Publications

2019
Stanford FC, Stevens JR, Stern TA ed. Facing Overweight and Obesity. Boston: MGH Psychiatry Academy; 2019. Publisher's VersionAbstract
Facing Overweight and Obesity is for anyone whose life is affected by this problem. Written by leading physicians in their fields, Facing Overweight and Obesity combines top-tier medical information and compassionate counsel on being overweight, with a caring approach to the emotional aspects of living with weight-related conditions. This book provides easily readable and trustworthy information; it is divided into chapters that ask and answer pertinent questions about being overweight and its medical, surgical, and psychiatric care. A glossary of terms and tables is provided to educate the reader (e.g., about nutrition, diet, exercise and risk-reduction); on-line resources and references are also provided.
Stanford FC, Lee M, Hur C. Race, Ethnicity, Sex, and Obesity: Is It Time to Personalize the Scale?. Mayo Clin Proc. 2019;94 (2) :362-363.
Palad CJ, Yarlagadda S, Stanford FC. Weight stigma and its impact on paediatric care. Curr Opin Endocrinol Diabetes Obes. 2019;26 (1) :19-24.Abstract
PURPOSE OF REVIEW: This review aims to evaluate current research findings relevant to weight stigmatization, to acknowledge the deleterious impact it has on the health of the paediatric population and to provide insight to optimize future guidelines for the treatment of individuals with overweight and obesity. RECENT FINDINGS: Obesity prevalence continues to rise in the USA with estimates in children from ages 2-19 years of 18.5%, an all-time high. With the increase in obesity, there has been a concomitant increase in weight stigma, which affects both youth and general population across varied levels of socioeconomic status and body sizes. SUMMARY: Weight stigma is a contributing phenomenon to the current obesity epidemic, as individuals with stigmatized experiences (weight-based teasing, bullying, victimization) have increased risks for acquiring adverse health outcomes that encompass the physical, behavioural and psychological. Weight stigma can also lead affected individuals to internalize such experiences which decrease their overall quality of life. Sources of stigma may come from peers, family, educators, media, as well as healthcare professionals, as highlighted in this review. Efforts to establish prevention and treatment strategies for weight stigma may generate further traction to help improve global obesity rates. VIDEO ABSTRACT.
2018
Stanford FC, Toth AT, Shukla AP, Pratt JS, Cena H, Biino G, Aronne LJ. Weight Loss Medications in Older Adults After Bariatric Surgery for Weight Regain or Inadequate Weight Loss: A Multicenter Study. Bariatr Surg Pract Patient Care. 2018;13 (4) :171-178.Abstract
Weight loss medications are effective to confer additional weight loss after bariatric surgery in the general population, but they have not been evaluated in adults 60 years of age and older. We performed a retrospective study identifying 35 patients who were ≥60 years old and had undergone Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG) from 2000 to 2014, and were subsequently prescribed weight loss medications. Linear regression analyses were performed to determine beta coefficients of certain predictor variables being associated with weight loss. Patients lost weight on medications with an average body mass index (BMI) change of -2.74 kg/m, standard deviation = 2.6 kg/m. RYGB patients lost a greater percentage of BMI on medication than SG (SG; -1.38 ± 1.49 kg/m and RYGB; -3.37 ± 2.83 kg/m,  = 0.0372). Patients with hypertension were less likely to lose weight on medications (β = 16.76,  = 0.004, and 95% confidence interval = 5.85-27.67). Weight loss medications are a useful treatment to confer additional weight loss in adults 60 years of age and older after RYGB and SG.
Stanford FC. Controversial issues: A practical guide to the use of weight loss medications after bariatric surgery for weight regain or inadequate weight loss. Surg Obes Relat Dis. 2018.
Griggs CL, Perez NP, Goldstone RN, Kelleher CM, Chang DC, Stanford FC, Pratt JS. National Trends in the Use of Metabolic and Bariatric Surgery Among Pediatric Patients With Severe Obesity. JAMA Pediatr. 2018;172 (12) :1191-1192.
