Publications

2018
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.
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.
Gomez G, Stanford FC. US health policy and prescription drug coverage of FDA-approved medications for the treatment of obesity. Int J Obes (Lond). 2018;42 (3) :495-500.Abstract
OBJECTIVE: Obesity is now the most prevalent chronic disease in the United States, which amounts to an estimated $147 billion in health care spending annually. The Affordable Care Act (ACA) enacted in 2010 included provisions for private and public health insurance plans that expanded coverage for lifestyle/behavior modification and bariatric surgery for the treatment of obesity. Pharmacotherapy, however, has not been included despite their evidence-based efficacy. We set out to investigate the coverage of Food and Drug Administration-approved medications for obesity within Medicare, Medicaid and ACA-established marketplace health insurance plans. METHODS: We examined coverage for phentermine, diethylpropion, phendimetrazine, Benzphentamine, Lorcaserin, Phentermine/Topiramate (Qysmia), Liraglutide (Saxenda) and Buproprion/Naltrexone (Contrave) among Medicare, Medicaid and marketplace insurance plans in 34 states. RESULTS: Among 136 marketplace health insurance plans, 11% had some coverage for the specified drugs in only nine states. Medicare policy strictly excludes drug therapy for obesity. Only seven state Medicaid programs have drug coverage. CONCLUSIONS: Obesity requires an integrated approach to combat its public health threat. Broader coverage of pharmacotherapy can make a significant contribution to fighting this complex and chronic disease.
Tauqeer Z, Gomez G, Stanford FC. Obesity in Women: Insights for the Clinician. J Womens Health (Larchmt). 2018;27 (4) :444-457.Abstract
As a leading cause of morbidity and mortality in the United States and worldwide, obesity is a disease that is frequently encountered in clinical practice today and requires a range of medical interventions. While obesity affects both men and women across all ages, multiple issues are particularly germane to women's health, particularly as obesity is more prevalent among women than men in the United States and obesity among women of reproductive health relates to the growing issue of childhood obesity. Discussed herein are the epidemiology and pathophysiology of obesity along with the impact of perinatal obesity on fetal programming. Guidance on screening and management of obesity through lifestyle intervention, pharmacologic therapy, and bariatric surgery, as well as avoidance of weight-promoting medications wherever possible, is elaborated. Particular attention is paid to the contribution of these modalities to weight loss as well as their impact on obesity-related comorbidities that affect a woman's overall health, such as type 2 diabetes and hypertension, and her reproductive and gynecologic health. With modest weight loss, women with obesity can achieve notable improvements in chronic medical conditions, fertility, pregnancy outcomes, and symptoms of pelvic floor disorders. Moreover, as children born to women after bariatric surgery-induced weight loss show improved metabolic outcomes, this demonstrates a role for maternal weight loss in reducing risk of development of metabolic disturbances in children. In light of the immense cost burden and mortality from obesity, it is important to emphasize the role of lifestyle intervention, pharmacologic management, and bariatric surgery for weight loss in clinical practice to mitigate the impact of obesity on women's health.
2017
Maffoni S, De Giuseppe R, Stanford FC, Cena H. Folate status in women of childbearing age with obesity: a review. Nutr Res Rev. 2017;30 (2) :265-271.Abstract
Several studies have described a positive association between elevated BMI and birth defects risk. Data on plasma concentration of folate in pregnant women with obesity have shown values far below those recommended, regardless of diet, while folate levels should increase before pregnancy to reduce neural tube defects. We report a descriptive review of the most recent studies (from 2005 to 2015) to evaluate folate status through a population of women of childbearing age affected by obesity. The literature contains few studies, which present conflicting results regarding folate status in non-pregnant women of childbearing age affected by obesity, and it appears that there is a modification in folate metabolism, with a reduction in plasma folate levels and an increase in erythrocyte folate uptake. In conclusion, the folate status in women of childbearing age should be assessed by both plasma and erythrocyte levels to start a personalised and more adequate supplementation before conception. Further studies need to be conducted in a larger population, which take into account variables that can affect folate metabolism, such as dietary intake, lifestyle and genetic factors, oral contraceptives or other drug use, previous weight-loss programmes, or a history of bariatric surgery.
