Maintained Weight Reduction Research Articles

0567 Tirzepatide for the Treatment of OSA: Rationale and Design of the SURMOUNT-OSA Phase 3 Trial

Abstract Introduction Weight reduction is a standard recommended component of OSA treatment in people with obesity or overweight; however, the challenge to achieve and maintain weight reduction has limited its clinical application outside of the benefit established after bariatric surgery. Currently no FDA-approved anti-obesity medication (AOM) has demonstrated clinically meaningful improvement in OSA severity and symptomology. Methods Tirzepatide is a single molecule GIP and GLP-1 receptor agonist. In SURMOUNT-1, a 72-week phase 3 clinical trial in participants with obesity or overweight, tirzepatide 15mg provided average reductions in body weight of 22.5% which occurred with beneficial effects on blood pressure, lipids, and physical functioning. In a linear meta regression model, we estimated that tirzepatide treatment would provide clinically meaningful apnea-hypopnea index decrease compared to placebo-treated participants with obesity and OSA. SURMOUNT-OSA, a placebo controlled 52-week, phase 3 trial, will investigate efficacy and safety of tirzepatide for the treatment of moderate to severe OSA (defined as AHI ≥15) in participants with obesity. SURMOUNT-OSA utilizes an umbrella master protocol and 2 Intervention-Specific Appendices (ISAs): ISA 1 includes participants with no current OSA treatment and ISA 2 includes participants using positive airway pressure therapy. Approximately 412 participants will be randomly assigned to placebo or tirzepatide across the entire master protocol, with approximately 206 participants in each ISA. While participants will receive tirzepatide or placebo based on a 1:1 randomization ratio, all participants will receive background lifestyle intervention for weight reduction. Results The primary endpoint for the individual ISAs is the difference in AHI response measured by polysomnography between tirzepatide and placebo arms at week 52. Secondary endpoints include hypoxic burden, functional outcomes and cardiometabolic biomarkers. The trial is utilizing a unique hierarchical functional outcomes endpoint based on Functional Outcomes of Sleep Questionnaire methodology. The trial employs wearables, such as home sleep testing and accelerometry to capture time to improvement as exploratory outcomes. Conclusion SURMOUNT-OSA aims to explore whether tirzepatide provides clinically meaningful improvement in obesity-related OSA by targeting an underlying etiology. Support (if any) Eli Lilly

Outcome of Total Knee Replacement in Morbid Obese Patients

Aim: The purpose of our study was to determine the outcomes of total knee replacement in morbidly obese patients. Methodology: This prospective analysis was carried out on 128 morbidly obese patients (BMI> 40 kg/m2) in the Department of Orthopedic Surgery, Federal Govt. Polyclinic Hospital (FGPC) Islamabad, Mardan Medical Complex, Mardan and Bacha Khan Medical Complex, Swabi for the duration from January, 2021 to June, 2022. Demographic details, anthropometric parameters, and radiological assessment were recorded. Pre and post-operative radiological assessments included alignment, implant position, and radiolucent lines presence around the implant were compared. Outcome of TKR such as pre and post-operative functional score, knee society score, age, diagnosis, gender, laterality, and type of prosthesis were assessed and compared. SPSS version 25 was used for data analysis. Results: Of the total 128 TKR in morbid obese patients, the incidence of unilateral and bilateral TKR was 10 (7.8%) and 118 (92.2%) respectively. The overall mean age of the patients was 62.00 ± 8.12 years. Out of 126 TKR patients, there were 11 (8.6%) males and 117 (91.4%) females. Out of 10 unilateral TKR groups, males and females were 4 (40%) and 6 (60%) respectively. In the bilateral TKR group, there were 7 (5.9%) males and 111 (94.1%) were females. The mean BMI was 42.84 ± 3.46 kg/m2 with a range of 40-60 kg/m2. Based on Knee Society Scores and Functional Scores, Pre-operative mean knee score and functional score was 26.4 and 48.8, p=0.01 compared to post-operative 83.7 and 74.2, p=0.07 respectively. A higher prevalence for post-operative radiolucent lines was 28% against pre-operative 9%, p=0.01 were observed. During follow-up, the complications rate was 17.2% (n=22). Post-TKR complications such as superficial wound infection, deep joint infection, and deep vein thrombosis was found in 12.5% (n=16), 1.6% (n=2), and 3.1% (n=4) respectively. Conclusion: Our study found that prior to total knee replacement, patients with BMI>40 kg/m2 should lose weight to maintain weight reduction criteria. Knee arthroplasty's growth rate and epidemiological changes in morbid obese patients were the particular issues regarding total knee replacement highlighted in the present study. Based on our study, morbidly obese patients could be suitable candidates for total knee replacement. Morbid obese patients should be counseled. Keywords: Total Knee Replacement, Unilateral, Bilateral, Morbid Obese Patients

