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Obesity phenotyping matches patients with more effective interventions
A phenotype-guided strategy for systematically matching weight-loss patients to their potentially ideal weight-loss drug roughly doubled treatment efficacy, compared with usual practice, in a single-center, randomized study with 268 patients.
In contrast, in 200 patients who received weight loss–drug therapy selected by routine means, 35% achieved greater than 10% loss compared with their starting weight, Andres J. Acosta, MD, said at the virtual ObesityWeek® Interactive 2020 meeting.
The phenotype-guided strategy also led to an average 16% weight loss from baseline after 12 months, compared with a 9% average loss among the usual-care controls, reported Dr. Acosta, a gastroenterologist at the Mayo Clinic in Rochester, Minn.
A “one-size-fits-all approach to weight loss treatment is not working,” he declared. “Our long-term goal is to develop a personalized approach to obesity management.”
Personalized weight loss treatment isn’t new
“The better we can match treatment to a patient’s needs, the more likely it will succeed. That’s not a brand new idea. They are trying to standardize the way that we classify the disorders that play a role in why a person gains weight or has trouble losing weight,” commented John D. Clark III, MD, an internal medicine physician and weight-management specialist at UT Southwestern Medical Center in Dallas.
The increased weight loss levels that Dr. Acosta reported in patients who underwent the study’s phenotyping protocol and received tailored treatment “are similar to the numbers we see when a patient’s treatment is the right fit for them. You see weight loss in these ranges,” Dr. Clark said in an interview.
The study run by Dr. Acosta and his associates consisted of two phases. First, they established normal and abnormal ranges for four different obesity phenotypes by studying 100 patients with obesity. The patients underwent an extensive and uniform workup designed to classify their obesity phenotype.
Four obesity phenotypes
The researchers categorized patients into one of four types:
- Disordered initial eating satiation, called ‘hungry brain,” and assessed by measuring food intake at a buffet, ad libidum meal.
- Disordered maintenance of satiety, called “hungry gut,” assessed by both a gastric-emptying study as well as patient self-assessment for postprandial fullness.
- “Emotional hunger,” assessed with two questionnaires.
- Disordered energy expenditure, called “slow burn,” assessed by measuring basal metabolic rate, and self-reports of both exercise and nonexercise activity.
Dr. Acosta estimated that the complete workup to assess all four potential phenotypes costs about $1,200.
The researchers then applied the 75th percentile value from each of these assessments to 450 patients with obesity in their clinic to see the prevalence of the four phenotypes. They identified a single phenotype in 58% of these patients, including 18% with hungry gut, 16% with hungry brain, 12% with emotional hunger, and 12% with slow burn. An additional 27% of the patients were positive for two or more phenotypes (including 9% who were positive for all four phenotypes), and 15% did not test positive for any of the four phenotypes.
Phenotype-guided treatments
They then applied their findings in a prospective randomized study that matched a drug intervention to each of the four phenotypes during a year-long, comprehensive weight-loss program at the Mayo Clinic’s Weight Management Clinic. The study randomized 100 patients to the phenotype-driven arm, with 68 of these patients receiving their assigned drug, and 200 patients served as controls. Patients averaged about 47 years old, and their average body mass index was about 41 kg/m2.
The investigational arm included 30 patients classified as having a hungry brain, with 20 of these patients treated with phentermine plus topiramate and 10 treated with lorcaserin (before it was withdrawn by the Food and Drug Administration); 12 with hungry gut and treated with liraglutide (Saxenda); 19 with emotional hunger who received naltrexone SR/bupropion SR (Contrave); and seven with slow burn who received phentermine.
The control arm included 200 patients seeking weight loss treatment at Mayo who did not undergo phenotyping and received their drug treatment based on their personal preference in consultation with their Mayo physician. In this group, drug treatment broke down as 106 patients (53%) on phentermine plus topiramate, 41 (21%) on liraglutide, 34 (17%) on phentermine alone, 14 (7%) on naltrexone SR/bupropion SR, and 5 patients (3%) on locaserin (percentages total 101% because of rounding).
Overall, phenotyping led to more patients treated with naltrexone SR/buproprion SR and lorcaserin and fewer treated with phentermine or phentermine and topiramate ER. All patients were eligible to also receive behavioral interventions as needed.
“We do a lot of testing to identify the phenotype,” in addition to gathering additional clues from a detailed history, said Dr. Acosta. Patients identified with more than one phenotype in routine practice at Mayo are often begun on more than one drug. When phenotyping fails to classify a patient, Dr. Acosta puts the patient on a low-calorie diet and then does a follow-up assessment “to see if the phenotype pops up as a metabolic adaptation.”
“This is something we’re all working toward” in the obesity management field. “How can we better identify the underlying causes in a way that can fit into the work flow. How can we move from research to things we can use daily in the clinic,” observed Dr. Clark. “We need a lot more investigation to determine how well this works in the real world. Are there other tools we can use that are not as expensive” as what Dr. Acosta used for this study?
“For this proof of concept study, it made sense to be very rigorous, but that probably is not realistic for every patient. What are other ways to get this information, or perhaps only use an extensive workup when initial weight loss attempts are unsuccessful,” Dr. Clark suggested.
A phenotype-guided strategy for systematically matching weight-loss patients to their potentially ideal weight-loss drug roughly doubled treatment efficacy, compared with usual practice, in a single-center, randomized study with 268 patients.
In contrast, in 200 patients who received weight loss–drug therapy selected by routine means, 35% achieved greater than 10% loss compared with their starting weight, Andres J. Acosta, MD, said at the virtual ObesityWeek® Interactive 2020 meeting.
