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Several new developments promise to improve the lot of the morbidly obese. Perhaps the most important of these is the gradual recognition that morbid obesity is a serious illness that is not the result of immorality or gluttony but is, in most cases, a disabling genetically determined handicap. The second advance was the agreement at the National Institutes of Health Consensus Conference, March 25-27, 1991 that medical therapies generally fail to control severe obesity and that surgery should be considered for those individuals who have a body mass index over 40 and, if the comorbidities of obesity, such as diabetes or sleep apnea, are present, to consider surgical intervention when the body mass index is greater than 35. The third development has been the improvement of bariatric surgery, ie, the surgery for morbid obesity, with better operations, better quality controls, and rigorous follow-up. This article reviews the newer concepts of morbid obesity as a disease, delineates the indications for surgery, describes the currently recommended operations, and presents the risks and benefits of these procedures.
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PMID:The surgical treatment of morbid obesity. 758 66

During 1976-1988 we diagnosed sleep apnea syndrome (SAS) in 1,620 adult men and women monitored in the Technion sleep laboratories. Their age at the time of diagnosis ranged between 21 and 79 years. Fifty-seven patients (53 men and 4 women) had died by 1990, 53% due to respiratory-cardiovascular causes. The observed/expected (O/E) mortality rates, calculated for men only, revealed excess mortality of patients under 70 years old. Excess mortality was significant in the fourth and fifth decades (3.33, p < 0.002; 3.23, p < 0.0002, respectively). In patients older than 70 O/E was 0.33 (p < 0.0007). Hierarchical multivariate analysis with four fixed variables [age, body mass index (BMI), hypertension and apnea index] and four additional variables added manually one at a time (heart disease, lung disease, diabetes, apnea duration) was used to determine the predictors of death from all causes, cardiopulmonary causes and from myocardial infarction (MI). All four major variables were found to be significant predictors of mortality from all causes, in addition to lung disease and heart disease. Only age and BMI were significant predictors of cardiopulmonary deaths in addition to lung disease. Age, BMI and hypertension predicted MI deaths in addition to lung disease. These results were interpreted to suggest that SAS affects death indirectly, most probably by being a risk factor for hypertension.
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PMID:Mortality in sleep apnea patients: a multivariate analysis of risk factors. 938 Oct 62

Complaints of sleep disturbance increase with age. Objective sleep assessments using polysomnography reveal sleep impairments (increased wakefulness and arousal from sleep; decreased slow wave sleep) even in healthy seniors. Both polysomnographic sleep and subjective sleep worsen in the presence of health impairments related to drug use, pain, cardiovascular disease, diabetes, depression, or other emotional disorders. In addition to normal aging and chronic disease, sleep complaints can also result from poor sleep habits, specific occult disorders during sleep, or some combination of these factors. Occult disorders include sleep apnea syndrome, periodic leg movements, and restless legs syndrome during sleep. Diagnosis and treatment of these and other sleep disorders is discussed. Both pharmacological and nonpharmacological treatments are considered, with an emphasis on behavioral and educative treatment approaches.
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PMID:Sleep and sleep disorders in older adults. 779 28

A 60-year-old obese woman was admitted for evaluation of excessive daytime sleepiness, loud snoring, cyanosis, systemic edema, hypertension and diabetes mellitus. Laboratory examination showed severe hypoxemia, hypercapnea, metabolic alkalosis, hypokalemia and hyperaldosteronism. CT scan showed a left adrenal tumor. A diagnosis of obstructive sleep apnea syndrome associated with primary aldosteronism was established. Metabolic alkalosis, hypokalemia and sodium retention due to hyperaldosteronism were thought to be factors exacerbating her sleep apnea.
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PMID:[A case report of obstructive sleep apnea syndrome associated with primary aldosteronism]. 818 53

The medical hazards of obesity are discussed. Risks include insulin resistance, diabetes mellitus, hypertriglyceridemia, decreased levels of high-density lipoprotein cholesterol, and increased levels of low-density lipoprotein cholesterol. Obesity is also associated with gallbladder disease and some forms of cancer as well as sleep apnea, chronic hypoxia and hypercapnia, and degenerative joint disease. Obesity is an independent risk factor for death from coronary heart disease. A central distribution of body fat enhances the risk for most of these conditions.
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PMID:Medical hazards of obesity. 836 92

The purpose of this report is to propose standards for the successful treatment of obesity. This process is somewhat arbitrary because obesity is a multifactorial disease and because standards need revision as diagnostic and treatment techniques improve. Weight loss, the classic standard of success, does not account for individual variability. Reduction in other measures of body size, such as body mass index, percentage of excess weight, and body fat, may be preferable. Improvement in known complications of obesity (diabetes mellitus, hypertension, hyperlipoproteinemia, sleep apnea, and psychosocial problems) are equally valid measures of success. Because obesity is a chronic disease, maintenance of weight loss is included as a standard of success. Response to obesity treatment varies, and thus criteria to define minimal, intermediate, and full success for each variable are necessary.
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PMID:Proposed standards for judging the success of the treatment of obesity. 836 96

Weight loss reduces many of the health hazards associated with obesity including insulin resistance, diabetes mellitus, hypertension, dyslipidemia, sleep apnea, hypoxemia and hypercarbia, and osteoarthritis. Potential adverse effects of weight loss include a greater risk for gallstone formation and cholecystitis, excessive loss of lean body mass, water and electrolyte problems, mild liver dysfunction, and elevated uric acid levels. Less consequential problems such as diarrhea, constipation, hair loss, and cold intolerance may also occur. The short-term adverse effects are not severe enough to contraindicate weight loss, nor do they outweigh its short-term benefits.
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PMID:Short-term medical benefits and adverse effects of weight loss. 836 5

