Diabetes Hub

Employees need to spend at least 2 hours of the work day on their feet, an international group of experts advised.

The group based this recommendation on studies showing possible links between illness and large amounts of time sitting. Among the findings of such research is that, in the United Kingdom, sedentary behavior occupies over 70% of the total waking hours of people with a high risk of chronic disease. Another data point used to reach the recommendation was that those with office jobs sit for 65%-75% of their time at work.

“In observational research, daily hours spent being sedentary (sitting), independent of levels of exercise or physical activity, are positively correlated with the risk of diabetes and cardiovascular disease, some cancers and premature mortality,” according to John P. Buckley of University Centre Shrewsbury and the University of Chester, England, and his colleagues. “For example, comprehensive reviews of the data found that compared with those who sit the least, those who sit the most have over twice the risk of developing type 2 diabetes and cardiovascular disease, and a 13% and 17% increased risk of cancer incidence and mortality, respectively.”

To potentially reduce the ill effects of prolonged sitting, the group of experts suggested that those with predominantly desk-based jobs adopt the following practices:

• Initially progress towards accumulating at least 2 hours a day of standing and performing light activity – such as walking – during work, and later increase the amount of time on foot to 4 hours a day (prorated to part-time hours).

• Take breaks from both seated- and standing-based work. Thus, sit-stand adjustable desk stations are highly recommended.

• Avoid prolonged static standing postures.

• If adding more standing to the work day causes pain that does not subside after altering posture, walking, or resting, then seek medical advice.

Such guidelines are justified even though longer-term intervention studies that assess standing and light activity in office environments are needed, according to the researchers.

Read the full report in the British Journal of Sports Medicine (2015 June 1 [doi:10.1136/bjsports-2015-094618]).

[email protected]

Employees need to spend at least 2 hours of the work day on their feet, an international group of experts advised.

The group based this recommendation on studies showing possible links between illness and large amounts of time sitting. Among the findings of such research is that, in the United Kingdom, sedentary behavior occupies over 70% of the total waking hours of people with a high risk of chronic disease. Another data point used to reach the recommendation was that those with office jobs sit for 65%-75% of their time at work.

“In observational research, daily hours spent being sedentary (sitting), independent of levels of exercise or physical activity, are positively correlated with the risk of diabetes and cardiovascular disease, some cancers and premature mortality,” according to John P. Buckley of University Centre Shrewsbury and the University of Chester, England, and his colleagues. “For example, comprehensive reviews of the data found that compared with those who sit the least, those who sit the most have over twice the risk of developing type 2 diabetes and cardiovascular disease, and a 13% and 17% increased risk of cancer incidence and mortality, respectively.”

To potentially reduce the ill effects of prolonged sitting, the group of experts suggested that those with predominantly desk-based jobs adopt the following practices:

• Initially progress towards accumulating at least 2 hours a day of standing and performing light activity – such as walking – during work, and later increase the amount of time on foot to 4 hours a day (prorated to part-time hours).

• Take breaks from both seated- and standing-based work. Thus, sit-stand adjustable desk stations are highly recommended.

• Avoid prolonged static standing postures.

• If adding more standing to the work day causes pain that does not subside after altering posture, walking, or resting, then seek medical advice.

Such guidelines are justified even though longer-term intervention studies that assess standing and light activity in office environments are needed, according to the researchers.

Read the full report in the British Journal of Sports Medicine (2015 June 1 [doi:10.1136/bjsports-2015-094618]).

[email protected]

Employees need to spend at least 2 hours of the work day on their feet, an international group of experts advised.

The group based this recommendation on studies showing possible links between illness and large amounts of time sitting. Among the findings of such research is that, in the United Kingdom, sedentary behavior occupies over 70% of the total waking hours of people with a high risk of chronic disease. Another data point used to reach the recommendation was that those with office jobs sit for 65%-75% of their time at work.