The phenotype-guided strategy also led to an average 16% weight loss from baseline after 12 months, compared with a 9% average loss among the usual-care controls, reported Dr. Acosta, a gastroenterologist at the Mayo Clinic in Rochester, Minn.
A “one-size-fits-all approach to weight loss treatment is not working,” he declared. “Our long-term goal is to develop a personalized approach to obesity management.”
Personalized weight loss treatment isn’t new
“The better we can match treatment to a patient’s needs, the more likely it will succeed. That’s not a brand new idea. They are trying to standardize the way that we classify the disorders that play a role in why a person gains weight or has trouble losing weight,” commented John D. Clark III, MD, an internal medicine physician and weight-management specialist at UT Southwestern Medical Center in Dallas.
The increased weight loss levels that Dr. Acosta reported in patients who underwent the study’s phenotyping protocol and received tailored treatment “are similar to the numbers we see when a patient’s treatment is the right fit for them. You see weight loss in these ranges,” Dr. Clark said in an interview.
The study run by Dr. Acosta and his associates consisted of two phases. First, they established normal and abnormal ranges for four different obesity phenotypes by studying 100 patients with obesity. The patients underwent an extensive and uniform workup designed to classify their obesity phenotype.
Four obesity phenotypes
The researchers categorized patients into one of four types:
- Disordered initial eating satiation, called ‘hungry brain,” and assessed by measuring food intake at a buffet, ad libidum meal.
- Disordered maintenance of satiety, called “hungry gut,” assessed by both a gastric-emptying study as well as patient self-assessment for postprandial fullness.
- “Emotional hunger,” assessed with two questionnaires.
- Disordered energy expenditure, called “slow burn,” assessed by measuring basal metabolic rate, and self-reports of both exercise and nonexercise activity.
Dr. Acosta estimated that the complete workup to assess all four potential phenotypes costs about $1,200.
The researchers then applied the 75th percentile value from each of these assessments to 450 patients with obesity in their clinic to see the prevalence of the four phenotypes. They identified a single phenotype in 58% of these patients, including 18% with hungry gut, 16% with hungry brain, 12% with emotional hunger, and 12% with slow burn. An additional 27% of the patients were positive for two or more phenotypes (including 9% who were positive for all four phenotypes), and 15% did not test positive for any of the four phenotypes.
Phenotype-guided treatments
They then applied their findings in a prospective randomized study that matched a drug intervention to each of the four phenotypes during a year-long, comprehensive weight-loss program at the Mayo Clinic’s Weight Management Clinic. The study randomized 100 patients to the phenotype-driven arm, with 68 of these patients receiving their assigned drug, and 200 patients served as controls. Patients averaged about 47 years old, and their average body mass index was about 41 kg/m2.
The investigational arm included 30 patients classified as having a hungry brain, with 20 of these patients treated with phentermine plus topiramate and 10 treated with lorcaserin (before it was withdrawn by the Food and Drug Administration); 12 with hungry gut and treated with liraglutide (Saxenda); 19 with emotional hunger who received naltrexone SR/bupropion SR (Contrave); and seven with slow burn who received phentermine.
The control arm included 200 patients seeking weight loss treatment at Mayo who did not undergo phenotyping and received their drug treatment based on their personal preference in consultation with their Mayo physician. In this group, drug treatment broke down as 106 patients (53%) on phentermine plus topiramate, 41 (21%) on liraglutide, 34 (17%) on phentermine alone, 14 (7%) on naltrexone SR/bupropion SR, and 5 patients (3%) on locaserin (percentages total 101% because of rounding).
Overall, phenotyping led to more patients treated with naltrexone SR/buproprion SR and lorcaserin and fewer treated with phentermine or phentermine and topiramate ER. All patients were eligible to also receive behavioral interventions as needed.
“We do a lot of testing to identify the phenotype,” in addition to gathering additional clues from a detailed history, said Dr. Acosta. Patients identified with more than one phenotype in routine practice at Mayo are often begun on more than one drug. When phenotyping fails to classify a patient, Dr. Acosta puts the patient on a low-calorie diet and then does a follow-up assessment “to see if the phenotype pops up as a metabolic adaptation.”
“This is something we’re all working toward” in the obesity management field. “How can we better identify the underlying causes in a way that can fit into the work flow. How can we move from research to things we can use daily in the clinic,” observed Dr. Clark. “We need a lot more investigation to determine how well this works in the real world. Are there other tools we can use that are not as expensive” as what Dr. Acosta used for this study?
“For this proof of concept study, it made sense to be very rigorous, but that probably is not realistic for every patient. What are other ways to get this information, or perhaps only use an extensive workup when initial weight loss attempts are unsuccessful,” Dr. Clark suggested.
A phenotype-guided strategy for systematically matching weight-loss patients to their potentially ideal weight-loss drug roughly doubled treatment efficacy, compared with usual practice, in a single-center, randomized study with 268 patients.
In contrast, in 200 patients who received weight loss–drug therapy selected by routine means, 35% achieved greater than 10% loss compared with their starting weight, Andres J. Acosta, MD, said at the virtual ObesityWeek® Interactive 2020 meeting.
The phenotype-guided strategy also led to an average 16% weight loss from baseline after 12 months, compared with a 9% average loss among the usual-care controls, reported Dr. Acosta, a gastroenterologist at the Mayo Clinic in Rochester, Minn.
A “one-size-fits-all approach to weight loss treatment is not working,” he declared. “Our long-term goal is to develop a personalized approach to obesity management.”
Personalized weight loss treatment isn’t new
“The better we can match treatment to a patient’s needs, the more likely it will succeed. That’s not a brand new idea. They are trying to standardize the way that we classify the disorders that play a role in why a person gains weight or has trouble losing weight,” commented John D. Clark III, MD, an internal medicine physician and weight-management specialist at UT Southwestern Medical Center in Dallas.
