A predictive model for non-completion of an intensive specialist obesity service in a public hospital : a case-control study

Background: Despite the growing evidence base supporting intensive lifestyle and medical treatments for severe obesity, patient engagement in specialist obesity services is difficult to achieve and poorly understood. To address this knowledge gap, we aimed to develop a model for predicting non-completion of a specialist multidisciplinary service for clinically severe obesity, termed the Metabolic Rehabilitation Programme (MRP). Method: Using a case-control study design in a public hospital setting, we extracted data from medical records for all eligible patients with a body mass index (BMI) of ≥35 kg/m2 with either type 2 diabetes or fatty liver disease referred to the MRP from 2010 through 2015. Non-completion status (case definition) was coded for patients whom started but dropped-out of the MRP within 12 months. Using multivariable logistic regression, we tested the following baseline predictors hypothesised in previous research: age, gender, BMI, waist circumference, residential distance from the clinic, blood pressure, obstructive sleep apnoea (OSA), current continuous positive airway pressure (CPAP) therapy, current depression/anxiety, diabetes status, and medications. We used receiver operating characteristics and area under the curve to test the performance of models. Results: Out of the 219 eligible patient records, 78 (35.6%) non-completion cases were identified. Significant differences between non-completers versus completers were: age (47.1 versus 54.5 years, p < 0.001); residential distance from the clinic (21.8 versus 17.1 km, p = 0.018); obstructive sleep apnoea (OSA) (42.9% versus 56.7%, p = 0.050) and CPAP therapy (11.7% versus 28.4%, p = 0.005). The probability of non-completion could be independently associated with age, residential distance, and either OSA or CPAP. There was no statistically significant difference in performance between the alternate models (69.5% versus 66.4%, p = 0.57). Conclusions: Non-completion of intensive specialist obesity management services is most common among younger patients, with fewer complex care needs, and those living further away from the clinic. Clinicians should be aware of these potential risk factors for dropping out early when managing outpatients with severe obesity, whereas policy makers might consider strategies for increasing access to specialist obesity management services

Class 3 obesity in a multidisciplinary metabolic weight management program : the effect of preexisting Type 2 diabetes on 6-month weight loss

Introduction. Class 3 obesity (BMI ≥ 40 kg/m2) is a growing health problem worldwide associated with considerable comorbidity including Type 2 diabetes mellitus (T2DM). The multidisciplinary medical management of obesity can be difficult in T2DM due to potential weight gain from medications including sulphonylureas and insulin. However, newer weight-neutral/losing diabetes medications can aid additional weight loss. The aim of this study was to compare weight loss outcomes of patients with and without T2DM, and in patients with T2DM, to compare diabetes outcomes and change in medications at 6 months. Methods. All patients entering a multidisciplinary weight management metabolic program in a publicly funded hospital clinic in Sydney between March 2018 and March 2019, with BMI ≥ 40 kg/m2 and aged ≥18 years were included. Data was collected from patient clinical and electronic notes at baseline and 6 months. Results. Of the 180 patients who entered the program, 53.3% had T2DM at baseline. There was no difference in percentage weight loss in those with or without T2DM (4:2±4:9% vs. 3:6±4:7%, p = 0:35). Additionally, T2DM patients benefited from a 0.47% reduction in HbA1c (p < 0:01) and a reduction in the number of medications from baseline to 6 months (1:8±1:0/patient vs. 1:0±1:2/patient, p < 0:001). T2DM patients who started on weigh-neutral/losing medications in the program lost more weight than those started on weight-gaining medications (7:7±5:3% vs. 2:4±3:8%, p = 0:015). Conclusions. Patients with class 3 obesity had significant weight loss at 6 months in this program. Patients with T2DM at baseline had comparable weight loss at 6 months, a significant improvement in glycaemic control, and a reduction in diabetes medication load. Additionally, patients with T2DM who were started on weight-neutral/losing medications lost significantly more weight than those started on weight-gaining medications, and these medications should be preferentially used in class 3 obesity and comorbid T2DM

Improvement in eating disorder risk and psychological health in people with class 3 obesity : effects of a multidisciplinary weight management program

This study aimed to evaluate the risk of eating disorders, psychological distress, and healthrelated quality of life (HRQoL) in people with class 3 obesity (body mass index (BMI) ≥ 40 kg/m2 ), and the effect of multidisciplinary weight management over 12 months. This retrospective cohort study included all adults with class 3 obesity who enrolled in a weight management program from March 2018 to December 2019. Questionnaires included the Eating Disorder Examination Questionnaire Short (EDE-QS), Kessler Psychological Distress Scale (K10), and 36-Item Short Form Survey (SF-36) for HRQoL. Physical and Mental Component Summary scores (PCS and MCS) were derived from the SF-36. Of 169 participants who completed 12 months in the program, 65.7% (n = 111) completed questionnaires at baseline and 12 months, with 6.0 ± 6.8% weight loss over this period. Compared to baseline, there was significant improvement at 12 months in EDE-QS (15.7 ± 6.6 vs. 13.6 ± 6.2, p = 0.002), K10 (25.7 ± 9.7 vs. 21.2 ± 9.4, p < 0.001), PCS (29.4 ± 10.1 vs. 36.1 ± 10.9, p < 0.001), and MCS scores (40.2 ± 12.4 vs. 44.0 ± 13.4, p = 0.001). All, apart from EDE-QS scores, remained significant after adjusting for weight change. This study highlights the importance of multidisciplinary management in people with class 3 obesity to help reduce eating disorder risk and psychological distress, and improve HRQoL, in addition to weight loss

