Publications

2022
Tanas R, Gil B, Marsella M, Nowicka P, Pezzoli V, Phelan SM, Queirolo S, Stanford FC, Pettoello-Mantovani M, Bernasconi S. Addressing Weight Stigma and -Weight-Based Discrimination in Children: Preparing Pediatricians to Meet the Challenge. J Pediatr. 2022.
Nimmala S, Kaur S, Singhal V, Mitchell DM, Stanford FC, Bouxsein ML, Lauze M, Huynh C, Pedreira CC, Lee H, et al. Changes in sex steroids and enteric peptides after sleeve gastrectomy in youth in relation to changes in bone parameters. J Clin Endocrinol Metab. 2022.Abstract
CONTEXT: Sleeve gastrectomy (SG) improves metabolic endpoints but is associated with impaired bone outcomes. OBJECTIVE: To determine mechanisms contributing to impaired bone health in youth following SG. DESIGN: 12-month longitudinal observational study. SETTING: Multi-disciplinary tertiary care hospital. PATIENTS: 64 youth 13-25 years old with moderate-to-severe obesity (51 females); 30 underwent SG and 34 were non-surgical controls (NS). INTERVENTION(S): SG based on a combined decision-making process between treatment team and patient. MAIN OUTCOME MEASURE(S): Fasting blood for enteric peptides, sex steroids, sclerostin, and bone turnover markers [N-terminal propeptide of type 1 procollagen (P1NP) and C-terminal telopeptide (CTX)]; DXA measures of areal bone mineral density (aBMD) and body composition; high resolution peripheral quantitative CT measures of volumetric BMD (vBMD); microfinite element analysis of strength estimates (distal radius and tibia). RESULTS: SG had greater reductions in BMI z-scores, serum estrone and the free androgen index (FAI) (p≤0.046) and greater increases in sclerostin, P1NP and CTX (p≤0.010) than NS. Fasting ghrelin decreased in SG vs. NS (p<0.0001); fasting PYY did not change. Most changes were driven by female SG participants. Among females (majority of study participants), after controlling for baseline age and race, reductions in aBMD Z-scores were positively associated with changes in BMI, lean mass, estrone, FAI, and ghrelin, and inversely with changes in sclerostin. Decreases in total vBMD of the radius and tibia were associated positively with decreases in BMI. Increases in CTX were associated with decreases in BMI, lean mass, and ghrelin, and increases in sclerostin. CONCLUSIONS: Bone loss after SG in youth is associated with changes in body composition, sex steroids, sclerostin and enteric peptides. These are potential targets for future preventative or therapeutic strategies.
Roser P, Bajaj SS, Stanford FC. International lack of equity in modern obesity therapy: the critical need for change in health policy. Int J Obes (Lond). 2022.
Yee V, Bajaj SS, Stanford FC. Paradox of telemedicine: building or neglecting trust and equity. Lancet Digit Health. 2022;4 (7) :e480-e481.
