Effects of outcome-driven insurance reimbursement on short-term weight control.

CONTEXT: Although most health insurers exclude coverage of weight control therapy, one local insurer offered partial reimbursement of the cost of a weight control program, using an incentive plan. OBJECTIVE: To determine whether outcome-driven insurer-based reimbursement improves participation in a weight control program and short-term weight loss outcomes. DESIGN: Cohort follow-up study between January 1998 and February 2001. SETTING: Community weight management program operated by an academic medical center. SUBJECTS: Obese participants who had the potential for reimbursement (Group A, n=25) and participants in the same program classes (Group B, n=100) who had no possibility for reimbursement. Subjects in Group B were selected from among 206 potential participants using a propensity score to match them with subjects in Group A on age, gender, ethnicity, starting BMI, starting weight, and educational, economic, and demographic variables. INTERVENTION: Group lifestyle-based weight management program. The insurer reimbursed half the cost of the program to obese participants who met minimum weight criteria, paid the program fee at enrollment, attended > or =10 of the 12 classes, and lost > or =6% of initial body weight after 12 weeks. MAIN OUTCOME MEASURES: Participation rates and weight loss outcomes. RESULTS: Group A subjects attended significantly more classes (mean+/-s.d.: 10.1+/-1.8 vs 8.2+/-2.5, P<0.001) and lost more weight than Group B subjects (6.1+/-3.1 vs 3.7+/-3.6%, P=0.002). While 84% of Group A subjects attended > or =10 classes, only 37% of Group B subjects did so (P<0.001); 56% of Group A subjects lost > or =6% of body weight, but only 20% of Group B subjects did so (P<0.001); 56% of Group A subjects achieved both the class attendance and weight loss goals, but only 14% of Group B subjects did so (P<0.001). Logistic regression estimated that Group A subjects had 8.2 times the odds of attending > or =10 classes and 4.5 times the odds of losing > or =6% of body weight of Group B subjects, after controlling for class attendance. CONCLUSIONS: Insurer-based reimbursement that is contingent upon initial financial commitment on the part of the patient, consistent program participation, and successful weight loss is associated with significantly better short-term weight control outcomes.

Analysis of weight loss with the biliopancreatic diversion of Larrad: absolute failures or relative successes?

BACKGROUND: The authors studied whether morbidly obese patients who failed in stated weight loss criteria may be considered absolute failures or relative successes. METHODS: 75 morbidly obese patients underwent biliopancreatic diversion (BPD) of Larrad, with a 4/5 gastrectomy (residual gastric volume 150-200 ml), a biliopancreatic limb divided 50 cm distal to Treitz' ligament, a 50-cm common limb and an alimentary limb of nearly all the bowel length (500-600 cm). Every patient had a follow-up of 5 years. A percent excess weight loss (%EWL) < 50% was considered a "failure". We analyzed the post-surgical changes in the preoperative obesity-related problems in these patients and the causes of the weight loss failure. RESULTS: At 5 years after the BPD of Larrad, 9 patients (12%) had a %EWL < 50%, with a mean %EWL of 36 in these patients. Most of these failed patients were cured or improved of their preoperative illnesses. The 2 males were alcoholics, and 6 of the 7 females had an abnormal psychological examination. Comparing the "failed" patients with the successful group, there is a statistically significant influence (p < 0.01) of lack of satiety, unmarried status, housewife or unemployed. CONCLUSION: Patients judged as a failure by weight loss criteria after bariatric surgery should not be considered absolute failures, because most of their preoperative illnesses were cured or improved, improving their quality of life. Thus, they are "relative successes".

Effect of weight reduction on serum ghrelin and TNFalpha concentrations in obese women.

