Bariatric surgery before pregnancy – Is this a solution to a big problem?
In the UK, 33% of pregnant women are overweight or obese and may experience gestational diabetes. Bariatric surgery commonly leads to greater and more sustained weight loss than do lifestyle approaches, and evidence that bariatric surgery can prevent, treat, or even “reverse” type 2 diabetes has increased enthusiasm for its use prior to pregnancy. However, there are also concerns that potential malnutrition or malabsorption resulting from these surgeries may lead to pregnancy complications.
In this article from America, pregnancy outcomes were examined in women from 2006 to 2011 who underwent bariatric surgery prior to pregnancy as compared with matched controls. (Early-pregnancy BMI in the control cohort was matched to pre-surgery BMI in the bariatric-surgery cohort). As compared with controls, women with a history of bariatric surgery had significantly lower incidences of gestational diabetes.
Obstetricians will most likely be seeing an increasing number of women who have undergone bariatric surgery before pregnancy although women are advised to delay conceiving until 12 to 24 months after surgery. But the current data, combined with previous reports, suggest that it may be prudent to monitor foetal growth in women who have undergone bariatric surgery, particularly in those who have had gastric bypass surgery.
The current study underscores that bariatric surgery has the potential to reduce the risks of gestational diabetes and large-for-gestational-age neonates but is also associated with some risks in pregnancy such as preterm birth, stillbirth, neonatal death, and major congenital malformations. Decisions regarding bariatric surgery in women of reproductive age should take into account the benefits and risks associated with this, not inconsequential procedure in terms of both pregnancy and long-term health.
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New function of obesity gene revealed
In research published by the New England Journal of Medicine, scientists at Harvard and MIT found that by tweaking certain pieces of the DNA code in the gene region responsible for coding the fat mass and obesity-associated protein, known popularly as the “FTO gene” or the “obesity gene”, they could cause the body to accelerate metabolism and burn excess fat that otherwise would have remained stored.
The FTO region harbours the strongest genetic association with obesity, yet the basis of this association remains elusive. To test how faulty genetics were at play in weight gain, the researchers took fat samples from Europeans holding both the variant of the FTO gene region linked to obesity and a normal FTO gene. They discovered that, in those with obesity, the DNA code of the FTO gene was activating two other associated genes, IRX3 and IRX5. Those genes, in turn, were preventing fat from being burnt through a process known as thermogenesis, where fat cells get rid of energy in the form of heat, instead of storing it as fat. This happens naturally in those with healthy FTO gene regions.
Testing on mice using the Crispr/Cas9 system, which edits the faulty DNA code to the correct sequence, the scientists were able to install the correct code, thereby preventing the body from storing excess fat. The process has so far proved successful in reversing obesity in mice, but is yet to be tested on humans.
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Chillies becoming hot topic in fight against obesity
Researchers in Australia have investigated the association between hot chilli pepper receptors (TRPV1) and the feeling of fullness in mice. As the stomach fills it begins to stretch, which activates nerves that inform the body that the stomach is filling and when it has reached capacity. The researchers found that this activity is regulated by TRPV1 receptors, also known as hot chilli pepper receptors. This builds on previous knowledge that capsaicin, the chemical that makes chillies hot, reduces food intake in humans.
The study also found that deletion of TRPV1 receptors dampened the response of gastric nerves to stretch. This resulted in a delayed feeling of fullness and consumption of more food, showing that the capsaicin mechanism is potentially vital in controlling how much food we eat. Dr Stephen Kentish, one of the study authors, hopes to ‘see how feasible this is as a potential treatment not just for obesity itself but maybe in the prevention of gaining weight.’ These exciting findings could inform further research in this area and lead to the development of novel therapies.
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Anti-fat bias from teachers
Obese people are often the target of stigmatisation and discrimination, they are sometimes stereotyped as lazy and unmotivated. There has been research into these kinds of behaviours towards adults, however the extent of weight stigmatisation amongst children in schools has received less attention. A recent report, carried out at the University of Newcastle in Australia, has shown that physical education (PE) teachers have strong anti-fat biases. The study tested 240 trainee PE teachers and non-PE trainees for explicit bias – negative views that they admitted – and implicit bias – using techniques such as word association to see what perceptions they associated with overweight.
Whilst many schools continue to encourage children to lead healthy lifestyles, the evidence shows that the raised awareness of obesity may actually be increasing the stigma associated with it. Interestingly, the study also showed that the trainees almost expect the children to underperform, even in things that don’t have anything to do with obesity, such as verbal reasoning skills. The study was unable to determine whether the teachers entered their programmes with pre-formed bias, or whether the bias developed over their time in training. School teachers directly influence their children’s behaviours and self-esteem, and this report highlights the fact that schools need to evaluate whether anti-fat bias exists within its staff. If the results are affirmatory, then appropriate staff development programmes need to be created that raise awareness not only for obesity, but for the stigmatisation that accompanies it.
