUSION Among overweight or obese patients with type 2 diabetes, intentional weight loss of 7-14% was typically required for full discontinuation of at least one anti-diabetic medication. Discontinuation of insulin was achieved at a mean weight reduction of 11% of initial body weight.

Maintenance of Lost Weight and Long-Term Management of Obesity

Weight loss can be achieved through a variety of modalities, but long-term maintenance of lost weight is much more challenging. Obesity interventions typically result in early weight loss followed by a weight plateau and progressive regain. This review describes current understanding of the biological, behavioral, and environmental factors driving this near-ubiquitous body weight trajectory and the implications for long-term weight management. Treatment of obesity requires ongoing clinical attention and weight maintenance-specific counseling to support sustainable healthful behaviors and positive weight regulation.

American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society

Review article American Society for Metabolic and Bariatric Surgery position statement on the impact of obesity and obesity treatment on fertility and fertility therapy Endorsed by the American College of Obstetricians and Gynecologists and the Obesity Society Michelle A. Kominiarek, M.D., Emily S. Jungheim, M.D., Kathleen M. Hoeger, M.D., M.P.H., Ann M. Rogers, M.D., Scott Kahan, M.D., M.P.H., Julie J. Kim, M.D.* Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, Illinois Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, Missouri Department of Obstetrics and Gynecology, University of Rochester School of Medicine and Dentistry, Rochester, New York Penn State Hershey Surgical Weight Loss Program, Hershey, Pennsylvania George Washington University; Washington D.C. Johns Hopkins Bloomberg School of Public Health; Baltimore, MD Harvard Medical School, Mount Auburn Weight Management, Mount Auburn Hospital, Cambridge, Massachusetts Received February 7, 2017; accepted February 8, 2017

Obesity Drug Outcome Measures: Results of a Multi-Stakeholder Critical Dialogue

There has been great interest in what role drugs should play in the treatment of obesity. Given the complex and multifactorial nature of obesity, drugs represent a valuable adjunct to traditional obesity treatments. However, obesity drugs present specific regulatory challenges, due to the sheer number of individuals affected, the heterogeneity of how obesity affects individuals differently, and the potential for drugs to be misused, especially by those seeking or profiting from cosmetic weight loss. There is a need to refine the characterization of the individuals most at risk from obesity to better assess the balance of benefits versus risks and determine appropriate candidates for drug therapy. As obesity affects feeling, functioning, and survival, outcome measures that reflect improvement in these domains should be explicitly incorporated into regulatory guidance. Regulators could benefit from mechanisms that limit or closely monitor off-label use and thereby allow approval of drugs for narrowly indicated populations.

The damaging effects of weight bias internalization

Prejudice, explicit bigotry, and implicit bias have become regular topics of national discourse in our current social and political environments. These discussions have included highly publicized examples of weight-based shaming (1), an unfortunate and frequent symptom of systemic weight stigmatization and discrimination in the United States. Despite increased public attention to weight stigma, few appreciate its extent and damaging impact on health.

Current practices of obesity pharmacotherapy, bariatric surgery referral and coding for counselling by healthcare professionals

Rates of obesity pharmacotherapy use, bariatric surgery and intensive behavioural counselling have been extremely low.

Obesity as a Disease: Current Policies and Implications for the Future

The recognition of obesity as a chronic disease is increasing. However, there is variable acknowledgment of it as a disease in health policies across the USA. The objective of this review is to describe how obesity meets the definition of a disease, explain its interpretation in current health policies, and explore implications for obesity in future health policy adoption and development. Perspectives are presented from scientific evidence, clinical practice, and health policy areas including Medicare, Medicaid, the Affordable Care Act, federal government agency guidance, and healthcare quality.

Triglyceride/HDL Ratio as a Screening Tool for Predicting Success at Reducing Anti-Diabetic Medications Following Weight Loss

Background and Objectives Intentional weight loss, by reducing insulin resistance, results in both better glycemic control and decreased need for anti-diabetic medications. However, not everyone who is successful with weight loss is able to reduce anti-diabetic medication use. In this retrospective cohort study, we assessed the predictive accuracy of baseline triglyceride (TGL)/HDL ratio, a marker of insulin resistance, to screen patients for success in reducing anti-diabetic medication use with weight loss. Methods Case records of 121 overweight and obese attendees at two outpatient weight management centers were analyzed. The weight loss intervention consisted of a calorie-restricted diet (~1000Kcal/day deficit), a behavior modification plan, and a plan for increasing physical activity. Results Mean period of follow-up was 12.5 ± 3.5 months. By study exit, mean weight loss and mean HbA1c% reduction were 15.4 ± 5.5 kgs and 0.5 ± 0.2% respectively. 81 (67%) in the study cohort achieved at least 1 dose reduction of any anti-diabetic medication. Tests for predictive accuracy of baseline TGL/HDL ratio ≤ 3 to determine success with dose reductions of anti-diabetic medications showed a sensitivity, specificity, positive predictive value, negative predictive value, area under the curve, likelihood ratio (LR) + and LR-of 81, 83, 90, 70, 78, 4.8 and 0.2, respectively. Reproducibility of TGL/HDL ratio was acceptable. Conclusion TGL/HDL ratio shows promise as an effective screening tool to determine success with dose reductions of anti-diabetic medications. The results of our study may inform the conduct of a systematic review using data from prior weight loss trials.