Background: Ghrelin causes weight gain by increasing food intake in rodents. Tumor necrosis factor alpha (TNFalpha) is produced by adipose tissue, modulates its metabolism and stimulates catabolic processes. The aim of our study was to evaluate whether weight loss treatment modulates serum concentrations of TNFalpha and ghrelin in obese women. Methods: The study groups included 46 women: 35 obese patients and 11 controls. Serum concentrations of ghrelin and TNFalpha were measured by ELISA before and after a 3-month weight reduction treatment that consisted of a 1000 kcal/day diet and physical exercises. Body composition was determined by impedance analysis using Bodystat. Results: There were no differences in plasma ghrelin concentrations between obese patients and controls. TNFalpha serum levels were higher in obese patients than in controls (p=0.000). The mean weight loss over the 3-month treatment period was 8.7+/-4.5 kg. Following weight loss, serum ghrelin concentration increased significantly (66.3+/-13.7 vs. 73.7+/-14.8 pg/ml; p=0.002) and TNFalpha concentrations decreased significantly (6.9+/-2.6 vs. 5.2+/-1.5 pg/ml; p=0.002). Ghrelin did not show a correlation with weight or percentage of body fat. There was a positive correlation between the increase in ghrelin and the decrease in body fat percentage during weight loss (p=0.002). Conclusion: The increase in serum ghrelin and the decrease in serum TNFalpha, as observed after weight reduction treatment in obese subjects, may constitute a counter-regulatory mechanism preventing further weight loss.

Clinical implications of obesity with specific focus on cardiovascular disease: a statement for professionals from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism: endorsed by the American College of Cardiology Foundation.

Obesity adversely affects cardiac function, increases the risk factors for coronary heart disease, and is an independent risk factor for cardiovascular disease. The risk of developing coronary heart disease is directly related to the concomitant burden of obesity-related risk factors. Modest weight loss can improve diastolic function and affect the entire cluster of coronary heart disease risk factors simultaneously. This statement from the American Heart Association Council on Nutrition, Physical Activity, and Metabolism reviews the relationship between obesity and the cardiovascular system, evaluates the effect of weight loss on coronary heart disease risk factors and coronary heart disease, and provides practical weight management treatment guidelines for cardiovascular healthcare professionals. The data demonstrate that weight loss and physical activity can prevent and treat obesity-related coronary heart disease risk factors and should be considered a primary therapy for obese patients with cardiovascular disease.

The duodenal switch operation for the treatment of morbid obesity.

OBJECTIVE: To determine the safety and efficacy of the duodenal switch procedure as surgical treatment of morbid obesity. SUMMARY BACKGROUND DATA: The longitudinal gastrectomy and duodenal switch procedure as performed for morbid obesity involves a 75% subtotal greater curvature gastrectomy and long limb suprapapillary Roux-en-Y duodenoenterostomy. This results in a restricted caloric intake and diversion of bile and pancreatic secretions to induce fat malabsorption. Broad acceptance of this procedure has been impeded because of concerns that the malabsorptive component may produce serious nutritional complications. METHODS: Review of data collected prospectively from all patients who underwent duodenal switch as the primary surgical treatment of morbid obesity at a single institution during the 10-year period beginning September 1992. Operative morbidity and mortality, weight loss, volume of food intake, and bowel function were recorded. Sequential measurements of serum albumin, hemoglobin, and calcium levels were obtained to assess metabolic function and nutrient absorption. RESULTS: Duodenal switch was performed as the primary operation in 701 (81%) of a total 863 patients undergoing bariatric surgery during the period of study. The average body mass index (BMI) was 52.8 (range, 34-95). Perioperative mortality was 1.4%, and morbidity (including leaks, wound dehiscence, splenectomy, and postoperative hemorrhage) occurred in 21 patients (2.9%). weight loss averaged 127 pounds at 1 year, 131 at 3 years, and 118 at 5 or more years (% EBWL of 69%, 73%, and 66%, respectively). The mean number of bowel movements was fewer than 3 per day. Patients reported and maintained a mean restriction of 63% of their preoperative intake (approximately 1600 calories), with no specific food intolerance, at 3 or more years follow-up. At 3 years, serum albumin remained at normal levels in 98% of patients, hemoglobin in 52%, and calcium in 71%. No patients reported dumping, and marginal ulcers were not seen. CONCLUSIONS: The longitudinal gastrectomy with duodenal switch is a safe and effective primary procedure for the treatment of morbid obesity. It has the advantage of allowing acceptable alimentation with a minimum of side effects while producing and maintaining significant weight loss. These results are achieved without developing significant dietary restrictions or clinical metabolic or nutritional complications.

Effect of low-calorie diets on plasma retinol-binding protein concentrations in overweight women.

