Extremely Obese Patients Research Articles

Quantitative Assessment of Intrahepatic Lipids Using Fat-Selective Imaging With Spectral-Spatial Excitation and In-/Opposed-Phase Gradient Echo Imaging Techniques Within a Study Population of Extremely Obese Patients

The aim of this study was to evaluate the feasibility of 2 established magnetic resonance imaging based techniques to quantify intrahepatic lipids (IHL) within a study population of extremely obese patients by means of a short, wide-bore MR scanner. Fat-selective imaging using a spectral-spatial excitation technique and in-phase/opposed-phase (IN/OP) gradient echo imaging were applied and results were compared. Results for IN/OP technique were corrected for T1- and T2*- relaxation effects. Furthermore, image quality was assessed for both techniques. Differences in regional fat distribution were assessed using parameter maps of voxel-wise calculated IHL. MR examinations of 20 extremely obese patients were included in the study (7 males, 13 females; mean age 40.4 +/- 12.6 years; mean body mass index 46.3 +/- 6.6 kg/m2). IHL, in terms of fat signal fractions, was calculated from simultaneously acquired IN/OP-images using a double-echo gradient echo technique. For correction of transverse relaxation effects an additional multiecho gradient echo sequence was applied in each subject, whereas correction of longitudinal relaxation was performed using literature values for T1 of water and lipid protons in the liver parenchyma. A highly selective spectral-spatial excitation technique with 6 binomial radiofrequency pulses was used for fat-selective imaging. In this case, signal intensity of adjacent subcutaneous adipose (approximately 100% fat) was used as an internal reference for IHL quantification. IN/OP-imaging provided sufficient image quality in all subjects, whereas fat-selective imaging was hampered by insufficient homogeneity of the static magnetic field in 1 of 20 subjects. Hepatic T2* values ranged from 20.1 milliseconds to 42.2 milliseconds. Results for IHL from both techniques were highly correlated with r(s) = 0.915 (P < 0.0001). Mean values for IHL were 16.5% +/- 9.2% and 10.6% +/- 7.3%, for IN/OP and spectral-spatial excitation technique, respectively, showing a slightly lower estimation of IHL by the spectral-spatial excitation method. In the examined cohort of extremely obese subjects a relatively high number of 4 out of 20 cases (20%) were found with uneven distribution of IHLs. The presented data confirm that both methods are reliable tools for quantification of IHL, if inherent drawbacks and limitations are taken into account. Inhomogeneity of the static magnetic field observed in examinations of extremely obese patients limits the use of spectral-spatial excitation, if performed without time-consuming shimming procedures. Necessity to correct for transverse and longitudinal relaxation effects using the IN/OP method requires additional measurements and postprocessing procedures, which might hamper the clinical applicability. Moreover, significant regional differences in IHL may exist in some patients especially if pronounced hepatic steatosis is present.

Family Physicians' Barriers to Cancer Screening in Extremely Obese Patients

Extremely obese women are less likely than nonobese women to receive breast and cervical cancer screening examinations. Reasons for this disparity are unclear and may stem from patient and/or physician barriers. This sequential mixed-methods study used individual in-depth interviews of 15 family physicians followed by a mail survey of 255 family physicians (53% response rate) to understand the barriers they faced in performing cancer screening examinations in extremely obese women. Barriers fell into three main areas: (i) difficulty doing pelvic and breast exams; (ii) inadequate equipment; and (iii) challenges overcoming patient barriers and refusal. This led some physicians to avoid performing breast and pelvic examinations on extremely obese women. Having more knowledge about specific examination techniques was associated with less difficulty in palpating lumps on breast and pelvic examinations (P < 0.005). Physicians perceived that embarrassment, aversion to undressing, and avoidance of discussions related to their weight were the most frequent barriers extremely obese women had with getting physical examinations. Educating and/or motivating patients and addressing fears were strategies used most frequently when patients refused mammograms or Pap smears. Interventions focusing on physician barriers, such as educating them on specific examination techniques, obtaining adequate equipment and supplies, and providing resources to assist physicians in dealing with patient barriers and refusal, may be fruitful in increasing cancer screening rates in extremely obese patients. Future research studies testing the effectiveness of these strategies are needed to improve cancer outcomes in this high-risk population.