“In observational research, daily hours spent being sedentary (sitting), independent of levels of exercise or physical activity, are positively correlated with the risk of diabetes and cardiovascular disease, some cancers and premature mortality,” according to John P. Buckley of University Centre Shrewsbury and the University of Chester, England, and his colleagues. “For example, comprehensive reviews of the data found that compared with those who sit the least, those who sit the most have over twice the risk of developing type 2 diabetes and cardiovascular disease, and a 13% and 17% increased risk of cancer incidence and mortality, respectively.”

To potentially reduce the ill effects of prolonged sitting, the group of experts suggested that those with predominantly desk-based jobs adopt the following practices:

• Initially progress towards accumulating at least 2 hours a day of standing and performing light activity – such as walking – during work, and later increase the amount of time on foot to 4 hours a day (prorated to part-time hours).

• Take breaks from both seated- and standing-based work. Thus, sit-stand adjustable desk stations are highly recommended.

• Avoid prolonged static standing postures.

• If adding more standing to the work day causes pain that does not subside after altering posture, walking, or resting, then seek medical advice.

Such guidelines are justified even though longer-term intervention studies that assess standing and light activity in office environments are needed, according to the researchers.

Read the full report in the British Journal of Sports Medicine (2015 June 1 [doi:10.1136/bjsports-2015-094618]).

[email protected]

SEATTLE – Patients with osteoarthritis often have other common chronic conditions, a scenario that has implications for both clinical care and research, according to Dr. Gillian Hawker.

“This is a critically important topic in our field,” she told attendees of the World Congress on Osteoarthritis. “We know from myriad studies that there are major challenges to the diagnosis and management of osteoarthritis ... But probably now what’s becoming a major issue is the high occurrence of coexisting medical problems, which have been shown to present competing demands to patients and physicians who are trying to balance a number of conditions in a single patient and contraindications to osteoarthritis therapies.”

Today, 90% of individuals aged 65 years and older with osteoarthritis have at least one other chronic condition, according to Dr. Hawker, the Sir John and Lady Eaton Professor and chair of medicine at the University of Toronto. Most commonly, those conditions are cardiovascular disease, diabetes, and hypertension, but about one-third of patients have depressed mood, which may affect adherence to and effectiveness of therapies.

Two main hypotheses have been proposed for the association of osteoarthritis and other common chronic conditions, according to Dr. Hawker. According to the first hypothesis, the shared risk factors of aging and obesity independently lead to both osteoarthritis, with resultant physical inactivity, and a cluster of metabolic perturbations including hypertension, hyperglycemia, and dyslipidemia. Collectively, these conditions increase risk for cardiovascular disease and diabetes.

In support of this hypothesis, “we have lots of data from qualitative research showing that people manage their osteoarthritis symptoms by giving up activities that exacerbate them, partly because they are afraid of taking painkillers and partly because nobody offers them anything that’s more effective,” Dr. Hawker noted. In addition, when patients juggle multiple health conditions, exercise is the most frequently dropped activity.

“Many have hypothesized that inability to walk, climb stairs, and be mobile would potentially impact the ability to self-manage physical activity, impacting numerous chronic conditions,” she said. Compelling evidence comes from research such as a cohort study of patients with symptomatic hip or knee osteoarthritis that found walking disability predicted a 30% increase in the risk of all-cause death and a 17% increase in the risk of cardiovascular events; among the subset with comorbid diabetes, walking disability and grip strength predicted the risk of hospitalization for diabetic complications (PLoS One 2014;9:e91286).

“These are large, well-controlled observational studies that do show consistent independent relationships between walking disability and cardiovascular events, diabetes complications, and all-cause death,” Dr. Hawker said, while acknowledging that the research is still hypothesis generating.

Of note, recent attention has focused on systemic inflammation and a metabolic osteoarthritis phenotype. When it comes to the pathogenesis of osteoarthritis, “we now are very comfortable understanding the local biomechanical effects separately from the systemic effects on our joints,” she said. Obesity is among the systemic factors implicated, with some data suggesting that adipokines affect joint tissues in a manner similar to mechanical stress.

