Extreme Obesity Research Articles

1356-P: Comparison of Serum Adipokines and Anthropometric Measures in Children with Type 1 Diabetes (T1D) and Obesity

Obesity or overweight occur in 40% of U.S. youth with T1D. While BMI is used to define obesity, it may not accurately reflect excess adiposity, which correlates better with metabolic dysfunction. However, it is difficult to measure adiposity without a research setting. In contrast, adipokines, which are produced by the adipose tissue, can be measured in serum. We aimed to analyze, in youth with T1D and obesity, the relationships of serum adipokines with measures of adiposity and cardiovascular risk factors. We studied participants in the T1D Exchange Metformin Study with a serum sample obtained before randomization (n=61, mean age=8.0 years [SD=3.0], 27.9% male, 82.0% non-Hispanic white, mean BMI percentile=99.0 ([SD=1.0], mean BMI Z-score=2.7 [SD=0.78], mean % of the 95th BMI percentile (%95th BMI pctle)=134.6 [SD=20.0]). We measured serum levels of adipokines and inflammatory markers. We studied the correlations between DEXA scan-derived measures of adiposity (e.g., % body fat) with adipokines (e.g., leptin, adiponectin) or anthropometric measures (e.g., % 95th BMI pctle [recommended measure for extreme obesity], BMI-Z score). DEXA % body fat was significantly correlated with % 95th BMI pctle (r=0.494, p<0.0001) or leptin (r=0.467, p=0.0002), without statistical difference between these two correlations (p = 0.857). The correlation between % body fat and BMI Z-score was weaker (r=0.29, p=0.0270). Higher adiponectin was correlated with cardiovascular protective factors, such as lower systolic blood pressure (p=0.039) and higher HDL cholesterol (p=0.001), while neither % 95th BMI pctle nor BMI Z-score were. Children with high adiponectin (>26.5 mg/L, distribution mean) were less likely to have high CRP >6 mg/L (1.6%) vs. children with low adiponectin (23.0%, p<0.05). Serum adipokines levels could be used as more convenient markers of adiposity than BMI measures, and potentially become therapeutic targets to improve clinical outcomes in children with T1D and obesity. Disclosure M.J. Redondo: None. X. Gu: None. S. Sisley: Advisory Panel; Self; Rhythm Pharmaceuticals, Inc. M. Tosur: None. A.F. Siller: None. M. Bondy: None. S. Devaraj: None.

Congenital Leptin Deficiency and Leptin Gene Missense Mutation Found in Two Colombian Sisters with Severe Obesity.

Background: Congenital leptin deficiency is a recessive genetic disorder associated with severe early-onset obesity. It is caused by mutations in the leptin (LEP) gene, which encodes the protein product leptin. These mutations may cause nonsense-mediated mRNA decay, defective secretion or the phenomenon of biologically inactive leptin, but typically lead to an absence of circulating leptin, resulting in a rare type of monogenic extreme obesity with intense hyperphagia, and serious metabolic abnormalities. Methods: We present two severely obese sisters from Colombia, members of the same lineal consanguinity. Their serum leptin was measured by MicroELISA. DNA sequencing was performed on MiSeq equipment (Illumina) of a next-generation sequencing (NGS) panel involving genes related to severe obesity, including LEP. Results: Direct sequencing of the coding region of LEP gene in the sisters revealed a novel homozygous missense mutation in exon 3 [NM_002303.3], C350G>T [p.C117F]. Detailed information and clinical measurements of these sisters were also collected. Their serum leptin levels were undetectable despite their markedly elevated fat mass. Conclusions: The mutation of LEP, absence of detectable leptin, and the severe obesity found in these sisters provide the first evidence of monogenic leptin deficiency reported in the continents of North and South America.

Tu1570 – Diagnostic Performance of Noninvasive Laboratory-Based Liver Fibrosis Scoring Tests in Nonalcoholic Fatty Liver Disease Patients with Extreme Obesity

Tu1570 – Diagnostic Performance of Noninvasive Laboratory-Based Liver Fibrosis Scoring Tests in Nonalcoholic Fatty Liver Disease Patients with Extreme Obesity

Melanocortin-4 Receptor and Lipocalin 2 Gene Variants in Spanish Children with Abdominal Obesity: Effects on BMI-SDS After a Lifestyle Intervention.