Campoverde Reyes KJ, Misra M, Lee H, Stanford FC. Weight Loss Surgery Utilization in Patients Aged 14-25 With Severe Obesity Among Several Healthcare Institutions in the United States. Front Pediatr. 2018;6 :251.Abstract
Obesity is associated with early co-morbidities and higher mortality. Even though weight loss surgery (WLS) in adolescents with severe obesity reliably achieves safe and lasting improvement in BMI and superior resolution of comorbid diseases, its utilization among young patients in the clinical practice stands unclear. To show the prevalence of weight loss surgery utilization rates in adolescents and young adults among several healthcare institutions in the United States. WLS in 14-25 years old between 2000 and 2017 was obtained from Washington University, Morehouse Medical, University of Texas, Wake Forest Baptist Medical Center, Beth Israel Deaconess Medical Center, Boston Children's Hospital, Boston Medical Center, and Partners Healthcare using the Shared Health Research Information Network (SHRINE) and Research Patient Data Registry (RPDR) web-based query tools. ICD-9 codes were used for bariatric surgery. Among 2500635 individuals, 18008 (0.7%) had severe obesity. At Partners, 1879 patients had severe obesity, of which 404 (21.5%) underwent WLS, whereas at Washington University, 44 (2.5%) of 1788 the underwent WLS. 13 (2.3%) of the 575 at BIDMC, 43 (1.5%) of the 2969 at BMC, and 37 (0.4%) of 8908 at BCH underwent WLS ( < 0.0001 for all). Even though WLS has shown to be the most effective treatment to create sustainable changes in metabolic derangements for moderate to severe obesity and its comorbidities, it has been underutilized. Further studies need to be conducted to ensure WLS is utilized for those patients who would achieve the most benefit.
Stanford FC, Kyle TK. Respectful Language and Care in Childhood Obesity. JAMA Pediatr. 2018;172 (11) :1001-1002.
Toth AT, Gomez G, Shukla AP, Pratt JS, Cena H, Biino G, Aronne LJ, Stanford FC. Weight Loss Medications in Young Adults after Bariatric Surgery for Weight Regain or Inadequate Weight Loss: A Multi-Center Study. Children (Basel). 2018;5 (9).Abstract
This paper presents a retrospective cohort study of weight loss medications in young adults aged 21 to 30 following Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) between November 2000 and June 2014. Data were collected from patients who used topiramate, phentermine, and/or metformin postoperatively. Percentage of patients achieving ≥5%, ≥10%, or ≥15% weight loss on medications was determined and percent weight change on each medication was compared to percent weight change of the rest of the cohort. Our results showed that 54.1% of study patients lost ≥5% of their postsurgical weight; 34.3% and 22.9% lost ≥10% and ≥15%, respectively. RYGB had higher median percent weight loss (-8.1%) than SG (-3.3%) ( = 0.0515). No difference was found in median percent weight loss with medications started at weight plateau (-6.0%) versus after weight regain (-5.4%) ( = 0.5304). Patients taking medications at weight loss plateau lost 41.2% of total body weight from before surgery versus 27.1% after weight regain ( = 0.076). Median percent weight change on metformin was -2.9% compared to the rest of the cohort at -7.7% ( = 0.0241). No difference from the rest of the cohort was found for phentermine ( = 0.2018) or topiramate ( = 0.3187). Topiramate, phentermine, and metformin are promising weight loss medications for 21 to 30 year olds. RYGB patients achieve more weight loss on medications but both RYGB and SG benefit. Median total body weight loss from pre-surgical weight may be higher in patients that start medication at postsurgical nadir weight. Participants on metformin lost significantly smaller percentages of weight on medications, which could be the result of underlying medical conditions.
Singhal V, Torre Flores LP, Stanford FC, Toth AT, Carmine B, Misra M, Bredella MA. Differential associations between appendicular and axial marrow adipose tissue with bone microarchitecture in adolescents and young adults with obesity. Bone. 2018;116 :203-206.Abstract
Marrow adipose tissue (MAT) in humans is distributed differentially across age and skeletal site. We have shown impaired microarchitecture and reduced bone strength at appendicular sites in conditions associated with high MAT of the axial skeleton in adults (including conditions of over- and undernutrition). Data are lacking regarding differences in MAT content of the appendicular versus the axial skeleton, and its relationship with bone microarchitecture and strength. Furthermore, data are conspicuously lacking in adolescents, a time when hematopoietic marrow is progressively converted to fatty marrow. The purpose of our study was to examine differential associations between appendicular (distal tibia) and axial (lumbar spine) MAT and bone microarchitecture and strength estimates of the distal tibia in adolescents with obesity. We hypothesized that compared to MAT of the axial skeleton (lumbar spine), MAT of the appendicular skeleton (distal tibia) would show stronger associations with bone microarchitecture and strength estimates of the appendicular skeleton (distal tibia). We evaluated 32 adolescents and young adults (27 females) with obesity; with a mean age of 17.8 ± 2.1 years and median body mass index (BMI) of 41.34 kg/m, who underwent dual energy X-ray absorptiometry (DXA) for total fat mass, proton MR spectroscopy (1H-MRS) of the distal tibia and 4th lumbar vertebra for MAT, high resolution peripheral quantitative computed tomography (HR-pQCT) of the distal tibia for volumetric bone mineral density (vBMD) and microarchitecture, and micro finite element analysis (FEA) for distal tibial strength estimates. Linear correlations between bone parameters and MAT were determined using the Spearman or Pearson methods, depending on data distribution. Lumbar spine MAT was inversely associated with age (r = -0.36; p = 0.037). Total and trabecular vBMD and trabecular number at the distal tibia were inversely associated with MAT at the distal tibia (r = -0.39, p = 0.025; r = -0.51, p = 0.003; r = -0.42, p = 0.015 respectively) but not with lumbar spine MAT (r = -0.19, p = 0.27; r = -0.18, p = 0.3; r = 0.005, p = 0.97 respectively). In adolescents and young adults with obesity, the associations between MAT and appendicular bone parameters differ depending on the site of MAT assessment i.e. axial vs. appendicular. Studies evaluating these endpoints in adolescents and young adults with obesity should take the site of MAT assessment into consideration.