According to the second main hypothesis proposed to explain the association between osteoarthritis and common chronic conditions, aging and obesity give rise to a cluster of metabolic factors (hypertension, hyperglycemia, and dyslipidemia) that independently increase the risk of symptomatic osteoarthritis. Again, the arthritis may result in the loss of physical activity and disability, which exacerbates the metabolic situation.

Evidence in support of this hypothesis comes from a variety of studies. For example, one has shown that the number of components of the metabolic syndrome is related to the adjusted risk of development and progression of knee osteoarthritis (Osteoarthritis Cartilage 2012;20:1217-26).

Overall, Dr. Hawker said, “we have some independent associations between metabolic syndrome and its components, and osteoarthritis – more so in the knee and hand, more so in women than in men, and more so in younger than in older individuals. And we have some data that suggest that symptomatic and disabling osteoarthritis has an association with increased risk of cardiovascular events and diabetes complications.” Here again, the studies have limitations, so the relative contributions of disability and systemic inflammation remain unknown, she cautioned.

Hypotheses aside, the association of osteoarthritis with common chronic conditions has implications for clinical care, Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “Clearly, all of these data, irrespective of the relationships, point to a pivotal role for physical activity, a combination of physical activities,” she said, noting that benefits include reductions in both metabolic alterations and physical impairment, and possibly alleviation of depressed mood and improved sleep.

Osteoarthritis may be an independent risk factor for cardiovascular disease. “Many are suggesting that, in fact, if it is the fifth component of metabolic syndrome, this should really influence how we think about cardiovascular disease prevention, that osteoarthritis patients should be screened and we should be thinking more seriously about how we use various therapies,” such as nonsteroidal anti-inflammatory drugs, she said.

Dr. Hawker endorsed future research on these topics. “In the 2014 OARSI guidelines, we showed collectively as a community that we don’t have enough trials in this population, which is the majority of our patients with osteoarthritis. So yes, conservative therapy is good, but I’d say that we need way more evidence for effective interventions in the population with osteoarthritis who are living with other chronic conditions.”

Specifically needed are large prospective studies of the temporal relationships that look at mechanisms beyond age and body mass index, she explained. These studies should assess incidence and progression separately, structure and symptoms separately, and both weight-bearing and non–weight-bearing joints.

“To date, I haven’t seen any evidence to show that treatment of metabolic syndrome or its components influences the incidence or progression of osteoarthritis. And I think we should be thinking about asking those questions as they may in fact be modifiable risk factors for osteoarthritis,” she said.

Also needed are trials assessing the impact of aggressive treatment of osteoarthritis disability, according to Dr. Hawker, who disclosed that she had no relevant conflicts of interest. “If we reduce osteoarthritis disability, particularly walking disability, can we actually impact the outcomes of cardiovascular disease and diabetes? I think that’s an important question,” she concluded.

SEATTLE – Patients with osteoarthritis often have other common chronic conditions, a scenario that has implications for both clinical care and research, according to Dr. Gillian Hawker.

“This is a critically important topic in our field,” she told attendees of the World Congress on Osteoarthritis. “We know from myriad studies that there are major challenges to the diagnosis and management of osteoarthritis ... But probably now what’s becoming a major issue is the high occurrence of coexisting medical problems, which have been shown to present competing demands to patients and physicians who are trying to balance a number of conditions in a single patient and contraindications to osteoarthritis therapies.”

Today, 90% of individuals aged 65 years and older with osteoarthritis have at least one other chronic condition, according to Dr. Hawker, the Sir John and Lady Eaton Professor and chair of medicine at the University of Toronto. Most commonly, those conditions are cardiovascular disease, diabetes, and hypertension, but about one-third of patients have depressed mood, which may affect adherence to and effectiveness of therapies.