Mutations leading to a reduced function of the melanocortin-4 receptor (MC4R) exert a major gene effect on extreme obesity. Recently it was shown that the bone derived hormone lipocalin 2 (LCN2) binds to the MC4R and activates a MC4R dependent anorexigenic pathway. We identified mutations in both genes and screened the effects of MC4R and LCN2 mutations on eating behavior and weight change after a lifestyle intervention. One hundred and twelve children (11.24 ± 2.6 years, BMI-SDS 2.91 ± 1.07) with abdominal obesity participated in a lifestyle intervention. MC4R and LCN2 coding regions were screened by Sanger sequencing. Eating behavior was assessed at baseline with the Children Eating Behavior Questionnaire (CEBQ). We detected three previously described non-synonymous MC4R variants (Glu42Lys, Thr150Ile, and Arg305Gln) and one non-synonymous polymorphism (Ile251Leu). Regarding LCN2, one known non-synonymous variant (Thr124Met) was detected. Eating behavior was described in carriers of the MC4R and LCN2 mutation and in non-carriers. MC4R and LCN2 mutations were detected in 2.42% and 0.84%, respectively, of Spanish children with abdominal obesity. A number of subjects with functional mutation variants in MC4R and LCN2 were able to achieve a reduction in BMI-SDS after a lifestyle intervention.

Association of body mass index with cardiac resynchronization therapy intention and left ventricular lead implantation failure: insights from the NCDR implantable cardioverter-defibrillator registry.

Cardiac resynchronization therapy with defibrillator (CRT-D) implantation involves left ventricular (LV) lead placement for biventricular pacing and is more complex than implantable cardioverter-defibrillator (ICD)-only implantation. Differences in the prescription of CRT-D versus ICD may result from clinician biases based on patient body habitus, and body habitus may be associated with LV lead implantation failure. We sought to evaluate whether patient body mass index (BMI) was associated with planned use and implantation failure of CRT-D therapy. We studied all patients enrolled in the National Cardiovascular Data Registry ICD Registry who met standard CRT-D criteria and received either an ICD or CRT-D between 2010 and 2012. BMI was categorized based on World Health Organization classification. Using hierarchical logistic regression, two multivariate models adjusted for patient demographic and clinical characteristics were fit based on the following outcome variables: (1) planned implantation with CRT-D versus ICD and (2) failed versus successful LV lead placement. Of 337,547 patients, 41,872 met inclusion criteria for the first analysis and 35,186 met criteria for the second analysis. After multivariable adjustment, patients with extreme (BMI > 40kg/m2) obesity were less likely to receive guideline-concordant CRT-D compared with patients with normal weight (adjusted odds ratio (AOR), 0.86; 95% confidence interval (CI), 0.75-0.99; p = 0.04). Extreme (BMI > 40kg/m2) obesity was associated with higher odds of failed LV lead placement (AOR, 1.35; 95% CI, 1.07-1.72, p = 0.01). Compared with normal weight patients, extremely obese (BMI > 40kg/m2) CRT-D eligible patients were less likely to be prescribed CRT-D and were at higher odds for failed LV lead placement.

MON-103 Chromosome 15q13.3 Microdeletion And MAGEL2 Gene Mutation In A Pediatric Patient With Extreme Obesity And Tall Stature: A Case Report