Family Physicians' Practices and Attitudes Regarding Care of Extremely Obese Patients

Despite the growing epidemic of extreme obesity in the United States, weight management is not adequately addressed in primary care. This study assessed family physicians' practices and attitudes regarding care of extremely obese patients and factors associated with them. A cross-sectional, self-administered survey was mailed to 500 family physicians in New Jersey (NJ) during March-May 2008. Measures included knowledge, weight management approaches, attitudes toward managing obesity, challenges with examinations, availability of supplies, and strategies to improve care. Response rate was 53% (N = 255). Bariatric surgery and weight loss medications were infrequently recommended, particularly in physicians with higher volume of extremely obese patients (odds ratio (OR) 0.38; 95% confidence interval (CI) 0.23, 0.62 and OR 0.51; 95% CI 0.31, 0.85 for surgery and medications, respectively). Higher knowledge was associated with increased frequency of recommendations of weight loss medications (P < 0.0001) and bariatric surgery (P < 0.0001). There was a high prevalence of negative attitudes, particularly in younger physicians and those with lower patient volume. Increased knowledge of weight-loss diets was associated with less dislike in discussing weight loss (P < 0.0001), less frustration (P = 0.0001), less belief that treatment is often ineffective (P < 0.0001), and less pessimism about patient success (P = 0.0002). Many providers encountered challenges performing examinations on extremely obese patients. More education of primary care physicians, particularly on bariatric surgery, specific examination techniques, and availability of community resources for obese persons is needed. Further research is needed to determine if interventions to increase knowledge of physicians will lead to less negative attitudes toward weight loss and extremely obese patients.

Analysis of Safety and Efficacy of Intragastric Balloon in Extremely Obese Patients

The implantation of an intragastric balloon constitutes a short-term effective non-surgical intervention to lose weight. The aim of this study was to evaluate retrospectively the clinical outcome and safety of gastric balloon therapy (GBT) in extremely obese patients. One hundred and nine super- and super-super-obese patients, 64 males and 45 females, mean age 39.1+/-8.4 years, mean body mass index (BMI) 68.8+/-8.9 kg/m2, who underwent GBT for weight loss, were studied retrospectively. GBT was assessed in massively obese patients concerning tolerance, weight loss, number of comorbidities and complications. A significant reduction in patients' weight and BMI was evident after GBT. Regarding safety, no major complications occurred. Minor complications at balloon placement and removal occurred in one (0.9%) and three patients (2.8%) respectively. Mean duration of GBT was 177.6+/-56.8 days. After GBT, the mean weight loss was 26.3+/-15.2 kg (p<0.001) and the mean BMI reduction was 8.7+/-5.1 kg/m2 (p<0.001) representing a mean percentage of excess BMI lost (%EBL) of 19.7+/-10.2. The highest BMI loss was observed in patients with BMI>80 kg/m2. A noteworthy improvement of comorbidities in 56.8% of the patients was also noted. Of the 109 patients, 69 received subsequent bariatric surgery. All the procedures were performed laparoscopically. Ten patients, with a mean BMI of 68.6+/-10.6 kg/m2 after the removal of the first BIB, received a second BIB resulting in a non-significant weight and BMI loss of 6.3+/-9.4 kg and 1.8+/-2.9 kg/m2, respectively. Our study indicates the safety and efficacy of GBT in extremely obese patients particularly as a first step before a definitive anti-obesity operation. GBT appears to be a safe, tolerable, and potentially effective procedure for the initial treatment of morbid obesity.