De Giuseppe R, Braschi V, Bosoni D, Biino G, Stanford FC, Nappi RE, Cena H. Dietary underreporting in women affected by polycystic ovary syndrome: A pilot study. Nutr Diet. 2018.Abstract
AIM: The first-line therapy for polycystic ovary syndrome (PCOS) is weight loss focussing on diet and regular exercise; measurement of diet and energy intake (EI) is important to determine associations between nutrients and health in women with PCOS. The EI underreporting (UR) is a condition characterised by reports of habitual EI that is implausibly low, compared with estimated requirements. This case-control study aims to evaluate UR in women with PCOS. METHODS: Thirty-six women with PCOS were enrolled according to the Rotterdam criteria; 37 healthy women were enrolled as controls. INCLUSION CRITERIA: age range 18-45 and body mass index ≥18.5 kg/m in subjects without eating disorders and/or diabetes mellitus. Nutritional assessment included: anthropometry, basal metabolic rate (BMR), weight history and physical activity assessment. Subjects completed a non-consecutive three-day dietary diary to identify energy and macronutrient intake. UR was calculated (Goldberg Index: EI/BMR). RESULTS: Although women with PCOS reported a significantly higher mean BMR than controls (P < 0.0001), their EI was lower (P < 0.001), suggesting an UR in 47.2% of women with PCOS versus 2.7% of controls (P < 0.0001). The EI from simple sugars was lower in women with PCOS than controls (P < 0.01). The protein intake was increased in controls than women with PCOS (P < 0.0001). Weight cycling was more frequent in women with PCOS (P < 0.001). Logistic regression analysis identified UR associated with PCOS (P = 0.001). CONCLUSIONS: Women with PCOS underreport foods rich in simple sugars rather than underreport their total dietary intake. These results may have implications for the interpretation of diet and health correlations in this patient population.
Pratt JSA, Browne A, Browne NT, Bruzoni M, Cohen M, Desai A, Inge T, Linden BC, Mattar SG, Michalsky M, et al. ASMBS pediatric metabolic and bariatric surgery guidelines, 2018. Surg Obes Relat Dis. 2018;14 (7) :882-901.Abstract
The American Society for Metabolic and Bariatric Surgery Pediatric Committee updated their evidence-based guidelines published in 2012, performing a comprehensive literature search (2009-2017) with 1387 articles and other supporting evidence through February 2018. The significant increase in data supporting the use of metabolic and bariatric surgery (MBS) in adolescents since 2012 strengthens these guidelines from prior reports. Obesity is recognized as a disease; treatment of severe obesity requires a life-long multidisciplinary approach with combinations of lifestyle changes, nutrition, medications, and MBS. We recommend using modern definitions of severe obesity in children with the Centers for Disease Control and Prevention age- and sex-matched growth charts defining class II obesity as 120% of the 95th percentile and class III obesity as 140% of the 95th percentile. Adolescents with class II obesity and a co-morbidity (listed in the guidelines), or with class III obesity should be considered for MBS. Adolescents with cognitive disabilities, a history of mental illness or eating disorders that are treated, immature bone growth, or low Tanner stage should not be denied treatment. MBS is safe and effective in adolescents; given the higher risk of adult obesity that develops in childhood, MBS should not be withheld from adolescents when severe co-morbidities, such as depressed health-related quality of life score, type 2 diabetes, obstructive sleep apnea, and nonalcoholic steatohepatitis exist. Early intervention can reduce the risk of persistent obesity as well as end organ damage from long standing co-morbidities.