The increased weight loss levels that Dr. Acosta reported in patients who underwent the study’s phenotyping protocol and received tailored treatment “are similar to the numbers we see when a patient’s treatment is the right fit for them. You see weight loss in these ranges,” Dr. Clark said in an interview.
The study run by Dr. Acosta and his associates consisted of two phases. First, they established normal and abnormal ranges for four different obesity phenotypes by studying 100 patients with obesity. The patients underwent an extensive and uniform workup designed to classify their obesity phenotype.
Four obesity phenotypes
The researchers categorized patients into one of four types:
- Disordered initial eating satiation, called ‘hungry brain,” and assessed by measuring food intake at a buffet, ad libidum meal.
- Disordered maintenance of satiety, called “hungry gut,” assessed by both a gastric-emptying study as well as patient self-assessment for postprandial fullness.
- “Emotional hunger,” assessed with two questionnaires.
- Disordered energy expenditure, called “slow burn,” assessed by measuring basal metabolic rate, and self-reports of both exercise and nonexercise activity.
Dr. Acosta estimated that the complete workup to assess all four potential phenotypes costs about $1,200.
The researchers then applied the 75th percentile value from each of these assessments to 450 patients with obesity in their clinic to see the prevalence of the four phenotypes. They identified a single phenotype in 58% of these patients, including 18% with hungry gut, 16% with hungry brain, 12% with emotional hunger, and 12% with slow burn. An additional 27% of the patients were positive for two or more phenotypes (including 9% who were positive for all four phenotypes), and 15% did not test positive for any of the four phenotypes.
Phenotype-guided treatments
They then applied their findings in a prospective randomized study that matched a drug intervention to each of the four phenotypes during a year-long, comprehensive weight-loss program at the Mayo Clinic’s Weight Management Clinic. The study randomized 100 patients to the phenotype-driven arm, with 68 of these patients receiving their assigned drug, and 200 patients served as controls. Patients averaged about 47 years old, and their average body mass index was about 41 kg/m2.
The investigational arm included 30 patients classified as having a hungry brain, with 20 of these patients treated with phentermine plus topiramate and 10 treated with lorcaserin (before it was withdrawn by the Food and Drug Administration); 12 with hungry gut and treated with liraglutide (Saxenda); 19 with emotional hunger who received naltrexone SR/bupropion SR (Contrave); and seven with slow burn who received phentermine.
The control arm included 200 patients seeking weight loss treatment at Mayo who did not undergo phenotyping and received their drug treatment based on their personal preference in consultation with their Mayo physician. In this group, drug treatment broke down as 106 patients (53%) on phentermine plus topiramate, 41 (21%) on liraglutide, 34 (17%) on phentermine alone, 14 (7%) on naltrexone SR/bupropion SR, and 5 patients (3%) on locaserin (percentages total 101% because of rounding).
Overall, phenotyping led to more patients treated with naltrexone SR/buproprion SR and lorcaserin and fewer treated with phentermine or phentermine and topiramate ER. All patients were eligible to also receive behavioral interventions as needed.
“We do a lot of testing to identify the phenotype,” in addition to gathering additional clues from a detailed history, said Dr. Acosta. Patients identified with more than one phenotype in routine practice at Mayo are often begun on more than one drug. When phenotyping fails to classify a patient, Dr. Acosta puts the patient on a low-calorie diet and then does a follow-up assessment “to see if the phenotype pops up as a metabolic adaptation.”
“This is something we’re all working toward” in the obesity management field. “How can we better identify the underlying causes in a way that can fit into the work flow. How can we move from research to things we can use daily in the clinic,” observed Dr. Clark. “We need a lot more investigation to determine how well this works in the real world. Are there other tools we can use that are not as expensive” as what Dr. Acosta used for this study?
“For this proof of concept study, it made sense to be very rigorous, but that probably is not realistic for every patient. What are other ways to get this information, or perhaps only use an extensive workup when initial weight loss attempts are unsuccessful,” Dr. Clark suggested.
FROM OBESITY WEEK 2020
‘Disordered eating’ drops after teens undergo bariatric surgery
Kristina M. Decker, PhD, a postdoctoral fellow at Cincinnati Children’s Hospital Medical Center, presented these findings during the virtual ObesityWeek 2020.
Dr. Decker and associates examined rates of disordered eating in more than 200 adolescents (aged 13-18 years) who were severely obese, of whom 141 underwent bariatric surgery and the remainder did not.
At baseline (presurgery), the teens in both groups had rates of disordered eating ranging from 11% to 50%, with higher rates in those who went on to have bariatric surgery.
Six years later, rates of disordered eating were much lower in those who had bariatric surgery.
The data nevertheless “underscore that young adults with persistent severe obesity are at high risk for poor health and well-being,” Dr. Decker said in an interview.
“This means disordered eating behaviors should be closely monitored” in all such patients, both those who undergo surgery and those who don’t, she stressed.
Robust findings because of long follow-up and controls
The findings are not unexpected, based on adult bariatric literature, but are “novel because of the age of the patients,” senior author Margaret H. Zeller, PhD, Cincinnati Children’s Hospital Medical Center and professor at the University of Cincinnati, added.
In a comment comment, psychologist Kajsa Järvholm, PhD, of the Childhood Obesity Unit at Skåne University Hospital, Malmö̈, Sweden, who has published related work, said that this is “a needed study.”
Notably, it had “long-term follow-up and a control group,” and it “confirms that adolescents are in better control of their eating after surgery.”
However, an important additional takeaway for clinicians is that “disordered eating is associated with other mental health problems and self-worth. Clinicians treating obesity must address problems related to eating disorders to improve outcomes and well-being,” she stressed.
How does bariatric surgery impact overeating, binge eating, in teens?
