Jane Salodof MacNeil

PHOENIX, ARIZ. — Intensive glycemic control—while beneficial for ICU patients in general—may be harmful to patients with traumatic brain injury, Paul M. Vespa, M.D., warned at a meeting sponsored by the Society of Critical Care Medicine.

“When you use intensive glycemic control, you see a higher incidence of abnormal markers in the microdialysis. We don't know yet whether that's going to be bad for the brain,” said Dr. Vespa, director of the neurocritical care program at the University of California, Los Angeles.

He urged monitoring of microdialysis values to prevent adverse effects in traumatic brain injury (TBI) patients receiving intensive glycemic control.

Dr. Vespa reported on a small, prospective study that used the Kety-Schmidt method to measure glucose metabolism in 50 patients with TBI who received intermittent subcutaneous insulin (goal of 100–160 mg/dL). Positron emission imaging (PET) was used to measure glucose and oxygen metabolism in 20 patients given continuous insulin infusions (goal of 90–120 mg/dL).

“There was no relationship between serum glucose and PET-derived measure of whole brain glucose metabolism,” Dr. Vespa said.

A microdialysis catheter was used for constant monitoring of the injured area of the brain during continuous insulin infusions in the 15 patients with baseline hyperglycemia. Ten responded with a 70% reduction on average in microdialysis glucose.

In responders, microdialysis values fell below 2 mmol/L 31% of the time, according to Dr. Vespa. In this same group, lactate/pyruvate ratios rose above 40 about 60% of the time. Nonresponders had low microdialysis glucose 10% of the time and high lactate/pyruvate ratios 23% of the time.

Dr. Vespa said these values put patients in a “danger or distress range” that has been associated with poor outcomes in published studies. These patients also had elevated lactate/pyruvate ratios, which he described along with low brain glucose as “surrogate markers of brain distress.”

His group is continuing its investigation but with a keen eye on microdialysis values.

“When we are treating the heart with a medication, we monitor the heart, we monitor cardiac enzymes, et cetera. When we treat the brain, most people are not monitoring the brain,” he said.

“This is a study that shows when we take a general medical critical care practice like insulin therapy and apply it to the brain-injured patient, we should be monitoring that patient's brain.”

Michael Diringer, M.D., chair of the SCCM session on clinical neuroscience research, praised Dr. Vespa for raising a red flag, but questioned whether the drop in microdialysis glucose is harmful in the absence of a change in glucose metabolism. Glucose levels went down in the blood, but the brain was using the same amount of glucose.

“So I don't know what that fall in the microdialysis means. It may not mean anything,” said Dr. Diringer of Washington University School of Medicine in St. Louis.

Dr. Vespa noted that in general, intensive insulin therapy has been shown to be beneficial for other types of critical care patients, who often develop hyperglycemia and insulin resistance although they were not diabetic prior to their illness.

PHOENIX, ARIZ. — Intensive glycemic control—while beneficial for ICU patients in general—may be harmful to patients with traumatic brain injury, Paul M. Vespa, M.D., warned at a meeting sponsored by the Society of Critical Care Medicine.

“When you use intensive glycemic control, you see a higher incidence of abnormal markers in the microdialysis. We don't know yet whether that's going to be bad for the brain,” said Dr. Vespa, director of the neurocritical care program at the University of California, Los Angeles.

He urged monitoring of microdialysis values to prevent adverse effects in traumatic brain injury (TBI) patients receiving intensive glycemic control.

Dr. Vespa reported on a small, prospective study that used the Kety-Schmidt method to measure glucose metabolism in 50 patients with TBI who received intermittent subcutaneous insulin (goal of 100–160 mg/dL). Positron emission imaging (PET) was used to measure glucose and oxygen metabolism in 20 patients given continuous insulin infusions (goal of 90–120 mg/dL).

“There was no relationship between serum glucose and PET-derived measure of whole brain glucose metabolism,” Dr. Vespa said.

A microdialysis catheter was used for constant monitoring of the injured area of the brain during continuous insulin infusions in the 15 patients with baseline hyperglycemia. Ten responded with a 70% reduction on average in microdialysis glucose.

In responders, microdialysis values fell below 2 mmol/L 31% of the time, according to Dr. Vespa. In this same group, lactate/pyruvate ratios rose above 40 about 60% of the time. Nonresponders had low microdialysis glucose 10% of the time and high lactate/pyruvate ratios 23% of the time.

Dr. Vespa said these values put patients in a “danger or distress range” that has been associated with poor outcomes in published studies. These patients also had elevated lactate/pyruvate ratios, which he described along with low brain glucose as “surrogate markers of brain distress.”

His group is continuing its investigation but with a keen eye on microdialysis values.

“When we are treating the heart with a medication, we monitor the heart, we monitor cardiac enzymes, et cetera. When we treat the brain, most people are not monitoring the brain,” he said.

“This is a study that shows when we take a general medical critical care practice like insulin therapy and apply it to the brain-injured patient, we should be monitoring that patient's brain.”

Michael Diringer, M.D., chair of the SCCM session on clinical neuroscience research, praised Dr. Vespa for raising a red flag, but questioned whether the drop in microdialysis glucose is harmful in the absence of a change in glucose metabolism. Glucose levels went down in the blood, but the brain was using the same amount of glucose.

“So I don't know what that fall in the microdialysis means. It may not mean anything,” said Dr. Diringer of Washington University School of Medicine in St. Louis.

Dr. Vespa noted that in general, intensive insulin therapy has been shown to be beneficial for other types of critical care patients, who often develop hyperglycemia and insulin resistance although they were not diabetic prior to their illness.

PHOENIX, ARIZ. — Intensive glycemic control—while beneficial for ICU patients in general—may be harmful to patients with traumatic brain injury, Paul M. Vespa, M.D., warned at a meeting sponsored by the Society of Critical Care Medicine.

“When you use intensive glycemic control, you see a higher incidence of abnormal markers in the microdialysis. We don't know yet whether that's going to be bad for the brain,” said Dr. Vespa, director of the neurocritical care program at the University of California, Los Angeles.

He urged monitoring of microdialysis values to prevent adverse effects in traumatic brain injury (TBI) patients receiving intensive glycemic control.

Dr. Vespa reported on a small, prospective study that used the Kety-Schmidt method to measure glucose metabolism in 50 patients with TBI who received intermittent subcutaneous insulin (goal of 100–160 mg/dL). Positron emission imaging (PET) was used to measure glucose and oxygen metabolism in 20 patients given continuous insulin infusions (goal of 90–120 mg/dL).

“There was no relationship between serum glucose and PET-derived measure of whole brain glucose metabolism,” Dr. Vespa said.

A microdialysis catheter was used for constant monitoring of the injured area of the brain during continuous insulin infusions in the 15 patients with baseline hyperglycemia. Ten responded with a 70% reduction on average in microdialysis glucose.

In responders, microdialysis values fell below 2 mmol/L 31% of the time, according to Dr. Vespa. In this same group, lactate/pyruvate ratios rose above 40 about 60% of the time. Nonresponders had low microdialysis glucose 10% of the time and high lactate/pyruvate ratios 23% of the time.

Dr. Vespa said these values put patients in a “danger or distress range” that has been associated with poor outcomes in published studies. These patients also had elevated lactate/pyruvate ratios, which he described along with low brain glucose as “surrogate markers of brain distress.”

His group is continuing its investigation but with a keen eye on microdialysis values.

“When we are treating the heart with a medication, we monitor the heart, we monitor cardiac enzymes, et cetera. When we treat the brain, most people are not monitoring the brain,” he said.

“This is a study that shows when we take a general medical critical care practice like insulin therapy and apply it to the brain-injured patient, we should be monitoring that patient's brain.”

Michael Diringer, M.D., chair of the SCCM session on clinical neuroscience research, praised Dr. Vespa for raising a red flag, but questioned whether the drop in microdialysis glucose is harmful in the absence of a change in glucose metabolism. Glucose levels went down in the blood, but the brain was using the same amount of glucose.

“So I don't know what that fall in the microdialysis means. It may not mean anything,” said Dr. Diringer of Washington University School of Medicine in St. Louis.

Dr. Vespa noted that in general, intensive insulin therapy has been shown to be beneficial for other types of critical care patients, who often develop hyperglycemia and insulin resistance although they were not diabetic prior to their illness.

LAS VEGAS — The hypothesis that leptin plays a role in regulating appetite gained ground in a small government study that found leptin levels affect how long a person can go before becoming hungry between meals or full when eating.