Two main hypotheses have been proposed for the association of osteoarthritis and other common chronic conditions, according to Dr. Hawker. According to the first hypothesis, the shared risk factors of aging and obesity independently lead to both osteoarthritis, with resultant physical inactivity, and a cluster of metabolic perturbations including hypertension, hyperglycemia, and dyslipidemia. Collectively, these conditions increase risk for cardiovascular disease and diabetes.

In support of this hypothesis, “we have lots of data from qualitative research showing that people manage their osteoarthritis symptoms by giving up activities that exacerbate them, partly because they are afraid of taking painkillers and partly because nobody offers them anything that’s more effective,” Dr. Hawker noted. In addition, when patients juggle multiple health conditions, exercise is the most frequently dropped activity.

“Many have hypothesized that inability to walk, climb stairs, and be mobile would potentially impact the ability to self-manage physical activity, impacting numerous chronic conditions,” she said. Compelling evidence comes from research such as a cohort study of patients with symptomatic hip or knee osteoarthritis that found walking disability predicted a 30% increase in the risk of all-cause death and a 17% increase in the risk of cardiovascular events; among the subset with comorbid diabetes, walking disability and grip strength predicted the risk of hospitalization for diabetic complications (PLoS One 2014;9:e91286).

“These are large, well-controlled observational studies that do show consistent independent relationships between walking disability and cardiovascular events, diabetes complications, and all-cause death,” Dr. Hawker said, while acknowledging that the research is still hypothesis generating.

Of note, recent attention has focused on systemic inflammation and a metabolic osteoarthritis phenotype. When it comes to the pathogenesis of osteoarthritis, “we now are very comfortable understanding the local biomechanical effects separately from the systemic effects on our joints,” she said. Obesity is among the systemic factors implicated, with some data suggesting that adipokines affect joint tissues in a manner similar to mechanical stress.

According to the second main hypothesis proposed to explain the association between osteoarthritis and common chronic conditions, aging and obesity give rise to a cluster of metabolic factors (hypertension, hyperglycemia, and dyslipidemia) that independently increase the risk of symptomatic osteoarthritis. Again, the arthritis may result in the loss of physical activity and disability, which exacerbates the metabolic situation.

Evidence in support of this hypothesis comes from a variety of studies. For example, one has shown that the number of components of the metabolic syndrome is related to the adjusted risk of development and progression of knee osteoarthritis (Osteoarthritis Cartilage 2012;20:1217-26).

Overall, Dr. Hawker said, “we have some independent associations between metabolic syndrome and its components, and osteoarthritis – more so in the knee and hand, more so in women than in men, and more so in younger than in older individuals. And we have some data that suggest that symptomatic and disabling osteoarthritis has an association with increased risk of cardiovascular events and diabetes complications.” Here again, the studies have limitations, so the relative contributions of disability and systemic inflammation remain unknown, she cautioned.

Hypotheses aside, the association of osteoarthritis with common chronic conditions has implications for clinical care, Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “Clearly, all of these data, irrespective of the relationships, point to a pivotal role for physical activity, a combination of physical activities,” she said, noting that benefits include reductions in both metabolic alterations and physical impairment, and possibly alleviation of depressed mood and improved sleep.

Osteoarthritis may be an independent risk factor for cardiovascular disease. “Many are suggesting that, in fact, if it is the fifth component of metabolic syndrome, this should really influence how we think about cardiovascular disease prevention, that osteoarthritis patients should be screened and we should be thinking more seriously about how we use various therapies,” such as nonsteroidal anti-inflammatory drugs, she said.

Dr. Hawker endorsed future research on these topics. “In the 2014 OARSI guidelines, we showed collectively as a community that we don’t have enough trials in this population, which is the majority of our patients with osteoarthritis. So yes, conservative therapy is good, but I’d say that we need way more evidence for effective interventions in the population with osteoarthritis who are living with other chronic conditions.”