“For teens with severe obesity, metabolic and bariatric surgery is the most effective treatment for improved cardiometabolic functioning, weight loss, and improved quality of life,” Dr. Decker stressed.
However, pre- and postsurgical disordered eating behaviors have been associated with a lower percentage change in body mass index (BMI), although this has not been well studied.
To investigate how disordered eating is affected by bariatric surgery in adolescents with severe obesity, researchers used data from Teen-LABS, which enrolled 242 participants aged 19 years and under who mainly underwent Roux-en-Y gastric bypass (67%) or sleeve gastrectomy (28%) from 2007 to 2012 at five adolescent bariatric surgery centers.
The current analysis examined data from 141 participants in Teen-LABS who underwent bariatric surgery at a mean age of 16.8 years. Mean BMI was 51.5, most were girls (80%), and they had diverse race/ethnicity (66% were White).
Researchers also identified a control group of 83 adolescents of a similar age and gender who had diverse race/ethnicity (54% White) and a mean BMI of 46.9.
At year 6, data were available for 123 young adults in the surgery group (who by then had a mean BMI of 39.7) and 63 young adults in the nonsurgery group (who had a mean BMI of 52.6).
At baseline and year 6, participants replied to questionnaires that identified three eating disorders: continuous eating (eating in an unplanned and repetitious way between meals and snacks), objective overeating (eating a “large” amount of food without loss of control), and objective binge eating (eating a “large” amount of food with loss of control).
At baseline, rates of continuous eating, overeating, and binge eating were higher in the surgical group (50%, 40%, and 30%, respectively) than the nonsurgical group (40%, 22%, and 11%, respectively).
Six years later, when participants were aged 19-24 years, rates of continuous eating, overeating, and binge eating had declined in the surgical group (to 17%, 5%, and 1%, respectively). In the nonsurgical group, only continuous eating and overeating declined (to 24% and 7%, respectively), and binge eating increased slightly (to 13%).
Disordered eating associated with low self-worth, anxiety, and depression
In young adulthood in both groups, disordered eating was associated with lower self-worth. In the surgical group, it was also associated with lower weight-related quality of life, and in the nonsurgical group, it was also associated with anxiety and/or depression.
“The current findings cannot tell us whether disordered eating is a direct result or caused by anxiety, depression, low self-worth, or poor quality of life,” Dr. Decker said.
“These findings do give us insight about what other areas of clinical concern might present together [in] young adults (e.g., disordered eating, low self-esteem).”
Bariatric surgery affects the amount of food people can eat at one time, she noted in reply to a question from the audience. If people eat too much at a time they can experience vomiting, dumping syndrome (where certain food is “dumped” into the small intestine without being digested, causing nausea and vomiting), and plugging (a sense of food becoming stuck).
The home environment and transition to adulthood might impact disordered eating in young adults, she said in reply to another question, but these issues were not examined in this study.
A version of this article originally appeared on Medscape.com.
Kristina M. Decker, PhD, a postdoctoral fellow at Cincinnati Children’s Hospital Medical Center, presented these findings during the virtual ObesityWeek 2020.
Dr. Decker and associates examined rates of disordered eating in more than 200 adolescents (aged 13-18 years) who were severely obese, of whom 141 underwent bariatric surgery and the remainder did not.
At baseline (presurgery), the teens in both groups had rates of disordered eating ranging from 11% to 50%, with higher rates in those who went on to have bariatric surgery.
Six years later, rates of disordered eating were much lower in those who had bariatric surgery.
The data nevertheless “underscore that young adults with persistent severe obesity are at high risk for poor health and well-being,” Dr. Decker said in an interview.
“This means disordered eating behaviors should be closely monitored” in all such patients, both those who undergo surgery and those who don’t, she stressed.
Robust findings because of long follow-up and controls
The findings are not unexpected, based on adult bariatric literature, but are “novel because of the age of the patients,” senior author Margaret H. Zeller, PhD, Cincinnati Children’s Hospital Medical Center and professor at the University of Cincinnati, added.
In a comment comment, psychologist Kajsa Järvholm, PhD, of the Childhood Obesity Unit at Skåne University Hospital, Malmö̈, Sweden, who has published related work, said that this is “a needed study.”
Notably, it had “long-term follow-up and a control group,” and it “confirms that adolescents are in better control of their eating after surgery.”
However, an important additional takeaway for clinicians is that “disordered eating is associated with other mental health problems and self-worth. Clinicians treating obesity must address problems related to eating disorders to improve outcomes and well-being,” she stressed.
How does bariatric surgery impact overeating, binge eating, in teens?
“For teens with severe obesity, metabolic and bariatric surgery is the most effective treatment for improved cardiometabolic functioning, weight loss, and improved quality of life,” Dr. Decker stressed.
However, pre- and postsurgical disordered eating behaviors have been associated with a lower percentage change in body mass index (BMI), although this has not been well studied.
To investigate how disordered eating is affected by bariatric surgery in adolescents with severe obesity, researchers used data from Teen-LABS, which enrolled 242 participants aged 19 years and under who mainly underwent Roux-en-Y gastric bypass (67%) or sleeve gastrectomy (28%) from 2007 to 2012 at five adolescent bariatric surgery centers.
The current analysis examined data from 141 participants in Teen-LABS who underwent bariatric surgery at a mean age of 16.8 years. Mean BMI was 51.5, most were girls (80%), and they had diverse race/ethnicity (66% were White).
Researchers also identified a control group of 83 adolescents of a similar age and gender who had diverse race/ethnicity (54% White) and a mean BMI of 46.9.
At year 6, data were available for 123 young adults in the surgery group (who by then had a mean BMI of 39.7) and 63 young adults in the nonsurgery group (who had a mean BMI of 52.6).