Non-pharmacologic treatment for obesity

Background: The prevalence of obesity has been rapidly increasing in the Korean population. Obesity is a well-known risk factor for various chronic diseases, including diabetes mellitus, hypertension, dyslipidemia, atherosclerosis, chronic kidney disease, degenerative arthritis, and autoimmune diseases. It also increases the risks of different malignancies, gall bladder disease, and pancreatitis.Current Concepts: Lifestyle intervention assisted by frequent behavioral therapy is crucial despite the modest amount of weight loss achieved. Energy intake restriction combined with increased physical activity can not only facilitate weight loss but also improve metabolic health. Furthermore, this combination can help maintain weight reduction during and after lifestyle interventions. Energy intake restriction with a daily deficit of 500–1,000 kcal and physical activity including aerobic exercise for 150 minutes or more per week and resistance training 2–4 times a week are generally recommended for obesity management.Discussion and Conclusion: Comprehensive lifestyle intervention should be individualized and supported by a multidisciplinary team. A long-term behavioral intervention is necessary for success in obesity treatment.

Impact of Vagotomy on Postoperative Weight Loss, Alimentary Intake, and Enterohormone Secretion After Bariatric Surgery in Experimental Translational Models.

Obesity may be treated by bariatric procedures and is related to enterohormone release modulation. Nevertheless, a majority of commonly used surgical procedures have a significant impact on vagus nerve function by breaking the connections with its gastric branches. In the case of an intragastric balloon (BAL), this interaction is unclear. However, BAL-induced weight reduction is not long-lasting. Interestingly, this method has not been used in combination with vagotomy (VAG). Thus, we evaluated, for the first time, the short- and long-term effects of combined BAL and VAG using the animal-based translational model and compared these effects with sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB). Wistar rats were fed a high-calorie diet for 8weeks to induce obesity before SG, RYGB, BAL + / - VAG. Animals' weight and eating behaviors were monitored weekly. After 90days, serum samples were collected to evaluate postprandial and fasting GLP-1, GIP, PYY, ghrelin, glucagon, insulin, leptin, and pancreatic polypeptide concentrations by fluorescent assay. VAG, SG, RYGB, and BAL + VAG significantly reduced body weight 30 and 90days after surgery. BAL alone induced temporal weight reduction observed after 30days, reversed after 90days. Calories intake was reduced at the first half of the observation period in all groups. Fluid intake was reduced in all groups except SG and BAL. Enterohormone profile for BAL + VAG was comparable to SG and RYGB but not BAL. VAG and BAL + VAG but not BAL alone maintain weight reduction, alimentary intake changes, and enterohormone release after long-term observation. VAG may improve the effectiveness of bariatric procedures for obesity treatment in clinical practice.

Effect of Bariatric Surgery on Glycaemic Control in King Fahad Hospital.

Background: Laparoscopic Sleeve Gastrectomy (LSG) is an approved procedure for weight reduction in obese patients. This outcome of weight loss is essential to achieve optimal control in patients with type 2 diabetes mellitus (T2DM).Objectives: This study was designed to evaluate the effect of LSG on glycemic control among a sample of obese patients in Al-Madinah Al-Munawwarah, Saudi Arabia, through assessment of reduction in hemoglobin A1c (HbA1c) associated with weight loss following LSG.Methods: In this cross-sectional study, we studied 102 patients with a body mass index (BMI) of ≥30 kg/m2 and aged ≥18 years who underwent LSG between January 2017 and December 2019. Patient age, characteristics, preoperative and postoperative records of BMI and HbA1c were collected. The data of BMI and HbA1c were analyzed based on baseline and mean postoperative readings with variable postoperative visits after LSG.Results: There was a 30% reduction in BMI and a 26.4% reduction in HbA1c following LSG from baseline in all patients. We noted 44 patients achieved BMI <40kg/m2 with HbA1c <6.5% and 32 patients achieved BMI <40kg/m2 with HbA1c <5.7% within a mean follow-up time of 10 months.Conclusions: Laparoscopic Sleeve Gastrectomy (LSG) has a positive effect on glycemic control in obese patients in short term, evidenced by the significant reduction of weight and HbA1c. Larger longitudinal studies are needed to assess the long-term impact of LSG glycemic control and the related factors associated with maintaining weight reduction and optimal glycemic control in Saudi Arabia for patients with obesity.