Eight patients with lipodystrophy ate shorter, less caloric, more satisfying meals after injections of exogenous leptin brought their leptin levels to normal ranges for their weight, according to investigator Jennifer McDuffie, Ph.D., of the National Institute of Child Health and Human Development's Unit on Growth and Obesity.

After 4 months of leptin therapy, the patients had an average weight loss of 5% and better glucose homeostasis, Dr. McDuffie reported at the annual meeting of the North American Association for the Study of Obesity. The time until patients became hungry increased by about an hour, and the time until they felt full during meals was cut by about 40 minutes.

“Insulin, glucose, and triglycerides all decreased about 50%,” she said at the meeting, cosponsored by the American Diabetes Association. Ghrelin levels dropped more than twofold.

NAASO president Louis J. Arrone, M.D., of Cornell University, New York City, praised the study as “a very nice demonstration of the appetite effect.” He told Dr. McDuffie, “A lot of people question whether leptin has an effect on appetite, and you have shown very conclusively that that it does.”

LAS VEGAS — The hypothesis that leptin plays a role in regulating appetite gained ground in a small government study that found leptin levels affect how long a person can go before becoming hungry between meals or full when eating.

Eight patients with lipodystrophy ate shorter, less caloric, more satisfying meals after injections of exogenous leptin brought their leptin levels to normal ranges for their weight, according to investigator Jennifer McDuffie, Ph.D., of the National Institute of Child Health and Human Development's Unit on Growth and Obesity.

After 4 months of leptin therapy, the patients had an average weight loss of 5% and better glucose homeostasis, Dr. McDuffie reported at the annual meeting of the North American Association for the Study of Obesity. The time until patients became hungry increased by about an hour, and the time until they felt full during meals was cut by about 40 minutes.

“Insulin, glucose, and triglycerides all decreased about 50%,” she said at the meeting, cosponsored by the American Diabetes Association. Ghrelin levels dropped more than twofold.

NAASO president Louis J. Arrone, M.D., of Cornell University, New York City, praised the study as “a very nice demonstration of the appetite effect.” He told Dr. McDuffie, “A lot of people question whether leptin has an effect on appetite, and you have shown very conclusively that that it does.”

LAS VEGAS — The hypothesis that leptin plays a role in regulating appetite gained ground in a small government study that found leptin levels affect how long a person can go before becoming hungry between meals or full when eating.

Eight patients with lipodystrophy ate shorter, less caloric, more satisfying meals after injections of exogenous leptin brought their leptin levels to normal ranges for their weight, according to investigator Jennifer McDuffie, Ph.D., of the National Institute of Child Health and Human Development's Unit on Growth and Obesity.

After 4 months of leptin therapy, the patients had an average weight loss of 5% and better glucose homeostasis, Dr. McDuffie reported at the annual meeting of the North American Association for the Study of Obesity. The time until patients became hungry increased by about an hour, and the time until they felt full during meals was cut by about 40 minutes.

“Insulin, glucose, and triglycerides all decreased about 50%,” she said at the meeting, cosponsored by the American Diabetes Association. Ghrelin levels dropped more than twofold.

NAASO president Louis J. Arrone, M.D., of Cornell University, New York City, praised the study as “a very nice demonstration of the appetite effect.” He told Dr. McDuffie, “A lot of people question whether leptin has an effect on appetite, and you have shown very conclusively that that it does.”

LAS VEGAS — A survey of 218 Louisiana physicians found widespread disapproval of obese patients and limited use of current clinical strategies for managing obesity, Catherine M. Champagne, Ph.D., reported in two posters at the annual meeting of the North American Association for the Study of Obesity.

Of respondents, 63% said most health professionals have negative attitudes toward obese patients, and 64% said obese patients are resistant to long-term change. Also, 74% agreed with a statement characterizing obese patients as inactive overeaters who usually do not follow their doctors' advice.

Asked about the weight loss options that they gave their patients, the physicians most often checked off calorie counting (31%), Weight Watchers (29%), and popular diet books (23%). Only 9% recommended exchange lists for weight management. Even fewer (2%) suggested meal replacements such as Slim-Fast.

“We need continuing education for primary care physicians in their office-based assessment and intervention practices,” said Dr. Champagne, chief of nutritional epidemiology/dietary assessment and counseling at the Pennington Biomedical Research Center in Baton Rouge, La.

Most physicians were concerned about obesity in their patients and the nation. Half the respondents ranked obesity as a very serious health risk in their practices, and 84% recognized obesity to be a disease similar to hypertension or diabetes, she said at the meeting, which was cosponsored by the American Diabetes Association.

In some cases, she added, patient attitudes might be factors in the physicians' choices. For example, 56% of physicians rarely or never prescribed weight-loss medications approved by the Food and Drug Administration. Their patients may not want to take these medications, she said. The Food Pyramid and Dietary Guidelines for Americans were almost as unpopular, with 39% of physicians saying they rarely or never encourage patients to follow them.

The survey was sent to all physicians listed in Louisiana's medical registry for East Baton Rouge and 13 rural parishes. About 22% responded, more than twice as many as expected, Dr. Champagne said.

LAS VEGAS — A survey of 218 Louisiana physicians found widespread disapproval of obese patients and limited use of current clinical strategies for managing obesity, Catherine M. Champagne, Ph.D., reported in two posters at the annual meeting of the North American Association for the Study of Obesity.

Of respondents, 63% said most health professionals have negative attitudes toward obese patients, and 64% said obese patients are resistant to long-term change. Also, 74% agreed with a statement characterizing obese patients as inactive overeaters who usually do not follow their doctors' advice.

Asked about the weight loss options that they gave their patients, the physicians most often checked off calorie counting (31%), Weight Watchers (29%), and popular diet books (23%). Only 9% recommended exchange lists for weight management. Even fewer (2%) suggested meal replacements such as Slim-Fast.

“We need continuing education for primary care physicians in their office-based assessment and intervention practices,” said Dr. Champagne, chief of nutritional epidemiology/dietary assessment and counseling at the Pennington Biomedical Research Center in Baton Rouge, La.

Most physicians were concerned about obesity in their patients and the nation. Half the respondents ranked obesity as a very serious health risk in their practices, and 84% recognized obesity to be a disease similar to hypertension or diabetes, she said at the meeting, which was cosponsored by the American Diabetes Association.

In some cases, she added, patient attitudes might be factors in the physicians' choices. For example, 56% of physicians rarely or never prescribed weight-loss medications approved by the Food and Drug Administration. Their patients may not want to take these medications, she said. The Food Pyramid and Dietary Guidelines for Americans were almost as unpopular, with 39% of physicians saying they rarely or never encourage patients to follow them.

The survey was sent to all physicians listed in Louisiana's medical registry for East Baton Rouge and 13 rural parishes. About 22% responded, more than twice as many as expected, Dr. Champagne said.

LAS VEGAS — A survey of 218 Louisiana physicians found widespread disapproval of obese patients and limited use of current clinical strategies for managing obesity, Catherine M. Champagne, Ph.D., reported in two posters at the annual meeting of the North American Association for the Study of Obesity.

Of respondents, 63% said most health professionals have negative attitudes toward obese patients, and 64% said obese patients are resistant to long-term change. Also, 74% agreed with a statement characterizing obese patients as inactive overeaters who usually do not follow their doctors' advice.

Asked about the weight loss options that they gave their patients, the physicians most often checked off calorie counting (31%), Weight Watchers (29%), and popular diet books (23%). Only 9% recommended exchange lists for weight management. Even fewer (2%) suggested meal replacements such as Slim-Fast.

“We need continuing education for primary care physicians in their office-based assessment and intervention practices,” said Dr. Champagne, chief of nutritional epidemiology/dietary assessment and counseling at the Pennington Biomedical Research Center in Baton Rouge, La.

Most physicians were concerned about obesity in their patients and the nation. Half the respondents ranked obesity as a very serious health risk in their practices, and 84% recognized obesity to be a disease similar to hypertension or diabetes, she said at the meeting, which was cosponsored by the American Diabetes Association.

In some cases, she added, patient attitudes might be factors in the physicians' choices. For example, 56% of physicians rarely or never prescribed weight-loss medications approved by the Food and Drug Administration. Their patients may not want to take these medications, she said. The Food Pyramid and Dietary Guidelines for Americans were almost as unpopular, with 39% of physicians saying they rarely or never encourage patients to follow them.

The survey was sent to all physicians listed in Louisiana's medical registry for East Baton Rouge and 13 rural parishes. About 22% responded, more than twice as many as expected, Dr. Champagne said.