At baseline and year 6, participants replied to questionnaires that identified three eating disorders: continuous eating (eating in an unplanned and repetitious way between meals and snacks), objective overeating (eating a “large” amount of food without loss of control), and objective binge eating (eating a “large” amount of food with loss of control).
At baseline, rates of continuous eating, overeating, and binge eating were higher in the surgical group (50%, 40%, and 30%, respectively) than the nonsurgical group (40%, 22%, and 11%, respectively).
Six years later, when participants were aged 19-24 years, rates of continuous eating, overeating, and binge eating had declined in the surgical group (to 17%, 5%, and 1%, respectively). In the nonsurgical group, only continuous eating and overeating declined (to 24% and 7%, respectively), and binge eating increased slightly (to 13%).
Disordered eating associated with low self-worth, anxiety, and depression
In young adulthood in both groups, disordered eating was associated with lower self-worth. In the surgical group, it was also associated with lower weight-related quality of life, and in the nonsurgical group, it was also associated with anxiety and/or depression.
“The current findings cannot tell us whether disordered eating is a direct result or caused by anxiety, depression, low self-worth, or poor quality of life,” Dr. Decker said.
“These findings do give us insight about what other areas of clinical concern might present together [in] young adults (e.g., disordered eating, low self-esteem).”
Bariatric surgery affects the amount of food people can eat at one time, she noted in reply to a question from the audience. If people eat too much at a time they can experience vomiting, dumping syndrome (where certain food is “dumped” into the small intestine without being digested, causing nausea and vomiting), and plugging (a sense of food becoming stuck).
The home environment and transition to adulthood might impact disordered eating in young adults, she said in reply to another question, but these issues were not examined in this study.
A version of this article originally appeared on Medscape.com.
Kristina M. Decker, PhD, a postdoctoral fellow at Cincinnati Children’s Hospital Medical Center, presented these findings during the virtual ObesityWeek 2020.
Dr. Decker and associates examined rates of disordered eating in more than 200 adolescents (aged 13-18 years) who were severely obese, of whom 141 underwent bariatric surgery and the remainder did not.
At baseline (presurgery), the teens in both groups had rates of disordered eating ranging from 11% to 50%, with higher rates in those who went on to have bariatric surgery.
Six years later, rates of disordered eating were much lower in those who had bariatric surgery.
The data nevertheless “underscore that young adults with persistent severe obesity are at high risk for poor health and well-being,” Dr. Decker said in an interview.
“This means disordered eating behaviors should be closely monitored” in all such patients, both those who undergo surgery and those who don’t, she stressed.
Robust findings because of long follow-up and controls
The findings are not unexpected, based on adult bariatric literature, but are “novel because of the age of the patients,” senior author Margaret H. Zeller, PhD, Cincinnati Children’s Hospital Medical Center and professor at the University of Cincinnati, added.
In a comment comment, psychologist Kajsa Järvholm, PhD, of the Childhood Obesity Unit at Skåne University Hospital, Malmö̈, Sweden, who has published related work, said that this is “a needed study.”
Notably, it had “long-term follow-up and a control group,” and it “confirms that adolescents are in better control of their eating after surgery.”
However, an important additional takeaway for clinicians is that “disordered eating is associated with other mental health problems and self-worth. Clinicians treating obesity must address problems related to eating disorders to improve outcomes and well-being,” she stressed.
How does bariatric surgery impact overeating, binge eating, in teens?
“For teens with severe obesity, metabolic and bariatric surgery is the most effective treatment for improved cardiometabolic functioning, weight loss, and improved quality of life,” Dr. Decker stressed.
However, pre- and postsurgical disordered eating behaviors have been associated with a lower percentage change in body mass index (BMI), although this has not been well studied.
To investigate how disordered eating is affected by bariatric surgery in adolescents with severe obesity, researchers used data from Teen-LABS, which enrolled 242 participants aged 19 years and under who mainly underwent Roux-en-Y gastric bypass (67%) or sleeve gastrectomy (28%) from 2007 to 2012 at five adolescent bariatric surgery centers.
The current analysis examined data from 141 participants in Teen-LABS who underwent bariatric surgery at a mean age of 16.8 years. Mean BMI was 51.5, most were girls (80%), and they had diverse race/ethnicity (66% were White).
Researchers also identified a control group of 83 adolescents of a similar age and gender who had diverse race/ethnicity (54% White) and a mean BMI of 46.9.
At year 6, data were available for 123 young adults in the surgery group (who by then had a mean BMI of 39.7) and 63 young adults in the nonsurgery group (who had a mean BMI of 52.6).
At baseline and year 6, participants replied to questionnaires that identified three eating disorders: continuous eating (eating in an unplanned and repetitious way between meals and snacks), objective overeating (eating a “large” amount of food without loss of control), and objective binge eating (eating a “large” amount of food with loss of control).
At baseline, rates of continuous eating, overeating, and binge eating were higher in the surgical group (50%, 40%, and 30%, respectively) than the nonsurgical group (40%, 22%, and 11%, respectively).
Six years later, when participants were aged 19-24 years, rates of continuous eating, overeating, and binge eating had declined in the surgical group (to 17%, 5%, and 1%, respectively). In the nonsurgical group, only continuous eating and overeating declined (to 24% and 7%, respectively), and binge eating increased slightly (to 13%).
Disordered eating associated with low self-worth, anxiety, and depression
In young adulthood in both groups, disordered eating was associated with lower self-worth. In the surgical group, it was also associated with lower weight-related quality of life, and in the nonsurgical group, it was also associated with anxiety and/or depression.
“The current findings cannot tell us whether disordered eating is a direct result or caused by anxiety, depression, low self-worth, or poor quality of life,” Dr. Decker said.
