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    <recommendedItem id="20100101_19_466"
                     title="Surgery Trumps Lifestyle Change for Teen Weight Loss (CME/CE)"
                     score="0.013"
                     href="http://www.medpagetoday.com/Pediatrics/Obesity/tb/18397?impressionId=1265799155653"
                     
      &lt;p&gt;Gastric banding resulted in significantly greater weight loss in obese teens than an intensive lifestyle modification program, a randomized trial showed.&lt;/p&gt;
&lt;p&gt;In the two-year study, 84% of patients in the surgery group lost at least half of their excess weight, compared with 12% who underwent the lifestyle intervention (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001), according to Paul O&apos;Brien, MD, of Monash University in Melbourne, Australia, and colleagues.&lt;/p&gt;
&lt;p&gt;None of the teens who had surgery had metabolic syndrome at the end of follow-up, compared with 22% in the control group (&lt;em&gt;P&lt;/em&gt;=0.025), the researchers reported in the Feb. 10 issue of the &lt;em&gt;Journal of the American Medical Association&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Although the improvements were substantial, O&apos;Brien and his colleagues stressed that &quot;the gastric banding approach to weight loss is not a quick fix.&quot;&lt;/p&gt;
&lt;p&gt;&quot;For optimal effectiveness,&quot; they wrote, &quot;it requires long-term supportive follow-up by trained health professionals.&quot;&lt;/p&gt;
&lt;p&gt;They also noted that the study demonstrates that lifestyle interventions can be effective for some teens and should remain the first option.&lt;/p&gt;
&lt;p&gt;Surgeons contacted for comment on the study unanimously touted the results as evidence that bariatric surgery can be a safe and effective means of weight loss for obese adolescents, a topic that remains controversial.&lt;/p&gt;
&lt;p&gt;J. Christopher Eagon, MD, a bariatric surgeon at Washington University in St. Louis, noted in an e-mail that the significance of the study lies in the fact that participants were randomized between surgery and medical management of weight.&lt;/p&gt;
&lt;p&gt;&quot;This helps to eliminate biases that may have been present in other studies of the effectiveness of bariatric surgery and should make the case for the benefits of surgery more compelling,&quot; Eagon wrote.&lt;/p&gt;
&lt;p&gt;There are more than five million obese adolescents in the U.S., according to O&apos;Brien and his colleagues, and obesity-related complications, once rare in pediatric populations, are becoming more common.&lt;/p&gt;
&lt;p&gt;Because of the generally disappointing results of lifestyle programs aimed at improving diet, increasing exercise, and modifying unhealthy behaviors, bariatric surgery, widely used in adults, has been explored as a strategy for reducing weight in these patients.&lt;/p&gt;
&lt;p&gt;But no randomized trials of bariatric surgery had been conducted in adolescents.&lt;/p&gt;
&lt;p&gt;So O&apos;Brien&apos;s group randomized 50 obese teens ages 14 to 18 (mean 16.5) to laparoscopic adjustable gastric banding or an intensive, supervised lifestyle modification program.&lt;/p&gt;
&lt;p&gt;The participants all had a body mass index of at least 35 kg/m&lt;sup&gt;2&lt;/sup&gt; and had obesity-related complications, such as hypertension, metabolic syndrome, asthma, back pain, physical limitations, and psychosocial difficulties.&lt;/p&gt;
&lt;p&gt;All had previously failed to lose weight through lifestyle changes.&lt;/p&gt;
&lt;p&gt;Before the study began, prospective participants attended a two-month program teaching them about healthy eating and the importance of physical activity.&lt;/p&gt;
&lt;p&gt;Those randomized to the lifestyle intervention were on a diet of 800 to 2,000 calories a day, and were instructed to increase activity and decrease sedentary behavior at regular visits with a physician, dietitian, exercise coordinator, nurse, and sports medicine physician. The program included six weeks with a personal trainer.&lt;/p&gt;