LAS VEGAS — One of the first studies to look at the effect of weight loss on ambulatory care costs has found a puzzling yo-yo pattern, Gregory A. Nichols, Ph.D., said at the annual meeting of the North American Association for the Study of Obesity.

Medical costs decreased an average of $350 per person for 458 Kaiser Permanente health plan members during the first enrollment year after they lost at least 5% of their body weight in the plan's voluntary Freedom From Diets program. However, these costs started to rebound 3-4 years later, driven up in large part by the health care needs of the patients who maintained their weight loss.

“There could be some explanation, but clearly we need to do a lot more work,” said Dr. Nichols, a senior research associate at Kaiser Permanente's Center for Health Research in Portland, Ore. The effect, he acknowledged, seems counterintuitive.

The study did find an economic advantage for Kaiser. Costs went up an average of $480 in the first enrollment year for the 547 patients who did not lose weight in the program. The net difference, $830, was statistically significant, he said.

Another conundrum, however, was that a control group of 2,290 Kaiser Permanente members who did not enroll in the program and did not lose weight had consistently lower costs than did the Freedom From Diets participants. The control group was matched for age, gender, and body mass index (BMI) of 35 kg/m

Dr. Nichols' study was supported by a grant from GlaxoSmithKline.

Audience members speculated that people who were enrolled in a voluntary program might be more inclined to incur health care costs than would those who were not. Another possible explanation, Dr. Nichols said, was that those who signed up for the weight loss program might have been more motivated because they had comorbidities.

In another presentation of Kaiser Permanente research, Jonathan Betz Brown, Ph.D., a senior investigator with Nichols, found that pharmaceutical savings were the only cost efficiency for 67 patients.

Reduced use of antidiabetic, antihyperglycemic, antihypertensive, and gastrointestinal drugs resulted in a $510 savings. Pharmaceutical costs went up $393 for candidates who did not have bariatric surgery, and $432 for general members of the health plan. Total medical costs for the bariatric patients rose, however, from $5,359 the year before surgery to $5,705 the year after and $6,013 2 years later.

Dr. Brown said the study might have been too short and too small to find a cost benefit so soon after an expensive procedure. The operation costs $29,824 on average, he said.

LAS VEGAS — One of the first studies to look at the effect of weight loss on ambulatory care costs has found a puzzling yo-yo pattern, Gregory A. Nichols, Ph.D., said at the annual meeting of the North American Association for the Study of Obesity.

Medical costs decreased an average of $350 per person for 458 Kaiser Permanente health plan members during the first enrollment year after they lost at least 5% of their body weight in the plan's voluntary Freedom From Diets program. However, these costs started to rebound 3-4 years later, driven up in large part by the health care needs of the patients who maintained their weight loss.

“There could be some explanation, but clearly we need to do a lot more work,” said Dr. Nichols, a senior research associate at Kaiser Permanente's Center for Health Research in Portland, Ore. The effect, he acknowledged, seems counterintuitive.

The study did find an economic advantage for Kaiser. Costs went up an average of $480 in the first enrollment year for the 547 patients who did not lose weight in the program. The net difference, $830, was statistically significant, he said.

Another conundrum, however, was that a control group of 2,290 Kaiser Permanente members who did not enroll in the program and did not lose weight had consistently lower costs than did the Freedom From Diets participants. The control group was matched for age, gender, and body mass index (BMI) of 35 kg/m

Dr. Nichols' study was supported by a grant from GlaxoSmithKline.

Audience members speculated that people who were enrolled in a voluntary program might be more inclined to incur health care costs than would those who were not. Another possible explanation, Dr. Nichols said, was that those who signed up for the weight loss program might have been more motivated because they had comorbidities.

In another presentation of Kaiser Permanente research, Jonathan Betz Brown, Ph.D., a senior investigator with Nichols, found that pharmaceutical savings were the only cost efficiency for 67 patients.

Reduced use of antidiabetic, antihyperglycemic, antihypertensive, and gastrointestinal drugs resulted in a $510 savings. Pharmaceutical costs went up $393 for candidates who did not have bariatric surgery, and $432 for general members of the health plan. Total medical costs for the bariatric patients rose, however, from $5,359 the year before surgery to $5,705 the year after and $6,013 2 years later.

Dr. Brown said the study might have been too short and too small to find a cost benefit so soon after an expensive procedure. The operation costs $29,824 on average, he said.

LAS VEGAS — One of the first studies to look at the effect of weight loss on ambulatory care costs has found a puzzling yo-yo pattern, Gregory A. Nichols, Ph.D., said at the annual meeting of the North American Association for the Study of Obesity.

Medical costs decreased an average of $350 per person for 458 Kaiser Permanente health plan members during the first enrollment year after they lost at least 5% of their body weight in the plan's voluntary Freedom From Diets program. However, these costs started to rebound 3-4 years later, driven up in large part by the health care needs of the patients who maintained their weight loss.

“There could be some explanation, but clearly we need to do a lot more work,” said Dr. Nichols, a senior research associate at Kaiser Permanente's Center for Health Research in Portland, Ore. The effect, he acknowledged, seems counterintuitive.

The study did find an economic advantage for Kaiser. Costs went up an average of $480 in the first enrollment year for the 547 patients who did not lose weight in the program. The net difference, $830, was statistically significant, he said.

Another conundrum, however, was that a control group of 2,290 Kaiser Permanente members who did not enroll in the program and did not lose weight had consistently lower costs than did the Freedom From Diets participants. The control group was matched for age, gender, and body mass index (BMI) of 35 kg/m

Dr. Nichols' study was supported by a grant from GlaxoSmithKline.

Audience members speculated that people who were enrolled in a voluntary program might be more inclined to incur health care costs than would those who were not. Another possible explanation, Dr. Nichols said, was that those who signed up for the weight loss program might have been more motivated because they had comorbidities.

In another presentation of Kaiser Permanente research, Jonathan Betz Brown, Ph.D., a senior investigator with Nichols, found that pharmaceutical savings were the only cost efficiency for 67 patients.

Reduced use of antidiabetic, antihyperglycemic, antihypertensive, and gastrointestinal drugs resulted in a $510 savings. Pharmaceutical costs went up $393 for candidates who did not have bariatric surgery, and $432 for general members of the health plan. Total medical costs for the bariatric patients rose, however, from $5,359 the year before surgery to $5,705 the year after and $6,013 2 years later.

Dr. Brown said the study might have been too short and too small to find a cost benefit so soon after an expensive procedure. The operation costs $29,824 on average, he said.

LAS VEGAS — With great enthusiasm, an overweight patient announces plans to embark on a fad diet. The physician is skeptical and wants to steer the person to a nutritionally balanced, low-calorie, low-fat regimen. Does it matter which diet the person chooses?

Cathy A. Nonas, R.D., a dietitian, describes herself as “the original anti-Atkins diet person.” She was so outspoken that the late Dr. Atkins refused to refer to her by name, she recalled at the annual meeting of the North American Association for the Study of Obesity.

Today Ms. Nonas, director of obesity and diabetes programs at North General Hospital in New York City, does not object to most of the fad diets her patients embrace. “I think the perfect short-term diet is anything that the patient is willing to adhere to that won't hurt the patient,” she said.

Even the cabbage diet produces weight loss in the short term. “The truth is, all diets work as long as you can adhere to them,” she said, describing long-term weight maintenance as a much tougher issue.

As for the nation's current diet craze, psychologist Gary D. Foster, Ph.D., said low-carbohydrate diets produce greater weight loss at 6 months than low-calorie, low-fat diets. The few studies to evaluate low-carbohydrate diets have reported remarkably consistent short-term results, he said, noting, however, that weight loss at 1 year was the same as for low-fat regimens.

Dr. Foster, clinical director of the Weight and Eating Disorders Program at the University of Pennsylvania, Philadelphia, described these trial results as encouraging but preliminary. So far, no effect has been seen on total cholesterol, he said at the meeting, cosponsored by the American Diabetes Association.

“We need fewer opinions and more data,” he said, predicting that an ongoing National Institutes of Health study will be more rigorous in addressing safety and efficacy. “I've never seen a topic in science that inflamed so many opinions based on so little data.”

Indeed, Holly R. Wyatt, M.D., warned that telling patients fad diets don't work could have the unintended effect of discouraging them from seeking medical advice.

“You have to be careful about saying, 'What you are doing is not working,'” said Dr. Wyatt, medical director of the Colorado Weigh program at the University of Colorado, Denver. “If you tell them that, and they just lost 10 pounds on the Atkins diet, they are going.”

LAS VEGAS — With great enthusiasm, an overweight patient announces plans to embark on a fad diet. The physician is skeptical and wants to steer the person to a nutritionally balanced, low-calorie, low-fat regimen. Does it matter which diet the person chooses?