Strategies to Counter Weight Loss-Induced Reductions in Metabolic Rate.

A significant percentage of the population is classified as obese, and there is a growing need to develop novel therapy to reduce body weight. It has long been appreciated that caloric restriction and exercise are the cornerstones of any weight loss method. This review outlines the challenges faced when attempting to achieve weight loss and the metabolic adaptations that ensue upon reductions in body weight which make sustaining weight loss extremely difficult. We discuss the need for novel approaches to weight loss that would increase basal metabolic rate and counter the biological adaptations that provide barriers for maintaining weight reduction. We introduce two metabolic processes, hypobaric hypoxia and cold exposure, which, when activated, cause increased metabolic rate even in the presence of reduced caloric intake. While we do not suggest that these are long-term viable options for methods to achieve weight loss, we are introducing these as pathways that may be targeted to eventually develop novel therapies to achieve sustainable weight loss.

Beneficial effects of lifestyle intervention in non-obese patients with non-alcoholic fatty liver disease

Around 10-20% of patients with non-alcoholic fatty liver disease (NAFLD) are non-obese. The benefit of weight reduction in such patients is unclear. We aim to study the efficacy of lifestyle intervention in non-obese patients with NAFLD and to identify factors that predict treatment response. A total of 154 community NAFLD patients were randomised to a 12-month lifestyle intervention programme involving regular exercise, or to standard care. The primary outcome was remission of NAFLD at Month 12 by proton-magnetic resonance spectroscopy. After the programme, the patients were prospectively followed until Year 6. The Asian body mass index (BMI) cut-off of 25 kg/m2 was used to define non-obese NAFLD. Patients were assigned to the intervention (n = 77) and control (n = 77) groups (39 and 38 in each group had baseline BMI <25 and ≥25 kg/m2, respectively). More patients in the intervention group achieved the primary outcome than the control group regardless of baseline BMI (non-obese: 67% vs. 18%, p <0.001; obese: 61% vs. 21%, p <0.001). Lifestyle intervention, lower baseline intrahepatic triglyceride, and reduction in body weight and waist circumference were independent factors associated with remission of NAFLD in non-obese patients. Half of non-obese patients achieved remission of NAFLD with 3-5% weight reduction; the same could only be achieved in obese patients with 7-10% weight reduction. By Year 6, non-obese patients in the intervention group remained more likely to maintain weight reduction and alanine aminotransferase normalisation than the control group. Lifestyle intervention is effective in treating NAFLD in both non-obese and obese patients. Weight reduction predicts remission of NAFLD in non-obese patients, but a modest weight reduction may be sufficient in this population. Some patients with non-alcoholic fatty liver disease (NAFLD) are non-obese. The optimal management of such patients is unclear. In this long-term follow-up study of a clinical trial, we show that remission of NAFLD can be achieved in 67% of non-obese patients after lifestyle intervention. The majority of patients can achieve NAFLD remission with modest weight loss of 3-10%. Non-obese patients are also more likely than obese patients to maintain weight reduction and normal liver enzymes in the long run.

A5173 - Liraglutide treatment in post-bariatric surgery patients who failed to maintain weight reduction

A5173 - Liraglutide treatment in post-bariatric surgery patients who failed to maintain weight reduction

Therapeutic effects of short- and intermediate-term tolvaptan administration for refractory ascites in patients with advanced liver cirrhosis.