Specifically needed are large prospective studies of the temporal relationships that look at mechanisms beyond age and body mass index, she explained. These studies should assess incidence and progression separately, structure and symptoms separately, and both weight-bearing and non–weight-bearing joints.

“To date, I haven’t seen any evidence to show that treatment of metabolic syndrome or its components influences the incidence or progression of osteoarthritis. And I think we should be thinking about asking those questions as they may in fact be modifiable risk factors for osteoarthritis,” she said.

Also needed are trials assessing the impact of aggressive treatment of osteoarthritis disability, according to Dr. Hawker, who disclosed that she had no relevant conflicts of interest. “If we reduce osteoarthritis disability, particularly walking disability, can we actually impact the outcomes of cardiovascular disease and diabetes? I think that’s an important question,” she concluded.

SEATTLE – Patients with osteoarthritis often have other common chronic conditions, a scenario that has implications for both clinical care and research, according to Dr. Gillian Hawker.

“This is a critically important topic in our field,” she told attendees of the World Congress on Osteoarthritis. “We know from myriad studies that there are major challenges to the diagnosis and management of osteoarthritis ... But probably now what’s becoming a major issue is the high occurrence of coexisting medical problems, which have been shown to present competing demands to patients and physicians who are trying to balance a number of conditions in a single patient and contraindications to osteoarthritis therapies.”

Today, 90% of individuals aged 65 years and older with osteoarthritis have at least one other chronic condition, according to Dr. Hawker, the Sir John and Lady Eaton Professor and chair of medicine at the University of Toronto. Most commonly, those conditions are cardiovascular disease, diabetes, and hypertension, but about one-third of patients have depressed mood, which may affect adherence to and effectiveness of therapies.

Two main hypotheses have been proposed for the association of osteoarthritis and other common chronic conditions, according to Dr. Hawker. According to the first hypothesis, the shared risk factors of aging and obesity independently lead to both osteoarthritis, with resultant physical inactivity, and a cluster of metabolic perturbations including hypertension, hyperglycemia, and dyslipidemia. Collectively, these conditions increase risk for cardiovascular disease and diabetes.

In support of this hypothesis, “we have lots of data from qualitative research showing that people manage their osteoarthritis symptoms by giving up activities that exacerbate them, partly because they are afraid of taking painkillers and partly because nobody offers them anything that’s more effective,” Dr. Hawker noted. In addition, when patients juggle multiple health conditions, exercise is the most frequently dropped activity.

“Many have hypothesized that inability to walk, climb stairs, and be mobile would potentially impact the ability to self-manage physical activity, impacting numerous chronic conditions,” she said. Compelling evidence comes from research such as a cohort study of patients with symptomatic hip or knee osteoarthritis that found walking disability predicted a 30% increase in the risk of all-cause death and a 17% increase in the risk of cardiovascular events; among the subset with comorbid diabetes, walking disability and grip strength predicted the risk of hospitalization for diabetic complications (PLoS One 2014;9:e91286).

“These are large, well-controlled observational studies that do show consistent independent relationships between walking disability and cardiovascular events, diabetes complications, and all-cause death,” Dr. Hawker said, while acknowledging that the research is still hypothesis generating.

Of note, recent attention has focused on systemic inflammation and a metabolic osteoarthritis phenotype. When it comes to the pathogenesis of osteoarthritis, “we now are very comfortable understanding the local biomechanical effects separately from the systemic effects on our joints,” she said. Obesity is among the systemic factors implicated, with some data suggesting that adipokines affect joint tissues in a manner similar to mechanical stress.

According to the second main hypothesis proposed to explain the association between osteoarthritis and common chronic conditions, aging and obesity give rise to a cluster of metabolic factors (hypertension, hyperglycemia, and dyslipidemia) that independently increase the risk of symptomatic osteoarthritis. Again, the arthritis may result in the loss of physical activity and disability, which exacerbates the metabolic situation.