&lt;p&gt;Teens in the surgery group were given instructions on correct eating and exercising at regular visits.&lt;/p&gt;
&lt;p&gt;Through two years, all but one of the teens in the surgery group completed the study; 18 of 25 in the lifestyle group completed.&lt;/p&gt;
&lt;p&gt;The mean weight loss was significantly greater in the surgery group (76.3 pounds versus 6.6), which equated to a significantly greater percentage of excess weight lost (78.8% versus 13.2%).&lt;/p&gt;
&lt;p&gt;The mean decrease in BMI was 12.7 kg/m&lt;sup&gt;2&lt;/sup&gt; in the surgery group and 1.3 kg/m&lt;sup&gt;2&lt;/sup&gt; in the lifestyle modification group.&lt;/p&gt;
&lt;p&gt;All differences were significant at &lt;em&gt;P&lt;/em&gt;&amp;lt;0.001.&lt;/p&gt;
&lt;p&gt;Insulin sensitivity improved in both groups, but to a larger extent in the surgery group (&lt;em&gt;P&lt;/em&gt;&amp;lt;0.001).&lt;/p&gt;
&lt;p&gt;Quality of life was also improved in the surgery group.&lt;/p&gt;
&lt;p&gt;Overall, adverse events occurred at similar rates in the surgery (48%) and lifestyle modification (44%) groups.&lt;/p&gt;
&lt;p&gt;There were no perioperative adverse events in the surgery group, but seven patients required revisional procedures during follow-up, for proximal pouch dilatation or tubing injury.&lt;/p&gt;
&lt;p&gt;The researchers said eating small meals slowly is an important way to avoid these problems.&lt;/p&gt;
&lt;p&gt;In an accompanying editorial, Edward Livingston, MD, a surgeon at the University of Texas Southwestern Medical Center in Dallas, said the high rate of revisional procedures is significant because the study authors &quot;are among the most experienced group in the world with these operations, suggesting that these complication rates will probably be higher in actual community practice.&quot;&lt;/p&gt;
&lt;p&gt;Added Jonathan Schoen, MD, a bariatric surgeon at the University of Colorado Hospital in Denver, in an e-mail: &quot;One thing to keep in mind is that the results they get in Australia with the band are the best in the world and are not uniformly reproducible.&quot;&lt;/p&gt;
&lt;p&gt;In addition to the uncertain generalizability to other settings, the researchers said the study may be limited by its length, which may not be long enough to assess outcomes from the surgery over time.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was funded by a grant from the National Health and Medical Research Council. The laparoscopic adjustable gastric bands used in the study were provided by the manufacturer, Allergan. The Center for Obesity Research and Education receives an unrestricted research support grant from Allergan.&lt;/p&gt;&lt;p&gt;O&apos;Brien did not make any financial disclosures. One of his co-authors reported having relationships with Allergan, Bariatric Advantage, Scientific Intake, SP Health Co., Optifast, Abbott Australasia, Eli Lilly Australia, Merck Sharp &amp;amp; Dohme Australia, Nestle Australia, and Roche Products Australia.&lt;/p&gt;&lt;p&gt;Livingston did not make any financial disclosures.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;&lt;p&gt;&lt;em&gt;This article was developed in collaboration with ABC News. &lt;/em&gt;&lt;img src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; mce_src=&quot;http://www.medpagetoday.com/upload/2009/10/1/14357_1.jpg&quot; alt=&quot;&quot;&gt;&lt;/p&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_391"
                     title="Rare Genetic Deletion Linked to Morbid Obesity (CME/CE)"
                     score="0.01"
                     href="http://www.medpagetoday.com/Genetics/GeneralGenetics/tb/18286?impressionId=1265799155653"
                     
      &lt;p&gt;Missing sections of DNA may have a powerful impact on weight for a small segment of the population, researchers said.&lt;/p&gt;