“These findings do give us insight about what other areas of clinical concern might present together [in] young adults (e.g., disordered eating, low self-esteem).”
Bariatric surgery affects the amount of food people can eat at one time, she noted in reply to a question from the audience. If people eat too much at a time they can experience vomiting, dumping syndrome (where certain food is “dumped” into the small intestine without being digested, causing nausea and vomiting), and plugging (a sense of food becoming stuck).
The home environment and transition to adulthood might impact disordered eating in young adults, she said in reply to another question, but these issues were not examined in this study.
A version of this article originally appeared on Medscape.com.
Obesity biggest risk for COVID-19 pneumonia, after age, male sex
In a large international study of patients admitted to the ICU with COVID-19, the likelihood of having severe pneumonia (i.e., needing invasive mechanical ventilation) increased stepwise with increasing body mass index (BMI) – independent of diabetes, hypertension, dyslipidemia, or current smoking.
The main finding was a linear correlation between BMI and need for invasive mechanical ventilation, after adjustment for center, age, sex, and other prespecified metabolic risk factors.
Risk was “highest for older people and males, but the next most important risk factor to developing severe pneumonia if infected [was] obesity,” said François Pattou, MD, Centre Hospitalier Universitaire de Lille (France), who presented the findings at the ObesityWeek 2020 virtual meeting. The results were also recently published in a preprint article in The Lancet.
Dr. Pattou and colleagues first reported back in April that obesity is one of the biggest risk factors for severe COVID-19 infection, especially in younger patients. Many further reports linked the two, and the French researchers then set out to conduct the current large, international, multicenter cohort study.
“The high number of patients included here [allowed us] to disentangle the role of various metabolic cofactors and to show that obesity, not diabetes or hypertension, was the main determinant of severe pneumonia [after age and gender],” Dr. Pattou said in an interview.
And the impact of obesity was most pronounced in women younger than 50 years.
Patients with severe obesity must protect themselves
Of interest, the study also found an “obesity paradox” for mortality after admission to the ICU.
Specifically, compared with leaner patients (BMI < 25 kg/m2), those with severe obesity (obesity class III, BMI ≥ 40) had an increased risk of dying within 28 days of admission to ICU. But patients with overweight to moderate obesity (BMI 25-39.9) had a lower risk of this outcome.
“The second original finding of our study,” Dr. Pattou continued, was the “nonlinear relation observed between BMI and all-cause mortality rate in ICU patients.”
Matteo Rottoli, MD, PhD, author of a related study reported by in July, said the new trial “confirms the findings of our study, which are that obesity is an independent risk factor for intensive care admission and death.”
Dr. Rottoli, from Alma Mater Studiorum, University of Bologna, Italy, and colleagues found that in their population of patients with COVID-19, a BMI > 35 was associated with a greater risk of death.
The takeaway message from the research is that “obesity should be considered one of the most important parameters to identify the population at risk” of getting COVID-19 who need to take extra precautions such as social distancing, Dr. Rottoli stressed.
Dr. Pattou agrees, particularly when it comes to severe obesity.
Intensive care physicians have learned a lot in the past months about COVID-19 pneumonia and how to address it (such as not precipitating intubation, using corticosteroids), he explained.
“Importantly, the general population has also learned a lot, and we can hope that patients with obesity, especially those with severe obesity, will take extra measures to protect themselves, resulting in a decrease of the incidence of severe pneumonia in young and severely obese patients,” he added.
Untangling BMI from other metabolic risk factors
Dr. Pattou said that, from Dec. 16, 2019, to Nov. 1, 2020, more than 45 million people worldwide tested positive for COVID-19 and more than 1.2 million people died from it.
Multiple studies have reported that, among people with COVID-19, those with obesity are at higher risk of hospitalization, ICU admission, invasive ventilation, and death, but it had not been clear if BMI was an independent risk factor.
Dr. Pattou and colleagues aimed to examine the relationship between BMI and COVID-19 pneumonia severity, defined by the need for mechanical ventilation (primary outcome), as well as 28-day all-cause mortality (secondary outcome) among patients admitted to the ICU.
They also sought to disentangle the effect of BMI from other metabolic risk factors (diabetes, hypertension, dyslipidemia, and current smoking) and examine the influence of age and sex on outcomes.
They performed a retrospective analysis of 1,461 patients with confirmed COVID-19 (positive reverse polymerase chain reaction test using a nasal or pharyngeal swab specimen) who were admitted to the ICU at 21 centers from Feb. 19 to May 11, 2020.
Participating centers were in France (13), Italy (3), the United States (1 in New York and 1 in Providence, R.I.), Israel (1), Belgium (1), and Spain (1).
Close to three-quarters of patients were men (73%), which is similar to multiple other studies, Dr. Pattou said. Patients were a mean age of 64 years and had a mean BMI of 28.1.
Half of patients had hypertension (52%), 29% had diabetes, 29% had hyperlipidemia, and 6.5% were current smokers.
Close to three-quarters (74%) required invasive mechanical ventilation, and 36% died within 28 days of ICU admission.
Each 5-kg/m2 increase in BMI was associated with a 27% increased risk of mechanical ventilation in the overall cohort and a 65% increased risk of this outcome among women younger than 50 years, after adjustment for other risk factors.
Male sex and each 10-year increase in age were associated with an 82% and a 17% increased risk of ventilation, respectively, but hypertension, diabetes, hyperlipidemia, and current smoking were not associated with a greater risk. After adjustment for center, age, sex, and prespecified metabolic risk factors, obesity class III (BMI ≥ 40) was associated with a 68% increase in mortality, compared with the risk seen in lean patients.
The findings were similar across different centers.