Background: Clinical practice guidelines call for consideration of genetic syndromes in evaluation of pediatric patients with extreme early onset obesity with clinical features of genetic obesity syndromes or strong family history of obesity. We describe a case of two genetic variations discovered in an obese pediatric patient. Clinical Case: 10-year-old female of African American descent who presented for evaluation of early onset extreme obesity. Patient noted to have history of hyperphagia with behavioral problems and concern for abnormal coordination. Family history was limited by fact that patient was adopted in infancy without sustained contact with biological family. On physical exam, her height was in the 98th percentile, weight >99th percentile, and BMI 194% of the 95th percentile (Z+3.01). She was noted to have acanthosis nigricans without dysmorphic features. She underwent laboratory evaluation notable for HbA1c in pre-diabetes range at 5.8% (<5.7%) and dyslipidemia with triglycerides elevated at 148mg/dL (35-110mg/dL). Given her early onset of extreme obesity, she underwent genetic testing for obesity syndromes. She was found to have a heterozygous variant of unknown significance of MAGEL2 gene (c. 2572A>T). Although this particular variant has not yet been reported in the literature, a single pathogenic variant in the paternally inherited MAGEL2 gene causes disease. Pathogenic variants in the MAGEL2 gene have been associated with Schaaf-Yang or Prader-Willi-like syndrome. Schaaf-Yang syndrome has clinical overlap with Prader-Willi syndrome with a wide phenotypic spectrum and can include short stature, hypogonadism, intellectual disability, hypotonia, feeding difficulties. Our patient’s clinical phenotype is unique as she has no reported history of hypotonia or feeding difficulties, no intellectual disability, tall stature, and no dysmorphic features on exam. She was noted to have a 1.5MB microdeletion on chromosome 15q13.3 on chromosomal microarray. 15q13.3 microdeletion has been associated with a highly variable phenotype which has been reported to include obesity, intellectual disability, epilepsy, and dysmorphism. Finally, she was found to have a heterozygous variant of unknown significance of TTC8 gene. Homozygous mutations in the TTC8 gene are found in Bardet-Biedl syndrome. Conclusion: This case describes a pediatric patient with extreme obesity found to have both a chromosome 15q13.3 microdeletion and variant in MAGEL2 gene with a unique phenotype. Genetic obesity syndromes should be considered in patients who present with early onset extreme obesity, particularly in the setting of a strong family history, physical exam findings, or neurodevelopmental abnormalities. Reference: Fountain MD, Aten E, Cho MT, et al. The phenotypic spectrum of Schaaf-Yang syndrome: 18 new affected individuals from 14 families. Genet Med. 2016;19(1):45-52.

SUN-312 Insulinoma in Extreme Obese Women Treated with Minimally Invasive Procedure

Introduction: Insulinoma is the most common functioning neuroendocrine tumor of the pancreas. Although rare, is the main cause of endogenous hyperinsulinemic hypoglycemia.The most common clinical manifestations are neurovegetative and neuroglycopenic symptoms secondary to hypoglycemia. Progressive weight gain is also an important clinical feature, due to the anabolic action of insulin and the need to feed periodically in an attempt to reduce hypoglycemia. The presence of neuroglycopenic symptoms, which sometimes may be confounded with psychiatric symptoms, may lead to delay or misdiagnosis. In our country, there are few publications about the early diagnosis and treatment of this neoplasm. Surgery still seems to be the best treatment option but, in selected case in which there are high surgical risk, the minimally invasive procedures, such as endoscopic ultrasound (EUS) guided ethanol ablation can be a good choice of treatment. We report a case of an insulinoma in a patient with extreme obesity,that was submitted to a less invasive treatment due to surgical risks. Case report: A 22-years old woman, presented progressive weight gain of 65 kg in 1 year (163kg, BMI: 59.6kg/m2). After using intragastric balloon for 6 months, she developed hypoglycemic symptoms. Prolonged fasting test (PFT), was performed and showed after 40 minutes plasma glucose: 44mg / dl (< or = 55mg/dl); C peptide: 3.2 ng / ml ( > or = 0,6ng/ml) , insulin: 47 mU / ml (> or = 3mU/ ml), anti-insulin antibody negative. EUS showed a homogeneous hypoechoic lesion in the cephalicregion of uncinate pancreas process and fine needle puncture showed cells with atypia of indeterminate significance. Magnetic Resonance Image of the abdomen showed a 1.9 cm hypervascular nodule in the cephalic portion of the pancreas, very close to cava vein. The main hypothesis was an insulinoma. Due to the patient's severe obesity and the tumor localization, a multidisciplinary team decided to do a minimally invasive procedure. EUS guided ethanol ablation with absolute ethanol and a fine needle aspiration were performed with general anesthesia without complications. On the following days of the procedure, surveillance for pancreatitis was performed. Anatomopathological showed immunohistochemistry positive for insulin and ki67% <1%. Laboratory exams of the 30th postoperative day: fasting glycemia: 89mg / dl, peptide C: 5.18ng / dl, insulin: 45.51 Uui / ml. After 6 months of the procedure, the patient remains without hypoglycemia and lost 10 kg. Conclusion: Insulinoma as described above is a rare condition, but should always be part of the differential diagnosis of obesity and hypoglycemia. Careful analysis and multidisciplinary decision-making for best behavior are key. Minimally invasive treatment is promising, with reduced surgical risks, shorter hospital stay and increased quality of life after the procedure. As seen in our case.

