Publications

2016
Stanford FC. Obesity and Breastfeeding: Exploring the Relationship. Breastfeed Med. 2016;11 :411-2.
Kyle TK, Stanford FC. Low utilization of obesity medications: What are the implications for clinical care?. Obesity (Silver Spring). 2016;24 (9) :1832.
Maffazioli GD, Stanford FC, Campoverde Reyes KJ, Stanley TL, Singhal V, Corey KE, Pratt JS, Bredella MA, Misra M. Comparing Outcomes of Two Types of Bariatric Surgery in an Adolescent Obese Population: Roux-en-Y Gastric Bypass vs. Sleeve Gastrectomy. Front Pediatr. 2016;4 :78.Abstract
BACKGROUND: Obesity is prevalent among adolescents and is associated with serious health consequences. Roux-en-Y Gastric Bypass (RYGB) and Sleeve Gastrectomy (SG) are bariatric procedures that cause significant weight loss in adults and are increasingly being performed in adolescents with morbid obesity. Data comparing outcomes of RYGB vs. SG in this age-group are scarce. This study aims to compare short-term (1-6 months) and longer-term (7-18 months) body mass index (BMI) and biochemical outcomes following RYGB and SG in adolescents/young adults. METHODS: A retrospective study using data extracted from medical records of patients 16-21 years who underwent RYGB or SG between 2012 and 2014 at a tertiary care academic medical center. RESULTS: Forty-six patients were included in this study: 24 underwent RYGB and 22 underwent SG. Groups did not differ for baseline age, sex, race, or BMI. BMI reductions were significant at 1-6 months and 7-18 months within groups (p < 0.0001), but did not differ by surgery type (p = 0.65 and 0.09, for 1-6 months and 7-18 months, respectively). Over 7-18 months, within-group improvement in low-density lipoprotein (LDL) (-24 ± 6 in RYGB, p = 0.003, vs. -7 ± 9 mg/dl in SG, p = 0.50) and non-high-density lipoprotein (non-HDL) cholesterol (-23 ± 8 in RYGB, p = 0.02, vs. -12 ± 7 in SG, p = 0.18) appeared to be of greater magnitude following RYGB. However, differences between groups did not reach statistical significance. When divided by non-alcoholic steatohepatitis stages (NASH), patients with Stage II-III NASH had greater reductions in alanine aminotransferase levels vs. those with Stage 0-I NASH (-45 ± 18 vs. -9 ± 3, p = 0.01) after 7-18 months. RYGB and SG groups did not differ for the magnitude of post-surgical changes in liver enzymes. CONCLUSION: RYGB and SG did not differ for the magnitude of BMI reduction across groups, though changes trended higher following RYGB. Further prospective studies are needed to confirm these findings.
Stanford FC, Alfaris N, Misra M. Metformin versus Placebo in Obese Pregnant Women without Diabetes. N Engl J Med. 2016;374 (25) :2501.
Alfaris N, Kyle TK, Nadai J, Stanford FC. A new era of addiction treatment amplifies the stigma of disease and treatment for individuals with obesity. Int J Obes (Lond). 2016;40 (9) :1335-6.
Kyle TK, Stanford FC. Body Fat Percentage Should Not Be Confused With Lifestyle Behaviors. Mayo Clin Proc. 2016;91 (6) :820-1.
Stanford FC, Kyle TK. Obesity Education Beyond Nutrition Education: Thinking Farther Outside the Box. Acad Med. 2016;91 (2) :164.
2015
Stanford FC, Pratt JS, Meireles OR, Bredella MA. Posterior reversible encephalopathy syndrome (PRES) after bariatric surgery--a potential consequence associated with rapid withdrawal of antihypertensive medications. BMJ Case Rep. 2015;2015.Abstract
A 61-year-old woman with a medical history of intracerebral haemorrhage, hypertension, hyperlipidaemia and carotid stenosis presented to the emergency department with altered mental status 3 weeks after undergoing a vertical sleeve gastrectomy for severe obesity. She presented with a hypertensive emergency and a National Institutes of Health Stroke Scale of 4. CT of the head was unrevealing. MRI showed an abnormal signal within the bilateral posterior border-zone areas, with several foci in the parietal and occipital lobes, and thalami, suggestive of posterior reversible encephalopathy syndrome (PRES). The patient was initially placed on a labetalol drip and her preoperative antihypertensive medications--amlodipine, captopril, triamterene and hydrochlorothiazide--were gradually reintroduced. She returned to her baseline and was stable on discharge. Rapid withdrawal of antihypertensive medications in the early postoperative period of bariatric surgery was the aetiology of PRES in this patient. This case report discusses postoperative care of bariatric surgery patients having hypertension.