How to investigate weight gain in an adult : ‘I’ve put on so much weight, doc’

The global prevalence of people with a body mass index (BMI) over 30 kg/m2 has doubled, over 40 kg/m2 quadrupled, and over 50 kg/m2 increased fivefold. It is projected in Australia that if current rates of weight gain continue, normal-weight adults will constitute less than a third of the population by 2025, and the obesity prevalence will have increased by 65%

Self-empowerment and health outcomes in obese adults with type 2 diabetes following completion of a multi-disciplinary metabolic rehabilitation program

Introduction: Type 2 diabetes mellitus (T2DM) is a worldwide epidemic yet; self-empowerment remains an important yet under-utilised aspect of daily self-care in patients with T2DM. Methods: We retrospectively administered the validated Diabetes Empowerment Scale (DES) to evaluate self-empowerment in 42 obese, adult patients with T2DM who completed a minimum 1-year participation in an intensive multi-disciplinary metabolic rehabilitation program. We sought to determine correlations with clinical outcomes in nine cardiometabolic parameters collected at baseline and subsequently 6-monthly till 30-months. Results: Over 87% of patients attended > 3 sessions/week, with 95% enrolled up to 30-months. Patients indicated a moderately high level of empowerment both globally and in all three DES domains. Subscale III (setting and achieving diabetes goals) was significantly and inversely correlated with % change in waist circumference (WCC) at 12-months (R = -0.337, P = 0.03) and % reduction in diastolic blood pressure at 24-months (r = -0.381, P = 0.01). Subscale II (assessing dissatisfaction and readiness to change) was positively correlated with duration of diagnosis (R = 0.354, P = 0.02). Furthermore, the number of exercise sessions attended was correlated with decreased 12-month % change in weight (r = -0.320, P = 0.04) and glycosylated haemoglobin (HbA1c) (r = -0.344, P = 0.03). Significant reduction was achieved in as early as 6-months for weight (-4.2 + 0.9%, P < 0.001), BMI (-3.9 + 0.9%, P = 0.002) and WCC (-2.8 + 0.7%, P = 0.004) and continued to decrease at 30 months (-8.6 + 1.4%, P < 0.001; -8.4 + 1.5%, P < 0.001; -5.0 + 1.3%, P < 0.001, respectively). Concurrent with weight reduction, significant improvement in HbA1c was also observed early at 6-months (-8.5 + 1.6%, P < 0.001) with maximum benefit at 24-months (-10.1 + 2.2%, P < 0.001). High-density lipoprotein cholesterol also reached a maximal increase at 24 months (10.6 + 4.3%, P = 0.049). Conclusion: Setting and achieving goals was associated with reductions in waist circumference and blood pressure. The role of empowerment-based intervention in conjunction with intensive multi-disciplinary rehabilitation on health outcomes in these patients remains under-researched and under-utilised in clinical practice

Halving your cake and eating it, too : a case-based discussion and review of metabolic rehabilitation for obese adults with diabetes

Background: The global epidemic of obesity will see normal weight adults constituting a mere one-third of the global population by 2025. Although appetite and weight are regulated by a complex integration of neurological, endocrine and gastrointestinal feedback mechanisms, there is a constant interaction between psychological state, physical impairment, presence of comorbid chronic disease and medications. Methods: We discuss two cases and reveal a practical approach to investigating and managing patients with obesity and diabetes in the ‘real world’. Within this scope, the aetiology, associated disease burden, and pharmacological therapies for the treatment of the obese patient with type 2 diabetes are reviewed. An insight into non-surgical metabolic rehabilitation is also provided. Summary: Lifestyle, including diet, exercise, medications, as well as genetic predisposition, and rarely, endocrinopathies should be considered in the assessment of the obese patient. Investigations are not complex and include cardiometabolic and nutritional screens and an assessment for institution of graded, safe levels of exercise. In more complicated patients, referral to a multidisciplinary outpatient program may be necessary and it is not uncommon for patients to lose between 10-20% of their initial weight. Despite this, metabolic surgery may be necessary as further weight loss with long-term weight maintenance may be medically indicated. The type of surgery is tailored to the patient’s medical risk and co-morbidities as well as likelihood of compliance with the required follow-up. Conclusion: It is the opinion of the authors that metabolic rehabilitation should be intensive, multidisciplinary, and have a supervised exercise program, as the gold standard of care. These suggestions are based on the clinical pearls gained over two decades of clinical experience working in one of Australia’s most innovative multidisciplinary metabolic rehabilitation programs caring for patients with severe obesity