SAT-088 A Novel Mutation In The Leptin Receptor Associated With Hypertriglyceridemia, Lipodystrophy And Non-alcoholic Fatty Liver

Background Leptin is an adipocyte-derived peptide hormone that acts in the hypothalamus to stimulate pathways that inhibit feeding and promote energy expenditure. Mutations in the gene encoding leptin or its receptor (LR) are rare and typically lead to extreme obesity. We describe a patient who presented with severe hypertriglyceridemia, non-alcoholic fatty liver (NAFL) and a clinical phenotype of partial lipodystrophy, who upon whole exome sequencing harbored a novel homozygous mutation in the Ig domain of the LR. Clinical case A 45-year-old woman with a past medical history of hypertension presented with abdominal pain and was diagnosed with hypertriglyceridemic pancreatitis. She denied alcohol or recreational drug use. Her BMI was 26 kg/m2, BP 167/109 mmHg, HR 106, and she had prominent central obesity with a paucity of adipose tissue on the extremities and gluteal region. Triglycerides (Tg) were 2,076 mg/dl, lipase 366 u/l, A1c of 6.0%, ALT 70 u/l, AST 27 u/l. Proteinuria was present, but serum and urine protein electrophoreses were normal. Abdominal CT was suggestive of liver steatosis and pancreatitis. Given her lipodystrophic features, elevated Tg, and fatty liver, we performed whole exome sequencing which revealed a novel homozygous mutation in the leptin receptor (p.S389N) that is predicted to be deleterious. Compared to other reported cases with LR mutations, our patient did not report excessive appetite and denied frequent childhood infections. Further workup showed low fasting leptin, 4.2 ng/ml (8.0-38.9 ng/ml for women with BMI 25-30s), fasting glucose of 114mg/dl and insulin of 21 ulU/ml. IGF-I was 141 ng/ml, FSH 4.6 mIU/mL, LH 3.8 U/ml, estradiol 60 pg/Ml, free testosterone 2.1 pg/ml, TSH 2.67 mlu/l, fT4 1.3ng/dl. Her family history was significant for pancreatitis in mother and maternal grandfather, nonalcoholic steatohepatitis (NASH) in her 14-year-old son and liver problems in her sister, but so far, no other members have been tested for the mutation. She was treated with fenofibrate for hypertriglyceridemia with subsequent decrease of Tg levels to 503 mg/dl. Conclusion Our case is unique in that our patient’s clinical features are less severe in comparison to those reported with other LR mutations. Given that this is a novel homozygous mutation in the Ig region of the LR, and it is predicted to be deleterious, it is still unclear how it relates to her lipodystrophic features and overall clinical presentation. This case highlights the gap in knowledge and the diversity in clinical presentations that may accompany LR mutations and would have been missed if it were not for whole exome sequencing. At the same time, this case raises questions regarding the role of the leptin in hypertriglyceridemia, NASH and NAFL, and to what degree emerging therapies for leptin deficiency can prevent the progression of NASH and NAFL disease, since currently there are no clear therapeutic guidelines.