Kyle TK, Stanford FC. Stumbling Toward Access to Evidence-Based Care for the Chronic Disease of Obesity. American Journal of Managed Care [Internet]. 2015;21 (SP13) :SP431;455. Publisher's Version ebdm915_full-lowrez-_stumbling_toward_access_to_evidence_based_care_for_the_chronic_disease_of_obesity.pdf
Kyle TK, Nadglowski JF, Claridy MD, Stanford FC. US Employee Wellness Programs and Access to Obesity Treatment in Employer-Sponsored Health Insurance . American Journal of Managed Care. 2015;21 (SP15) :SP513-15.Abstract

Objectives. Under provisions of the Affordable Care Act (ACA), employers may impose substantial penalties on employees who miss specific wellness goals. This study examined the prevalence of employer practices linking wellness programs, goals for weight, and other health indicators, with access to evidence-based obesity treatment. Methods. The study utilized a representative sample of 9644 US adults designed to match US population demographics based on gender, age, and geographic location in May 2013. Respondents were asked whether their employer (1) requires participation in a wellness program to receive full health benefits, (2) sets goals for weight and other health indicators, and (3) includes coverage for evidence-based obesity treatment in their health plan. Descriptive statistics provided sample characteristics and distribution of all variables. Pearson’s chi-square analyses were used to evaluate differences in the responses for each outcome, with further assessment through multivariable logistic regression models. Results. The study found 16% of employers required participation in wellness programs to receive full health benefits. Most programs set targets for weight and related health indicators, but they did not typically provide coverage for evidence-based obesity treatments. Conclusions. For people seriously affected by obesity, the coverage gap described here is problematic because substantial improvement in their condition is unlikely without evidence-based treatment.

workwellness_ebdm1115.pdf
Stanford FC, Kyle TK. Why food policy and obesity policy are not synonymous: the need to establish clear obesity policy in the United States. Int J Obes (Lond). 2015;39 (12) :1667-8.
Thomas DM, Kyle TK, Stanford FC. The gap between expectations and reality of exercise-induced weight loss is associated with discouragement. Prev Med. 2015;81 :357-60.Abstract
BACKGROUND: Exercise interventions result in modest weight loss, yet exercise is frequently prescribed for weight loss. PURPOSE: To identify individuals who become discouraged when exercise fails to achieve weight loss. METHODS: Representative samples of U.S. adults were recruited using Google Consumer Surveys in August-October 2014. Respondents were asked about beliefs and potential discouragement regarding the role of exercise and weight loss. An analysis of variance was performed to predict individuals that become discouraged if exercise does not lead to weight loss. RESULTS: The belief that exercise is a very effective way to lose weight was common (71% of respondents). Stronger belief that exercise is an effective way to lose weight (p<0.001) in individuals with higher weight status (p=0.04) positively predicted discouragement with exercise. Higher weight status combined with the belief that exercise reduces weight was a significant positive predictor of discouragement (p=0.01). CONCLUSIONS: Individuals with higher weight status that believe that exercise is an effective way to lose weight are more likely to become discouraged when exercise does not lead to weight loss. Prescribing exercise for weight loss might contribute to discouragement. Future studies should evaluate ways to encourage exercise without promoting the belief that exercise will yield weight loss.
Stanford FC, Johnson ED, Claridy MD, Earle RL, Kaplan LM. The Role of Obesity Training in Medical School and Residency on Bariatric Surgery Knowledge in Primary Care Physicians. Int J Family Med. 2015;2015 :841249.Abstract
Objective. US primary care physicians are inadequately educated on how to provide obesity treatment. We sought to assess physician training in obesity and to characterize the perceptions, beliefs, knowledge, and treatment patterns of primary care physicians. Methods. We administered a cross-sectional web-based survey from July to October 2014 to adult primary care physicians in practices affiliated with the Massachusetts General Hospital (MGH). We evaluated survey respondent demographics, personal health habits, obesity training, knowledge of bariatric surgery care, perceptions, attitudes, and beliefs regarding the etiology of obesity and treatment strategies. Results. Younger primary care physicians (age 20-39) were more likely to have received some obesity training than those aged 40-49 (OR: 0.08, 95% CI: 0.008-0.822) or those 50+ (OR: 0.03, 95% CI: 0.004-0.321). Physicians who were young, had obesity, or received obesity education in medical school or postgraduate training were more likely to answer bariatric surgery knowledge questions correctly. Conclusions. There is a need for educational programs to improve physician knowledge and competency in treating patients with obesity. Obesity is a complex chronic disease, and it is important for clinicians to be equipped with the knowledge of the multiple treatment modalities that may be considered to help their patients achieve a healthy weight.
