Sunday, January 27, 2019

Mouth and Gut Bacteria May Aid in Overweight And Obesity Treatment

Studies done at The Washington University St. Louis Medical School have shown that trillions of bacteria live in our gut. These bacteria perform specific activities such as extracting calories from food we eat and managing nutrients. These bacteria are common to all of us, however, each individual has a unique set of the bacteria.  Studies at Washington University have shown that the composition of the bacteria plays an important role in weight control. A more recent study done at Penn State University is suggesting that mouth bacteria in infants may predict obesity later in life.
The researchers at Washington University studied mice, and concluded that obese mice had more of the bacteria called Firmicutes in their gut, and fewer of  the bacteria called Bacteroidetes.  Firmicutes are associated  with obesity and Bacteroidetes are associated with leanness. These same bacteria were found in the mouths of participants in the Penn State University study. The researchers indicated that an imbalance in these two sets of bacteria could lead to obesity.
The researchers concluded that “the children who had rapid weight gain as infants, which is a strong risk factor for childhood obesity, had fewer groups of bacteria or less diversity in their mouth bacteria. These children also had a higher ratio of Firmicutes to Bacteroidetes, two of the most common bacteria groups of the human microbiota.”
One of the study’s researchers indicated that “There's … a certain balance of these two common bacteria groups, Firmicutes and Bacteroidetes, that tends to work best under normal healthy conditions, and disruptions to that balance could lead to dysregulation in digestion,”
Of course researchers will need to determine the full effect of these two types of bacteria in the creation of fat tissue, and the value of the bacteria in the mouth for predicting obesity. And researchers need to determine what diets lead to the optimal composition of these bacteria. However, gaining knowledge about these bacteria may enable us to better fight, predict, and avoid obesity. 


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Sunday, January 20, 2019

Using Artificial Intelligence to Treat Prediabetes

Prediabetes is a chronic disease that afflicts 84% of the adults in the U.S., and having prediabetes raises the risk for diabetes heart disease stroke and other problems. The  Centers for Disease Control and Prevention (CDC) established the Diabetes Prevention Program (DPP) to address prediabetes. That program is based on a study, funded by the National Institutes of Diabetes and Digestive and Kidney Disease (NIDDK). The study was done and reported on between 1996 and 2002. The services delivered in the DPP can potentially be replicated with the help of artificial intelligence.

The original DPP study indicated that for those with prediabetes, lifestyle modification plus diet and increased physical activity could reduce the risk of diabetes by 58%. The study was done using highly trained individuals -- registered dietitians, for example -- to deliver the one-on-one counseling. The one-on-one program was later translated into a group based program. This group based program was less costly than the original one-on-one program. Still, additional efforts are underway to reduce the cost of the program. One of these programs uses artificial intelligence and telemedicine to deliver the counseling.

The program is called the Lark Weight Loss Health Coach AI (HCAI). In a study, HCAI was used to determine the effectiveness of conversational artificial intelligence (AI) when used as a mobile app for smart phones. The study also measured the user acceptability of the methodology.

There were 70 participants in the study, and the study's standards met the CDC’s criteria for the CDC’s diabetes prevention program. The criteria were those used for the original DPP trials. Although more research needs to be done, the results were quite promising.

The investigators concluded that “the use of an AI health Coach is associated with weight loss comparable to in-person lifestyle interventions. It can also encourage behavior changes and have higher user acceptability. Research into AI and its application in telemedicine should be pursued, with clinical trials investigating effects on weight, health behaviors, and user engagement and acceptability.”

If this approach proves beneficial, it could increase the number of people with prediabetes who can get treatment while lowering the cost. Healthcare providers should keep abreast of this type of research, because it can be quite important in the future.

Friday, December 28, 2018

How Does Exercise Help Us Manage Weight

There was a 2015 New York Time magazine article that argued that exercise alone is not a good way to lose weight. The author implied that a well-chosen diet was a lot more effective for losing weight than exercise. Indeed, what you eat counts more than your physical activity when trying to get rid of excess body fat. Still, exercise is important in weight loss and weight management. For example, exercise affects some of our genes and some of our hormones.