&lt;p&gt;Nearly all teens and adults found to have a particular deletion of roughly 30-genes on chromosome 16p11.2 were obese  --  most morbidly so  --  with a body mass index of at least 40 kg/m&lt;sup&gt;2&lt;/sup&gt;, Philippe Froguel, MD, PhD, of Imperial College London, and colleagues reported in &lt;em&gt;Nature&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;While the variant appeared to explain only a small proportion of morbid obesity  --  0.7% in the study population  --  it was never present in healthy, normal-weight controls.&lt;/p&gt;
&lt;p&gt;&quot;Although the recent rise in obesity in the developed world is down to an unhealthy environment, with an abundance of unhealthy food and many people taking very little exercise, the difference in the way people respond to this environment is often genetic,&quot; Froguel said in a prepared statement.&lt;/p&gt;
&lt;p&gt;But with further findings like these, it may be possible to identify such individuals through genetic testing, he said.&lt;/p&gt;
&lt;p&gt;If so, &quot;We can then offer them appropriate support and medical interventions, such as the option of weight-loss surgery, to improve their long-term health,&quot; Froguel declared.&lt;/p&gt;
&lt;p&gt;Although researchers speculate that one in 20 cases of obesity may have a genetic cause, the genetic component remains largely elusive.&lt;/p&gt;
&lt;p&gt;Even accounting for such a small fraction of cases, the newly discovered 16p11.2 variant would be the second most frequent known genetic cause of obesity, Froguel&apos;s group said.&lt;/p&gt;
&lt;p&gt;Extensive genome-wide association studies have linked numerous single nucleotide polymorphisms (SNPs) to obesity, but added all together they account for only a small fraction of the known heritable component, the researchers said.&lt;/p&gt;
&lt;p&gt;&quot;The &apos;common disease, common variant&apos; hypothesis is increasingly coming under challenge,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Their team first identified the genetic deletion in teen and adults with learning difficulties or delayed development.&lt;/p&gt;
&lt;p&gt;Because the 31 individuals who had the nearly identical deletions of at least 593 kilobases at chromosome 16p11.2 in one copy of their DNA all had a BMI of over 30 kg/m&lt;sup&gt;2&lt;/sup&gt;, the researchers decided to dig a little deeper.&lt;/p&gt;
&lt;p&gt;&quot;Cohorts with extreme phenotypes that include obesity may be enriched for rare but very potent risk variants,&quot; making them easier to discover, they wrote.&lt;/p&gt;
&lt;p&gt;So they undertook a case-control study among 312 patients at three centers in Britain and France who presented with congenital malformations, developmental delay, or both, in addition to obesity.&lt;/p&gt;
&lt;p&gt;The same deletions were seen in 2.9% of these individuals.&lt;/p&gt;
&lt;p&gt;The function of the missing genes are not well known, but some have previously been associated with delayed development, autism, and schizophrenia.&lt;/p&gt;
&lt;p&gt;Notably, though, the frequency of deletion of these genes in the obese case-control cohort was &quot;appreciably higher&quot; than the less than 1% seen in the autism and other studies that didn&apos;t include obesity as an inclusion criteria, the researchers said.&lt;/p&gt;
&lt;p&gt;A second independent survey of genetic data at eight cytogenetic centers in France, Switzerland, and Estonia turned up a 0.6% rate among 3,947 people with developmental delay, malformations, or both, but who were not selected for obesity (&lt;em&gt;P&lt;/em&gt;=0.00022 versus the cohort selected for obesity).&lt;/p&gt;
&lt;p&gt;Analysis of those with the missing genes revealed an age-dependent link to weight: All four teens and adults were obese. Children were often obese (four of 15) or overweight (two of 15). Children under 2 years all had normal weight.&lt;/p&gt;
&lt;p&gt;So to see whether the deletion was independent of neurodevelopmental problems, Froguel&apos;s group examined genome-wide association study data from general population cohorts totaling 11,856 individuals along with 2,772 from childhood obesity and adult morbid obesity case-control studies, 931 in an extreme early-onset obesity study, and 141 who had bariatric weight-loss surgery.&lt;/p&gt;