Cathy A. Nonas, R.D., a dietitian, describes herself as “the original anti-Atkins diet person.” She was so outspoken that the late Dr. Atkins refused to refer to her by name, she recalled at the annual meeting of the North American Association for the Study of Obesity.

Today Ms. Nonas, director of obesity and diabetes programs at North General Hospital in New York City, does not object to most of the fad diets her patients embrace. “I think the perfect short-term diet is anything that the patient is willing to adhere to that won't hurt the patient,” she said.

Even the cabbage diet produces weight loss in the short term. “The truth is, all diets work as long as you can adhere to them,” she said, describing long-term weight maintenance as a much tougher issue.

As for the nation's current diet craze, psychologist Gary D. Foster, Ph.D., said low-carbohydrate diets produce greater weight loss at 6 months than low-calorie, low-fat diets. The few studies to evaluate low-carbohydrate diets have reported remarkably consistent short-term results, he said, noting, however, that weight loss at 1 year was the same as for low-fat regimens.

Dr. Foster, clinical director of the Weight and Eating Disorders Program at the University of Pennsylvania, Philadelphia, described these trial results as encouraging but preliminary. So far, no effect has been seen on total cholesterol, he said at the meeting, cosponsored by the American Diabetes Association.

“We need fewer opinions and more data,” he said, predicting that an ongoing National Institutes of Health study will be more rigorous in addressing safety and efficacy. “I've never seen a topic in science that inflamed so many opinions based on so little data.”

Indeed, Holly R. Wyatt, M.D., warned that telling patients fad diets don't work could have the unintended effect of discouraging them from seeking medical advice.

“You have to be careful about saying, 'What you are doing is not working,'” said Dr. Wyatt, medical director of the Colorado Weigh program at the University of Colorado, Denver. “If you tell them that, and they just lost 10 pounds on the Atkins diet, they are going.”

LAS VEGAS — With great enthusiasm, an overweight patient announces plans to embark on a fad diet. The physician is skeptical and wants to steer the person to a nutritionally balanced, low-calorie, low-fat regimen. Does it matter which diet the person chooses?

Cathy A. Nonas, R.D., a dietitian, describes herself as “the original anti-Atkins diet person.” She was so outspoken that the late Dr. Atkins refused to refer to her by name, she recalled at the annual meeting of the North American Association for the Study of Obesity.

Today Ms. Nonas, director of obesity and diabetes programs at North General Hospital in New York City, does not object to most of the fad diets her patients embrace. “I think the perfect short-term diet is anything that the patient is willing to adhere to that won't hurt the patient,” she said.

Even the cabbage diet produces weight loss in the short term. “The truth is, all diets work as long as you can adhere to them,” she said, describing long-term weight maintenance as a much tougher issue.

As for the nation's current diet craze, psychologist Gary D. Foster, Ph.D., said low-carbohydrate diets produce greater weight loss at 6 months than low-calorie, low-fat diets. The few studies to evaluate low-carbohydrate diets have reported remarkably consistent short-term results, he said, noting, however, that weight loss at 1 year was the same as for low-fat regimens.

Dr. Foster, clinical director of the Weight and Eating Disorders Program at the University of Pennsylvania, Philadelphia, described these trial results as encouraging but preliminary. So far, no effect has been seen on total cholesterol, he said at the meeting, cosponsored by the American Diabetes Association.

“We need fewer opinions and more data,” he said, predicting that an ongoing National Institutes of Health study will be more rigorous in addressing safety and efficacy. “I've never seen a topic in science that inflamed so many opinions based on so little data.”

Indeed, Holly R. Wyatt, M.D., warned that telling patients fad diets don't work could have the unintended effect of discouraging them from seeking medical advice.

“You have to be careful about saying, 'What you are doing is not working,'” said Dr. Wyatt, medical director of the Colorado Weigh program at the University of Colorado, Denver. “If you tell them that, and they just lost 10 pounds on the Atkins diet, they are going.”

LAS VEGAS — In theory, team management of obese patients makes a lot of sense.

But in the real world, it may not be possible, because the obesity epidemic is too big, trained specialists too few, and resources too scarce, Arthur Frank, M.D., said at the annual meeting of North American Association for the Study of Obesity.

Primary care physicians must diagnose and treat obese patients in their practices, according to Dr. Frank, medical director of the weight management program at George Washington University in Washington. Primary care physicians need to provide such care even if they have no special skills in managing obesity or access to the nutritionists, dietitians, behavioral counselors, and other specialists who make up weight management teams.

“In the United States, there are 220 million adults over age 18. If 65% are overweight or obese, we have 143 million adults who need care. How can any system care for 143 million people who are overweight or obese?” Dr. Frank asked, laying the problem at the front door of primary care practices.

His remarks opened a workshop on office management of obesity—a subject revisited several times during the meeting, cosponsored by the American Diabetes Association. Here are some practical suggestions from experts in the field:

Guidelines and Other Tools

“The best way to describe the current management of obesity is clinical inertia,” Robert E. Kushner, M.D., said. “If the patient doesn't lose weight, what does the doctor do? He talks louder.”

Treatment guidelines are part of the problem, said Dr. Kushner, medical director of the Wellness Institute at Northwestern University, Chicago. There are too many of them—more than 2,000 at last count, including 135 at the National Guidelines Clearinghouse (

www.guidelines.gov

For example, he quoted an algorithm that concluded with a recommendation for the clinician and patient to determine goals and strategies for weight loss. “What is a clinician supposed to do with this?”

Putting aside such caveats, he recommended “The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,” available on the North American Association for the Study of Obesity (NAASO) Web site (

www.naaso.org/information/practicalguide.asp

Still, “for managing obesity, guidelines are not enough. We really have to get down to tools,” Dr. Kushner said.

To start, he suggested large blood pressure cuffs, gowns, office chairs, and scales that can accommodate a patient who weighs 350 lbs. Medical history forms should have questions focused on obesity. Patients can be given diet and activity diaries along with specific instructions on how to cut calories and exercise more.

Tell patients to get a pedometer; patients who keep track of how many steps they take each day will become more active over time. “The pedometer—it's not rocket science,” he said. “It's not going to win a Nobel Prize, but what a useful tool to … get accountability.”

Getting Started

First impressions count, advised Donald Schumacher, M.D. Attitude, body language, and the amount of time a physician spends listening as opposed to lecturing a patient are all important when an overweight person seeks help.

“The last thing someone overweight needs is one more lecture,” said Dr. Schumacher, in private practice in Charlotte, N.C. Physicians must form a partnership with these vulnerable patients, and the role of the physician, staff, and patient should be established in the first visit.

Establishing the therapeutic bond is the most important first step, said Peter D. Vash, M.D., of the Lindora Medical Clinic of the University of California, Los Angeles. “Somehow the words, 'I can help you; please work with me,' to my mind set the stage for weight-loss success,” he said, calling the 7-10 minutes when the patient is with the physician “a therapeutic window of opportunity.”

The initial plan should go slow and be sensitive to the individual, Dr. Schumacher said. Ethnicity, work schedule, travel demands, and the obligations of motherhood are among the factors to consider.

Making too many changes too fast will lose the patient, he said. “Your patients have failed before. You do not want to set your patients up to fail once again.”

Some obese patients will ask their physicians to cite diabetes or hypertension or another condition as the primary diagnosis when billing for an office visit, Dr. Frank said. There is no code for obesity, and the cost might not be reimbursed if the real reason is stated.

Should the physician agree? Some clinicians argue that this is legitimate, because treating obesity can reduce metabolic syndrome, but Dr. Frank said not all physicians are comfortable with that solution. “This is a common ethical problem.”

Stages of Care

Physicians are doing a relatively good job of identifying and working with severely obese patients with comorbid conditions, but mildly overweight patients remain a missed opportunity, Dr. Kushner said.

“Everyone who is substantially obese was at one time a little bit overweight,” Dr. Frank observed. He urged physicians to do more to identify and help patients “who have an early or mild form of the disease.”

“Primary care physicians must treat obesity in an aggressive manner,” Dr. Vash said, highlighting the relationships between obesity, diabetes, and hypertension. “If you don't deal aggressively with obesity, obesity will chew up and maim your patient.”

Diet and physical activity remain the mainstay of weight-control programs, but pharmacotherapy also has a place, said Daniel H. Bessesen, M.D., of the University of Colorado, Denver.