SAT-115 Body Image Dissatisfaction and Distortion in Bariatric Patients

Background: Obesity prevalence has been increasing progressively worldwide. Bariatric surgery is considered one of the most important treatment modalities for class III obesity. Obese individuals may present distortion of body image perception. : To assess body image perception in bariatric patients, 65 subjects were evaluated using the Stunkard Figure Rating Scale (SFRS). SFRS figures are rated from 1 to 9, ranging from extreme thinness (= 1) to extreme obesity (= 9). Patients selected the figure they thought represented how they looked and indicated the one that corresponded to their ideal body image. Forty-two patients were evaluated before gastroplasty and 23 in the post-operatory phase (10.8 ± 9.9 months after surgery). Data from patients in pre- vs. post-operatory groups were compared. Post-bariatric patients were older (44.7 ± 12.1 vs. 36.1 ± 11.3 years; p = 0.0065) and there was a predominance of female patients in both pre- and post-bariatric groups (88.1% and 100%, respectively; p = 0.1521). Weight was higher in pre-bariatric subjects (118.0 ± 17.8 vs. 83.0 ± 16.1 kg; p < 0.0001) and, after surgery, patients’ excess weight loss corresponded to 63.4 ± 27.2%. As expected, BMI was lower in the post-bariatric group (31.84 ± 6.53 vs. 43.88 ± 9.20 kg/m²; p < 0.0001). The SFRS evidenced that pre-bariatric patients represented themselves with a mean value of 7.9 ± 0.6, which was significantly higher than the representation of post-bariatric patients (6.0 ± 1.8; p < 0.0001). There was no difference regarding the silhouette that represented their own ideal, when the two groups were compared (pre-bariatric = 3.6 ± 1.1, post-bariatric = 3.4 ± 1.2; p = 0.4400). Pre-bariatric patients revealed higher dissatisfaction with their body image (4.4 ± 1.1) than post-bariatric subjects (2.6 ± 1.7; p < 0.0001). However, body image distortion was higher in the post-bariatric patients (1.4 ± 1.0 vs. 0.8 ± 0.6; p = 0.0038), particularly due to image overestimation, which was present in 21.74% of this group and was absent in patients interviewed before surgery. Body image dissatisfaction was correlated with age (r = -0.2486; p = 0.0495), weight (r = 0.3726; p = 0.0022), and BMI (r = 0.3521; p = 0.0040), while image distortion was higher in females (r = 0.2525; p = 0.0424). We concluded that image dissatisfaction is highly prevalent in bariatric patients and persists after surgery. Self-perception of corporal and psychological modifications that take place after surgery could explain the higher prevalence of body image distortion in the post-operatory.

Successful peritoneal dialysis for the end-stage kidney disease associated with Prader\u2013Willi syndrome: a case report

Prader–Willi Syndrome (PWS) is characterized by hyperphagia, severe obesity, and mental retardation from early childhood and occurs 1/10,000 to 1/15,000 live births in Japan. There is high prevalence of diabetes mellitus because of hyperphagia. The patient may sometimes face the necessity of renal replacement therapy (RRT) because of end-stage kidney disease (ESKD) caused by diabetes-associated kidney disease (DKD). Since mental retardation and extreme obesity usually prevent to introduce peritoneal dialysis (PD), hemodialysis (HD) has been the first choice of RRT. In this report, we experienced one case of patient with PWS suffering from ESKD due to DKD who started PD as an initial RRT and succeeded to continue for total of 40 months. The patient was 37-year-old man at the time of initiation of dialysis. PD was chosen for RRT because we suspected that he might have more technical difficulties for continuing HD. After several episodes of peritonitis, he successfully continues PD without peritonitis for next 27 months until the present time with good support by his family member. To our best knowledge, this is the first reported case of ESKD associated with PWS who was successfully treated with PD for long period.

Outcomes From a Sequential Multiple Assignment Randomized Trial of Weight Loss Strategies for African American Adolescents With Obesity.

Minority adolescents are at highest risk for obesity and extreme obesity; yet, there are few clinical trials targeting African American adolescents with obesity. The purpose of the study was to develop an adaptive family-based behavioral obesity treatment for African American adolescents using a sequential multiple assignment randomized trial (SMART) design. Fit Families was a SMART where 181 African American adolescents (67% female) aged 12-17 were first randomized to office-based versus home-based behavioral skills treatment delivered from a Motivational Interviewing foundation. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based behavioral skills treatment or contingency management with voucher-based reinforcement for adolescent weight loss and for caregiver adherence to the program. All interventions were delivered by community health workers. The primary outcome was treatment retention and percent overweight. All adolescents reduced percent overweight by -3.20%; there were no significant differences in percent overweight based on treatment sequence. Adolescents receiving home-based delivery in Phase 1 and contingency management in Phase 2 completed significantly more sessions than those receiving office-based treatment and continued skills without CM (M = 8.03, SD = 3.24 and M = 6.62, SD = 2.95, respectively). The effect of contingency management was strongest among older and those with lower baseline confidence. Younger adolescents experienced greater weight reductions when receiving continued skills (-4.90% compared with -.02%). Behavioral skills training can be successfully delivered to African American adolescents with obesity and their caregivers by community health workers when using a home-based service model with incentives. More potent interventions are needed to increase reductions in percent overweight and may need to be developmentally tailored for younger and older adolescents.