&lt;p&gt;All adult carriers of the deletion were obese with the exception of one who was apparently diabetic. Each of the seven children and adolescents who carried the variant had a BMI in the top 0.1% for their age and gender.&lt;/p&gt;
&lt;p&gt;None had any reported developmental or cognitive problems. Four had reported hyperphagia with excessive hunger and food intake.&lt;/p&gt;
&lt;p&gt;Altogether, the 16p11.2 deletions predicted 29.8-fold elevated risk of obesity (&lt;em&gt;P&lt;/em&gt;=0.00000058) and 43.0-fold elevated risk of morbid obesity (&lt;em&gt;P&lt;/em&gt;=0.000000064) compared with lean or normal weight.&lt;/p&gt;
&lt;p&gt;By extrapolation, the researchers extrapolated that about 0.4% of all morbidly obese cases are attributable to an inherited 16p11.2 deletion, with 0.3% arising from a de novo deletion in the same genetic region.&lt;/p&gt;
&lt;p&gt;&quot;Although they may be heterogeneous in nature, these deletions are highly likely to be the causal variants,&quot; they wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The study was supported by &quot;Le Conseil Regional Nord Pas de Calais/FEDER&quot; along with various governmental and industry supporters for the various component studies.&lt;/p&gt;&lt;p&gt;The researchers reported no financial conflicts of interest.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20100101_19_183"
                     title="Gastric Bypass Extends Life for Most Patients (CME/CE)"
                     score="-0.002"
                     href="http://www.medpagetoday.com/PrimaryCare/Obesity/tb/18020?impressionId=1265799155653"
                     
      &lt;p&gt;For most patients in most categories, bariatric surgery increases life expectancy, according to a new mathematical model.&lt;/p&gt;
&lt;p&gt;Only when short-term mortality following bariatric surgery is expected to be high or the likelihood of success is low will the procedure fail to improve life expectancy, researchers reported in the January &lt;em&gt;Archives of Surgery&lt;/em&gt;.&lt;/p&gt;
&lt;p&gt;Computer modeling predicted that a hypothetical &quot;base case&quot; patient  --  a 42-year-old woman with a body mass index of 45  --  would gain 2.95 years of additional survival following bariatric surgery, according to Daniel P. Schauer, MD, of the University of Cincinnati, and colleagues.&lt;/p&gt;
&lt;p&gt;Surgery failed to be beneficial in the model only when 30-day mortality reached 9.5% or the likelihood that surgery would not add life-years was 2% or less, they found.&lt;/p&gt;
&lt;p&gt;Baseline 30-day mortality in the model was 0.2%, and the baseline efficacy of surgery in extending life expectancy was 53%.&lt;/p&gt;
&lt;p&gt;&quot;While not all patients are guaranteed a good outcome, our model indicates that gastric bypass increases life expectancy for most patient subgroups,&quot; they concluded.&lt;/p&gt;
&lt;p&gt;Their analysis was based on a Markov decision model using published data to estimate 30-day mortality following bariatric surgery and the efficacy of surgery in reducing long-term death rates.&lt;/p&gt;
&lt;p&gt;The latter had two components: reduction in excess mortality associated with obesity, and research data on long-term mortality following bariatric surgery.&lt;/p&gt;
&lt;p&gt;Excess mortality estimates came from National Health Interview Survey data on some 400,000 participants from 1991 to 1996 linked to the National Death Index. Inputs on surgery efficacy were derived from a 2007 study of nearly 8,000 patients who had undergone gastric bypass and the same number of medically treated or untreated obese controls.&lt;/p&gt;
&lt;p&gt;That study found that the procedure cut death rates by half during about seven years of follow-up. (See &lt;a href=&quot;http://www.medpagetoday.com/PrimaryCare/Obesity/6480&quot; mce_href=&quot;http://www.medpagetoday.com/PrimaryCare/Obesity/6480&quot; target=&quot;_blank&quot;&gt;Missing Link Found: Bariatric Surgery Reduces Mortality&lt;/a&gt;)&lt;/p&gt;