Medication may not help people shed as much weight as they want or need to lose, but it can boost weight loss by about 5%. The is similar to what can be achieved with behavior modification. Pharmacotherapy and behavioral interventions together can be more effective than either strategy by itself, Dr. Bessesen said.

Yet many physicians refuse to prescribe weight-loss medications. Dr. Bessesen summed up their reasons: The drugs don't work for everyone, they cost too much, and they have side effects. Yet the same can be said of many widely used blood pressure drugs, and diets have side effects, too.

“Our mindset is completely different with other health problems. I think you have to ask yourself, why is that?” he said.

More weight-loss drugs “are coming down the pipe in the next 10 years,” he added. “This is going to be a bigger issue in the future.”

Dr. Schumacher suggested that clinicians prepare patients for weight gain, so they won't be too embarrassed or frustrated to come back. “You need to remind them that they will lapse, and that's not a personal flaw. That's life, and you will be with them if they lapse.”

Gary D. Foster, Ph.D., said low-carbohydrate diets produce greater weight loss at 6 months than low-calorie, low-fat diets. The few studies to evaluate low-carbohydrate diets have reported remarkably consistent short-term results, he said, noting, however, that weight loss at one 1 year was the same as for low-fat regimens.

Dr. Foster, a psychologist and obesity researcher at the University of Pennsylvania in Philadelphia, urged patience when patients do gain back weight. “The patient needs to know we are going to be treating him in a nonjudgmental way,” he said, recommending the clinician assume the reason is “lack of planning or skills, rather than a lack of motivation.”

Figure out what got in the way of adherence, then come up with a plan for how the patient will deal with the same situation in the future, he advised.

LAS VEGAS — In theory, team management of obese patients makes a lot of sense.

But in the real world, it may not be possible, because the obesity epidemic is too big, trained specialists too few, and resources too scarce, Arthur Frank, M.D., said at the annual meeting of North American Association for the Study of Obesity.

Primary care physicians must diagnose and treat obese patients in their practices, according to Dr. Frank, medical director of the weight management program at George Washington University in Washington. Primary care physicians need to provide such care even if they have no special skills in managing obesity or access to the nutritionists, dietitians, behavioral counselors, and other specialists who make up weight management teams.

“In the United States, there are 220 million adults over age 18. If 65% are overweight or obese, we have 143 million adults who need care. How can any system care for 143 million people who are overweight or obese?” Dr. Frank asked, laying the problem at the front door of primary care practices.

His remarks opened a workshop on office management of obesity—a subject revisited several times during the meeting, cosponsored by the American Diabetes Association. Here are some practical suggestions from experts in the field:

Guidelines and Other Tools

“The best way to describe the current management of obesity is clinical inertia,” Robert E. Kushner, M.D., said. “If the patient doesn't lose weight, what does the doctor do? He talks louder.”

Treatment guidelines are part of the problem, said Dr. Kushner, medical director of the Wellness Institute at Northwestern University, Chicago. There are too many of them—more than 2,000 at last count, including 135 at the National Guidelines Clearinghouse (

www.guidelines.gov

For example, he quoted an algorithm that concluded with a recommendation for the clinician and patient to determine goals and strategies for weight loss. “What is a clinician supposed to do with this?”

Putting aside such caveats, he recommended “The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,” available on the North American Association for the Study of Obesity (NAASO) Web site (

www.naaso.org/information/practicalguide.asp

Still, “for managing obesity, guidelines are not enough. We really have to get down to tools,” Dr. Kushner said.

To start, he suggested large blood pressure cuffs, gowns, office chairs, and scales that can accommodate a patient who weighs 350 lbs. Medical history forms should have questions focused on obesity. Patients can be given diet and activity diaries along with specific instructions on how to cut calories and exercise more.

Tell patients to get a pedometer; patients who keep track of how many steps they take each day will become more active over time. “The pedometer—it's not rocket science,” he said. “It's not going to win a Nobel Prize, but what a useful tool to … get accountability.”

Getting Started

First impressions count, advised Donald Schumacher, M.D. Attitude, body language, and the amount of time a physician spends listening as opposed to lecturing a patient are all important when an overweight person seeks help.

“The last thing someone overweight needs is one more lecture,” said Dr. Schumacher, in private practice in Charlotte, N.C. Physicians must form a partnership with these vulnerable patients, and the role of the physician, staff, and patient should be established in the first visit.

Establishing the therapeutic bond is the most important first step, said Peter D. Vash, M.D., of the Lindora Medical Clinic of the University of California, Los Angeles. “Somehow the words, 'I can help you; please work with me,' to my mind set the stage for weight-loss success,” he said, calling the 7-10 minutes when the patient is with the physician “a therapeutic window of opportunity.”

The initial plan should go slow and be sensitive to the individual, Dr. Schumacher said. Ethnicity, work schedule, travel demands, and the obligations of motherhood are among the factors to consider.

Making too many changes too fast will lose the patient, he said. “Your patients have failed before. You do not want to set your patients up to fail once again.”

Some obese patients will ask their physicians to cite diabetes or hypertension or another condition as the primary diagnosis when billing for an office visit, Dr. Frank said. There is no code for obesity, and the cost might not be reimbursed if the real reason is stated.

Should the physician agree? Some clinicians argue that this is legitimate, because treating obesity can reduce metabolic syndrome, but Dr. Frank said not all physicians are comfortable with that solution. “This is a common ethical problem.”

Stages of Care

Physicians are doing a relatively good job of identifying and working with severely obese patients with comorbid conditions, but mildly overweight patients remain a missed opportunity, Dr. Kushner said.

“Everyone who is substantially obese was at one time a little bit overweight,” Dr. Frank observed. He urged physicians to do more to identify and help patients “who have an early or mild form of the disease.”

“Primary care physicians must treat obesity in an aggressive manner,” Dr. Vash said, highlighting the relationships between obesity, diabetes, and hypertension. “If you don't deal aggressively with obesity, obesity will chew up and maim your patient.”

Diet and physical activity remain the mainstay of weight-control programs, but pharmacotherapy also has a place, said Daniel H. Bessesen, M.D., of the University of Colorado, Denver.

Medication may not help people shed as much weight as they want or need to lose, but it can boost weight loss by about 5%. The is similar to what can be achieved with behavior modification. Pharmacotherapy and behavioral interventions together can be more effective than either strategy by itself, Dr. Bessesen said.

Yet many physicians refuse to prescribe weight-loss medications. Dr. Bessesen summed up their reasons: The drugs don't work for everyone, they cost too much, and they have side effects. Yet the same can be said of many widely used blood pressure drugs, and diets have side effects, too.

“Our mindset is completely different with other health problems. I think you have to ask yourself, why is that?” he said.

More weight-loss drugs “are coming down the pipe in the next 10 years,” he added. “This is going to be a bigger issue in the future.”

Dr. Schumacher suggested that clinicians prepare patients for weight gain, so they won't be too embarrassed or frustrated to come back. “You need to remind them that they will lapse, and that's not a personal flaw. That's life, and you will be with them if they lapse.”

Gary D. Foster, Ph.D., said low-carbohydrate diets produce greater weight loss at 6 months than low-calorie, low-fat diets. The few studies to evaluate low-carbohydrate diets have reported remarkably consistent short-term results, he said, noting, however, that weight loss at one 1 year was the same as for low-fat regimens.

Dr. Foster, a psychologist and obesity researcher at the University of Pennsylvania in Philadelphia, urged patience when patients do gain back weight. “The patient needs to know we are going to be treating him in a nonjudgmental way,” he said, recommending the clinician assume the reason is “lack of planning or skills, rather than a lack of motivation.”

Figure out what got in the way of adherence, then come up with a plan for how the patient will deal with the same situation in the future, he advised.

LAS VEGAS — In theory, team management of obese patients makes a lot of sense.

But in the real world, it may not be possible, because the obesity epidemic is too big, trained specialists too few, and resources too scarce, Arthur Frank, M.D., said at the annual meeting of North American Association for the Study of Obesity.

Primary care physicians must diagnose and treat obese patients in their practices, according to Dr. Frank, medical director of the weight management program at George Washington University in Washington. Primary care physicians need to provide such care even if they have no special skills in managing obesity or access to the nutritionists, dietitians, behavioral counselors, and other specialists who make up weight management teams.

“In the United States, there are 220 million adults over age 18. If 65% are overweight or obese, we have 143 million adults who need care. How can any system care for 143 million people who are overweight or obese?” Dr. Frank asked, laying the problem at the front door of primary care practices.