Exercise can change the way our genes function. For instance, according to one study, exercise can reduce the effects of a gene called the "fat gene." Specifically, the gene called the “fat mass obesity associated” or FTO gene has been shown to heighten the risk of obesity. This gene was documented in 2007. But a recent study concluded that exercise “can reduce the weight-gaining effects of the  ... FTO gene, by about 30%."

And based on another study, exercise causes an increase in a hormone that boosts the metabolism. This boost in metabolism can help manage weight. The hormone is called FGF21. According to the study, the hormone "boosts the process of the body converting food into energy, helping the body burn more calories even while resting – thus helping in weight loss."

The study also gave us information that was quite interesting. The investigators found that the production of FGF21 from cardio training was three times larger than it was from strength training. Thus, to raise the metabolic rate -- at least with respect to FGF21 -- cardio training appears to be more effective than strength training.

So, we know that exercise is beneficial to our health, including weight management. Exercise affects our hormones and genes. Exercise can lessen the effects of excess weight on our health. Therefore, obesity medicine specialists should counsel their patients on the benefits of exercise with or without associated weight loss.

Sunday, December 23, 2018

Belviq May Give Weight Loss Drugs a Boost

In general, there are three approaches to weight loss and weight management. These approaches are lifestyle modification (including diet and exercise), weight loss surgery, and antiobesity drugs. While each approach can be successful, each one of these approaches has associated problems. Changes in lifestyle are hard for individuals to adhere to for a long period of time. Weight loss surgery can give rise to serious complications. And antiobesity drugs have often produced disappointing weight loss results and severe side effects. But one drug, Belviq, is showing positive results.

Over the past several years, four antiobesity drugs have gained FDA approval and become available for the treatment of obesity. These drugs are Qsymia (phentermine/topiramate), produced by Vivus, Belviq (lorcaserin) produced by Arena, Contrave (bupropion/naltrexone), produced by Orexigen and Saxenda (liraglutide), produced by Novo Nordisk. These drugs give providers new tools to fight obesity. But the drugs have not had the impact that some desired.

However, one of the antiobesity drugs, Belviq, may change that. For example, according to one study, Belviq did not increase the participants' risk of major cardiovascular events compared to the placebo group.  Cardiovascular problems have been a concern since the days of the antiobesity drug, fen/phen (fenfluramine/phentermine), which was taken off the market in 1997.

Also, "Weight loss of at least 5% occurred in 38.7% of those assigned [Belviq] vs. 17.4% of those assigned placebo." Further, the "Researchers observed small but significant improvements in in BP, heart rate, triglyceride levels and HbA1c during the course of the study ..."

Therefore, the study may motivate providers to prescribe Belviq for weight loss. One stumbling block is the cost of the drug, which is $280.00 per month, retail. But if the cost-benefit ratio can be justified by payers, and if commercial insurers start to reimburse providers for the drug, the drug will likely see an increase in use.

Friday, November 30, 2018

The Diabetes Prevention Program Services May One Day Be Commercially Reimbursed

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) helped lead a study to determine if lifestyle changes could prevent type 2 diabetes. The study was named the Diabetes Prevention Program (DPP). The researchers concluded that a relatively small amount of weight loss, along with healthy eating and physical activity, can prevent type 2 diabetes for those people with prediabetes. The positive results eventually led Medicare, including Medicare Advantage, to start reimbursing suppliers who offer a modified version of the type 2 diabetes prevention program, called the Medicare Diabetes Prevention Program (MDPP). The MDPP might lead to commercial insurer reimbursement for the DPP services.

The Diabetes Prevention Program or DPP trial was started in 1996 by The NIDDK to determine if weight loss promoted by healthy eating and physical activity could be used to prevent type 2 diabetes in persons with prediabetes. The study was a randomized trial consisting of three groups. One of the groups used diet, exercise and lifestyle modification for the prediabetes treatment, one of the groups used metformin for the treatment, and one of the groups was the placebo group. All three groups contained prediabetic subjects that were overweight but not obese. Results from the study were reported in 2002.
The specific goal of the study was to determine if individuals with prediabetes could avoid type 2 diabetes by losing 7% of their weight through diet, exercise, and lifestyle modification. During the approximately 2.8-year period of the study, it was concluded that the intensive lifestyle group experienced a 58% reduction in the incidence of type 2 diabetes, and that the metformin group experienced a 31% reduction compared to the placebo group. After ten years, the type 2 diabetes incidence "was reduced by 34% ... in the lifestyle group and 18% .. in the metformin group compared with placebo."