Tolvaptan, an oral arginine vasopressin V2 receptor antagonist, became available for hepatic ascites. We evaluated the therapeutic efficacy and safety of tolvaptan administration to treat refractory ascites. Data were collected from 15 hospitalized patients with cirrhosis (hepatitis C, 10; alcoholism, five) after adding tolvaptan (3.75-11.25 mg/day) to conventional diuretics. Bodyweights and serum sodium and creatinine concentrations were measured. Tolvaptan was continued for 4 weeks or longer for a median follow-up period of 42 days (range, 28-56). In the first week (introduction phase), tolvaptan significantly reduced median weight (66.6, 65.9 and 63.1 kg on days 0, 1 and 7, respectively; P < 0.004). The numbers of good responders (≥3 kg reduction in 4 days), responders (<3 kg weight reduction) and non-responders (no weight reduction) were seven (46.7%), six (40.0%) and two of the 15 (13.3%), respectively. The two non-responders had concomitant chylous pleural effusion or spontaneous bacterial peritonitis. All patients continued tolvaptan for 2 weeks or longer and six (40%, three good responders and three responders) were treated for a median of 42 days without additional intervention. During this intermediate-term administration of tolvaptan, the median weight reduction was statistically significant (65.4, 61.9 and 56.9 kg on days 0, 7 and 42, respectively; P < 0.030) and there was no serum sodium imbalance or renal dysfunction; but two of these six developed hepatic coma. Tolvaptan safely alleviated fluid retention caused by hepatic cirrhosis. Intermediate-term administration of tolvaptan apparently helped maintain weight reduction achieved during the introduction phase.

The physiology underlying Roux-en-Y gastric bypass: a status report.

Obesity and its related comorbidities can be detrimental for the affected individual and challenge public health systems worldwide. Currently, the only available treatment options leading to clinically significant and maintained body weight loss and reduction in obesity-related morbidity and mortality are based on surgical interventions. This review will focus on two main clinical effects of Roux-en-Y gastric bypass (RYGB), namely body weight loss and change in eating behavior. Animal experiments designed to understand the underlying physiological mechanisms of these post-gastric bypass effects will be discussed. Where appropriate, reference will also be made to vertical sleeve gastrectomy. While caloric malabsorption and mechanical restriction seem not to be major factors in this respect, alterations in gut hormone levels are invariably found after RYGB. However, their causal role in RYGB effects on eating and body weight has recently been challenged. Other potential factors contributing to the RYGB effects include increased bile acid concentrations and an altered composition of gut microbiota. RYGB is further associated with remarkable changes in preference for different dietary components, such as a decrease in the preference for high fat or sugar. It needs to be noted, however, that in many cases, the question about the necessity of these alterations for the success of bariatric surgery procedures remains unanswered.

The physiology of altered eating behaviour after Roux-en-Y gastric bypass.

Obesity and its related comorbidities can be detrimental for the affected individual, as well as constituting a major challenge to public health systems worldwide. Currently, the most effective treatment option leading to clinically significant and maintained body weight loss and reduction in obesity-related morbidity and mortality is obesity surgery, which is recommended for patients with a body mass index of >40kgm(-2), or >35kgm(-2) if obesity-associated comorbidities, such as type2 diabetes mellitus, are present. This report focuses on the altered eating behaviour after the most common of these operations, the Roux-en-Y gastric bypass. Animal and human experiments designed to understand the underlying physiological mechanisms of altered taste and appetite are discussed.

Abstract 400: Cannabinoid 1 Receptor Blockade Diminishes Obesity and Dyslipidemia via Peripheral Activation of Brown Adipose Tissue