Bennett SE, Schmitt WP, Stanford FC, Baron JM. Case 22-2018: A 64-Year-Old Man with Progressive Leg Weakness, Recurrent Falls, and Anemia. N Engl J Med. 2018;379 (3) :282-289.
Palad CJ, Stanford FC. Use of people-first language with regard to obesity. Am J Clin Nutr. 2018;108 (1) :201-203.
Umoren O, Stanford FC. Letter to the Editor. Clin Nurse Spec. 2018;32 (4) :171.
Stanford FC, Tauqeer Z, Kyle TK. Media and Its Influence on Obesity. Curr Obes Rep. 2018;7 (2) :186-192.Abstract
PURPOSE OF REVIEW: To review how the media frames obesity and the effect it has upon on public perceptions. RECENT FINDINGS: The scientific and public health understanding of obesity increasingly points away from individual behaviors and toward medical and community factors, but diffusion of this knowledge is slow. Growing awareness of the importance of body positivity is driving attention to the harms of weight bias and fat shaming. Health science reporting related to obesity, nutrition, and physical activity tends to perpetuate myths and misunderstandings. Moving forward, greater attention to accurate messages about obesity and evidence-based interventions will be essential for progress to reduce suffering and the impact on public health from this chronic disease.
Byrd AS, Toth AT, Stanford FC. Racial Disparities in Obesity Treatment. Curr Obes Rep. 2018;7 (2) :130-138.Abstract
PURPOSE OF REVIEW: Obesity rates in the USA have reached pandemic levels with one third of the population with obesity in 2015-2016 (39.8% of adults and 18.5% of youth). It is a major public health concern, and it is prudent to understand the factors which contribute. Racial and ethnic disparities are pronounced in both the prevalence and treatment of obesity and must be addressed in the efforts to combat obesity. RECENT FINDINGS: Disparities in prevalence of obesity in racial/ethnic minorities are apparent as early as the preschool years and factors including genetics, diet, physical activity, psychological factors, stress, income, and discrimination, among others, must be taken into consideration. A multidisciplinary team optimizes lifestyle and behavioral interventions, pharmacologic therapy, and access to bariatric surgery to develop the most beneficial and equitable treatment plans. The reviewed studies outline disparities that exist and the impact that race/ethnicity have on disease prevalence and treatment response. Higher prevalence and reduced treatment response to lifestyle, behavior, pharmacotherapy, and surgery, are observed in racial and ethnic minorities. Increased research, diagnosis, and access to treatment in the pediatric and adult populations of racial and ethnic minorities are proposed to combat the burgeoning obesity epidemic and to prevent increasing disparity.
Voss JD, Pavela G, Stanford FC. Obesity as a threat to national security: the need for precision engagement. Int J Obes (Lond). 2018.
Patel DK, Stanford FC. Safety and tolerability of new-generation anti-obesity medications: a narrative review. Postgrad Med. 2018;130 (2) :173-182.Abstract
The prevalence of obesity and associated comorbidities is rising. Despite their weight-loss efficacy, new generation anti-obesity medications are only prescribed to a minority of adults with obesity, possibly, which in part may be due to safety concerns. This review presents detailed safety profiles for orlistat, phentermine/topiramate, lorcaserin, naltrexone/bupropion and liraglutide 3.0 mg, and discusses the associated risk-benefit profiles. Two anti-obesity medications presented safety issues that warranted further discussion; phentermine/topiramate (fetal toxicity) and liraglutide 3.0 mg (risk of gallstone disease and mild, acute pancreatitis), whereas the adverse events associated with orlistat, lorcaserin, and naltrexone/bupropion were mostly transient tolerability issues. The difficulties surrounding the objective determination of risk-benefit for anti-obesity medications is discussed. The need for more long-term data, thorough patient assessment, individualization of pharmacological interventions and adherence to stopping rules to maximize risk-benefit are highlighted. Overall, the majority of new generation anti-obesity medications present encouraging tolerability profiles; however, in some cases a lack of long-term clinical trials confounds the accurate determination of risk-benefit.
Kyle TK, Stanford FC, Nadglowski JF. Addressing Weight Stigma and Opening Doors for a Patient-Centered Approach to Childhood Obesity. Obesity (Silver Spring). 2018;26 (3) :457-458.

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