The concentrations of total protein, albumin and retinol-binding protein, a major transport protein for vitamin A, are significantly decreased by protein-calorie malnutrition. weight-loss diets, sometimes involving severe energy deficits over prolonged periods of time, are common in the United States. The effect, if any, of prolonged low calorie weight-loss diets with normal intakes of protein on albumin, total protein and retinol-binding protein concentrations (and potentially on vitamin A metabolism) had not been extensively studied. We measured total protein, albumin, apo + holo retinol-binding protein and holo-free- and holo-transthyretin-bound retinol-binding protein concentrations during the course of a nutritionally adequate weight-loss diet (50% calorie restriction). We found that this type of dieting did not affect total protein, albumin or apo + holo, holo-free or holo-transthretin-bound retinol-binding protein concentrations significantly. This suggests that protein intake is more critical than caloric intake for retinol-binding protein status.

Weight Loss and weight maintenance, ambulatory blood pressure and cardiac autonomic tone in obese persons with the metabolic syndrome.

BACKGROUND: Cardiac autonomic function may play a role in obesity-associated hypertension. Most studies on the effects of weight loss on blood pressure and autonomic function do not distinguish between acute or continuing weight loss and steady-state weight maintenance after weight loss. OBJECTIVES: We sought to clarify the changes in ambulatory blood pressure, heart rate and heart rate variability as assessed by spectral analysis during rapid weight loss and extended weight maintenance. PARTICIPANTS: Abdominally obese (body mass index 35.2 +/- 2.1 kg/m2, waist 114.3 +/- 9.0 cm) men and women (n = 41) with the metabolic syndrome. METHODS AND RESULTS: The 34 men and women completing the 1-year weight maintenance period lost 14.6 +/- 3.5 kg during the 9-week very-low-calorie diet and maintained a 12.5 +/- 7.5 kg weight loss to the end of the trial. Ambulatory 24-h blood pressure decreased dramatically during the diet (-9.0 +/- 8.0/-4.6 +/- 4.9 mmHg), but had risen to near baseline levels by the end of weight maintenance (-2.2 +/- 8.2 /-1.2 +/- 6.1 mmHg). Night-time heart rate decreased (-5.5 +/- 9.6 beats/min, P = 0.012), and heart rate variability total and low-frequency power measured during 5 min of controlled breathing increased by 46-56% (P = 0.003-0.09) during rapid weight loss. These changes gradually attenuated during weight maintenance, and only the change in night-time heart rate was still of borderline significance after 1 year of weight maintenance (-3.6 +/- 8.6 beats/min, P = 0.063). Heart rate variability high-frequency power tended to increase during weight loss and weight maintenance. CONCLUSION: Despite successful weight maintenance, the decrease in ambulatory blood pressure after rapid weight loss was largely transient. The increase in parasympathetic tone was more sustained, but also gradually attenuated during 1 year of weight maintenance.

A pilot study on safety and pharmacokinetics of infliximab for the cancer anorexia/weight loss syndrome in non-small-cell lung cancer patients.

BACKGROUND: weight loss predicts a poor prognosis for patients with non-small-cell lung cancer. Tumor necrosis factor alpha (TNFalpha) is a mediator of this weight loss, yet no studies have tested infliximab, an IgG monoclonal antibody that blocks the binding of TNFalpha to its p55 and p75 receptors, for this indication. The safety and pharmacokinetics of infliximab in combination with docetaxel, a commonly used chemotherapy agent for non-small-cell lung cancer, were explored in this pilot study. METHODS/RESULTS: Four patients with metastatic non-small-cell lung cancer were treated initially with infliximab 5 mg/kg per day intravenously once a week on weeks 1, 3 and 5, and docetaxel 36 mg/m2 per day intravenously once a week on weeks 1, 2, 3, 4, 5 and 6 of an 8-week treatment cycle. Therapy was well tolerated with no grade 4 or 5 adverse events. Maximal serum concentrations of infliximab at 1, 3 and 5 weeks were (mean+/-SD) 108+/-11, 135+/-19, and 139+/-6 microg/ml, respectively, and appeared similar to historical concentrations from non-cancer patients not receiving concomitant chemotherapy (144+/-68 microg/ml). One patient manifested weight stability. One patient manifested a partial tumor response, one stable disease, and two disease progression. Median survival within the cohort was 203 days (range 111 to 324 days). CONCLUSIONS: The above combination appears safe, and docetaxel does not appear to increase serum concentrations of infliximab. A larger study testing the role of this combination for weight loss in non-small-cell lung cancer patients is ongoing and utilizes the doses described above.