93 The BMI Paradox in Burn Patients

Despite the fact that obesity is a known risk factor for comorbidities and complications, there is evidence suggesting a survival advantage for patients classified by body mass index (BMI) as overweight or obese. Investigated in various clinical areas, this “BMI paradox” has yet to be explored in the burn patient population. We sought to clarify whether this paradigm exists in burn patients. Data collected on 519 adult patients admitted to an American Burn Association/American College of Surgeons Verified Burn Center between 2009 and 2017 was utilized. Univariable and multivariable logistic regression were used to determine the association between in-hospital mortality and the National Heart, Lung and Blood Institute(NIH) BMI classifications (underweight <18.5 kg/m2, normal 18.5–24.9 kg/m2, overweight 25–29.9 kg/m2, obesity class I 30–34.9 kg/m2, obesity class II 35–39.9 kg/m2 and extreme obesity >40 kg/m2). The mean BMI of inpatients treated for burns was 29.56 (SD 10.64). For every kg/m2 increase in BMI, the odds of death decreased, with an adjusted odds ratio 0.82 (95% CI 0.71–0.96; p<0.01). When adjusted for total burn surface area, being in the obese class I rather than the normal classification was associated with an adjusted odds ratio of mortality of 0.032 (95% CI 0.0012 - 0.92; p<0.05), whereas having a BMI >40 kg/m2 had an odds ratio of 0.00. The adjusted odds ratio if underweight was 12.11 (95%CI 1.55–94.62; p<0.05). There was no statistically significant difference in odds of mortality between a normal and an overweight BMI. The “BMI paradox” exists in burn care. Further investigation is needed to elucidate what specific phenotypic aspects confer this benefit and how these can enhance the care of burn patients. Alters understanding of predictors of outcome.

Erosive tooth wear and caries experience in children and adolescents with obesity

Clinical SignificanceA large consumption of fermentable carbohydrates, for instance the high intake of sweetened beverages, is an important risk factor for overweight and obesity. As lemonades and fruit juices present high sugar content and quite low pH-values, overweight and obese children might also have an increased risk for dental caries and erosive tooth wear. ObjectivesThe aim was to analyze the prevalence and severity of erosive tooth wear and caries experience in children and adolescents with overweight, obesity and extreme obesity compared to children with normal weight and to determine a possible association between erosive tooth wear and caries experience. Methods223 children (4–17 years, n = 1476 primary and n = 4110 permanent teeth) were examined using standardized dental indices (BEWE, ICDAS, DMFT). Demographic and socio-economic data, eating habits, oral hygiene, fluoride supply and details of medical history were obtained from a questionnaire. Weight classification was based on age- and gender-specific relative body mass indices (BMI). Statistical analyses were done by Chi2-tests, Kruskal-Wallis tests, logistic and linear regressions. To determine a possible association between erosive tooth wear and caries experience Chi2-tests (prevalence to prevalence) and Spearman correlations (severity to severity) were performed (p < 0.05). ResultsErosive tooth wear and caries experience in primary and permanent teeth were significantly increased in children with obesity and extreme obesity compared to normal weight children (p < 0.05). Higher BMI, age, gender, and the consumption of erosive snacks/beverages were identified as statistically significant risk factors for erosive tooth wear. Higher BMI, age, socio-economic factors, poor toothbrushing habits, and consumption of cariogenic beverages were identified as significant caries risk factors. Erosive tooth wear and caries showed a weak correlation in children with (extreme) obesity (Φ = 0.110 to 0.248). ConclusionsHigher BMI of children and adolescents is significantly associated with a higher risk for erosive tooth wear and caries.