Stanford FC, Kyle TK, Claridy MD, Nadglowski JF, Apovian CM. The influence of an individual's weight perception on the acceptance of bariatric surgery. Obesity (Silver Spring). 2015;23 (2) :277-81.Abstract
OBJECTIVE: This study assessed the proportion of US adults with excess weight and obesity who consider bariatric surgery to be appropriate for themselves and how their own weight perception influences this consideration. METHODS: A stratified sample of 920 US adults in June 2014 was obtained through an online survey. The respondents were queried about bariatric surgery acceptability and personal weight perception. Average body mass index (BMI) was determined for each demographic variable, and responses were characterized according to BMI and concordance with perceived weight status. Chi-square analyses served to assess perceived weight concordance in relation to bariatric acceptance. RESULTS: Only 32% of respondents with Class III obesity indicated that bariatric surgery would be an acceptable option for them, most often because they considered it to be too risky. Respondents with Class III obesity and concordant perception of weight status were more likely (P < 0.03) than discordant Class III respondents to accept bariatric surgery. Likewise, concordant respondents with excess weight, but not obesity, were more likely (P < 0.001) to correctly consider bariatric surgery to be inappropriate for them. CONCLUSIONS: Despite good safety and efficacy, many persons still believe bariatric surgery is too risky. Weight perception concordance or discordance influences one's decision to consider this treatment option.
Stanford FC, Jones DB, Schneider BE, Blackburn GL, Apovian CM, Hess DT, Chiodi S, Robert S, Bourland AC, Wee CC. Patient race and the likelihood of undergoing bariatric surgery among patients seeking surgery. Surg Endosc. 2015;29 (9) :2794-9.Abstract
BACKGROUND: Ethnic minority adults have disproportionately higher rates of obesity than Caucasians but are less likely to undergo bariatric surgery. Recent data suggest that minorities might be less likely to seek surgery. Whether minorities who seek surgery are also less likely to proceed with surgery is unclear. METHODS: We interviewed 651 patients who sought bariatric surgery at two academic medical centers to examine whether ethnic minorities are less likely to proceed with surgery than Caucasians and whether minorities who do proceed with surgery have higher illness burden than their counterparts. We collected patient demographics and abstracted clinical data from the medical records. We then conducted multivariable analyses to examine the association between race and the likelihood of proceeding with bariatric surgery within 1 year of initial interview and to compare the illness burden by race and ethnicity among those who underwent surgery. RESULTS: Of our study sample, 66% were Caucasian, 18% were African-American, and 12% were Hispanics. After adjustment for socioeconomic factors, there were no racial differences in who proceeded with bariatric surgery. Among those who proceeded with surgery, illness burden was comparable between minorities and Caucasian patients with the exception that African-Americans were underrepresented among those with reflux disease (0.4, 95% CI 0.2-0.7) and depression (0.4, 0.2-0.7), and overrepresented among those with anemia (4.8, 2.4-9.6) than Caucasian patients. CONCLUSIONS: Race and ethnicity were not independently associated with likelihood of proceeding with bariatric surgery. Minorities who proceeded with surgery did not clearly have higher illness burden than Caucasian patients.
2014
Stanford FC, Durkin MW, Stallworth JR, Powell CK, Poston MB, Blair SN. Factors that influence physicians' and medical students' confidence in counseling patients about physical activity. J Prim Prev. 2014;35 (3) :193-201.Abstract
Less than half of US adults and two-thirds of US high school students do not meet current US guidelines for physical activity. We examined which factors promoted physicians' and medical students' confidence in counseling patients about physical activity. We established an online exercise survey targeting attending physicians, resident and fellow physicians, and medical students to determine their current level of physical activity and confidence in counseling patients about physical activity. We compared their personal level of physical activity with the 2008 Physical Activity Guidelines of the US Department of Health and Human Services (USDHHS). We administered a survey in 2009 and 2010 that used the short form of the International Physical Activity Questionnaire. A total of 1,949 individuals responded to the survey, of whom 1,751 (i.e., 566 attending physicians, 138 fellow physicians, 806 resident physicians, and 215 medical students) were included in this analysis. After adjusting for their BMI, the odds that physicians and medical students who met USDHHS guidelines for vigorous activity would express confidence in their ability to provide exercise counseling were more than twice that of physicians who did not meet these guidelines. Individuals who were overweight were less likely to be confident than those with normal BMI, after adjusting for whether they met the vigorous exercise guidelines. Physicians with obesity were even less likely to express confidence in regards to exercise counseling. We conclude that physicians and medical students who had a normal BMI and met vigorous USDHHS guidelines were more likely to feel confident about counseling their patients about physical activity. Our findings suggest that graduate medical school education should focus on health promotion in their students, as this will likely lead to improved health behaviors in their students' patient populations.