His remarks opened a workshop on office management of obesity—a subject revisited several times during the meeting, cosponsored by the American Diabetes Association. Here are some practical suggestions from experts in the field:

Guidelines and Other Tools

“The best way to describe the current management of obesity is clinical inertia,” Robert E. Kushner, M.D., said. “If the patient doesn't lose weight, what does the doctor do? He talks louder.”

Treatment guidelines are part of the problem, said Dr. Kushner, medical director of the Wellness Institute at Northwestern University, Chicago. There are too many of them—more than 2,000 at last count, including 135 at the National Guidelines Clearinghouse (

www.guidelines.gov

For example, he quoted an algorithm that concluded with a recommendation for the clinician and patient to determine goals and strategies for weight loss. “What is a clinician supposed to do with this?”

Putting aside such caveats, he recommended “The Practical Guide: Identification, Evaluation, and Treatment of Overweight and Obesity in Adults,” available on the North American Association for the Study of Obesity (NAASO) Web site (

www.naaso.org/information/practicalguide.asp

Still, “for managing obesity, guidelines are not enough. We really have to get down to tools,” Dr. Kushner said.

To start, he suggested large blood pressure cuffs, gowns, office chairs, and scales that can accommodate a patient who weighs 350 lbs. Medical history forms should have questions focused on obesity. Patients can be given diet and activity diaries along with specific instructions on how to cut calories and exercise more.

Tell patients to get a pedometer; patients who keep track of how many steps they take each day will become more active over time. “The pedometer—it's not rocket science,” he said. “It's not going to win a Nobel Prize, but what a useful tool to … get accountability.”

Getting Started

First impressions count, advised Donald Schumacher, M.D. Attitude, body language, and the amount of time a physician spends listening as opposed to lecturing a patient are all important when an overweight person seeks help.

“The last thing someone overweight needs is one more lecture,” said Dr. Schumacher, in private practice in Charlotte, N.C. Physicians must form a partnership with these vulnerable patients, and the role of the physician, staff, and patient should be established in the first visit.

Establishing the therapeutic bond is the most important first step, said Peter D. Vash, M.D., of the Lindora Medical Clinic of the University of California, Los Angeles. “Somehow the words, 'I can help you; please work with me,' to my mind set the stage for weight-loss success,” he said, calling the 7-10 minutes when the patient is with the physician “a therapeutic window of opportunity.”

The initial plan should go slow and be sensitive to the individual, Dr. Schumacher said. Ethnicity, work schedule, travel demands, and the obligations of motherhood are among the factors to consider.

Making too many changes too fast will lose the patient, he said. “Your patients have failed before. You do not want to set your patients up to fail once again.”

Some obese patients will ask their physicians to cite diabetes or hypertension or another condition as the primary diagnosis when billing for an office visit, Dr. Frank said. There is no code for obesity, and the cost might not be reimbursed if the real reason is stated.

Should the physician agree? Some clinicians argue that this is legitimate, because treating obesity can reduce metabolic syndrome, but Dr. Frank said not all physicians are comfortable with that solution. “This is a common ethical problem.”

Stages of Care

Physicians are doing a relatively good job of identifying and working with severely obese patients with comorbid conditions, but mildly overweight patients remain a missed opportunity, Dr. Kushner said.

“Everyone who is substantially obese was at one time a little bit overweight,” Dr. Frank observed. He urged physicians to do more to identify and help patients “who have an early or mild form of the disease.”

“Primary care physicians must treat obesity in an aggressive manner,” Dr. Vash said, highlighting the relationships between obesity, diabetes, and hypertension. “If you don't deal aggressively with obesity, obesity will chew up and maim your patient.”

Diet and physical activity remain the mainstay of weight-control programs, but pharmacotherapy also has a place, said Daniel H. Bessesen, M.D., of the University of Colorado, Denver.

Medication may not help people shed as much weight as they want or need to lose, but it can boost weight loss by about 5%. The is similar to what can be achieved with behavior modification. Pharmacotherapy and behavioral interventions together can be more effective than either strategy by itself, Dr. Bessesen said.

Yet many physicians refuse to prescribe weight-loss medications. Dr. Bessesen summed up their reasons: The drugs don't work for everyone, they cost too much, and they have side effects. Yet the same can be said of many widely used blood pressure drugs, and diets have side effects, too.

“Our mindset is completely different with other health problems. I think you have to ask yourself, why is that?” he said.

More weight-loss drugs “are coming down the pipe in the next 10 years,” he added. “This is going to be a bigger issue in the future.”

Dr. Schumacher suggested that clinicians prepare patients for weight gain, so they won't be too embarrassed or frustrated to come back. “You need to remind them that they will lapse, and that's not a personal flaw. That's life, and you will be with them if they lapse.”

Gary D. Foster, Ph.D., said low-carbohydrate diets produce greater weight loss at 6 months than low-calorie, low-fat diets. The few studies to evaluate low-carbohydrate diets have reported remarkably consistent short-term results, he said, noting, however, that weight loss at one 1 year was the same as for low-fat regimens.

Dr. Foster, a psychologist and obesity researcher at the University of Pennsylvania in Philadelphia, urged patience when patients do gain back weight. “The patient needs to know we are going to be treating him in a nonjudgmental way,” he said, recommending the clinician assume the reason is “lack of planning or skills, rather than a lack of motivation.”

Figure out what got in the way of adherence, then come up with a plan for how the patient will deal with the same situation in the future, he advised.

LAS VEGAS – Adding a weight-loss medication to cognitive-behavioral therapy for binge-eating disorder produced a higher remission rate and greater weight loss than cognitive-behavioral therapy alone in a randomized, double-blind, placebo-controlled trial.

More than a third (36%) of 25 obese binge eaters had a 5% weight loss with the combination of cognitive-behavioral therapy (CBT) and orlistat (Xenical), Carlos M. Grilo, Ph.D., reported at the annual meeting of North American Association for the Study of Obesity.

Fewer patients in the control group met the 5% standard for weight loss: only 8%, compared with the 36% of patients on combined therapy. The control group of 25 patients received CBT and a placebo.

Remission was achieved by nearly two-thirds (64%) of the combination therapy group during the 12-week study, and 52% were still in remission 3 months after the end of treatment, according to Dr. Grilo, director of the eating disorder program in the department of psychiatry at Yale University, New Haven.

In the control group, only 36% achieved remission, which was defined as no binge eating for at least 28 consecutive days.

The dosage of orlistat used in the combined therapy group was 120 mg, three times a day.

The average weight loss of 4.4 kg in the combined therapy group was small, but it was encouraging because helping binge eaters to achieve any degree of weight loss has been a major challenge. “This may appear modest, but with this patient group, it is a promising first step,” Dr. Grilo said at the meeting, which was cosponsored by the American Diabetes Association. The control group lost less weight on average–only 1.9 kg.

The Eating Disorder Examination interview was used to assess outcomes. After patients finished the program, they were encouraged to stay on a three-meal, three-snack-a-day regimen.

The trial enrolled 50 consecutive obese patients, mean age 47, who met strict criteria for binge eating. Predominantly white and female, the population averaged 13.5 binge-eating episodes per month and had an average body mass index of 36 kg/m2. Sixty percent had at least one additional psychiatric disorder, the most common of which was major depression.

The approach needs to be extended to other groups, especially diabetic binge eaters who were excluded from the study, he said.

LAS VEGAS – Adding a weight-loss medication to cognitive-behavioral therapy for binge-eating disorder produced a higher remission rate and greater weight loss than cognitive-behavioral therapy alone in a randomized, double-blind, placebo-controlled trial.

More than a third (36%) of 25 obese binge eaters had a 5% weight loss with the combination of cognitive-behavioral therapy (CBT) and orlistat (Xenical), Carlos M. Grilo, Ph.D., reported at the annual meeting of North American Association for the Study of Obesity.

Fewer patients in the control group met the 5% standard for weight loss: only 8%, compared with the 36% of patients on combined therapy. The control group of 25 patients received CBT and a placebo.

Remission was achieved by nearly two-thirds (64%) of the combination therapy group during the 12-week study, and 52% were still in remission 3 months after the end of treatment, according to Dr. Grilo, director of the eating disorder program in the department of psychiatry at Yale University, New Haven.

In the control group, only 36% achieved remission, which was defined as no binge eating for at least 28 consecutive days.

The dosage of orlistat used in the combined therapy group was 120 mg, three times a day.

The average weight loss of 4.4 kg in the combined therapy group was small, but it was encouraging because helping binge eaters to achieve any degree of weight loss has been a major challenge. “This may appear modest, but with this patient group, it is a promising first step,” Dr. Grilo said at the meeting, which was cosponsored by the American Diabetes Association. The control group lost less weight on average–only 1.9 kg.