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Tesco weigh in on obesity crisis
Tesco is axing sugary drinks that target children. This would see some of Britain’s best-selling brands, such as Ribena and Capri-Sun disappear from shelves from September 2015. This move comes after Public Health England published a report entitled ‘Carbohydrates and Health’, calling for a 20% tax on sugary drinks to help combat obesity. David Beardmore, Tesco’s soft drinks director explained that the “supermarket is removing the drinks from its shelves as part of negotiations for a range overhaul of its children’s juice category”. The ban is not across all forms of sugary drinks, the focus will be small cartons and bottles of added sugar drinks that commonly see their way into children’s lunch boxes.
In a statement, regarding the decision, Tesco said: “We want to help our customers make healthier choices and that’s why we have pledged to continue to cut sugar from the food and drink on our shelves. From September all the children’s juice drinks we sell will have no added sugar in them because we know it’ll make a positive difference to children’s health.”
Read more here and here
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Benefits of laparoscopic sleeve gastrectomy diminish with time
Five years after weight loss surgery, patients can regain the weight that they had initially lost, according to a recent Israeli study. It has long been known that surgery remains an effective treatment for weight loss, however long-term follow-up data remains sparse. Whilst also seeing a gain in weight, a recurrence of diabetes was also noted. The study followed 443 who underwent sleeve gastrectomy. After the first year patients had lost 77% of their original weight, after 5 years the weight loss was only 56%. With regards to the diabetes, 51% saw it disappear in the first year, however by the fifth year only 20% of patients were diabetes-free.
The intention of a sleeve gastrectomy is to reduce the size of the stomach similar to that of a banana. Dr Andrei Keidar, one of the researchers, explains that several reasons could contribute to the fact that weight is regained. “The main reason is that the stomach dilates, meaning you can eat more. The appetite also comes back so patients want to eat more.” Furthermore, he described how the effectiveness of weight loss surgery has a behavioural aspect and “if you don’t change your behaviour, you are going to regain weight”. A large limitation of the study was that many patients dropped out at each stage but the follow-up rates in this study correlate with similar studies of its kind.
The benefits of this weight loss surgery are still relevant as meaningful health changes are seen with just 5% weight loss, so having lost 50% after five years is still going to vastly improve one’s health. More worrying however is the re-occurrence in diabetes.
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Exercise-mimic molecule may help treat diabetes and obesity
A new molecule that acts as an exercise mimicker could potentially treat type 2 diabetes and obesity, according to scientists from the University of Southampton.
The new molecule, compound 14, was developed by Professor Ali Tavassoli. The molecule blocks the function of the cellular enzyme ATIC, which holds an important role in metabolism. The blocking of ATIC leads to an accumulation of a molecule called ZMP (5-aminoimidazole-4-carboxamide ribonucleotide) in cells, activating the cells’ main energy sensor, an enzyme called AMP-activated protein kinase (AMPK) that monitors and responds to changes in the intracellular AMP/ATP ratio. Activation of AMPK causes the cells to believe that they are low in energy, which forces the cells to increase energy levels by boosting the metabolism and increasing the uptake of glucose from the blood stream.
The study, recently published in Chemistry and Biology, tested compound 14 on a mouse model of metabolic syndrome to show therapeutic viability.
“The issue is that established drugs do not successfully enable patients with type 2 diabetes to achieve glycaemic control and some can even result in weight gain, a leading factor driving the diabetes epidemic. In contrast, this new molecule seems to reduce glucose levels and at the same time decrease body weight, but only if the subject is obese,” says co-author Dr. Felino Cagampang.
This study still warrants further research to determine how compound 14 works on treating type 2 diabetes and obesity in mice, and if this can be applied to humans, particularly if there are fewer side effects.
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Weight loss – a futile exercise?
This is a conclusion from a large UK-based study conducted over 10 years. The analysis covered nearly 300,000 adults with data taken from the UK Clinical Practice Research Database, which is an anonymised database of longitudinal patient electronic medical records. Being the world’s largest primary care database and containing more than 7% of the UK population, the data is thought to be largely representative of the UK.
The study found that the chance of returning to a normal weight whilst being obese was 1 in 210 for men and 1 in 124 for women over a year. In morbidly obese patients these figures were 6 times worse in each group. Additionally, the research found that the probability of obese patients with BMI 30-34.9 (simple obesity) achieving a 5% weight reduction were 1 in 12 for men and 1 in 10 for women, however most had regained this weight and more after 5 years.
