Gastric pacing for morbid obesity: plasma levels of gastrointestinal peptides and leptin.

OBJECTIVE: A gastric pacemaker has been developed to treat morbid obesity. Patients experience increased satiety, the ability to reduce food intake, and a resultant weight loss. However, the mechanism behind the changed eating behavior in paced patients is still under investigation. RESEARCH METHODS AND PROCEDURES: This study was performed on 11 morbidly obese patients (mean BMI, 46.0 kg/m2) treated with gastric pacing. The peripheral blood levels of satiety signals of cholecystokinin (CCK), somatostatin, glucagon-like peptide-1 (GLP-1), and leptin were studied 1 month before gastric pacer implantation, 1 month after implantation, and 6 months after activation of electrical stimulation. Blood samples were drawn 12 hours after fasting and in response to a hypocaloric meal (270 kcal). Patients were followed monthly for vital signs and weight level. RESULTS: Gastric pacing resulted in a significant weight loss of a mean of 10.4 kg (4.4 BMI units). No negative side effects or complications were observed during the treatment. After activation of the pacemaker, meal-related response of CCK and somatostatin and basal levels of GLP-1 and leptin were significantly reduced (p < 0.05) compared with the tests before gastric pacing. The weight loss correlated significantly with a decrease of leptin levels (R = 0.79, p < 0.01). DISCUSSION: Gastric pacing is a novel and promising therapy for morbid obesity. Activation of the gastric pacer was associated with a decrease in plasma levels of CCK, somatostatin, GLP-1, and leptin. More studies are necessary to elucidate the correlations between satiety, weight loss, and digestive neuro-hormone changes.

Characteristics of bariatric surgery in an integrated VA Health Care System: follow-up and outcomes.

BACKGROUND: Since the 1991 NIH consensus conference, obesity surgery has been increasingly accepted as a form of therapy for morbid obesity. Approximately 40% of Veteran patients are obese and would potentially benefit from the operations. METHODS: Records were reviewed for all obesity operations performed at the Veterans Administration Greater Los Angeles Health Care System between January 1997 and April 2002. Morbidity, mortality, weight loss, and extent of follow-up were the outcomes measures assessed. RESULTS: Forty-six [11 Female (24%), 35 Male (76%)] patients underwent Roux-Y gastric bypass during the 63-month period we reviewed. There was one death from pulmonary hypertension unexpectedly encountered in the operating room. There was a single major complication: an anastomotic leak successfully treated with intravenous antibiotics. The Computerized Patient Record System contained extensive weight loss information, with dozens of weight measurements for these patients before and after surgery. weight loss was sustained in all but 2 patients during the follow-up period. The only patients lost to follow-up were those referred from medical centers outside the boundaries of our integrated health care system. CONCLUSION: (1) The VA population has the opposite male/female ratio of populations reported in most weight loss studies. Because the health risks attributable to obesity are greater in males, the VA represents an important population to study that may benefit significantly from weight loss surgery. (2) Extensive clinical information available in the computerized medical record combined with frequent accession of health care resources by our patients resulted in a database rich in follow-up data for a population where long-term outcomes are traditionally difficult to obtain. (3) There was very low surgical morbidity and mortality in a high-risk population. This contrasts with the results of most volume-outcome studies and occurred in a low-volume hospital by a high-volume surgical and medical team. (4) Distinct patterns of weight loss were observed.

Weight Loss increases 11beta-hydroxysteroid dehydrogenase type 1 expression in human adipose tissue.

The global epidemic of obesity has heightened the need to understand the mechanisms that underpin its pathogenesis. Clinical observations in patients with Cushing's syndrome have highlighted the link between cortisol and central obesity. However, although circulating cortisol levels are normal or reduced in obesity, local regeneration of cortisol, from inactive cortisone, by 11beta-hydroxysteroid dehydrogenase type 1 (11betaHSD1) has been postulated as a pathogenic mechanism. Although levels of expression of 11betaHSD1 in adipose tissue in human obesity are debated in the literature, global inhibition of 11betaHSD1 improves insulin sensitivity. We have determined the effects of significant weight loss on cortisol metabolism and adipose tissue 11betaHSD1 expression after 10-wk ingestion of a very low calorie diet in 12 obese patients (six men and six women; body mass index, 35.9 +/- 0.9 kg/m2; mean +/- SE). All patients achieved significant weight loss (14.1 +/- 1.3% of initial body weight). Total fat mass fell from 41.8 +/- 1.9 to 32.0 +/- 1.7 kg (P < 0.0001). In addition, fat-free mass decreased (64.4 +/- 3.4 to 58.9 +/- 2.9 kg; P < 0.0001) and systolic blood pressure and total cholesterol also fell [systolic blood pressure, 135 +/- 5 to 121 +/- 5 mm Hg (P < 0.01); total cholesterol, 5.4 +/- 0.2 to 4.8 +/- 0.2 mmol/liter (P < 0.05)]. The serum cortisol/cortisone ratio increased after weight loss (P < 0.01). 11betaHSD1 mRNA expression in isolated adipocytes increased 3.4-fold (P < 0.05). Decreased 11betaHSD1 activity and expression in obesity may act as a compensatory mechanism to enhance insulin sensitivity through a reduction in tissue-specific cortisol concentrations. Inhibition of 11betaHSD1 may therefore be a novel, therapeutic strategy for insulin sensitization.