Objectives: The endocannabinoid system is an important player in energy metabolism by regulating appetite, lipolysis and energy expenditure. Chronic blockade of the cannabinoid 1 receptor (CB1R) leads to long-term maintained weight loss and reduction of dyslipidemia in experimental and human obesity. Brown adipose tissue (BAT) that burns lipids towards heat using UCP1, recently emerged as a major player in lipoprotein metabolism and is present and active in human adults. The aim of the present study was to elucidate the mechanism by which CB1R blockade reverses dyslipidemia and obesity, with special focus on BAT. Methods and results: Diet-induced obese APOE*3-Leiden.CETP transgenic mice, a well-established model for human-like lipoprotein metabolism, were treated with the systemic CB1R blocker rimonabant (10 mg/kg/day) for 4 weeks. Rimonabant persistently decreased body weight (-25%, p&lt;0.001), fat mass (-32%, p&lt;0.001) and plasma triglyceride (TG) levels (-60%, p&lt;0.05), despite a modest and transient reduction in food intake. Interestingly, rimonabant reduced plasma TG levels, not by affecting VLDL-TG production by the liver, but rather by selectively increasing VLDL-TG clearance by BAT (+40%, p&lt;0.05). This was accompanied by increased energy expenditure (+20%, p&lt;0.05), decreased lipid droplet size and increased UCP1 content in BAT (+28%, p&lt;0.05), all pointing to increased BAT activity. Next, we demonstrated that the CB1R is highly expressed in BAT and that in vitro blockade of the CB1R in cultured brown adipocytes resulted in 2.5-fold upregulation of UCP1. Importantly, the in vivo results could be fully recapitulated using the strictly peripheral CB1R antagonist AM6545 (10 mg/kg/day) that does not induce hypophagia. Conclusion: CB1R blockade reduces dyslipidemia and obesity by peripheral activation of BAT. Selective targeting of peripheral CB1R in BAT has thus great therapeutic potential in decreasing dyslipidemia and obesity and ultimately cardiovascular diseases.

Impact of the hepatic branch of the vagus and Roux-en-Y gastric bypass on the hypoglycemic effect and glucagon-like peptide-1 in rats with type 2 diabetes mellitus

BackgroundThe impact of the hepatic branch of the vagus and Roux-en-Y gastric bypass (RYGB) on the hypoglycemic effect and glucagon-like peptide-1 (GLP-1) in rats with type 2 diabetes mellitus (T2DM) was investigated, and interactions were preliminarily analyzed. MethodsA total of 45 rats with T2DM were divided into four groups: sham operation (S, n = 10), sham operation with the hepatic branch of the vagus resected (SV, n = 11), RYGB (n = 12), and RYGB without preservation of the vagus (RYGBV, n = 12). Body mass, fasting blood glucose (FBG), fasting serum insulin, and concentrations of fasting serum GLP-1 were examined in the first, second, fourth, and eighth week before and after surgery. The effects of RYGB and the hepatic branch of the vagus on GLP-1 levels in the eighth postoperative week were also analyzed. ResultsRYGB caused a significant reduction in the weight of rats with T2DM (P < 0.05), improved the levels of serum GLP-1 and insulin (P < 0.05), and decreased FBG level (P < 0.05). Retention of the hepatic branch of the vagus maintained weight reduction for a longer period (P < 0.05) and increased the levels of serum GLP-1 and insulin (P < 0.05), but had no impact on FBG level (P > 0.05). ConclusionsRYGB had better therapeutic efficacy in rats with T2DM. Care should be taken during RYGB surgery to preserve the hepatic branch of the vagus.

Dieta hipoglucídica en el tratamiento de la diabetes tipo 2

The low carbohydrate diet was introduced in the 1960's, in the middle of the biggest controversies in the field of nutrition: Are fats or sugars primarily responsible for obesity and most cardiovascular risk factors that accompany it? The official academic stance opted for the former, ignoring any other option. However, in recent years different types of diets low in carbohydrates have been observed, which, due to their results and proven safety, have become very popular. The scientific world has finally shown interest in them. These diets achieve their goals, mainly due to its greater adherence, increased thermogenesis, increased satiety and postprandial hyperinsulinemia reduction. This would lead to a maintained weight reduction and improvement in several cardiovascular risk factors. However, most studies show a wide disparity in the carbohydrate content (5%-40%), thus it is necessary to specify and correctly define this type of diet, in order to serve as a basis for developing further studies. The greatest benefits of this diet have been documented in type 2 diabetes, particularly in the metabolic syndrome, polycystic ovary syndrome and non-alcoholic hepato-steatosis.

Should lifestyle modifications be promoted to prevent breast cancer?

Should lifestyle modifications be promoted to prevent breast cancer?