The study raised questions against the efficacy of current obesity treatments, saying that ‘current nonsurgical obesity treatments are failing’. It called for research to develop new and much more effective approaches to obesity management programmes that stop further weight gain and maintain weight loss. One of the authors of the paper, Professor Martin Gulliford commented that ‘the greatest opportunity for stemming the current obesity epidemic is in wider-reaching public health policies to prevent obesity in the population’.
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Anxiety about Eating Disorders?
A study, performed by Nadia Micali at UCL and others, on almost six thousand 14 and 16 year olds in the Avon Longitudinal Study of Parents and Children (ALSPAC) found that all eating disorders (EDs) are predictive of later anxiety disorders. EDs are associated with high morbidity and mortality, and a previous study in America had shown them to be associated with depressive symptoms, drug use, binge drinking, and overweight or obesity. This study was conducted with the aim of finding out whether a range of eating disorders, including purging disorder, were prospectively associated with depression, anxiety disorders, substance abuse, and self-harm. It reported that all were associated with depression, and all but anorexia nervosa predicted drug use and self-harm. Those with anorexia nervosa were more likely to be underweight, but those with binge eating disorder and bulimia nervosa were more likely to be overweight or obese. Furthermore, the study found that the prevalence of eating disorders almost doubled between the ages of 14 and 16.
The study recommended improving identification of adolescents with eating disorders and behaviours in the community and delivering early intervention programmes, thereby identifying any risk of development into a full blown eating disorder and also limiting the chances of mental health problems in the future. It has highlighted how much of an effect eating disorders have on the general health of the public, whilst also showing that more needs to be done to curb adolescent eating disorders in order to protect their future.
Read MoreIs bariatric surgery justified for the super-obese elderly?
Ample evidence supports the safety and effectiveness of bariatric surgery in the general adult population, but more information is needed in patients age 60 years and older (elderly). In England, in 2012/13, the annual Health and Social Care Information Centre (HSCIC) statistics show over 8,000 bariatric surgery procedures were performed. Many more surgical procedures were carried out on women than men (in 2012/13, 6,080 for women and 1,944 for men).
There has been no data until now on the efficacy of bariatric surgery in the super-obese elderly. A new study from combined hospitals in London identified 50 consecutive patients undergoing bariatric surgery aged 60 years or over, and compared the outcomes of the super-obese (BMI≥50; n=26) with those of BMI<50. Mean follow-up was 33 months. It was found there were no significant differences between the groups in terms of comorbidities, operation-type or peri-operative complications.
Since life expectancy is naturally limited in elderly patients, quality of life is an important outcome measure. The study found quality of life outcomes were as good, if not better, for super-obese elderly patients as compared to morbidly obese. This trend is potentially counter intuitive since the super-obese patients were heavier at the end of the study period, with a greater proportion remaining obese.
Therefore, although super obese elderly patients may not lose as much weight during bariatric surgery compared to their lighter counterparts, their quality of life is enhanced, thus bariatric surgery may be justified more psychologically then physically in this group. This leads to the super obese elderly having a more positive attitude that may help them control their weight and exercise more frequently.
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Weight perceptions of English adolescents: cause for celebration or concern?
A new study has shown the greater part of normal-weight adolescents (84% of girls, 83% of boys) correctly acknowledge themselves as ‘about the right weight’. Overestimation of weight and overall size has become very uncommon, with only 7% of normal-weight teens (11% of girls, 4% of boys) identifying themselves as ‘too heavy’. This can be considered a celebration at a time when body image is often a cause for concern.
On the contrary, only 60% of obese adolescents (68% of girls, 53% of boys) correctly recognise themselves as ‘too heavy’, whilst 39% (32% of girls, 47% of boys) underestimate, identifying themselves as ‘too light’ or ‘about the right weight’. This lack of awareness however is a cause for concern, particularly for future health issues, but may be part of a wider acceptance, or normalisation, of obesity in society both of which need to be addressed to stem the obesity epidemic.
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Following in the father’s footsteps
Does the effect of the growing obesity epidemic only come from the mother? No! New research has shown conditions that can affect a father’s health can ultimately alter the genes he passes down to his children. This is a new and upcoming area of study that is receiving a lot more attention, alongside the influence of the father’s health after birth.
An observational study conducted by Emily Freeman and colleagues found that a father’s weight status was a better predictor of obesity risk than a mother’s. It was concluded: “father’s are a key influence in shaping the family environment that leads to the development of child obesity”. Interventions that are used to test the effectiveness of treating overweight fathers are a significant and novel strategy. The interventions can have a major impact on weight status in the childhood obesity epidemic and consequently should be a priority.
Fathers may ultimately be a strategic target for prevention and treatment of childhood obesity.
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