Majmudar MD, Chandra S, Yakkala K, Kennedy S, Agrawal A, Sippel M, Ramu P, Chaudhri A, Smith B, Criminisi A, et al. Smartphone camera based assessment of adiposity: a validation study. NPJ Digit Med. 2022;5 (1) :79.Abstract
Body composition is a key component of health in both individuals and populations, and excess adiposity is associated with an increased risk of developing chronic diseases. Body mass index (BMI) and other clinical or commercially available tools for quantifying body fat (BF) such as DXA, MRI, CT, and photonic scanners (3DPS) are often inaccurate, cost prohibitive, or cumbersome to use. The aim of the current study was to evaluate the performance of a novel automated computer vision method, visual body composition (VBC), that uses two-dimensional photographs captured via a conventional smartphone camera to estimate percentage total body fat (%BF). The VBC algorithm is based on a state-of-the-art convolutional neural network (CNN). The hypothesis is that VBC yields better accuracy than other consumer-grade fat measurements devices. 134 healthy adults ranging in age (21-76 years), sex (61.2% women), race (60.4% White; 23.9% Black), and body mass index (BMI, 18.5-51.6 kg/m2) were evaluated at two clinical sites (N = 64 at MGH, N = 70 at PBRC). Each participant had %BF measured with VBC, three consumer and two professional bioimpedance analysis (BIA) systems. The PBRC participants also had air displacement plethysmography (ADP) measured. %BF measured by dual-energy x-ray absorptiometry (DXA) was set as the reference against which all other %BF measurements were compared. To test our scientific hypothesis we run multiple, pair-wise Wilcoxon signed rank tests where we compare each competing measurement tool (VBC, BIA, …) with respect to the same ground-truth (DXA). Relative to DXA, VBC had the lowest mean absolute error and standard deviation (2.16 ± 1.54%) compared to all of the other evaluated methods (p < 0.05 for all comparisons). %BF measured by VBC also had good concordance with DXA (Lin's concordance correlation coefficient, CCC: all 0.96; women 0.93; men 0.94), whereas BMI had very poor concordance (CCC: all 0.45; women 0.40; men 0.74). Bland-Altman analysis of VBC revealed the tightest limits of agreement (LOA) and absence of significant bias relative to DXA (bias -0.42%, R2 = 0.03; p = 0.062; LOA -5.5% to +4.7%), whereas all other evaluated methods had significant (p < 0.01) bias and wider limits of agreement. Bias in Bland-Altman analyses is defined as the discordance between the y = 0 axis and the regressed line computed from the data in the plot. In this first validation study of a novel, accessible, and easy-to-use system, VBC body fat estimates were accurate and without significant bias compared to DXA as the reference; VBC performance exceeded those of all other BIA and ADP methods evaluated. The wide availability of smartphones suggests that the VBC method for evaluating %BF could play an important role in quantifying adiposity levels in a wide range of settings.Trial registration: ClinicalTrials.gov Identifier: NCT04854421.
Claridy MD, Perez NP, Czepiel KS, Acholonu NO, Stanford FC. Association Between Weight Promoting Medication Use and Weight Status Among Children and Adolescents in the United States. Acad Pediatr. 2022.Abstract
OBJECTIVES: The objectives of this study were to 1) examine the prevalence of prescription medication use overall and 2) examine the association between weight promoting medication (WPM) use by therapeutic class and weight status among a nationally representative sample of the children and adolescents in the United States. This study also further investigated antidepressant medication use among this population. METHODS: This cross-sectional study used data from the National Health and Nutrition Examination Survey from 2013 to 2018. Children and adolescents ages 2 to 19 years were included in this study. RESULTS: Of the 68,057,468 derived participants (34,507,154 [50.7%] male; 33,564,059 [49.3%] aged 2-10 years; 34,905,058 [51.3%] non-Hispanic White), 14,895,618 (22.2%) used a prescription medication in the prior 30 days, 21.7% (3,235,323) of which were considered weight promoting. There was no significant difference between weight status and WPM use for overall prescription medication use. Nevertheless, for overall antidepressant medication use, those with obesity were less likely to be prescribed antidepressant WPM when compared to those with normal weight (adjusted odds ratios 0.4; 95% confidence interval 0.2-0.7). CONCLUSIONS: These findings suggest that although there was no significant association between WPM use and weight status overall when examining the association by therapeutic class, most children with obesity were not using antidepressant WPM. This is reassuring and potentially an active attempt at avoiding the use of medications that have an exacerbating effect on weight gain. When choosing antidepressant medications, providers, parents, and patients consider the WPM effects and appropriately choose a medication best suited to the child's health status.
Johnson VR, Washington TB, Chhabria S, Wang EH-C, Czepiel K, Reyes KCJ, Stanford FC. Food as Medicine for Obesity Treatment and Management. Clin Ther. 2022.Abstract
PURPOSE: Nutrition is an important lifestyle modification used in the treatment of obesity. The purpose of this review is to highlight different dietary interventions used to promote weight loss in both adults and children. METHODS: A search using PubMed was performed for articles on topics related to nutrition and management and/or treatment of obesity in adults adolescents and children. The literature was reviewed and pertinent sources were used for this narrative review. DISCUSSION: There are many effective nutrition interventions used to treat obesity, including altering macronutrient composition, implementing different dietary patterns, and changing meal timing. Although these interventions can induce weight loss in adults, management of obesity in children is more difficult given their varied nutrition needs in growth and development. The use of food as medicine in obesity treatment is individualized based on patient's age, food preference, and concurrent medical conditions. IMPLICATIONS: Given the multifactorial etiology of obesity, treatment requires multidisciplinary care beyond nutrition intervention.