Evidence in support of this hypothesis comes from a variety of studies. For example, one has shown that the number of components of the metabolic syndrome is related to the adjusted risk of development and progression of knee osteoarthritis (Osteoarthritis Cartilage 2012;20:1217-26).

Overall, Dr. Hawker said, “we have some independent associations between metabolic syndrome and its components, and osteoarthritis – more so in the knee and hand, more so in women than in men, and more so in younger than in older individuals. And we have some data that suggest that symptomatic and disabling osteoarthritis has an association with increased risk of cardiovascular events and diabetes complications.” Here again, the studies have limitations, so the relative contributions of disability and systemic inflammation remain unknown, she cautioned.

Hypotheses aside, the association of osteoarthritis with common chronic conditions has implications for clinical care, Dr. Hawker said at the meeting, which was sponsored by the Osteoarthritis Research Society International. “Clearly, all of these data, irrespective of the relationships, point to a pivotal role for physical activity, a combination of physical activities,” she said, noting that benefits include reductions in both metabolic alterations and physical impairment, and possibly alleviation of depressed mood and improved sleep.

Osteoarthritis may be an independent risk factor for cardiovascular disease. “Many are suggesting that, in fact, if it is the fifth component of metabolic syndrome, this should really influence how we think about cardiovascular disease prevention, that osteoarthritis patients should be screened and we should be thinking more seriously about how we use various therapies,” such as nonsteroidal anti-inflammatory drugs, she said.

Dr. Hawker endorsed future research on these topics. “In the 2014 OARSI guidelines, we showed collectively as a community that we don’t have enough trials in this population, which is the majority of our patients with osteoarthritis. So yes, conservative therapy is good, but I’d say that we need way more evidence for effective interventions in the population with osteoarthritis who are living with other chronic conditions.”

Specifically needed are large prospective studies of the temporal relationships that look at mechanisms beyond age and body mass index, she explained. These studies should assess incidence and progression separately, structure and symptoms separately, and both weight-bearing and non–weight-bearing joints.

“To date, I haven’t seen any evidence to show that treatment of metabolic syndrome or its components influences the incidence or progression of osteoarthritis. And I think we should be thinking about asking those questions as they may in fact be modifiable risk factors for osteoarthritis,” she said.

Also needed are trials assessing the impact of aggressive treatment of osteoarthritis disability, according to Dr. Hawker, who disclosed that she had no relevant conflicts of interest. “If we reduce osteoarthritis disability, particularly walking disability, can we actually impact the outcomes of cardiovascular disease and diabetes? I think that’s an important question,” she concluded.

WASHINGTON – Gestational diabetes was identified as a significant, independent risk factor for developing non-alcoholic fatty liver disease later in life, according to a study of more than 1,000 women followed for 25 years.

This study “is the first to show a strong association between gestational diabetes in young adulthood and non-alcoholic fatty liver disease in middle-age,” Dr. Veeral Ajmera of the department of gastroenterology at the University of California, San Francisco, reported at the annual Digestive Disease Week.

The study evaluated 1,115 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, who had at least one delivery, did not have a diabetes diagnosis before pregnancy, and had a CT evaluation for hepatic steatosis at the 25-year visit, in 2010 and 2011. Women were excluded if they did not have a complete CT scan at that time, they had more than 14 drinks of alcohol per week, used medications associated with steatosis, or had chronic viral hepatitis or HIV infections.

At baseline the median age was 25-26 years, about 55%-56% were black, and the prevalence of hypertension (2%-3%) and dyslipidemia were similar. The CARDIA study enrolled about 5,100 men and women aged 18-30 years at four U.S. medical centers in the mid 1980s. Patients had 7 study visits over a 25-year follow-up period.

Of the 1,115 women evaluated, 124 (11%) went on to develop GDM and 75 (7%) met the CT definition for NAFLD (liver attenuation less than or equal to 40 Hounsfield units on CT scan) by the 25-year follow-up, when they were a median age of 50-51 years.