Based on positive results from the original DPP study, Medicare carried out its own test to determine if the DPP methods could be cost effective for Medicare beneficiaries. The DPP was found to be cost effective for Medicare beneficiaries. Therefore, Medicare began offering its diabetes prevention program in April of 2018. The program is called the Medicare Diabetes Prevention Program or MDPP.

And since commercial insurers reimburse for the MDPP under Medicare Advantage programs, these insurers may one day make the DPP services a covered benefit for "commercially insured populations."

Wednesday, November 28, 2018

The EndoBarrier, Obesity and Type 2 Diabetes

G.I. Dynamics of Lexington Massachusetts is the producer of the EndoBarrier. The EndoBarrier is an intestinal liner that mimics some of the functions of gastric bypass surgery. The liner is placed in the stomach, endoscopically, through the mouth. By serving as a barrier in the intestine, the device limits the amount of calories absorbed by the body during digestion. The device aids in the management of obesity and type 2 diabetes.

The “EndoBarrier bridges the gap between pharmaceuticals and surgery by providing a safer and more effective way to control glucose and weight loss for individuals who are underserved by drugs and injections but for whom surgery is not an option.”

While the EndoBarrier could bridge the gap between pharmaceuticals and surgery for the treatment of obesity as well as type 2 diabetes, it may be common, one day, to use the device in combination with pharmaceuticals. In fact, in 2013, G.I. Dynamics said that the company's collaboration with other companies might “lead to improvements in the device, as well as potential combinations of drug treatment and EndoBarrier Therapy to optimize patient outcomes.”

A recent study indicates that the EndoBarrier is an “effective treatment for obesity and type 2 diabetes.” Thirty-one patients completed a 12 month study which showed that there was a weight reduction and a reduction in HbA1c. The investigators concluded that “the EndoBarrier appears to be a safe and effective treatment strategy in overweight patients with poor glycemic control despite medical therapy or in those who are eligible but decline bariatric surgery.”

Healthcare providers should monitor the advances in devices used to treat overweight, obesity and type 2 diabetes. These devices, including the EndoBarrier, will no doubt add to the overweight, obesity and type 2 diabetes treatment arsenals. These devices will indeed fill a gap between pharmaceuticals and surgery. And providers who are well informed will be able to counsel patients on the risks and benefits of the EndoBarrier and other similar devices. 

Monday, October 29, 2018

Healthy BMIs

Based on a study done a few years back, The Centers for Disease Control and Prevention (CDC) suggested “that people who are modestly overweight actually have a lower risk of death than those of normal weight.” The CDC's suggestion implied that, in general, people with a BMI greater than 25 may generally be healthier than people whose BMI is lower than 25. However, subsequent studies have indicated that BMIs in the range of 20 to 24.9 are usually the healthiest BMIs.

The NIH classifies body weight as follows: A normal weight BMI is between 18.5 and 24.9. Overweight is between 25 and 29.9. A BMI between 29.9 and 39.9 is designated as obesity. And a BMI of 40 or more is considered to be extreme obesity.

A study done in Australia and the Netherlands looked at 246,000 subjects. At first the data indicated that the healthiest BMI range agreed with the CDC’s findings -- something above 25. However, "after adjusting their findings to exclude people with preexisting illnesses and smokers—two groups that tend to have lower body weights despite their poor health—the study authors found BMIs at the high end of 'normal' had lower mortality rates than people in the 'overweight' category."

Indeed, one of the most common chronic illnesses is hypertension. It’s associated with type 2 diabetes and cardiovascular problems. Well, one study concluded that "Being as lean as possible within the normal body mass index range may be the best suggestion in relation to primary prevention of hypertension." So being lean, not overweight, is the healthier state -- at least for hypertension.

Healthcare providers should push back on the idea that BMIs greater than 25, in general, are healthier than BMIs between 20 and 24.9, except in special cases. Very muscular individuals, for example, may have a higher body weight for their height than normal, but still be healthy. Further, these more muscular individuals could be healthier than someone of normal BMI. However, in most instances, a BMI between 20 and 24.9 is desirable for good health.

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