Invited Commentary

Invited Commentary

Renal injury in the extremely obese patients with normal renal function

We studied the glomerular architecture in renal biopsies of 95 patients undergoing bariatric surgery for extreme obesity but whose renal function was normal. The comparison group was 40 control patients having protocol biopsies. These latter patients had normal weight and renal function, were non-diabetic, non-hypertensive, and were undergoing nephrectomy or donating a kidney. Logistic regression models determined associations between the clinical and biochemical variables and glomerular lesions. Arterial hypertension, sleep apnea syndrome (SAS), and microalbuminuria were prevalent in the obese patients, as was hyperglycemia to a lesser extent. Focal and segmental glomerulosclerosis was present in only five extremely obese (EO) patients but absent in controls. Increased mesangial matrix, podocyte hypertrophy, mesangial cell proliferation, and glomerulomegaly were more frequent in the obese cohort than in the control group. Body mass index was a significant independent risk factor associated with glomerular lesions in all 135 patients and in the 95 EO patients, whereas SAS was associated with glomerulomegaly only in the EO. Our study shows that EO patients who lack overt clinical renal symptoms have a variety of glomerular abnormalities that correlate with body mass.

A Prospective Multicenter Study of 163 Sleeve Gastrectomies: Results at 1 and 2 Years

Good results obtained after laparoscopic sleeve gastrectomy (LSG), in terms of weight loss and morbidity, have been reported in few recent studies. Our team has designed a multicenter prospective study for the evaluation of the effectiveness and feasibility of this operation as a restrictive procedure. From January 2003 to September 2006, 163 patients (68% women) with an average age of 41.57 years, were operated on with a LSG. Indications for this procedure were morbid obese [body mass index (BMI)>40 kg/m2] or severe obese patients (BMI>35 kg/m2) with severe comorbidities (diabetes, sleep apnea, hypertension...) with high-volume eating disorders and superobese patients (BMI>50 kg/m2). The average BMI was 45.9 kg/m2. Forty-four patients (26.99%) were superobese, 84 (51.53%) presented with morbid obesity, and 35 (21.47%) were severe obese patients. Prospective evaluations of excess weight loss, mortality, and morbidity have been analyzed. Laparoscopy was performed in 162 cases (99.39%). No conversion to laparotomy had to be performed. There was no operative mortality. Perioperative complications occurred in 12 cases (7.36%). The reoperation rate was 4.90% and the postoperative morbidity was 6.74% due to six gastric fistulas (3.66%), in which four patients (2.44%) had a previous laparoscopic adjustable gastric banding. Long-term morbidity was caused by esophageal reflux symptoms (11.80%). The percentage of loss in excessive body weight was 48.97% at 6 months, 59.45% at 1 year (120 patients), 62.02% at 18 months, and 61.52% at 2 years (98 patients). No statistical difference was noticed in weight loss between obese and extreme obese patients. The sleeve gastrectomy seems to be a safe and effective restrictive bariatric procedure to treat morbid obesity in selected patients. LSG may be proposed for volume-eater patients or to prepare superobese patients for laparoscopic gastric bypass or laparoscopic duodenal switch. However, weight regained, quality of life, and evolution ofmorbidities due to obesity need to be evaluated in a long-term follow up.

Cardiac Procedures in Patients With a Body Mass Index Exceeding 45: Outcomes and Long-Term Results