Stanford FC, Taveras EM. The Massachusetts school-based body mass index experiment: gleaning implementation lessons for future childhood obesity reduction efforts. Obesity (Silver Spring). 2014;22 (4) :973-5.Abstract
In 2009, Massachusetts (MA) Department of Public Health (DPH) implemented new regulations that required public schools in the state to measure height and weight, determine body mass index (BMI), and notify parents of children in grades 1, 4, 7, and 10 of their child's weight status. After 3 years of implementation, MA DPH recently abandoned parental notification of school-based BMI screening results citing several concerns including flaws in the ability to monitor the way that the BMI screening results were communicated from the schools to parents/guardians and some reports of breaches in confidentiality of students' measurements. In this article, we review implementation issues that could have impacted the success of the MA DPH regulation as well as lessons to be learned and potentially applied to future childhood obesity efforts.
2013
Vann LH, Stanford FC, Durkin MW, Hanna A, Knight LM, Stallworth JR. "Moving and losing": A pilot study incorporating physical activity to decrease obesity in the pediatric population. J S C Med Assoc. 2013;109 (4) :116-20.Abstract
OBJECTIVE: This study was developed as a pilot study to determine if targeted interventions regarding increasing physical activity level through the use of pedometers and fitness DVDs would result in a decrease in BMI in overweight or obese children. METHODS: 24 children aged 4-17 taking part in "Moving and Losing" were randomized to (1) Control Group; (2) Pedometer Group; (3) DVD Group; (4) Pedometer + DVD Group and asked to complete self-report physical activity logs at visit one and two. Baseline, midpoint, and endpoint weight, height, Body Mass Index (BMI) were measured for outcome variables. RESULTS: Almost half (42%) of participants turned in their activity logs and pedometers at midpoint, but at endpoint less than a quarter of participants turned in their pedometers and/or activity logs. BMI increased by 4.1% in the Control Group, 8.7% in the Pedometer Group, and 6.7% in the DVD Group. BMI decreased by 0.3% in the Pedometer + DVD Group. CONCLUSION: The use of pedometers and fitness DVDs may not be culturally acceptable in African-American female children and adolescents from South Carolina who are overweight or obese. Further studies should look into in-depth needs assessments and planning processes that include participants as stakeholders.
Stanford FC, Durkin MW, Stallworth JR, Blair SN. Comparison of physical activity levels in physicians and medical students with the general adult population of the United States. Phys Sportsmed. 2013;41 (4) :86-92.Abstract
OBJECTIVE: Physicians who are physically fit have a higher likelihood of counseling their patients about physical activity. We sought to determine if the amount of physical activity in physicians and medical students differs from the general adult population of the United States and if geographic differences in physical activity levels exist. METHODS: A cross-sectional survey was distributed to physicians and medical students throughout the United States to determine their level of physical activity according to US Department of Health and Human Services (DHHS) 2008 guidelines; data were collected from participants from June 2009 through January 2010. Our data set was compared with physical activity data from the Centers for Disease Control and Prevention (CDC) and we used geographic regions defined by the US Census Bureau. RESULTS: Our survey respondents contained 631 attending physicians, 159 fellow physicians, 897 resident physicians, and 262 medical students. Only 64.5% of the general US adult population meets DHHS guidelines for physical activity, but 78% of the survey participants fulfilled the guidelines. The percentage of US adults who do not engage in leisure-time physical activity is 25.4% compared with 5.8% of survey participants. Survey respondents in the southern region had the lowest physical activity levels and participants in the western region had the highest levels. CONCLUSION: Physicians and medical students engage in more physical activity than the general US adult population. Regional differences in the general population's physical activity also persisted in physicians and medical students. Therefore, physicians who complete less physical activity may be less likely to encourage patients to engage in physical activity in geographic areas where the adult population is less active.
2012
Stanford FC, Durkin MW, Blair SN, Powell CK, Poston MB, Stallworth JR. Determining levels of physical activity in attending physicians, resident and fellow physicians and medical students in the USA. Br J Sports Med. 2012;46 (5) :360-4.Abstract
OBJECTIVE: Evidence suggests that the level of physical activity of physicians can be correlated directly with physician counselling patterns about this behaviour. Our objective was to determine if medical students, resident and fellow physicians and attending physicians meet the physical activity guidelines set forth by the US Department of Health and Human Services. METHODS: A representative cross-sectional web-based survey was conducted in June 2009-January 2010 throughout the USA (N=1949). Using the short form of the International Physical Activity Questionnaire, the authors gathered demographical data and information related to physical activity, the level of training, the number of work hours per week, body mass index (BMI), confidence about counselling about physical activity and frequency with which the physical activity is encouraged to his/her patients. RESULTS: Based on the 1949 respondents, attending physicians (84.8%) and medical students (84%) were more likely than resident (73.2%) and fellow physicians (67.9%) to meet physical activity guidelines. CONCLUSION: Physicians and medical students engage in more physical activity and tend to have a lower BMI than the general population. Resident and fellow physicians engage in less physical activity than attending physicians and medical students.

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