Kedrin D, Gandhi S-CC, Wolf M, Roper J, Yilmaz O, Corey K, Khalili H, Stanford FC, Gala M. Bariatric Surgery Prior to Index Screening Colonoscopy Is Associated With a Decreased Rate of Colorectal Adenomas in Obese Individuals. Clin Transl Gastroenterol. 2017;8 (2) :e73.Abstract
OBJECTIVES: Obesity is an important risk factor for the development of colorectal cancer (CRC). Although the impact of bariatric surgery on CRC is conflicting, its impact on precursor lesions is unknown. The aim of this study was to determine whether bariatric surgery before index screening colonoscopy is associated with decreased development of colorectal adenomas. METHODS: We performed a retrospective cohort study of bariatric surgery patients who had undergone index, screening colonoscopy at an academic center from 2001 to 2014. Patients who had bariatric surgery at least 1 year before index colonoscopy were compared with those who had surgery after colonoscopy, using multivariable logistic regression to control for presurgical body mass index, sex, gender, race, type of surgery, aspirin use, metformin use, smoking, and age at colonoscopy. RESULTS: One hundred and twenty-five obese individuals who had bariatric surgery before colonoscopy were compared with 223 individuals who had colonoscopy after surgery. Adenomatous polyps were found in 16.8% of individuals who had surgery first vs. 35.5% who had colonoscopy before bariatric surgery (unadjusted odds ratio (OR) 0.37, 95% confidence interval (CI): 0.21-0.64, P=0.0003). After multivariable adjustment, bariatric surgery before index screening colonoscopy was associated with a decreased risk of adenomas at index colonoscopy (adjusted OR 0.37, 95% CI: 0.19-0.69, P=0.002). CONCLUSIONS: Bariatric surgery is associated with a decreased risk of colorectal adenomas in obese individuals without a family history of CRC.
Wilson ER, Kyle TK, Nadglowski JF, Stanford FC. Obesity coverage gap: Consumers perceive low coverage for obesity treatments even when workplace wellness programs target BMI. Obesity (Silver Spring). 2017;25 (2) :370-377.Abstract
OBJECTIVE: Evidence-based obesity treatments, such as bariatric surgery, are not considered essential health benefits under the Affordable Care Act. Employer-sponsored wellness programs with incentives based on biometric outcomes are allowed and often used despite mixed evidence regarding their effectiveness. This study examines consumers' perceptions of their coverage for obesity treatments and exposure to workplace wellness programs. METHODS: A total of 7,378 participants completed an online survey during 2015-2016. Respondents answered questions regarding their health coverage for seven medical services and exposure to employer wellness programs that target weight or body mass index (BMI). Using χ tests, associations between perceptions of exposure to employer wellness programs and coverage for medical services were examined. Differences between survey years were also assessed. RESULTS: Most respondents reported they did not have health coverage for obesity treatments, but more of the respondents with employer wellness programs reported having coverage. Neither the perception of coverage for obesity treatments nor exposure to wellness programs increased between 2015 and 2016. CONCLUSIONS: Even when consumers have exposure to employer wellness programs that target BMI, their health insurance often excludes obesity treatments. Given the clinical and cost-effectiveness of such treatments, reducing that coverage gap may mitigate obesity's individual- and population-level effects.
Cena H, Stanford FC, Ochner L, Fonte ML, Biino G, De Giuseppe R, Taveras E, Misra M. Association of a history of childhood-onset obesity and dieting with eating disorders. Eat Disord. 2017;25 (3) :216-229.Abstract
This was a retrospective, observational chart review conducted on a convenience sample of 537 outpatients, aged 16-60 years, referred to an Italian Dietetic and Nutrition University Center. The study aimed to look at the association between a history of childhood obesity and dieting behaviors with development of eating disorders (EDs) at a later age. Subjects with a history of EDs (n = 118), assessed using both self-report and health records, were compared with those with no EDs (n = 419), who were attending the clinic mainly for primary prevention of metabolic and cardiovascular risk. Logistic regression analysis was performed to assess the association of childhood-onset obesity with development of an ED at a later age. Childhood-onset obesity, gender, maternal history of eating disorders, and dieting were associated with a positive history of EDs at a later age (p < .05). It is important to raise professional awareness of early symptoms of EDs in children with a history of obesity and treat them accordingly.
Stanford FC, Alfaris N, Gomez G, Ricks ET, Shukla AP, Corey KE, Pratt JS, Pomp A, Rubino F, Aronne LJ. The utility of weight loss medications after bariatric surgery for weight regain or inadequate weight loss: A multi-center study. Surg Obes Relat Dis. 2017;13 (3) :491-500.Abstract
BACKGROUND: Patients who undergo bariatric surgery often have inadequate weight loss or weight regain. OBJECTIVES: We sought to discern the utility of weight loss pharmacotherapy as an adjunct to bariatric surgery in patients with inadequate weight loss or weight regain. SETTING: Two academic medical centers. METHODS: We completed a retrospective study to identify patients who had undergone bariatric surgery in the form of a Roux-en-Y gastric bypass (RYGB) or a sleeve gastrectomy from 2000-2014. From this cohort, we identified patients who were placed on weight loss pharmacotherapy postoperatively for inadequate weight loss or weight regain. We extracted key demographic data, medical history, and examined weight loss in response to surgery and after the initiation of weight loss pharmacotherapy. RESULTS: A total of 319 patients (RYGB = 258; sleeve gastrectomy = 61) met inclusion criteria for analysis. More than half (54%; n = 172) of all study patients lost≥5% (7.2 to 195.2 lbs) of their total weight with medications after surgery. There were several high responders with 30.3% of patients (n = 96) and 15% (n = 49) losing≥10% (16.7 to 195.2 lbs) and≥15% (25 to 195.2 lbs) of their total weight, respectively, Topiramate was the only medication that demonstrated a statistically significant response for weight loss with patients being twice as likely to lose at least 10% of their weight when placed on this medication (odds ratio = 1.9; P = .018). Regardless of the postoperative body mass index, patients who underwent RYGB were significantly more likely to lose≥5% of their total weight with the aid of weight loss medications. CONCLUSIONS: Weight loss pharmacotherapy serves as a useful adjunct to bariatric surgery in patients with inadequate weight loss or weight regain.