Obesity has become a public health crisis. Although prior studies in obese patients undergoing cardiac surgical procedures have shown variable effects on outcomes, data are limited for extremely obese patients (body mass index [BMI] > or = 45). We undertook this study to evaluate outcomes in this cohort. A retrospective analysis was performed on 14,571 patients in our database who underwent cardiac operations from 1992 to 2005. Patient demographics, comorbidities, and outcomes were recorded. A univariate analysis between two groups: BMI 21 to 34.9 and BMI 45 or more was performed. Logistic regression models were used to identify independent risk factors for 30-day mortality. Long-term follow-up of the extreme obese group was achieved. We identified 128 extreme obese patients, and 480 patients with a BMI of 21.0 to 34.9 were randomly selected for comparison. Univariate analysis showed significant differences in age, gender, and multiple comorbidities, as well as in cardiopulmonary bypass and cross-clamp times, operative procedure, and transfusion requirements. Extreme obese patients had a higher incidence of infection, acute renal failure, and 30-day mortality. Logistic regression analysis showed BMI, preoperative renal insufficiency, and transfusion status to be independent risk factors for 30-day mortality. Follow-up data did not reveal significant functional improvements. Long-term survival was 33.6% at 12 years. Extreme obese patients undergoing cardiac surgical procedures have higher perioperative morbidity and mortality compared with a lower BMI group. BMI and preoperative renal insufficiency increase mortality in both groups, whereas transfusion does so only in the extreme obese. These patients can realize acceptable outcomes from cardiac procedures, but continue to suffer from the comorbidities of obesity.

Change in Mental Symptoms in Extreme Obesity Patients after Gastric Banding, Part II: Six-Year Follow up

Apart from increased somatic morbidity, extreme obesity causes grave psychosocial and psychopathological problems. We examined a sample of 50 extremely adipose women (BMI < 40 kg/m2) from 2000 to 2003 to find out whether surgical reduction of stomach volume leads to lasting change in Body Mass Index (BMI), psychosocial symptoms, and health related quality of life. We found that positive changes in BMI reduction, psychosocial symptoms, and health related quality of life could be expected three years after gastric banding (Int. J Psychiatry Med 2005; 35:109-122). During the following three years, we continued to observe these patients to determine long-term effects. Fifty adipose women who had taken part in the first study from 2004 to 2006 were surveyed. Annual primary outcome measures were BMI, self-reported changes on the scales of the Three-Factor Eating Questionnaire (TFEQ), Hospital Anxiety and Depression Scale (HADS-D), and Health Survey (SF-36). At the 6-year mark, significant changes in BMI (p < 0.01), significantly increased employment (0.012) and the existence of a partnership (p < 0.01), plus significant changes on all three scales of the TFEQ (p < 0.01), on both scales of the HADS-D (anxiety: p < 0.05; depression: p < 0.011), and all scales of the SF-36 Health Survey (all p < 0.01) were observed. The positive changes in BMI reduction, i.e., increased employment and subjects living in a partnership, improvement in eating behavior, reduction in anxiety and depressive symptoms, and improvement in health related quality of life were also confirmed as remaining stable over a 3-year observation period, i.e., for a total of six years.

Long-term Changes in Blood Pressure in Extremely Obese Patients Who Have Undergone Bariatric Surgery

Long-term Changes in Blood Pressure in Extremely Obese Patients Who Have Undergone Bariatric Surgery

The Prognostic Significance of Regular Binge Eating in Extremely Obese Gastric Bypass Patients

The prognostic significance of binge eating for extremely obese patients who undergo bariatric surgery is uncertain. We examined the relation of preoperative binge eating to preoperative presentation and 12-month postoperative outcomes. 139 extremely obese gastric bypass surgery patients completed assessments of binge eating and eating disorders (Eating Disorder Examination-Questionnaire version), body dissatisfaction (Body Shape Questionnaire), depression (Beck Depression Inventory), and self-esteem (Rosenberg Self-Esteem Scale) before surgery and again 12 months postsurgery. At baseline, 60% of patients denied binge eating, 16% reported binge eating infrequently (less than once weekly), and 24% reported binge eating at least weekly. At 12 months postsurgery, 8.8% reported infrequent binge eating and only 0.7% reported binge eating weekly. At baseline, infrequent binge eaters and regular binge eaters differed little from each other but had significantly elevated eating and psychosocial problems relative to non-binge eaters. Statistically significant and clinically robust improvements in weight and in all measures of functioning were observed at 12 months postsurgery across all groups. At 12-month follow-up, patients who reported regular binge eating at baseline had significantly higher levels of eating-specific concerns (but not psychosocial concerns) than the infrequent binge eaters and non-binge eaters; the infrequent and non-binge eaters did not differ from each other. Significant time-by-binge eating interactions indicated that the regular versus infrequent binge-eating groups improved differently over time; infrequent binge eaters had sharper improvements than regular binge eaters and non-binge eaters. Binge eating is common in extremely obese bariatric surgery candidates and is associated with heightened eating and psychological problems. Regular binge eating preoperatively, however, does not appear to be a potent negative prognostic indicator for gastric bypass surgery. Our findings, which are limited to 12 months postsurgery, highlight substantial improvements in weight and psychosocial functioning, and these robust improvements differ little by binge-eating status.