The Eating Disorder Examination interview was used to assess outcomes. After patients finished the program, they were encouraged to stay on a three-meal, three-snack-a-day regimen.

The trial enrolled 50 consecutive obese patients, mean age 47, who met strict criteria for binge eating. Predominantly white and female, the population averaged 13.5 binge-eating episodes per month and had an average body mass index of 36 kg/m2. Sixty percent had at least one additional psychiatric disorder, the most common of which was major depression.

The approach needs to be extended to other groups, especially diabetic binge eaters who were excluded from the study, he said.

LAS VEGAS – Adding a weight-loss medication to cognitive-behavioral therapy for binge-eating disorder produced a higher remission rate and greater weight loss than cognitive-behavioral therapy alone in a randomized, double-blind, placebo-controlled trial.

More than a third (36%) of 25 obese binge eaters had a 5% weight loss with the combination of cognitive-behavioral therapy (CBT) and orlistat (Xenical), Carlos M. Grilo, Ph.D., reported at the annual meeting of North American Association for the Study of Obesity.

Fewer patients in the control group met the 5% standard for weight loss: only 8%, compared with the 36% of patients on combined therapy. The control group of 25 patients received CBT and a placebo.

Remission was achieved by nearly two-thirds (64%) of the combination therapy group during the 12-week study, and 52% were still in remission 3 months after the end of treatment, according to Dr. Grilo, director of the eating disorder program in the department of psychiatry at Yale University, New Haven.

In the control group, only 36% achieved remission, which was defined as no binge eating for at least 28 consecutive days.

The dosage of orlistat used in the combined therapy group was 120 mg, three times a day.

The average weight loss of 4.4 kg in the combined therapy group was small, but it was encouraging because helping binge eaters to achieve any degree of weight loss has been a major challenge. “This may appear modest, but with this patient group, it is a promising first step,” Dr. Grilo said at the meeting, which was cosponsored by the American Diabetes Association. The control group lost less weight on average–only 1.9 kg.

The Eating Disorder Examination interview was used to assess outcomes. After patients finished the program, they were encouraged to stay on a three-meal, three-snack-a-day regimen.

The trial enrolled 50 consecutive obese patients, mean age 47, who met strict criteria for binge eating. Predominantly white and female, the population averaged 13.5 binge-eating episodes per month and had an average body mass index of 36 kg/m2. Sixty percent had at least one additional psychiatric disorder, the most common of which was major depression.

The approach needs to be extended to other groups, especially diabetic binge eaters who were excluded from the study, he said.

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

SANTA FE, N.M. — Vaginal estrogen should always be prescribed to menopausal women undergoing pelvic or urogynecologic surgery, Marvin H. Terry Grody, M.D., advised at a conference on gynecologic surgery sponsored by Omnia Education.

Estrogen therapy is essential to preserve the strength and elasticity of connective tissue and, ultimately, to extend the success of reconstructive surgery, according to Dr. Grody of Robert Wood Johnson Medical School in Camden, NJ.

“The pelvis is full of estrogen receptors going all the way from the urethra to the anus and extending unquestionably into the ligament supports of the pelvis that suspend the vault [and] suspend the uterus and the cervix, and the anterior and posterior upper reaches of the vagina,” he said. “Why are estrogen receptors there? They have a purpose, and to make our operations work, they ought to be fulfilled.”

Endometrial cancer is not usually a concern when preoperative estrogen is prescribed, according to Dr. Grody, given that in these surgeries, the uterus has often been or will be removed. Possible cardiovascular and breast cancer effects are a worry to women as well as to physicians, however, and he warned that oral estrogen might elicit medical and/or legal concerns.

“The only way I see that we can handle this and play it safe for both the patient and ourselves is to use vaginal estrogen in one form or another in an appropriate dosage,” Dr. Grody noted.

Vaginal cream, pulvules, and tablets are each an option, he said, citing a Duke University study that found half a gram of Premarin cream three times a week produced adequate effects in the pelvis without systemic distribution (Obstet. Gynecol. 1994;84:215–8).

Dr. Grody recommended starting vaginal estrogen at least 6 weeks before surgery and urging the patient to stay on vaginal estrogen for the rest of her life.”

SANTA FE, N.M. — Vaginal estrogen should always be prescribed to menopausal women undergoing pelvic or urogynecologic surgery, Marvin H. Terry Grody, M.D., advised at a conference on gynecologic surgery sponsored by Omnia Education.

Estrogen therapy is essential to preserve the strength and elasticity of connective tissue and, ultimately, to extend the success of reconstructive surgery, according to Dr. Grody of Robert Wood Johnson Medical School in Camden, NJ.

“The pelvis is full of estrogen receptors going all the way from the urethra to the anus and extending unquestionably into the ligament supports of the pelvis that suspend the vault [and] suspend the uterus and the cervix, and the anterior and posterior upper reaches of the vagina,” he said. “Why are estrogen receptors there? They have a purpose, and to make our operations work, they ought to be fulfilled.”

Endometrial cancer is not usually a concern when preoperative estrogen is prescribed, according to Dr. Grody, given that in these surgeries, the uterus has often been or will be removed. Possible cardiovascular and breast cancer effects are a worry to women as well as to physicians, however, and he warned that oral estrogen might elicit medical and/or legal concerns.

“The only way I see that we can handle this and play it safe for both the patient and ourselves is to use vaginal estrogen in one form or another in an appropriate dosage,” Dr. Grody noted.

Vaginal cream, pulvules, and tablets are each an option, he said, citing a Duke University study that found half a gram of Premarin cream three times a week produced adequate effects in the pelvis without systemic distribution (Obstet. Gynecol. 1994;84:215–8).

Dr. Grody recommended starting vaginal estrogen at least 6 weeks before surgery and urging the patient to stay on vaginal estrogen for the rest of her life.”

SANTA FE, N.M. — Vaginal estrogen should always be prescribed to menopausal women undergoing pelvic or urogynecologic surgery, Marvin H. Terry Grody, M.D., advised at a conference on gynecologic surgery sponsored by Omnia Education.

Estrogen therapy is essential to preserve the strength and elasticity of connective tissue and, ultimately, to extend the success of reconstructive surgery, according to Dr. Grody of Robert Wood Johnson Medical School in Camden, NJ.

“The pelvis is full of estrogen receptors going all the way from the urethra to the anus and extending unquestionably into the ligament supports of the pelvis that suspend the vault [and] suspend the uterus and the cervix, and the anterior and posterior upper reaches of the vagina,” he said. “Why are estrogen receptors there? They have a purpose, and to make our operations work, they ought to be fulfilled.”

Endometrial cancer is not usually a concern when preoperative estrogen is prescribed, according to Dr. Grody, given that in these surgeries, the uterus has often been or will be removed. Possible cardiovascular and breast cancer effects are a worry to women as well as to physicians, however, and he warned that oral estrogen might elicit medical and/or legal concerns.

“The only way I see that we can handle this and play it safe for both the patient and ourselves is to use vaginal estrogen in one form or another in an appropriate dosage,” Dr. Grody noted.

Vaginal cream, pulvules, and tablets are each an option, he said, citing a Duke University study that found half a gram of Premarin cream three times a week produced adequate effects in the pelvis without systemic distribution (Obstet. Gynecol. 1994;84:215–8).

Dr. Grody recommended starting vaginal estrogen at least 6 weeks before surgery and urging the patient to stay on vaginal estrogen for the rest of her life.”

SANTA FE, N.M. — Leaving the anterior wall of the vagina unsupported is a leading cause of failure in surgeries for vaginal vault prolapse, Thomas M. Julian, M.D., said at a conference on gynecologic surgery sponsored by Omnia Education.

“The reason we see so many recurrences is we don't attach the anterior vaginal wall. You have to attach the anterior vagina to something,” said Dr. Julian, director of the division of gynecology at the University of Wisconsin in Madison.

Dr. Julian said he came to this conclusion because he was troubled by the number of patients who were referred to his medical center for repair of failed operations. He did not believe the problem originated with the surgeons doing these operations, but with the techniques they used. Reviewing established procedures, he found a common denominator was no incorporated support to the anterior wall of the vagina.

The roots of vaginal vault prolapse can often be found in hysterectomy, according to Dr. Julian. The surgeon attaches the broken segments of uterosacral ligament to each other. “Now that will probably support those two uterosacral ligaments really well, but it won't support the vagina unless you sew [them] back to the vagina at some point,” he said.

Over time, the vagina descends until repair of the vaginal vault becomes necessary. Whichever repair procedure is used, Dr. Julian said locating and avoiding the ureter during surgery becomes a major concern.