“To our knowledge, this study represents the first international collaborative effort to explore the association of BMI with the outcomes of pneumonia among COVID-19 patients admitted to ICU,” said the investigators.
They conclude that “available evidence should foster more focused and effective interventions in COVID-19 patients with the highest risk of severe pneumonia, in order to reduce future strain on intensive care resources worldwide, and inform physio-pathological research to elucidate the mechanism of severe lung damage in COVID-19.”
The study did not receive specific funding. The authors have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
In a large international study of patients admitted to the ICU with COVID-19, the likelihood of having severe pneumonia (i.e., needing invasive mechanical ventilation) increased stepwise with increasing body mass index (BMI) – independent of diabetes, hypertension, dyslipidemia, or current smoking.
The main finding was a linear correlation between BMI and need for invasive mechanical ventilation, after adjustment for center, age, sex, and other prespecified metabolic risk factors.
Risk was “highest for older people and males, but the next most important risk factor to developing severe pneumonia if infected [was] obesity,” said François Pattou, MD, Centre Hospitalier Universitaire de Lille (France), who presented the findings at the ObesityWeek 2020 virtual meeting. The results were also recently published in a preprint article in The Lancet.
Dr. Pattou and colleagues first reported back in April that obesity is one of the biggest risk factors for severe COVID-19 infection, especially in younger patients. Many further reports linked the two, and the French researchers then set out to conduct the current large, international, multicenter cohort study.
“The high number of patients included here [allowed us] to disentangle the role of various metabolic cofactors and to show that obesity, not diabetes or hypertension, was the main determinant of severe pneumonia [after age and gender],” Dr. Pattou said in an interview.
And the impact of obesity was most pronounced in women younger than 50 years.
Patients with severe obesity must protect themselves
Of interest, the study also found an “obesity paradox” for mortality after admission to the ICU.
Specifically, compared with leaner patients (BMI < 25 kg/m2), those with severe obesity (obesity class III, BMI ≥ 40) had an increased risk of dying within 28 days of admission to ICU. But patients with overweight to moderate obesity (BMI 25-39.9) had a lower risk of this outcome.
“The second original finding of our study,” Dr. Pattou continued, was the “nonlinear relation observed between BMI and all-cause mortality rate in ICU patients.”
Matteo Rottoli, MD, PhD, author of a related study reported by in July, said the new trial “confirms the findings of our study, which are that obesity is an independent risk factor for intensive care admission and death.”
Dr. Rottoli, from Alma Mater Studiorum, University of Bologna, Italy, and colleagues found that in their population of patients with COVID-19, a BMI > 35 was associated with a greater risk of death.
The takeaway message from the research is that “obesity should be considered one of the most important parameters to identify the population at risk” of getting COVID-19 who need to take extra precautions such as social distancing, Dr. Rottoli stressed.
Dr. Pattou agrees, particularly when it comes to severe obesity.
Intensive care physicians have learned a lot in the past months about COVID-19 pneumonia and how to address it (such as not precipitating intubation, using corticosteroids), he explained.
“Importantly, the general population has also learned a lot, and we can hope that patients with obesity, especially those with severe obesity, will take extra measures to protect themselves, resulting in a decrease of the incidence of severe pneumonia in young and severely obese patients,” he added.
Untangling BMI from other metabolic risk factors
Dr. Pattou said that, from Dec. 16, 2019, to Nov. 1, 2020, more than 45 million people worldwide tested positive for COVID-19 and more than 1.2 million people died from it.
Multiple studies have reported that, among people with COVID-19, those with obesity are at higher risk of hospitalization, ICU admission, invasive ventilation, and death, but it had not been clear if BMI was an independent risk factor.
Dr. Pattou and colleagues aimed to examine the relationship between BMI and COVID-19 pneumonia severity, defined by the need for mechanical ventilation (primary outcome), as well as 28-day all-cause mortality (secondary outcome) among patients admitted to the ICU.
They also sought to disentangle the effect of BMI from other metabolic risk factors (diabetes, hypertension, dyslipidemia, and current smoking) and examine the influence of age and sex on outcomes.
They performed a retrospective analysis of 1,461 patients with confirmed COVID-19 (positive reverse polymerase chain reaction test using a nasal or pharyngeal swab specimen) who were admitted to the ICU at 21 centers from Feb. 19 to May 11, 2020.
Participating centers were in France (13), Italy (3), the United States (1 in New York and 1 in Providence, R.I.), Israel (1), Belgium (1), and Spain (1).
Close to three-quarters of patients were men (73%), which is similar to multiple other studies, Dr. Pattou said. Patients were a mean age of 64 years and had a mean BMI of 28.1.
Half of patients had hypertension (52%), 29% had diabetes, 29% had hyperlipidemia, and 6.5% were current smokers.
Close to three-quarters (74%) required invasive mechanical ventilation, and 36% died within 28 days of ICU admission.
Each 5-kg/m2 increase in BMI was associated with a 27% increased risk of mechanical ventilation in the overall cohort and a 65% increased risk of this outcome among women younger than 50 years, after adjustment for other risk factors.
Male sex and each 10-year increase in age were associated with an 82% and a 17% increased risk of ventilation, respectively, but hypertension, diabetes, hyperlipidemia, and current smoking were not associated with a greater risk. After adjustment for center, age, sex, and prespecified metabolic risk factors, obesity class III (BMI ≥ 40) was associated with a 68% increase in mortality, compared with the risk seen in lean patients.
The findings were similar across different centers.
“To our knowledge, this study represents the first international collaborative effort to explore the association of BMI with the outcomes of pneumonia among COVID-19 patients admitted to ICU,” said the investigators.