Renal biopsy findings in patients with extreme obesity: more heterogeneous than you think

The number of obese and morbidly obese patients is increasing and so is the burden of renal disease in these patients. In a large series of biopsies from the morbidly obese patient population, Choung etal. show that there is heterogeneity in the renal disease affecting this population. It is imperative that the underlying renal disease in obese patients be correctly diagnosed for optimal management.

Anthropometrical phenotypes are important when explaining obstructive sleep apnea in female bariatric cohorts.

Central obesity is the main risk factor for obstructive sleep apnea (OSA). Whether there exists a central-obesity anthropometric that better explains apnea-hypopnea index (AHI) variability in the general population and in sleep cohorts is unknown, and this is even less explored among increasing grades of obesity. The objective of the study is to investigate whether there is an anthropometric that better explains AHI variability in a sample of morbidly obese women awaiting bariatric surgery (BS). A prospective multicentre cross-sectional study was conducted in consecutive women before BS. Demographic and anthropometric characteristics included age, body mass index (BMI), neck circumference (NC), waist circumference (WC), hip circumference (HC) and waist-to-hip ratio (WHR). OSA was diagnosed by polysomnography. The capacity of anthropometrics to explain AHI variance was investigated using regression linear models. A total of 115 women were evaluated: age, 44±10years; BMI, 46±5kg/m2 ; AHI, 35±26 events/hr. AHI was associated with all anthropometrics except weight, height and HC. The best univariate predictor was WHR, which accounted for 15% of AHI variance. The simplest model (age+BMI) accounted for 9%, which increased to 20% when applying more complex measurements (age+BMI+NC+WC+HC). The explanatory capacity did not change significantly when applying a simpler model (age+WHR+NC, 19%). In this female morbidly obese cohort, anthropometrics explained one-fifth of AHI variability. WHR is the best univariate parameter and models including waist and neck data provide more information than BMI when explaining AHI variability. Thus, even in young women with extreme obesity, OSA seems to be linked to a specific central-obesity phenotype rather than to a whole-obesity pattern.

Clinical performance of Rb-82 myocardial perfusion PET and Tc-99m-based SPECT in patients with extreme obesity

BackgroundWe evaluated the performance of stress imaging with technetium-99m-labeled tetrofosmin single-photon emission computed tomography (SPECT) and rubidium-82 positron emission tomography (PET) in patients with extreme obesity, defined as body mass index ≥40 kg/m2. MethodsWe identified patients with extreme obesity who underwent angiography in our center and either stress SPECT or PET within the previous six months. Cohorts of patients with extreme obesity and a <5% pretest likelihood of CAD who underwent SPECT (N = 25) or PET (N = 25) were also included. ResultsIn total, 108 patients who underwent SPECT (N = 57) or PET (N = 51) were identified. Scan interpretation was classified as definitely normal or abnormal in 83.3% of PET and 60.5% of SPECT scans, respectively (P < .01). PET demonstrated higher diagnostic accuracy and normalcy rate. PET was found to have higher specificity for the pooled cohort. Similar findings were observed using stenosis cut-offs of ≥50% and ≥70%. ConclusionsIn patients with extreme obesity, PET enabled more definitive scan interpretation with less artifact compared to SPECT. PET provided higher diagnostic accuracy and specificity in the detection of obstructive coronary artery disease.

Body image dissatisfaction in individuals with obesity seeking bariatric surgery: exploring the burden of new mediating factors.

For bariatric surgery candidates body image dissatisfaction (BID) may influence both psychological well-being and motivation to obtain surgery. This study aims to examine possible psychiatric predictors of BID. In particular, we explored the burden of new associated factors such as early trauma and attachment style (AS), which have not been assessed in previous literature. In this study, 536 patients with extreme obesity (mean Body Mass Index, BMI=43 kg/m2, SD=6.62) undergoing presurgical psychiatric evaluations as part of a mandatory workup before surgery were chosen as participants. A semi-structured clinical interview was performed to assess psychiatric diagnosis and patients' history of early trauma. BID was assessed using the Body Shape Questionnaire (BSQ). Depression, binge eating, and AS were assessed using self-report instruments. Binge eating behavior (p<0.0001), depression severity (p<0.0001), female gender (p<0.0001), and the "need for approval" dimension of insecure AS (p<0.0001) were found to be independent and significant predictors of BSQ score. However, early trauma and BMI were not included in the significant regression model (F4,442=90.784, p<0.0001, adjR2=0.446). Our results increased the understanding of BID among individuals with extreme obesity. Similar to previous studies, we reported that binge-eating, depressive symptoms, and gender influenced BID. Neither early trauma nor BMI were associated with BID. Our novel finding was the significance of insecure AS. Implications for multidisciplinary approaches to obesity treatment are discussed. Identifying critical features of BID to be targeted in pre- and post-operative behavioral interventions may open new possibilities for providing effective support for individuals over the course of their therapy. For some individuals living with obesity, developmental and relational processes such as insecure AS may play a substantial role in the development of BID.