We report experiences in 3 patients with acromegaly while using the somatostatin analogue octreotide. In case 1, a 44 year old male developed pneumococcal meningitis 3 months after having transphenoidal surgery for a pituitary tumour. This occurred with the re-emergence of communication between the surgical tract and the C.S.F. In case 2 a 52 year old male with insulin resistant diabetes mellitus requiring 240 units/day, with greatly elevated growth hormone concentrations was able to stop insulin within 5 days of starting octreotide. In case 3, a 52 year old male with sleep apnoea syndrome, respiratory failure and resistant heart failure made a dramatic improvement which is maintained 2 years later. All cases were associated with substantial falls in growth hormone and insulin like growth factor-1 concentrations.
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PMID:Experiences with octreotide in acromegaly. 844 80

The United States is experiencing an epidemic of obesity among both adults and children. Approximately 35 percent of women and 31 percent of men age 20 and older are considered obese, as are about one-quarter of children and adolescents. While government health goals for the year 2000 call for no more than 20 percent of adults and 15 percent of adolescents to be obese, the prevalence of this often disabling disease is increasing rather than decreasing. Obesity, of course, is not increasing because people are consciously trying to gain weight. In fact, tens of millions of people in this country are dieting at any one time; they and many others are struggling to manage their weight to improve their appearance, feel better, and be healthier. Many programs and services exist to help individuals achieve weight control. But the limited studies paint a grim picture: those who complete weight-loss programs lose approximately 10 percent of their body weight, only to regain two-thirds of it back within 1 year and almost all of it back within 5 years. These figures point to the fact that obesity is one of the most pervasive public health problems in this country, a complex, multifactorial disease of appetite regulation and energy metabolism involving genetics, physiology, biochemistry, and the neurosciences, as well as environmental, psychosocial, and cultural factors. Unfortunately, the lay public and health-care providers, as well as insurance companies, often view it simply as a problem of willful misconduct--eating too much and exercising too little. Obesity is a remarkable disease in terms of the effort required by an individual for its management and the extent of discrimination its victims suffer. While people often wish to lose weight for the sake of their appearance, public health concerns about obesity relate to this disease's link to numerous chronic diseases that can lead to premature illness and death. The scientific evidence summarized in Chapter 2 suggests strongly that obese individuals who lose even relatively small amounts of weight are likely to decrease their blood pressure (and thereby the risk of hypertension), reduce abnormally high levels of blood glucose (associated with diabetes), bring blood concentrations of cholesterol and triglycerides (associated with cardiovascular disease) down to more desirable levels, reduce sleep apnea, decrease their risk of osteoarthritis of the weight-bearing joints and depression, and increase self-esteem. In many cases, the obese person who loses weight finds that an accompanying comorbidity is improved, its progression is slowed, or the symptoms disappear. Healthy weights are generally associated with a body mass index (BMI; a measure of whether weight is appropriate for height, measured in kg/m2) of 19-25 in those 19-34 years of age and 21-27 in those 35 years of age and older. Beyond these ranges, health risks increase as BMI increases. Health risks also increase with excess abdominal/visceral fat (as estimated by a waist-hip ratio [WHR] > 1.0 for males and > 0.8 for females), high blood pressure (> 140/90), dyslipidemias (total cholesterol and triglyceride concentrations of > 200 and > 225 mg/dl, respectively), non-insulin-dependent diabetes mellitus, and a family history of premature death due to cardiovascular disease (e.g., parent, grandparent, sibling, uncle, or aunt dying before age 50). Weight loss usually improves the management of obesity-related comorbidities or decreases the risks of their development. The high prevalence of obesity in the United States together with its link to numerous chronic diseases leads to the conclusion that this disease is responsible for a substantial proportion of total health-care costs. We estimate that today's health-care costs of obesity exceed $70 billion per year.(ABSTRACT TRUNCATED AT 400 WORDS)
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PMID:Weighing the options: criteria for evaluating weight-management programs. The Committee to Develop Criteria for Evaluating the Outcomes of Approaches to Prevent and Treat Obesity. 865 36

The increased mortality among patients with obstructive sleep apnea syndrome has been explained in part by the increased incidence of arterial and pulmonary hypertension. A decreased heart rate variability (HRV) has been shown to be associated with an increased mortality as well. We investigated 53 patients, admitted to the hospital for chest pain for sleep-related breathing disorders (SRBD) with an ambulatory screening device (MESAM-IV). HRV was recorded simultaneously. All patients received coronary artery catheterization and 36 had significant coronary artery disease (CAD; 67.9%). Standard time domain parameters were compared by a 4-way Anova for patients with an oxygen desaturation index of more and less than 5/hour and the factors CAD, diabetes and beta-blocker use. The percentage of differences between RR intervals that differ more than 50 ms (pNN > 50: 9.0 +/- 11.1 vs. 19.2 +/- 22.2%: p < 0.05) as well as the root mean square of these differences (38.0 +/- 29.0 vs. 59.2 +/- 51.5 ms; p < 0.05) were significantly decreased in patients with SRBD. In an hourly breakdown the number of desaturations was not correlated with a change in HRV. Mean oxygen saturation was significantly decreased in patients with SRBD (95.2 +/- 1.8 vs. 96.2 +/- 1.42%, p < 0.05), and positively correlated with the pNN > 50 (r = 0.34, p < 0.01). This correlation might suggest a more profound pathophysiological interaction between HRV and SRBD than short-term vagal activation alone. The results favor HRV for inclusion in future risk stratification models in patients with sleep apnea syndrome.
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PMID:Heart rate variability in patients with sleep-related breathing disorders. 890 76


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