Nutrition Counseling in Clinical Practice: How Clinicians Can Do Better

Despite overwhelming evidence that relatively small dietary changes can significantly improve health, clinicians seldom discuss nutrition with their patients. Poor nutritional intake and nutrition-related health conditions, such as cardiovascular disease (CVD), diabetes, obesity, hypertension, and many cancers, are highly prevalent in the United States,1 yet only 12% of office visits include counseling about diet.2 Even among highrisk patients with CVD, diabetes, or hyperlipidemia, only 1 in 5 receive nutrition counseling.2 It is likely that many patients receive most of their nutrition information from other, and often unreliable, sources. These data may reflect the minimal training, time, and reimbursement allocated to nutrition counseling (and preventive services in general) in clinical practice.3 Most physicians and other health care professionals receive limited education on nutrition in medical school (or other professional schools) or in postgraduate training. Just 25% of medical schools offer a dedicated nutrition course, a decline since the status of nutrition education in US medical schools was first assessed in 1985, and few medical schools achieve the 30 hours of nutrition education recommended by the National Academy of Sciences.4 As a result, physicians report inadequate nutrition knowledge and low self-efficacy for counseling patients about diet.3 In addition, time pressures, especially in primary care, limit opportunities to counsel on nutrition or address preventive issues beyond patients’ acute complaints. Lack of time is frequently cited as the greatest barrier to counseling on nutrition and obesity.3 Moreover, nutrition and behavioral counseling have traditionally been nonreimbursed services. Few state Medicaid programs cover nutrition or obesity counseling, and before 2012, Medicare explicitly excluded coverage for obesity counseling; although now a reimbursed service for Medicare beneficiaries, just 1% of eligible Medicare beneficiaries receive this counseling.5 Dietitian counseling is also excluded by Medicare, unless patients have diabetes or renal disease. Although the Affordable Care Act mandates coverage for services graded A or B by the US Preventive Services Task Force, including nutrition counseling for patients with CVD risk factors and obesity counseling for patients with a body mass index of 30 or greater, existing private health insurance benefits are inconsistent, and the covered services are often unclear to both clinicians and patients, thereby limiting use. Furthermore,healthbehaviorchangecounselingisoften frustrating given the current food environment, in whichlessnutritiousfoodstendtobelessexpensive, larger portioned, more easily accessible, and more heavily marketed than healthier options, making patient adherence to nutrition advice challenging.6 Conflicting and confusing nutrition messages from popular books, blogs, and other media further complicate patient decision making. Despite these unfavorable trends, there has been progress in this area. The evidence base supporting the benefits of nutrition intervention and behavioral counseling is expanding. Renewed focus on nutrition education in health care professional training is being driven by both student demand and the health care system. Although time pressures and reimbursement remain impediments, incentives and reimbursement options for nutrition and behavioral counseling are growing, and value-based care and health care team approaches hold promise to better align time demands and incentives for long-term care management. Initiatives to integrate clinical care and community resources offer opportunities to leverage resources that alleviate the clinician’s time commitment. There is evidence of some success; for instance, the amount of sugar-sweetened beverages consumed by individuals in the United States has declined substantially over the past 10 years.7 Clinicians can take the following reasonable steps to include nutrition counseling into the flow of daily practice: 1. Start the conversation. Several short, validated screening questionnaires are available to quickly assess need for nutrition counseling, such as the Starting the Conversation tool8 (Table). This approach can be efficiently used prior to seeing the patient at an appointment, either delivered by medical assistants as part of vital sign assessment or as prescreening paperwork for patients to complete online or in the waiting room. 2. Structure the encounter, using methods such as the “5 A’s” (assess, advise, agree, assist, arrange), which has been adapted from tobacco counseling. Motivational interviewing, which has documented efficacy in numerous behavior change settings, is particularly helpful to engage patients who are not yet committed or are hesitant to consider behavioral change. 3. Focus on small steps. Changing lifelong nutrition behaviors can seem overwhelming, but even exceedingly small shifts can have an effect (Table). For example, increasing fruit intake by just 1 serving per day has the estimated potential to reduce cardiovascular mortality risk by 8%, the equivalent of 60 000 fewer deaths annually in the United States and 1.6 million deaths globally.9 Other examples include reducing intake of sugar-sweetened beverages, fast food meals, processedmeats,andsweets,while increasingvegetables, legumes,nuts,andwholegrains.Emphasizetopatients that every food choice is an opportunity to accrue benefits, and even small ones add up. Small substitutions still allow for “treats,” such as replacing potato chips and cheese dip with tortilla chips and salsa, the latter VIEWPOINT