Bariatric surgery : the GP’s role in patient selection and management

GPs have a crucial role in selecting patients for consideration of bariatric surgery and providing long-term follow up and support after surgery. Practical tips are provided on selecting patients, managing them immediately after surgery, recognising complications, long-term monitoring and preventing nutritional deficiencies

Divide and conquer : the multidisciplinary approach to achieving significant long-term weight loss and improved glycemic control in obese patients with type 2 diabetes

Type 2 diabetes has become a worldwide epidemic, esti¬mated to affect 1 in 14 adults, or 380 million people, globally by 2025.The problem is particularly acute in Australia, where the preva¬lence of diagnosed diabetes more than doubled between 1989 and 2005, amounting to 3 million people affected by the disease. Diabetes is the most common reason for renal dialysis, blindness in people < 60 years of age, nontraumatic lower-limb amputation, and cardiovascular dis¬ease and is the sixth-highest cause of death by disease in Australia

Application of 2D shearwave elastography for screening of NAFLD in people with class 3 obesity

INTRODUCTION: Early and accurate detection of significant liver fibrosis allows timely management of cirrhosis and related comorbidities. Liver biopsy, the diagnostic gold standard, is invasive and risks complications. Non-invasive methods such as 2D Shear Wave Elastography (SWE) are increasingly being used, but the presence of severe obesity could lead to technical difficulties. This study aimed to assess the applicability of SWE in screening for non-alcoholic fatty liver disease (NAFLD) associated liver fibrosis in people with class 3 obesity. MATERIALS AND METHODS: This was a cross-sectional study conducted in a publicly funded, multidisciplinary weight management program in Sydney, Australia. All patients enrolled between February 2021 and February 2022, who had at least one physician appointment, were included. Participants were aged ≥ 18 years with body mass index (BMI) ≥ 40 kg/m2 and at least one weight-related medical comorbidity. A Fibrosis-4 (FIB-4) index score of 1.45 and AST to Platelet Ratio Index (APRI) score of 0.7 were considered as cut-off scores for significant fibrosis. SWE was performed by a single operator using Acoustic Radiation Force Impulse (ARFI) ultrasound system enabled with ElastPQ imaging (EQI) SWE. EQI liver stiffness values were calculated to estimate the likelihood of liver fibrosis, and 6.43 kPa was considered as cut-off score for significant fibrosis. RESULTS: The mean (SD) weight of participants (n = 50; age 47.9 (13.9) years; 59% females; 68% Caucasians; 56% Type 2 diabetes, 23% Hypertension, 6% known NAFLD) was 148.4 (29.7) kg with a BMI of 51.5 (8.7) kg/m2. A Liver EQI was obtained for all elastography scans in spite of their high BMI, with a reliability indicator (Liver EQI IQR/Med) below 30%, indicating that all tests were reliable for reporting. The mean Liver EQI Med value was 5.1 (1.2) kPa, mean FIB-4 score was 0.9 (0.5), and mean APRI score was 0.2 (0.1). Using SWE, 2/50 participants had a liver-stiffness value above cut-off score for significant fibrosis. There was a positive correlation between Liver EQI Med value and FIB-4 score (r = 0.451, p = 0.003) and APRI score (r = 0.337, p = 0.029). FIB-4 score had a statistically significant positive correlation with age (r = 0.671, p < 0.001) and APRI score (r = 0.618, p < 0.001). CONCLUSION: SWE is a feasible non-invasive technique for the assessment of liver fibrosis that can provide reliable results in the vast majority of people with class 3 obesity. SWE can be used to support the detection of significant fibrosis in addition to blood tests, thus limiting the need for liver biopsy only among those with suspected significant fibrosis

A Novel Multidisciplinary Intervention for Long-Term Weight Loss and Glycaemic Control in Obese Patients with Diabetes

Introduction. Obesity and diabetes are difficult to treat in public clinics. We sought to determine the effectiveness of the Metabolic Rehabilitation Program (MRP) in achieving long-term weight loss and improving glycaemic control versus “best practice” diabetes clinic (DC) in obese patients using a retrospective cohort study. Methods. Patients with diabetes and BMI > 30 kg/m2 who attended the MRP, which consisted of supervised exercise and intense allied health integration, or the DC were selected. Primary outcomes were improvements in weight and glycaemia with secondary outcomes of improvements in blood pressure and lipid profile at 12 and 30 months. Results. Baseline characteristics of both cohorts (40 MRP and 40 DC patients) were similar at baseline other than age (63 in MRP versus 68 years in DC, P=0.002). At 12 months, MRP patients lost 7.65 ± 1.74 kg versus 1.76 ± 2.60 kg in the DC group (P<0.0001) and 9.70 ± 2.13 kg versus 0.98 ± 2.65 kg at 30 months (P<0.0001). Similarly, MRP patients had significant absolute reductions in %HbA1c at 30 months versus the DC group (−0.86 ± 0.31% versus 0.12% ± 0.33%, P<0.038), with nonsignificant improvements in lipids and blood pressure in MRP patients. Conclusion. Further research is needed to establish the MRP as an effective strategy for achieving sustained weight loss and improving glycaemic control in obese patients with type 2 diabetes