Czepiel KS, Stanford FC. The Many Names of Fatty Liver Disease: Strengths and Limitations of Metabolic (Dysfunction)-Associated Fatty Liver Disease. Child Obes. 2022.
Townsend MJ, Claridy MD, Bajaj SS, Tu L, Stanford FC. Obesity and Eligibility for Obesity Treatments Among Adults With Disabilities in the U.S. Am J Prev Med. 2022.Abstract
INTRODUCTION: Obesity has been associated with disability; yet, the proportion who meet clinical criteria for obesity treatment among adults with disabilities remains poorly defined. Characterization of obesity and treatment eligibility by disability type may prioritize high-need groups. This study assessed the prevalence of obesity and eligibility for antiobesity pharmacotherapy and/or bariatric surgery in adults with disability. METHODS: This cross-sectional weighted analysis of the 2019 National Health Interview Survey, including self-reported health and sociodemographic information, was conducted in 2021. Burden of obesity defined by BMI and odds of meeting consensus criteria for antiobesity pharmacotherapy and/or surgery were calculated by functional disability type: vision, hearing, cognition, communication, mobility, and self-care. RESULTS: From 29,170 community-dwelling adult respondents (59.1% response), the overall prevalence of disability was 10%. The prevalence of obesity among adults with a disability was 40.1% vs 30.5% for U.S. adults overall (p<0.0001). An estimated 17.1% with disability met the criteria for both bariatric surgery and antiobesity pharmacotherapy; another 39.8% were eligible for pharmacotherapy alone (vs 7.9% and 33.2%, respectively, for adults overall; p<0.0001). In fully adjusted models, disability was associated with greater ORs for mild obesity (OR=1.2; 95% CI=1.1, 1.4), moderate‒severe obesity (OR=2.1; 95% CI=1.8, 2.3), and criteria for bariatric surgery (OR=2.4; 95% CI=2.1, 2.7) and pharmacotherapy (OR=1.3; 95% CI=1.2, 1.4). Mobility, self-care, and cognition disabilities were associated with eligibility for bariatric surgery and antiobesity pharmacotherapy. CONCLUSIONS: Individuals with disabilities have higher odds of obesity and eligibility for antiobesity treatments. Comorbidities should be considered, accommodations should be provided, and insurance coverage should be expanded to ensure access to antiobesity treatments for adults with disabilities.
Yee V, Bajaj SS, Stanford FC. Building a pandemic supply chain - equity over equality. Nat Med. 2022.
Callahan EA, Vafiadis DK, Cameron KA, Stanford FC. A call for solutions for healthy aging through a systems-based, equitable approach to obesity. J Am Geriatr Soc. 2022.
Aaron DG, Stanford FC. Medicine, structural racism, and systems. Soc Sci Med. 2022;298 :114856.Abstract
Medicine is having a reckoning with systemic racism. While some continue to believe medicine is apolitical and grounded purely in science, history and research reveal that medicine is inseparable from underlying systems, laws, and policies. Obesity is a useful case study. Weight loss trials have shown the immense difficulty in achieving and sustaining weight loss without addressing overlying systems. Barriers are double for Black, Indigenous, and People of Color (BIPOC) with obesity, who must contend with multiple layers of oppressive systems. Increasingly, illness is not a matter of bad luck, but is a function of oppressive structures. COVID-19 likely originates in a deteriorating environment, we have an increasing global burden of disease from oppressive sales of food, sugar, alcohol, guns, nicotine, and other harmful products, and social inequality and resource hoarding are at a peak. Medicine can and must participate in redefining these systems. In doing so, it must center the experiences of BIPOC and push change that alleviates power disparities.