A Prospective Study of Body Dissatisfaction and Concerns in Extremely Obese Gastric Bypass Patients: 6- and 12-Month Postoperative Outcomes

Body image is a multifaceted construct commonly associated with obesity. This study examined changes in body dissatisfaction, and shape and weight concerns in bariatric surgery patients from baseline to 6 and 12 months post-surgery. 109 extremely obese patients who underwent gastric bypass surgery completed the Body Shape Questionnaire (BSQ), and the Shape and Weight Concern subscales of the Eating Disorder Examination-Questionnaire (EDE-Q) at baseline, and 6 and 12 months post-surgery. Patients experienced substantial weight loss and reported statistically significant reductions in BSQ, and Shape and Weight Concern scores from baseline to 6 and 12 months post-surgery. Improvements on the BSQ and Shape Concern scale were maintained between 6 and 12 months post-surgery, while patients reported continued reductions in weight and Weight Concern scale scores. Moreover, at 6 and 12 months follow-up, over 80% of female patients had body image scores comparable to published norms. Correlations between change in BMI and the body image measures were variable, and degree of weight loss did not predict body image scores 6 or 12 months post-surgery. Results from the present study illustrate significant and immediate post-surgical reductions in body dissatisfaction and concerns, along with weight loss in bariatric patients. Such improvements indicate a normalization of body image-related concerns in these patients, the majority of who remain overweight or obese despite the substantial post-surgical weight losses. Changes in weight and body image relate poorly to each other, suggesting that mediating factors may be involved.

Effect of Drastic Weight Loss after Bariatric Surgery on Renal Parameters in Extremely Obese Patients

Obesity is a health problem that is reaching epidemic proportions. Extreme obesity (body mass index [BMI] > or =40 kg/m2) is a type of obesity that usually does not respond to medical treatment, with surgery being the current treatment of choice. Extreme obesity is associated with cardiovascular disease, type 2 diabetes, dyslipidemia, and hypertension. Recently, obesity has been related with high rate of renal lesions, but renal function and renal parameters in extreme obesity scarcely are documented. The objective of this study was to evaluate the effect of weight loss after bariatric surgery (BS) on BP, renal parameters, and renal function in 61 extremely obese (EO) patients after 24 mo of follow-up. A total of 61 EO adults (37 women) were studied prospectively before and 24 mo after surgery. Control subjects were 24 healthy, normal-weight adults (15 women). Anthropometric, BP, and renal parameters were determined. Presurgery weight, BMI, GFR, 24-h proteinuria, and 24-h albuminuria were higher in the EO patients than in control subjects (P < 0.001). All parameters improved at 12 mo after BS. However, during the second year of follow-up, only 24-h albuminuria (P = 0.006) and BMI (P = 0.014) continued to improve. At 24 mo after BS, obesity-related renal alterations considerably improved. This improvement was observed mainly in the first year after surgery, when the majority of weight loss occurred. However, 24-h albuminuria still improves during the second year of follow-up. It is possible that this decrease in 24-h albuminuria is not GFR related but rather is attributable to the persistence of the decrease in BMI and to the improvement of other weight-related metabolic factors.