Butsch SW, Stanford FC. Caloric restriction improves health-related quality of life in healthy normal weight and overweight individuals. Evid Based Med. 2017;22 (1) :33.
Misra M, Ackerman KE, Bredella MA, Stanford FC, Faje AT, Nordberg A, Derrico NP, Bouxsein ML. Racial Differences in Bone Microarchitecture and Estimated Strength at the Distal Radius and Distal Tibia in Older Adolescent Girls: a Cross-Sectional Study. J Racial Ethn Health Disparities. 2017;4 (4) :587-598.Abstract
BACKGROUND: Previous studies have demonstrated that an individual's race and ethnicity are important determinants of their areal bone mineral density (aBMD), assessed by dual-energy X-ray absorptiometry. However, there are few data assessing the impact of race on bone microarchitecture and strength estimates, particularly in older adolescent girls and young adults. We hypothesized that bone microarchitecture and strength estimates would be superior in Blacks compared to White and Asian American adolescent girls and young adults of similar age based on reports of higher aBMD in Blacks. METHODS: We assessed BMD using dual-energy X-ray absoptiometry (DXA), bone microarchitecture at the distal radius and distal tibia using high-resolution peripheral quantitative computed tomography (HRpQCT) and estimated measures of bone strength using micro-finite element analysis (FEA) in 35 White, 15 Asian American, and 10 Black girls 14-21 years. RESULTS: After controlling for height, most DXA measures of aBMD and aBMD Z scores were higher in Black girls compared with Whites and Asian Americans. HRpQCT and FEA showed that at the distal radius, Blacks had greater cortical perimeter, cortical area, trabecular thickness, trabecular BMD, estimated failure load, and stiffness than the other two groups. For the distal tibia, trabecular number and BMD were higher in Blacks than Asian Americans. CONCLUSIONS: Particularly at the distal radius, adolescent and young adult White and Asian American girls have less favorable bone microarchitecture and lower bone strength than Blacks, possibly explaining the lower risk of fracture seen in Blacks. LEVEL OF EVIDENCE: Level II.
2016
Stanford FC, Butsch SW. Metabolically Healthy Obesity and Development of Chronic Kidney Disease. Ann Intern Med. 2016;165 (10) :742-743.
Cena H, De Giuseppe R, Biino G, Persico F, Ciliberto A, Giovanelli A, Stanford FC. Evaluation of eating habits and lifestyle in patients with obesity before and after bariatric surgery: a single Italian center experience. Springerplus. 2016;5 (1) :1467.Abstract
BACKGROUND: The study evaluated and compared the eating habits and lifestyle of patients with moderate to severe obesity who have undergone Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG). METHODS: Food frequency (FF), food habits (FH), physical activity and life style (PA) as well as smoking habits (SH) were analyzed in 50 RYGB (25 M; aged: 24-64) and 50 SG patients (25 M; aged: 22-63) by means of a validated questionnaire, before (T0) and 6 months (T1) post bariatric surgery. A score for each section (FF, FH, PA, SH) was calculated. RESULTS: ANOVA analysis (age/sex adjusted): FF and FH scores improved at T1 (RYGB and SG: p < 0.001); PA score improved but not significantly; SH score did not change at T1 neither in RYGB nor in SG. Mixed models: FF and PA scores did not correlate with age, gender, weight, BMI, neither in RYGB nor in SG; FH score was negatively correlated both with weight (RYGB: p = 0.002) and BMI (SG: p = 0.003); SH score was positively correlated with age, in SG (p = 0.002); the correlation was stronger in females than in males (p = 0.004). CONCLUSIONS: Although dietary habits improved, patients did not change their physical activity level or their smoking habits. Patients should receive adequate lifestyle counseling to ensure the maximal benefit from bariatric surgery.

Pages