Millions Of Overweight People Unaware Of Cardiometabolic Dangers

Experts meeting at the 2nd International Congress on Abdominal Obesity (ICAO) issued a warning that millions of individuals around the globe are at risk from the cardiometabolic consequences of being overweight. Worryingly, the experts suggest that these people are not being identified by their doctors.

The International Chair on Cardiometabolic Risk (ICCR) released the statement from the ICAO, at a symposium sponsored by GlaxoSmithKline. The statement suggests that the media tends to focus on extremes when discussing obesity: either skinny celebrities who gain or lose a few pounds or the morbidly obese who need the help of fire-fighters to leave their homes. As the proportion of the general population which is overweight or obese increases, so the perception of what is the norm of a healthy weight is being reset. In the minds of society as a whole, including healthcare practitioners, the mental picture of an overweight or obese person has been reset inaccurately to a far heavier model.

Yet it is the millions across the world with BMIs above 25 who may already be suffering the early stages of high blood pressure, dyslipidemia and diabetes, who could benefit most from early intervention, say ICCR.

"Many primary care doctors may be treating obese patients with BMIs of 30 and above for the symptoms related to increased cardiometabolic risk, like pre-diabetes, dyslipidemia and hypertension, but not treating them for the underlying cause, their excess visceral adiposity," commented Professor Jean-Pierre Després, Scientific Director of ICCR and Professor, Faculty of Medicine, University Laval, Québec, Canada. Visceral adiposity is fat stored in the abdomen and around the vital organs. Excess visceral fat increases the risk of serious diseases, such as type 2 diabetes, stroke and heart disease.

"A patient with a BMI of 29 or 31 is the norm today yet when we think of an obese person, we tend to visualise someone with a much higher BMI of 40 plus. Patients with lower BMIs but higher levels of hidden, visceral fat are more difficult to identify yet can be at as much cardiometabolic risk as more obviously obese individuals", continued Professor Després. ICCR emphasised the need for urgent action to target these at-risk patients in order to slow the increasing rate of obesity across the world and stem the rising levels of diabetes and cardiovascular disease.

New research released at the Congress from the INternational Study of Prediction of Intra-abdominal adiposity and its RElationships with cardioMEtabolic risk/Intra-Abdominal Adiposity (INSPIRE ME IAA) supports the ICCR's position. INSPIRE ME IAA recruited 4,504 patients from 29 countries and showed harmful cardiometabolic risk profiles among non-diabetic, study participants, even among sub-groups of moderately overweight patients with an excess of visceral adipose tissue.

ICCR called for a renewed focus on what actually constitutes a healthy weight and how healthcare professionals support people in attaining and maintaining it. "In addition to patients who are clearly obese, we need to pay attention to overweight patients with visceral obesity who do not realise the potential dangers of the fat within their abdomen. Their doctor may not make this connection either. Yet a modest weight loss of just five or ten percent could result in a substantial loss of visceral adipose tissue and make all the difference to these people" stated Professor Després.

Modest gradual weight loss is recognised by most experts as the best way to lose and keep off weight, yet the diet industry and media fuel unrealistic expectations by promoting 'crash diets' and extreme dieters who slim to a fraction of their previous size. A lack of information and guidance on realistic approaches to and interventions which support modest weight loss is also considered by ICCR as a factor in the failure to reverse the tide of obesity.

As an organisation which strongly advocates a multidisciplinary approach to treating cardiometabolic risk factors, ICCR believes it is in a strong position to drive a renewed effort to overcome the multi-factorial barriers preventing healthcare professionals from turning the tide in the battle against obesity. ICCR also told the Congress it will seek to encourage and broaden the conversation around the concept of healthy weight in the hope of resetting the conversation around abdominal obesity, realistic weight loss and health.

Knee Replacement Surgeries Take More Time, Are More Costly In Overweight Individuals

Knee replacement surgery takes far more time to conduct in overweight and obese patients than in normal weight patients, according to recent research at Hospital for Special Surgery in New York. The study will be presented at the American Academy of Orthopaedic Surgeons annual meeting, held Feb. 15-19 in San Diego, Calif. The study has implications for hospital staff scheduling surgeries, operating room utilization and personnel staffing, and also raises the question of whether knee replacements should be reimbursed based on time.

"When we schedule surgery, the body mass index is never considered," said Geoffrey Westrich, M.D., an adult reconstruction and joint replacement surgeon and co-director of Joint Replacement Research at Hospital for Special Surgery who led the study. "If I have four or five knee replacements in a day, they will just put them on the OR schedule but they don't look at whether a person is heavy or obese class II or obese class III. What this study shows is that the utilization is greatly increased. If you have a 20 percent greater utilization for someone who is obese and if you multiply that by five or six knee replacements over the course of a day, at the end of the day the operating room staff could be finishing up two hours later. In many cases, the hospital has to pay the staff overtime which greatly increases hospital expenditures."

Obesity causes a variety of health problems, including an increased need for total knee arthroplasty (TKA) or knee replacement surgery extra weight puts extra stress on knees. Researchers at Hospital for Special Surgery wondered whether weight might impact the time it took to perform a knee replacement. "Intuitively, one would think that as people get heavier, knee replacement surgery may be more difficult and more time consuming because the fatty tissue makes surgery more difficult," Dr. Westrich said. "Now that we have collected data on the different stages of knee replacement surgery, we wanted to use the objective data to determine if there was an increase in the time of surgery based on a patient's weight and whether we could correlate a patient's weight or BMI with the different steps of knee replacement surgery."

The investigators retrospectively reviewed a consecutive series of 454 TKAs conducted by one surgeon at HSS between 2005 and 2009. They categorized patients into groups based on the World Health Organization classification of body mass index: normal weight 18.5-25 kg/m2, overweight 25-30 kg/m2, obese class I 30-35 kg/m2, obese class II 35-40 kg/m2, and obese class III >40 kg/m2. The investigators then correlated weight with five factors: anesthesia induction time, tourniquet time, time spent surgically closing the knee after completing the procedure, total surgery time, and total amount of time spent in the operating room. The tourniquet time is measured from the time of the initial incision, includes the time it takes to implant the knee prosthesis, and ends when the bone cement is hard. The closure time is not included in the tourniquet time.

The investigators found that as BMI increased, so did the time it took to perform all parts of the surgery. "As BMI increased, surgery times progressively increased," Dr. Westrich said. In patients who were a healthy weight, the overall room time was two hours and increased as weight category increased; for obese class III patients, it was two hours and 24 minutes, a difference that was 20 % greater and highly statistically significant. In comparing normal weight to obese class III patients, the times were also greater for obese patients in total room time (24 minutes, P<0.01), surgery time (16 minutes, P<0.01), tourniquet time (7.5 minutes, P<0.01), anesthesia time (4.5 minutes, P=0.005) and closure time (8 minutes, P<0.01).

Obesity is a growing epidemic in the United States with currently 71 percent of individuals over the age of 60 classified as obese. While the number of obese people has grown, so has the number of TKAs performed between 2000 and 2004, there was a 53 percent increase in the number of TKAs conducted in the United States. Dr. Westrich said that, in this study, seventy percent of his patients were classified as overweight or obese I, II, III and 50 percent were obese class I, II, III. The number of obese people being scheduled for TKAs will likely increase.

"Before this particular study, we knew that when people are heavier, we knew the surgery could be more challenging but we never had objective data to support it," Dr. Westrich said. "Hospitals should not only take into account the type of surgery and its complexity, but also the patient's body mass index when appropriately allocating OR time."