Bajaj SS, Stanford FC. The Ukrainian refugee crisis and the pathology of racism. BMJ. 2022;376 :o661.
Bajaj SS, Jain B, Kyle TK, Gallagher C, Stanford FC, Srivastava G. Overcoming congressional inertia on obesity requires better literacy in obesity science. Obesity (Silver Spring). 2022.Abstract
Obesity-focused health policies, including the landmark Treat and Reduce Obesity Act, have stalled at the federal level over the past decade. Congressional inaction on obesity reflects both misconceptions of obesity as a lifestyle choice and limited awareness for the burden obesity imposes on our health care system. Given these challenges, we argue that health professionals must bolster their efforts to partner with public figures with obesity and to directly educate the public. These strategies may help destigmatize obesity and build awareness of obesity as a disease. Furthermore, we suggest that these strategies may empower patients to flex their unrealized political muscle and demand more from their elected leaders. A bold, multilevel approach that elicits a public demand for change can propel obesity policy into the 21st century.
Bajaj SS, Maki L, Stanford FC. Vaccine apartheid: global cooperation and equity. Lancet. 2022.
Bajaj SS, Jain B, Stanford FC. Weight gain after in vitro fertilization: a potential consequence of controlled ovarian stimulation. J Assist Reprod Genet. 2022.Abstract
In the USA, 42% of adult women were estimated to have obesity, and 13% of women of childbearing age similarly have impaired fecundity. Obesity is associated with infertility such that patients with obesity often seek out in vitro fertilization (IVF) services. Here, we report on the case of a woman with childhood-onset class II obesity who had been undergoing treatment with phentermine and topiramate prior to undergoing 3 cycles of IVF. With each cycle, the patient temporarily gained 13-15 lbs. during controlled ovarian stimulation (COS). Weight gain from COS may be clinically relevant and merits further study to optimize weight status across women's reproductive life and to better assist women who gain weight secondary to IVF. Incorporating weight monitoring into IVF protocols may also help better characterize the scope of weight gain from COS.
Akam EY, Nuako AA, Daniel AK, Stanford FC. Racial Disparities and Cardiometabolic Risk: New Horizons of Intervention and Prevention. Curr Diab Rep. 2022.Abstract
PURPOSE OF REVIEW: Cardiometabolic diseases are a leading cause of morbidity and mortality in the USA and disproportionately impact racial and ethnic minorities. Multiple factors contribute to this disparity including genetic and socioeconomic factors, the latter of which contributes to disparities both through systemic barriers such as healthcare access and by directly impacting metabolism through epigenetics and environment-related alterations in the gut microbiome. This review will discuss advances in medicine that can be used to identify, prognosticate, and treat cardiometabolic diseases, and how these may be used to address existing disparities. RECENT FINDINGS: There is growing research aimed at identifying novel cardiometabolic disease targets and expanding the use of existing pharmacotherapies based on comorbidities. Advances in metabolomics and genomics can give insight into an individual's unique biochemical profile, providing the means for earlier identification of disease and specific treatment targets. Moreover, developments in telehealth and related medical device technologies can expand access to underserved minority populations and improve control of chronic conditions such as diabetes and hypertension. Precision medicine may be integral to bridging the racial gap in cardiometabolic disease outcomes. Developments in genomics, metabolomics, wearable medical devices, and telehealth can result in personalized treatments for patients that account for the socioeconomic and genetic factors that contribute to poor health outcomes in minorities. As research in this field rapidly progresses, special efforts must be made to ensure inclusion of racial and ethnic minority populations in clinical research and equal access to all treatment modalities.
Bajaj SS, Stanford FC. COVID-19: LMICs need antivirals as well as vaccines. Nature. 2022;602 (7895) :33.
Townsend MJ, Reddy N, Stanford FC. Geography and equity: expanding access to obesity medicine diplomate care. Int J Obes (Lond). 2022.
Jain B, Khatri E, Stanford FC. Racial disparities in senior healthcare: System-level interventions. J Am Geriatr Soc. 2022.

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