Weight reduction, fertility and contraception.

PIP: The significance of weight and body composition with regard to the fertile menstrual cycle has excited much interest. There is global imbalance of resources and problems of widespread chronic malnutrition in many 3rd world countries. This emphasizes the great importance of the possible effects of diet, body weight, and body composition on fecundity (ability to reproduce), fertility (reproductive performance), and pregnancy outcome. Frisch and Revelle suggested that a critical body weight is required for a girl to progress through puberty, menstruate, and finally develop ovulatory cycles. They postulated a direct relationship between weight and menarche and suggested that before menarche will occur at least 17% of the body weight needs to be made up of fat. The Frisch hypothesis is not universally accepted, and it seems highly unlikely that a single age unrelated body weight is always the trigger for menarche. Many of the data used in Frische's original studies were derived rather than directly observed. It seems likely that both body weight and composition are important and that the peripheral conversion of androgens to estrogens in fat plays a role in pubertal development, but the actual signal whcih triggers the hypothalamic events leading eventually through puberty to menstruation and ovulation remains unkown. Acute malnutrition, as seen during famine, is assoicated with a dramatic decrease in fertility. It is usually secondary to amenorrhea and annovulation. In developing countries weight related amenorrhea and delayed menarche are largely the result of nutritonal deprivation and the demands of lactation on women of boderline body weight, but a different pattern is seen in Western countries. The outstanding example of weight reduction resulting in infertility is seen in patients with anorexia nervosa. These women have extreme self imposed weight loss, a distorted perception of their body image, and disturbance in their attitude towards their feelings of hunger and satiety. Self imposed weight loss is the most common single cause of secondary amenorrhea seen in the Western world. While diagnosis of the gross anoretic is perhaps rarely missed, the more subtle degrees of weight loss and their effect on the menstrual cycle are often overlooked. Simple weight loss of more than 30% of body fat will cause menstrual dysfunction and ultimately amenorrhea. There is no clearly defined threshold between infertility and normal reproductive health, and there will always be women who become pregnant despite suboptimal weight. Patients with simple weight loss may be sufficiently motivated to restore their weight to normal levels, with resultant spontaneous resumption of ovulation.

Analysis of weight loss outcomes using VLCD in black and white overweight and obese women with and without metabolic syndrome.

OBJECTIVE:: To evaluate the efficacy of very low calorie diet (VLCD) in black and white obese women. Changes in weight, metabolic profile, and body composition are assessed. METHOD:: Patients are enrolled in a self-paid, university-based, outpatient weight loss program. All are prescribed VLCD (500-800 Cal/day), an exercise regimen, and group behavioral counseling. Black and white patients are matched for age, weight, body mass index, and by metabolic syndrome (MS) status. RESULTS:: A total of 304 black and white women (152 in each group) were included the analysis. Approximately 40% of patients had MS (white women: 39.5%; black women: 41.2%). Mean baseline weights were similar. After 12 weeks, weight reduction of 9.97% was seen in white women and 9.02% drop was seen in black women (both P<0.0001). However, the degree of weight change was not different between the groups (P=0.244). Marked improvements in fasting glucose, total cholesterol, LDL, triglyceride, and blood pressures (BP) were observed (all P<0.01); however, no difference between cohorts were seen. Patients with MS had higher baseline weight, BP, glucose and triglyceride levels when compared to patients without MS (all P<0.01). Significant reductions in % body fat were seen in white and black patients, independent of MS status. CONCLUSION:: Obese patients, independent of race, were able to achieve significant weight loss when enrolled in a structured outpatient program. weight loss significantly correlated with all aspects of MS. Our results suggest that differences seen in past studies may be influenced by socioeconomic and behavioral factors rather than differences in physiological response to dieting.International Journal of obesity (2005) 29, 436-442. doi:10.1038/sj.ijo.0802864 Published online 15 February 2005.

Relationship between cholesteryl ester transfer protein and atherogenic lipoprotein profile in morbidly obese women.