One surgical option, the classic McCall culdeplasty, does a good job of pulling up the vaginal apex, Dr. Julian said. However, he added, it has a high incidence of catching the ureter, and it does nothing to support the anterior wall.

Sacrospinous ligament fixation also presents problems. “The recurrence of other pelvic support defects using this operation was unacceptably high,” he said.

One problem he cited is that surgeons often proceed by touch without seeing the ligament. “If you are not seeing, I don't think you are going to be able to do the operation,” he said.

Another occurs in women who have already been operated on several times. As the vagina becomes shorter, vaginal apex repairs may no longer reach to the anterior sacrospinous ligament. When that happens, surgeons make a suture bridge, which can pull and cause pain, Dr. Julian said.

The procedure itself pulls the vagina to one side, leaving the other side open to recurrence—and does not support the anterior wall, he added.

The Inmon-Meeks prespinous suspension, he continued, represents a major improvement, using the iliococcygeus fascia to support the posterior wall of the vagina. The anterior wall is still suspended, however.

A newer technique, intravaginal slingplasty, gives more support to the apex and has cure rates of 91% and 94% without major complications, according to two published reports from Australian surgeons (Int. Urogynecol. J. Pelvic Floor Dysfunct. 2002;13:4–8 and Int. Urogynecol. J. Pelvic Floor Dysfunct. 2001;12:296–303). “This is the new and coming thing that is going to be touted for suspending the vaginal apex,” Dr. Julian said, adding that it still does not support the anterior wall.

He said he has been using a technique in which the uterosacral ligament provides the missing support. The surgeon puts a finger in the rectum to find the ligament and then grasps the uterosacral ligament with a clamp. The surgeon subsequently places two sutures from lateral to medial (to avoid catching the ureter) attaching the ligament to the vagina. This pulls the vagina back, anchoring the anterior wall and posterior wall and restoring the axis of the vagina.

“All straining is going to push the vagina into the sacrum instead of the hiatus,” Dr. Julian said, adding, “It's not a new concept. … People have thought of it in the past, thought of it abdominally. For some reason we got out of doing that.”

SANTA FE, N.M. — Leaving the anterior wall of the vagina unsupported is a leading cause of failure in surgeries for vaginal vault prolapse, Thomas M. Julian, M.D., said at a conference on gynecologic surgery sponsored by Omnia Education.

“The reason we see so many recurrences is we don't attach the anterior vaginal wall. You have to attach the anterior vagina to something,” said Dr. Julian, director of the division of gynecology at the University of Wisconsin in Madison.

Dr. Julian said he came to this conclusion because he was troubled by the number of patients who were referred to his medical center for repair of failed operations. He did not believe the problem originated with the surgeons doing these operations, but with the techniques they used. Reviewing established procedures, he found a common denominator was no incorporated support to the anterior wall of the vagina.

The roots of vaginal vault prolapse can often be found in hysterectomy, according to Dr. Julian. The surgeon attaches the broken segments of uterosacral ligament to each other. “Now that will probably support those two uterosacral ligaments really well, but it won't support the vagina unless you sew [them] back to the vagina at some point,” he said.

Over time, the vagina descends until repair of the vaginal vault becomes necessary. Whichever repair procedure is used, Dr. Julian said locating and avoiding the ureter during surgery becomes a major concern.

One surgical option, the classic McCall culdeplasty, does a good job of pulling up the vaginal apex, Dr. Julian said. However, he added, it has a high incidence of catching the ureter, and it does nothing to support the anterior wall.

Sacrospinous ligament fixation also presents problems. “The recurrence of other pelvic support defects using this operation was unacceptably high,” he said.

One problem he cited is that surgeons often proceed by touch without seeing the ligament. “If you are not seeing, I don't think you are going to be able to do the operation,” he said.

Another occurs in women who have already been operated on several times. As the vagina becomes shorter, vaginal apex repairs may no longer reach to the anterior sacrospinous ligament. When that happens, surgeons make a suture bridge, which can pull and cause pain, Dr. Julian said.

The procedure itself pulls the vagina to one side, leaving the other side open to recurrence—and does not support the anterior wall, he added.

The Inmon-Meeks prespinous suspension, he continued, represents a major improvement, using the iliococcygeus fascia to support the posterior wall of the vagina. The anterior wall is still suspended, however.

A newer technique, intravaginal slingplasty, gives more support to the apex and has cure rates of 91% and 94% without major complications, according to two published reports from Australian surgeons (Int. Urogynecol. J. Pelvic Floor Dysfunct. 2002;13:4–8 and Int. Urogynecol. J. Pelvic Floor Dysfunct. 2001;12:296–303). “This is the new and coming thing that is going to be touted for suspending the vaginal apex,” Dr. Julian said, adding that it still does not support the anterior wall.

He said he has been using a technique in which the uterosacral ligament provides the missing support. The surgeon puts a finger in the rectum to find the ligament and then grasps the uterosacral ligament with a clamp. The surgeon subsequently places two sutures from lateral to medial (to avoid catching the ureter) attaching the ligament to the vagina. This pulls the vagina back, anchoring the anterior wall and posterior wall and restoring the axis of the vagina.

“All straining is going to push the vagina into the sacrum instead of the hiatus,” Dr. Julian said, adding, “It's not a new concept. … People have thought of it in the past, thought of it abdominally. For some reason we got out of doing that.”

SANTA FE, N.M. — Leaving the anterior wall of the vagina unsupported is a leading cause of failure in surgeries for vaginal vault prolapse, Thomas M. Julian, M.D., said at a conference on gynecologic surgery sponsored by Omnia Education.

“The reason we see so many recurrences is we don't attach the anterior vaginal wall. You have to attach the anterior vagina to something,” said Dr. Julian, director of the division of gynecology at the University of Wisconsin in Madison.

Dr. Julian said he came to this conclusion because he was troubled by the number of patients who were referred to his medical center for repair of failed operations. He did not believe the problem originated with the surgeons doing these operations, but with the techniques they used. Reviewing established procedures, he found a common denominator was no incorporated support to the anterior wall of the vagina.

The roots of vaginal vault prolapse can often be found in hysterectomy, according to Dr. Julian. The surgeon attaches the broken segments of uterosacral ligament to each other. “Now that will probably support those two uterosacral ligaments really well, but it won't support the vagina unless you sew [them] back to the vagina at some point,” he said.

Over time, the vagina descends until repair of the vaginal vault becomes necessary. Whichever repair procedure is used, Dr. Julian said locating and avoiding the ureter during surgery becomes a major concern.

One surgical option, the classic McCall culdeplasty, does a good job of pulling up the vaginal apex, Dr. Julian said. However, he added, it has a high incidence of catching the ureter, and it does nothing to support the anterior wall.

Sacrospinous ligament fixation also presents problems. “The recurrence of other pelvic support defects using this operation was unacceptably high,” he said.

One problem he cited is that surgeons often proceed by touch without seeing the ligament. “If you are not seeing, I don't think you are going to be able to do the operation,” he said.

Another occurs in women who have already been operated on several times. As the vagina becomes shorter, vaginal apex repairs may no longer reach to the anterior sacrospinous ligament. When that happens, surgeons make a suture bridge, which can pull and cause pain, Dr. Julian said.

The procedure itself pulls the vagina to one side, leaving the other side open to recurrence—and does not support the anterior wall, he added.

The Inmon-Meeks prespinous suspension, he continued, represents a major improvement, using the iliococcygeus fascia to support the posterior wall of the vagina. The anterior wall is still suspended, however.

A newer technique, intravaginal slingplasty, gives more support to the apex and has cure rates of 91% and 94% without major complications, according to two published reports from Australian surgeons (Int. Urogynecol. J. Pelvic Floor Dysfunct. 2002;13:4–8 and Int. Urogynecol. J. Pelvic Floor Dysfunct. 2001;12:296–303). “This is the new and coming thing that is going to be touted for suspending the vaginal apex,” Dr. Julian said, adding that it still does not support the anterior wall.

He said he has been using a technique in which the uterosacral ligament provides the missing support. The surgeon puts a finger in the rectum to find the ligament and then grasps the uterosacral ligament with a clamp. The surgeon subsequently places two sutures from lateral to medial (to avoid catching the ureter) attaching the ligament to the vagina. This pulls the vagina back, anchoring the anterior wall and posterior wall and restoring the axis of the vagina.

“All straining is going to push the vagina into the sacrum instead of the hiatus,” Dr. Julian said, adding, “It's not a new concept. … People have thought of it in the past, thought of it abdominally. For some reason we got out of doing that.”