Analysis of extreme obesity in two pedigrees due to leptin receptor mutation

This study reported two women with extreme obesity who underwent metabolic surgery due to their mutations in leptin receptor (LEPR). Genomic DNA was extracted from the anticoagulant blood samples of the two patients and their parents. A panel of genes related to metabolic diseases or whole exon sequencing was screened and the results were confirmed by Sanger sequencing. This is the first time that these three mutations in LEPR were reported. Two patients complained insatiety and early-onset obesity since childhood at clinics. Patient 1 was a 39-year-old woman with height 150 cm, weight 130 kg, and BMI 57.8 kg/m2. Serum leptin level was 156.4 μg/L. A homozygous mutation of c. 2317G>T was found in exon 15 of LEPR gene in patient 1, which was descended from her father and mother respectively. Patient 2 was a 37-year-old woman with height 158 cm, weight 167 kg, and BMI 67 kg/m2. Serum leptin level was 193.4 μg/L. Genetic analysis showed compound heterozygous mutations of c. 1482delT and c. 1892C>A. Her father showed heterozygous c. 1482delT mutation, and her mother carried heterozygous c. 1892C > A mutation. Two patients all underwent metabolic surgery with body weight reduction of about 22 kg and 40 kg respectively after first six months. However, the follow-up studies showed that the body weight of patient 1 rebounded to pre-surgery level in two years and patient 2 did not further lose weight in the following six months. Key words: Leptin receptor; Monogenic obesity; Compound heterozygous mutation; Metabolic surgery

Outcomes in Cardiogenic Shock from Acute Coronary Syndrome Depending on Severity of Obesity

We reviewed 54,044 adult cases of cardiogenic shock (CS) accompanying acute coronary syndrome from the 2005 to 2014 Nationwide Inpatient Sample. We evaluated outcomes among patients who were nonobese, obese (body mass index 30.0 to 39.9 kg/m2) and extremely-obese (body mass index ≥40 kg/m2). A multivariate analysis was performed to assess their impact on in-hospital mortality. There were 3,602 (6.6%) and 1,610 (2.9%) admissions among patients who were obese and extremely-obese. Those obese and extremely-obese were younger compared with the nonobese (62.7 vs 61.2 vs 68.8 years, respectively; p <0.01) but had significantly greater comorbidity burden. CS patients who were not-obese were most likely to have an associated ST elevation myocardial infarction, compared with the obese and extremely-obese (67.7% vs 65.9% vs 60.7%; p <0.01). Compared to the nonobese, patients who were obese had higher rates of percutaneous coronary intervention (55.8% vs 51.5%; p <0.01) and coronary artery bypass grafting (24.0% vs 16.0%; p <0.01) whereas those extremely-obese had higher coronary artery bypass grafting rates (23.9% vs 16.0%; p <0.01) but similar percutaneous coronary intervention rates (51.1% vs 51.5%; p = 0.74). Short-term mechanical support use was lowest among the nonobese followed by the extremely-obese and obese. Adjusted analysis revealed that obesity predicted less (adjusted odd ratio 0.82, 95% confidence interval 0.76 to 0.90) and extreme-obesity predicted higher in-hospital mortality (adjusted odds ratio 1.17, 95% confidence interval 1.05 to 1.32) compared with the nonobese. In conclusion, obesity and extreme-obesity are associated with greater comorbidity burden among ACS related CS admissions. Obesity predicted less in-hospital mortality, whereas extreme obesity was associated with elevated in-hospital mortality.

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery

Obesity in Adolescents and Youth: The Case for and against Bariatric Surgery