They conclude that “available evidence should foster more focused and effective interventions in COVID-19 patients with the highest risk of severe pneumonia, in order to reduce future strain on intensive care resources worldwide, and inform physio-pathological research to elucidate the mechanism of severe lung damage in COVID-19.”
The study did not receive specific funding. The authors have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
In a large international study of patients admitted to the ICU with COVID-19, the likelihood of having severe pneumonia (i.e., needing invasive mechanical ventilation) increased stepwise with increasing body mass index (BMI) – independent of diabetes, hypertension, dyslipidemia, or current smoking.
The main finding was a linear correlation between BMI and need for invasive mechanical ventilation, after adjustment for center, age, sex, and other prespecified metabolic risk factors.
Risk was “highest for older people and males, but the next most important risk factor to developing severe pneumonia if infected [was] obesity,” said François Pattou, MD, Centre Hospitalier Universitaire de Lille (France), who presented the findings at the ObesityWeek 2020 virtual meeting. The results were also recently published in a preprint article in The Lancet.
Dr. Pattou and colleagues first reported back in April that obesity is one of the biggest risk factors for severe COVID-19 infection, especially in younger patients. Many further reports linked the two, and the French researchers then set out to conduct the current large, international, multicenter cohort study.
“The high number of patients included here [allowed us] to disentangle the role of various metabolic cofactors and to show that obesity, not diabetes or hypertension, was the main determinant of severe pneumonia [after age and gender],” Dr. Pattou said in an interview.
And the impact of obesity was most pronounced in women younger than 50 years.
Patients with severe obesity must protect themselves
Of interest, the study also found an “obesity paradox” for mortality after admission to the ICU.
Specifically, compared with leaner patients (BMI < 25 kg/m2), those with severe obesity (obesity class III, BMI ≥ 40) had an increased risk of dying within 28 days of admission to ICU. But patients with overweight to moderate obesity (BMI 25-39.9) had a lower risk of this outcome.
“The second original finding of our study,” Dr. Pattou continued, was the “nonlinear relation observed between BMI and all-cause mortality rate in ICU patients.”
Matteo Rottoli, MD, PhD, author of a related study reported by in July, said the new trial “confirms the findings of our study, which are that obesity is an independent risk factor for intensive care admission and death.”
Dr. Rottoli, from Alma Mater Studiorum, University of Bologna, Italy, and colleagues found that in their population of patients with COVID-19, a BMI > 35 was associated with a greater risk of death.
The takeaway message from the research is that “obesity should be considered one of the most important parameters to identify the population at risk” of getting COVID-19 who need to take extra precautions such as social distancing, Dr. Rottoli stressed.
Dr. Pattou agrees, particularly when it comes to severe obesity.
Intensive care physicians have learned a lot in the past months about COVID-19 pneumonia and how to address it (such as not precipitating intubation, using corticosteroids), he explained.
“Importantly, the general population has also learned a lot, and we can hope that patients with obesity, especially those with severe obesity, will take extra measures to protect themselves, resulting in a decrease of the incidence of severe pneumonia in young and severely obese patients,” he added.
Untangling BMI from other metabolic risk factors
Dr. Pattou said that, from Dec. 16, 2019, to Nov. 1, 2020, more than 45 million people worldwide tested positive for COVID-19 and more than 1.2 million people died from it.
Multiple studies have reported that, among people with COVID-19, those with obesity are at higher risk of hospitalization, ICU admission, invasive ventilation, and death, but it had not been clear if BMI was an independent risk factor.
Dr. Pattou and colleagues aimed to examine the relationship between BMI and COVID-19 pneumonia severity, defined by the need for mechanical ventilation (primary outcome), as well as 28-day all-cause mortality (secondary outcome) among patients admitted to the ICU.
They also sought to disentangle the effect of BMI from other metabolic risk factors (diabetes, hypertension, dyslipidemia, and current smoking) and examine the influence of age and sex on outcomes.
They performed a retrospective analysis of 1,461 patients with confirmed COVID-19 (positive reverse polymerase chain reaction test using a nasal or pharyngeal swab specimen) who were admitted to the ICU at 21 centers from Feb. 19 to May 11, 2020.
Participating centers were in France (13), Italy (3), the United States (1 in New York and 1 in Providence, R.I.), Israel (1), Belgium (1), and Spain (1).
Close to three-quarters of patients were men (73%), which is similar to multiple other studies, Dr. Pattou said. Patients were a mean age of 64 years and had a mean BMI of 28.1.
Half of patients had hypertension (52%), 29% had diabetes, 29% had hyperlipidemia, and 6.5% were current smokers.
Close to three-quarters (74%) required invasive mechanical ventilation, and 36% died within 28 days of ICU admission.
Each 5-kg/m2 increase in BMI was associated with a 27% increased risk of mechanical ventilation in the overall cohort and a 65% increased risk of this outcome among women younger than 50 years, after adjustment for other risk factors.
Male sex and each 10-year increase in age were associated with an 82% and a 17% increased risk of ventilation, respectively, but hypertension, diabetes, hyperlipidemia, and current smoking were not associated with a greater risk. After adjustment for center, age, sex, and prespecified metabolic risk factors, obesity class III (BMI ≥ 40) was associated with a 68% increase in mortality, compared with the risk seen in lean patients.
The findings were similar across different centers.
“To our knowledge, this study represents the first international collaborative effort to explore the association of BMI with the outcomes of pneumonia among COVID-19 patients admitted to ICU,” said the investigators.
They conclude that “available evidence should foster more focused and effective interventions in COVID-19 patients with the highest risk of severe pneumonia, in order to reduce future strain on intensive care resources worldwide, and inform physio-pathological research to elucidate the mechanism of severe lung damage in COVID-19.”
The study did not receive specific funding. The authors have reported no relevant financial relationships.
A version of this article originally appeared on Medscape.com.