&lt;p&gt;Schauer and colleagues obtained rates of inhospital mortality following bariatric surgery from the 2005 National Inpatient Survey, then multiplied them by three to estimate 30-day mortality.&lt;/p&gt;
&lt;p&gt;The researchers explained that according to earlier research, inhospital death rates typically underestimate 30-day mortality by a factor of two to three.&lt;/p&gt;
&lt;p&gt;Their threefold correction factor represents &quot;a conservative estimate that biases the model against gastric bypass surgery,&quot; they wrote.&lt;/p&gt;
&lt;p&gt;Schauer and colleagues tested this correction factor and other aspects of the model in sensitivity analyses.&lt;/p&gt;
&lt;p&gt;The biggest gains in life expectancy occurred in younger women with relatively high BMI values, the model showed.&lt;/p&gt;
&lt;p&gt;The age effect was less important than BMI at the time of surgery. A 35-year-old woman with BMI of 45 would gain about 3.2 years of extra life, whereas at 55, a similarly obese woman would gain about 2.5 extra years.&lt;/p&gt;
&lt;p&gt;But a 35-year-old woman with BMI of 55 could expect to live five more years with surgery, the model indicated.&lt;/p&gt;
&lt;p&gt;Men in general derived less survival benefit from bariatric surgery, particularly with advancing age at the time of the procedure.&lt;/p&gt;
&lt;p&gt;At 35, the difference in life expectancy gained was roughly 10%, but by age 75 it had grown to about 50%.&lt;/p&gt;
&lt;p&gt;The sensitivity analyses found that relatively large changes in most parameters used in the model did not affect the overall results substantially.&lt;/p&gt;
&lt;p&gt;The effect of 30-day mortality on whether or not surgery was beneficial for long-term survival was related to BMI and gender.&lt;/p&gt;
&lt;p&gt;For women with a BMI of 40, 30-day mortality of more than 5% would mean surgery was not helpful, but short-term mortality had to exceed 15% for surgery not to be preferable for those with BMI of 55 or more. These thresholds were about 10% higher for men.&lt;/p&gt;
&lt;p&gt;The efficacy of surgery in reducing mortality was less important for older men, the analysis also showed. A 75-year-man with a BMI of 35 could expect only a very slight gain in life span  --  perhaps one or two months.&lt;/p&gt;
&lt;p&gt;&quot;Younger patients have lower surgical risk and more time over which to realize the benefits of surgery. For older patients, the gain is smaller, and for some, gastric bypass surgery will decrease life expectancy,&quot; Schauer and colleagues wrote.&lt;/p&gt;
&lt;p&gt;However, they identified several potentially serious limitations to the analysis.&lt;/p&gt;
&lt;p&gt;The study of long-term mortality following bariatric surgery was conducted at a single center and was not randomized. Additionally, long-term complications, such as need for repeat surgery, were not addressed in the model. Certain other risks that might be heightened after bariatric surgery were excluded as well, and quality of life was not modeled.&lt;/p&gt;
&lt;p&gt;&quot;The decision analysis presented here is a step forward in understanding optimal patient selection but also highlights some of the areas for which better data are needed,&quot; the researchers wrote.&lt;/p&gt;
&lt;div style=&quot;float:left;border-style:solid;border-width:1px;border-color:#8dabbc;font-family:arial;font-size:12px;background-color:#DBE9F2;padding:5px;&quot;&gt;&lt;p&gt;The National Institute of Diabetes and Digestive and Kidney Diseases funded the study.&lt;/p&gt;&lt;p&gt;No potential conflicts of interest were reported.&lt;/p&gt;&lt;/div&gt;&lt;div style=&quot;clear:both;&quot;&gt;&lt;/div&gt;
    </recommendedItem>
    <recommendedItem id="20090101_6_236"
                     title="Preoperative Endoscopy Suggested for Asymptomatic Bariatric Surgery Patients"
                     score="-0.005"
                     href="