Feasibility and indicative results from a 12-month low-energy liquid diet treatment and maintenance programme for severe obesity

Background

There is no established primary care solution for the rapidly increasing numbers of severely obese people with body mass index (BMI) > 40 kg/m².

Aim

This programme aimed to generate weight losses of ≥15 kg at 12 months, within routine primary care.

Design and setting

Feasibility study in primary care.

Method

Patients with a BMI ≥40 kg/m² commenced a micronutrient-replete 810–833 kcal/day low-energy liquid diet (LELD), delivered in primary care, for a planned 12 weeks or 20 kg weight loss (whichever was the sooner), with structured food reintroduction and then weight-loss maintenance, with optional orlistat to 12 months.

Result

Of 91 patients (74 females) entering the programme (baseline: weight 131 kg, BMI 48 kg/m², age 46 years), 58/91(64%) completed the LELD stage, with a mean duration of 14.4 weeks (standard deviation [SD] = 6.0 weeks), and a mean weight loss of 16.9 kg (SD = 6.0 kg). Four patients commenced weight-loss maintenance omitting the food-reintroduction stage. Of the remaining 54, 37(68%) started and completed food reintroduction over a mean duration of 9.3 weeks (SD = 5.7 weeks), with a further mean weight loss of 2.1 kg (SD = 3.7 kg), before starting a long-term low-fat-diet weight-loss maintenance plan. A total of 44/91 (48%) received orlistat at some stage. At 12 months, weight was recorded for 68/91 (75%) patients, with a mean loss of 12.4 kg (SD = 11.4 kg). Of these, 30 (33% of all 91 patients starting the programme) had a documented maintained weight loss of ≥15 kg at 12 months, six (7%) had a 10–15 kg loss, and 11 (12%) had a 5–10 kg loss. The indicative cost of providing this entire programme for wider implementation would be £861 per patient entered, or £2611 per documented 15 kg loss achieved.

Conclusion

A care package within routine primary care for severe obesity, including LELD, food reintroduction, and weight-loss maintenance, was well accepted and achieved a 12-month-maintained weight loss of ≥15 kg for one-third of all patients entering the programme.     

Type and intensity of activity and risk of mobility limitation: the mediating role of muscle parameters

OBJECTIVES: To investigate the association between different types of physical activity behavior and incident mobility limitation in older men and women and to examine whether muscle parameters mediate these associations. DESIGN: Cohort study with 4.5-year follow-up. SETTING: Metropolitan areas surrounding Pittsburgh, Pennsylvania, and Memphis, Tennessee. A random sample of white Medicare beneficiaries and all age-eligible blacks. PARTICIPANTS: Three thousand seventy-five black and white men and women aged 70 to 79 with no self-reported difficulty walking one-quarter of a mile or climbing 10 steps, enrolled in the Health, Aging and Body Composition (Health ABC) Study. MEASUREMENTS: Participants were classified as exercisers (reporting > or = 1,000 kcal/wk of exercise activity), lifestyle active (reporting < 1,000 kcal/wk of exercise activity and > or = 2,719 kcal/wk of total physical activity), or inactive (reporting < 1,000 kcal/wk of exercise activity and < 2,719 kcal/wk of total physical activity). The study outcome, incident mobility limitation, was defined as two consecutive, semiannual self-reports of any difficulty walking one quarter of a mile or climbing 10 steps. Thigh muscle area, thigh muscle attenuation (a marker of fat infiltration in muscle), appendicular lean soft tissue mass, and isokinetic knee extensor strength were examined as potential mediators. RESULTS: Over 4.5 years, 34.3% of men and 47.4% of women developed mobility limitation. Inactive persons had twice the risk of incident mobility limitation as exercisers (hazard ratio (HR)=2.08, 95% confidence interval (CI)=1.60-2.70, for men, HR=1.98, 95% CI=1.51-2.60, for women). Lifestyle-active men and women had an intermediate risk (HR=1.47 and 1.44, respectively). For the lifestyle active and inactive, absence of walking activity conferred an additional risk of mobility limitation. Muscle parameters did not mediate the relationship between physical activity and mobility limitation, except for knee extensor strength in men. CONCLUSION: Exercise and an active lifestyle that includes walking protect against mobility loss in older men and women. Activity effects on muscle parameters do not explain this association.     

Cross-sectional associations between trunk muscle composition, back pain, and physical function in the health, aging and body composition study

BACKGROUND: Associations between trunk muscle composition and physical function have not been examined previously in older adults. We hypothesized that lower trunk muscle area and attenuation (higher fat infiltration) are associated with decreased functional capacity. METHODS: The study sample consisted of a biracial cohort of well functioning men (739) and women (788) aged 70-79 from the Pittsburgh site of the Health, Aging and Body Composition (Health ABC) study. Computed tomography was used to measure trunk muscle area (cm2) and muscle attenuation (Hounsfield Unit [HU]) of the following muscle groups: lumbar paraspinals, lateral abdominals, and rectus abdominis. An average score was calculated for both trunk area and attenuation. The Health ABC Physical Performance Battery (PPB) and its individual components (usual and narrow walk, chair stands, and standing balance) were used to measure functional capacity. RESULTS: Linear regression analyses adjusting for demographic factors, height, body fat, thigh muscle composition, disease status, and low back pain (LBP) found that average trunk muscle area was not associated with any element of functional capacity (p >.10), whereas average trunk muscle attenuation was positively associated with the Health ABC Physical Performance Battery (p <.05) and chair stands (p <.001). Participants reporting higher LBP severity during the past year had lower muscle attenuation (p <.001 for trend), but there was no difference in average trunk muscle area according to LBP status. CONCLUSIONS: Findings suggest a link between trunk muscle composition and history of LBP as well as reduced functional capacity in older adults. Improving trunk muscle quality may lead to reduced LBP severity and improved functional status.     

Supernumerary intrathoracic rib,a rare congenital anomaly: Case report and review of the literature

A 17‐year‐old female who presented with cough, chest pain, dyspnea, and hemoptysis was found to have an intrathoracic rib. Patients who are diagnosed with intrathoracic ribs are most often asymptomatic and should undergo limited diagnostic workup. Intrathoracic ribs are rare congenital anomalies incidentally identified after chest radiography performed for another indication, as is the case with this patient. In this case, further evaluation was necessary due to persistent symptoms. Here, we used contrast‐enhanced ultrasound after chest radiography and computed tomography to further evaluate the fatty intrathoracic mass and exclude vascular features suggestive of a tumor.