OBJECTIVE: obesity is associated with increased morbidity and mortality from atherosclerotic disease. Lipid abnormalities contribute to the increased relative risk in obese subjects. Cholesteryl ester transfer protein (CETP) mass is increased in these patients and might mediate the atherogenic lipoprotein pattern observed in obesity. METHODS AND RESULTS: Twenty-one morbidly obese, middle-aged, female subjects participated in this prospective study. Subjects were examined before and 1 year after surgical treatment. Fat mass was determined by body impedance analysis; CETP mass, by ELISA; CETP activity, by exogenous substrate assay; and LDL particle diameter, by gradient gel electrophoresis. Mean weight loss after 1 year was 28.7 kg; mean fat mass loss was 22.6 kg. Mean CETP mass decreased from 1.81 to 1.32 microg/mL (P=0.008); mean CETP activity decreased from 244 to 184 nmol x mL(-1) x h(-1) (P=0.004); and in parallel, the mean diameter of LDL particles increased (256.8 to 258.4 A, P=0.04). CONCLUSIONS: We conclude that weight loss is associated with a pronounced decrease in CETP mass and activity and a consistent increase in LDL particle diameter. After 1 year of this prospective study in morbidly obese subjects undergoing weight loss by surgical treatment, it has been determined that some features of the atherogenic lipoprotein profile can be reversed.

Laparoscopic adjustable gastric banding: a prospective comparison of two commonly used bands.

BACKGROUND: Surgery for morbid obesity has increased since the introduction of the adjustable gastric bands (AGB), which can be placed laparoscopically. There are two AGB in wide use: the Swedish Adjustable Gastric Band (SAGB, Obtech), and the Lap-Band (Inamed Health). We present the results of a comparative study between the 2 AGB. METHODS: 101 patients with a minimal follow-up of 6 months were included. 49 patients received a Swedish Adjustable Gastric Band (SAGB), and the remaining 52 received the Lap-Band (LB). Postoperative weight loss and complications were compared at set intervals of 3 months in the first postoperative year, and 6 months in the years following. RESULTS: Mean follow-up was 9.9 months for the SAGB and 7.2 months for the LB. All but 5 procedures were performed laparoscopically. Mean operating-time was 102 minutes for the SAGB and 86 minutes for the LB. No significant difference in complications was noted between the 2 AGB. 1 SAGB was repositioned and 2 were removed, compared to 2 repositions and 2 removals of the LB. We excluded 5 patients with leakage of a SAGB due to technical failure. Mean preoperative weight kg/BMI of the SAGB patients was 133/45.3; in the LB patients 138/46.4. Mean weight loss at 6 months was 28 kg with the SAGB and 30 kg with the LB, and mean weight loss at 1 year 36 kg and 38 kg respectively. After 2 years, weight loss was 46 kg and 42 kg respectively. CONCLUSION: There was no significant difference in postoperative weight loss and complications between the SAGB and the LB.

National institute for clinical excellence (NICE) guidance for anti-obesity medication: is it being followed?

Background: anti-obesity medication is being used increasingly by some general practitioners (GP) for obesity management (Lawrence, 2002). The aim of this audit was to identify whether the anti-obesity medication prescribed by GPs was in accordance with the NICE guidance (NICE, 2001a,b). Method: The medical notes and electronic patient records of 154 patients prescribed either Orlistat ( Xenical ) or Sibutramine ( Meridia ) between September 2002 and April 2003, were examined. Information about patients' weight, previous weight loss, previous dietary and physical activity advice, behaviour modification, time on medication, weight loss achieved and blood pressure were recorded and comparisons made with the NICE guidance. Results: NICE guidanceOrlistat ( Xenical ) (n = 103)Sibutramine ( Meridia ) (n = 51)Only for individuals who have lost at least 2.5 kg in the preceding month20% achieved this weight loss56% attempted to lose weightBMI calculated66% calculated 71% calculatedDietary advice given 80% received advice49% received advicePhysical activity discussed36% physical activity discussed26% physical activity discussedBehavioural modification10% documented0% documentedweight loss after starting drug 4 weeksNone required by NICE22% lost at least 2 kg weight 3 months17% patients lost >5% of initial body weight16% patients lost >5% of initial body weight 6 months3% lost >10% of initial body weight8% lost >10% initial body weightBlood pressure /pulse rate monitoringNone required74% BP initially checked; 20% BP >145/90 mm Hg; 9% pulse rate checkedNo more than 12 months on medication8% patients prescribed for >12 months4% patients prescribed for >12 monthsBMI, body mass index; BP, blood pressure. Conclusion: The results show that the majority of patients prescribed with Orlistat ( Xenical ) and Sibutramine ( Meridia ) are not treated in accordance with the NICE guidance. The recommendation is that GPs are given further training about the optimum treatment associated with the prescription of anti-obesity medication. References: Lawrence, G. (2002) Prescribing Advisor. Personal communication. NICE (2001a) NHS National Institute for Clinical ExcellenceGuidance. Technology Appraisal Guidance No 22. Guidance on the use of Orlistat ( Xenical ) for the treatment of obesity. NICE (2001b) NHS National Institute for Clinical Excellence Guidance. Technology Appraisal Guidance No 31. Guidance on the use of Sibutramine ( Meridia ) for the treatment of obesity.