Relation of Childhood Sexual Abuse and Other Forms of Maltreatment to 12-Month Postoperative Outcomes in Extremely Obese Gastric Bypass Patients

The prognostic significance of sexual abuse for extremely obese patients who undergo bariatric surgery is uncertain. This study examined self-reported childhood sexual abuse and other forms of childhood maltreatment in relation to preoperative presentation and to 12-month postoperative outcomes in gastric bypass patients. 137 extremely obese patients undergoing gastric bypass surgery completed a questionnaire battery before surgery and again 12 months after surgery. Weight loss was determined with measured weight and height, childhood maltreatment was assessed with the Childhood Trauma Questionnaire, and associated eating disorder and psychological functioning were assessed with established measures. 32% of patients self-reported childhood sexual abuse, 37% reported some form of non-sexual childhood abuse or neglect, and 31% reported no form of childhood maltreatment. Significant and clinically robust improvements in weight and in all measures of eating and psychological functioning were observed at 12 months after surgery. Patients who reported histories of childhood sexual abuse and other forms of childhood maltreatment differed little from patients who reported no childhood maltreatment in body mass index, eating disorder features, and psychological functioning both pre- and postoperatively at 12-month follow-up. Patients who reported childhood sexual abuse had statistically significantly higher levels of depression at 12 months after surgery, although the depression levels represented significant reductions from pre-surgery and fell within the non-depressed range. Extremely obese patients who seek gastric bypass surgery report higher rates of childhood maltreatment than normative community samples. A history of childhood maltreatment, including reports of sexual abuse, does not appear to be a negative prognostic indicator for gastric bypass surgery.

Long-term Changes in Blood Pressure in Extremely Obese Patients Who Have Undergone Bariatric Surgery

Systolic and diastolic pressure and the incidence of hypertension in very obese patients decline after bariatric surgery and do not rebound. Chart review. Surgical practice in a university medical center. Women and men, 18 years or older, with a body mass index (BMI) (calculated as weight in kilograms divided by the square of height in meters) of 40 or greater, having no previous surgical intervention for extreme obesity. Vertical-banded gastroplasty or Roux-en-Y gastric bypass. Systolic and diastolic blood pressure, BMI, and antihypertensive medications. Patients underwent Roux-en-Y gastric bypass (n = 285; mean initial BMI, 55.7) or vertical banded gastroplasty (n = 62; mean initial BMI, 48.5); half of each group was hypertensive at evaluation. The BMI dropped in both groups after surgery and stabilized at about 35 within 18 months. Systolic pressure changes were generally modest, although diastolic pressure declined significantly after surgery. In patients with untreated stage 1 hypertension, marked reductions in systolic and diastolic pressures occurred after surgery. Many patients taking antihypertensive medications before surgery discontinued them after surgery and remained normotensive. Blood pressure reductions that occur after bariatric surgery and substantial weight loss depend on the blood pressure status of patients before surgery: normotensive patients and hypertensive patients taking antihypertensive medications show small postsurgical pressure reductions, while patients with elevated blood pressure before surgery show notable postsurgical pressure drops. The overall incidence of hypertension after bariatric surgery declines substantially and remains low.

Evaluation of Impedance Cardiography during Anesthesia in Extremely Obese Patients

In three anesthetized markedly obese patients, non-invasive stroke volumes (the transthoracic electrical impedance method) were compared to simultaneously obtained invasively measured stroke volumes (dye-dilution method). Close correlations were obtained (r = 0.90--0.98) between the two methods, although constant lower impedance stroke volumes were found in these patients when the values usually employed for the electrical resistivity of the blood (zeta) were used for calculation of the impedance stroke volume. No statistically significant difference (P greater than 0.10) between the two methods was found when a zeta of 175 ohm X cm was used for the calculations, or when the percentage changes in stroke volumes were analyzed. The impedance method is safe and reliable; it also permits non-invasive measurements of stroke volume during anesthesia in markedly obese patients.