Weight changes in type 2 diabetes and the impact of gender

Many studies suggest that weight gain occurs during treatment of type 2 diabetes, irrespective of the treatment type. The aim of this study was to address the questions (i) whether weight gain is inevitable in patients treated for type 2 diabetes, and (ii) whether treatment escalation is prompted by a rise in glycaemic control [haemoglobin A 1c (HbA 1c)] or weight gain. A diabetes database was used to identify all patients with type 2 diabetes attending our clinic between 1 January 1990 and 31 December 2000. To facilitate further analysis, independent anonymized database resources were established. Data collected included height, weight, gender, HbA(1c), age and diabetes treatment at each visit. One thousand and eighty-four patients were included; after 6 months of treatment, patients' average weight had reduced by 1.0 kg (s.d. 4.6) (p < 0.001). Sixty per cent of the patients had either a decrease or no change in weight, while 40% demonstrated a weight gain. Women demonstrated more weight loss than men. After a mean follow-up of 50 months (s.d. 25.7), 439 patients (40%) who received treatment with diet alone, diet followed by metformin or metformin alone demonstrated a maintained weight reduction in addition to improved glycaemic control. A rise in HbA(1c) rather than weight gain prompted treatment change. This study provides evidence that weight gain is not a necessary consequence of the treatment of type 2 diabetes. Women were more successful than men in losing weight, and diet, with or without the addition of metformin, was the treatment type most usually associated with weight loss.

Use of a time-restricted access to food diet to achieve and maintain weight reduction in mice.

Recent years have seen the development of mouse models of a wide range of psychological disorders and afflictions to the central nervous system, including Alzheimer's disease, anorexia nervosa, abnormal anxiety, attention deficit hyperactivity disorder, autism, major depression, Fragile X Syndrome, Huntington's disease, obsessive-compulsive disorder, Parkinson's disease, schizophrenia, and Tourette's syndrome. Mouse models are used chiefly to study neurophysiological processes, but behavior is sometimes studied as well. One reason to study the behavior is to help establish the validity of the model: Do the mice manifest the expected behavioral abnormalities? Furthermore, the study of behavior may provide new insights into underlying neurophysiological processes. Behavior also affords a means to measure the efficacy of treatments designed to prevent, mitigate or reverse neurophysiological abnormalities. Behavior analysts have taken an increasing interest in mice as research subjects to judge from recent publications in The Journal of the Experimental Analysis of Behavior (e.g., Belke & Garland, 2007; Leslie, Shaw, Gregg, McCormick, Reynolds, & Dawson, 2005; McKerchar, Zarcone, & Fowler, 2005; Papachristos & Gallistel, 2006; Zarcone, Chen, & Fowler, 2007). However, behavior analytic animal research traditionally has been conducted with pigeons and rats, and unfamiliarity with mice may deter some from pursuing research with mouse models. To help remedy this concern, we examined whether time-restricted feeding procedures would provide a simple means of allowing researchers to achieve and maintain an appropriate level of food deprivation in mice. There are two basic strategies used to establish food deprivation in operant research. One strategy is to restrict the amount of food subjects are allowed to consume and the other is to restrict the length of time subjects are allowed to eat (as shorthand, these are referred to below as and diets, respectively). Under the former approach, subjects are weighed daily and the size of the food ration is adjusted to maintain weights at a given level (and by extension, ensure a constant level of food deprivation). Hurwitz and Davis (1983) observed that this procedure quickly predominated behavior-analytic animal research, although it is not without disadvantage. The restricted-amount procedure requires that subjects be housed individually to ensure that all subjects receive the appropriate of food. This, in turn, limits research on social processes. The restricted-amount procedure is also impractical to implement because the weight of both the subject and the food ration must be carefully monitored. The difficulty of calculating an appropriate amount of food is compounded if the amount of food subjects earn during data collection is inconstant or if data collection is not performed daily. In view of the shortcomings of the restricted-amount procedure, Hurwitz and Davis recommended that researchers use instead the restricted-time procedure. Hurwitz and Davis demonstrated the relative advantages of this approach using six, male, Long-Evans rats. Subjects had food access for 1 or 2 hours each day (1 hr when the food was placed inside the subjects' cages, 2 hrs when the food was available through an external wire-mesh hopper). They found that when the procedure was introduced, subjects lost approximately 20% of their free-feeding weights, achieving in a few days the 80% level of weight reduction used in many animal studies. Continued use of the procedure, however, did not result in further weight loss, and by the end of 20 days of observations, mean weights had stabilized to 78.5% of free-feeding levels. Hurwtiz and Davis found that the procedure was effective even when subjects could obtain additional food during experimental sessions with a variable-interval schedule of reinforcement. …

Total knee replacement in morbidly obese patients

The results of 41 consecutive total knee replacements performed on morbidly obese patients with a body mass index > 40 kg/m(2), were compared with a matched group of 41 similar procedures carried out in non-obese patients (body mass index < 30 kg/m(2)). The groups were matched for age, gender, diagnosis, type of prosthesis, laterality and pre-operative Knee Society Score. We prospectively followed up the patients for a mean of 38.5 months (6 to 66). No patients were lost to follow-up. At less than four years after operation, the results were worse in the morbidly obese group compared with the non-obese, as demonstrated by inferior Knee Society Scores (mean knee score 85.7 and 90.5 respectively, p = 0.08; mean function score 75.6 and 83.4, p = 0.01), a higher incidence of radiolucent lines on post-operative radiographs (29% and 7%, respectively, p = 0.02), a higher rate of complications (32% and 0%, respectively, p = 0.001) and inferior survivorship using revision and pain as end-points (72.3% and 97.6%, respectively, p = 0.02). Patients with a body mass index > 40 kg/m(2) should be advised to lose weight prior to total knee replacement and to maintain weight reduction. They should also be counselled regarding the inferior results which may occur if they do not lose weight before surgery.

Short-term meal replacements followed by dietary macronutrient restriction enhance weight loss in polycystic ovary syndrome

Polycystic ovary syndrome (PCOS), a common condition in women, improves with weight loss. Meal replacements in short-term weight loss and strategies for weight maintenance have not been investigated in PCOS. We compared in overweight women with PCOS the effects of meal replacements in short-term weight-loss and longer-term carbohydrate- or fat-restriction strategies on weight maintenance and improvements in reproductive and metabolic variables. Overweight women with PCOS (n = 43; x +/- SD age: 32.1 +/- 5.2 y; weight: 96.1 +/- 18.4 kg) followed an 8-wk weight-loss regimen (2 meal replacements/d, 4904.4 +/- 127 kJ; phase 1) and then a 6-mo weight-maintenance carbohydrate- (<120 g/d) or fat- (<50 g/d) restriction regimen (phase 2). Thirty-four women completed phase 1, and 23 women completed phase 2; the proportion of dropouts was similar in the 2 groups. During phase 1, significant (P < 0.05) reductions in weight (5.6 +/- 2.4 kg), waist circumference (6.1 +/- 2.5 cm), body fat (4.1 +/- 2.2 kg), insulin (2.8 +/- 1.1 mU/L), total testosterone (0.3 +/- 0.7 nmol/L), and free androgen index (3.1 +/- 4.6) occurred; these changes were sustained during phase 2. No significant differences between diet groups were seen for any variables. At 6 mo, both approaches resulted in a net weight loss of 4.7 +/- 4.6 kg. Improvements in menstrual cyclicity occurred for 16 (57.1%) of 28 subjects. Meal replacements are an effective strategy for the short-term management of PCOS. Advice on moderate fat or carbohydrate restriction was equally effective in maintaining weight reduction and improving reproductive and metabolic variables.

What Becomes of Patients One Year after the Intragastric Balloon has been Removed?

The BioEnterics Intragastric Balloon (BIB) is a saline-filled balloon recommended to remain in the gastric cavity for a maximum of 6 months. Is this short period sufficient to change patients' lifestyle and eating practices to maintain weight reduction after BIB removal? 100 patients who received a BIB were included in this prospective study and followed for 1 year after BIB removal. The post-implantation follow-up visits took place monthly, during which the patient was seen by the surgeon, dietitian, and if necessary, psychologist. At BIB removal, mean weight loss for the group was 12.0 kg. Mean percent excess weight loss (%EWL) was 39.8%. 12 months after removal of the BIB, mean weight loss was 8.6 kg and mean %EWL was 26.8% for the group as a whole. The results 1 year after removal of the BIB were encouraging. Because the BIB is a temporary non-surgical and non-pharmaceutical treatment for obesity that is reversible and repeatable, we recommend it to patients who have previously failed traditional methods of weight reduction. Careful patient follow-up is of primary importance in avoiding complications and supporting efficacy of the treatment. Although 1 year follow-up cannot be considered long term, these results are encouraging. Concurrent behavior modification is needed for durable weight loss.