At 25 years, 14% of those with a history of GDM had NAFLD, compared with 5.8% of those who did not have GDM, for an unadjusted odds ratio of 2.56 (p <0.01), Dr. Ajmera said.

In the statistical analysis, the researchers determined that baseline homeostatic model assessment of insulin resistance (HOMA-IR) and baseline triglycerides were also ”strongly associated” with NAFLD at year 25.

“Importantly,” he noted, the measure of the association between GDM and NAFLD remained statistically significant, after adjusting for these covariates (OR, 2.29). At the start of the study, women who went on to develop GDM had significantly higher body mass index (BMI), HOMA-IR, waist circumference, and triglycerides than those who did not develop GDM, but the magnitude of those differences was small.

Additionally, after adjustment for a diagnosis of diabetes at year 25, the association between a history of GDM and NAFLD was stronger (OR, 1.99) than the association between a diagnosis of diabetes at year 25 and NAFLD (OR, 1.5), he said.

The researchers added BMI to their multivariate analysis to determine whether women with a gestational diabetes history gained more weight, and whether that weight explained the increased prevalence of NAFLD, “and found that the association between gestational diabetes and non-alcoholic fatty liver disease remained,” Dr. Ajmera added.

Evaluations of race, baseline BMI, and baseline HOMA-IR as effect modifiers of the relationship between GDM and NAFLD were not significant.

“Gestational diabetes represents insulin resistance unmasked by the stress of pregnancy, and offers the unique opportunity to identify those at risk of NAFLD at a young age,” Dr. Ajmera concluded.

Limitations of the study included not being able to determine if the women had NAFLD before they were diagnosed with GDM. However, based on the participants’ young age at enrollment, that is unlikely, he said. In addition, the researchers had no information on liver biochemistry tests, which, however, are not sensitive or specific for diagnosing NAFLD. The strengths of the study include the length of follow-up of a large biracial population, with measurement of well-characterized metabolic covariates measured, he added.

Dr. Ajmera reported having no relevant financial disclosures. The CARDIA study is supported by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.

[email protected]

WASHINGTON – Gestational diabetes was identified as a significant, independent risk factor for developing non-alcoholic fatty liver disease later in life, according to a study of more than 1,000 women followed for 25 years.

This study “is the first to show a strong association between gestational diabetes in young adulthood and non-alcoholic fatty liver disease in middle-age,” Dr. Veeral Ajmera of the department of gastroenterology at the University of California, San Francisco, reported at the annual Digestive Disease Week.

The study evaluated 1,115 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, who had at least one delivery, did not have a diabetes diagnosis before pregnancy, and had a CT evaluation for hepatic steatosis at the 25-year visit, in 2010 and 2011. Women were excluded if they did not have a complete CT scan at that time, they had more than 14 drinks of alcohol per week, used medications associated with steatosis, or had chronic viral hepatitis or HIV infections.

At baseline the median age was 25-26 years, about 55%-56% were black, and the prevalence of hypertension (2%-3%) and dyslipidemia were similar. The CARDIA study enrolled about 5,100 men and women aged 18-30 years at four U.S. medical centers in the mid 1980s. Patients had 7 study visits over a 25-year follow-up period.

Of the 1,115 women evaluated, 124 (11%) went on to develop GDM and 75 (7%) met the CT definition for NAFLD (liver attenuation less than or equal to 40 Hounsfield units on CT scan) by the 25-year follow-up, when they were a median age of 50-51 years.

At 25 years, 14% of those with a history of GDM had NAFLD, compared with 5.8% of those who did not have GDM, for an unadjusted odds ratio of 2.56 (p <0.01), Dr. Ajmera said.

In the statistical analysis, the researchers determined that baseline homeostatic model assessment of insulin resistance (HOMA-IR) and baseline triglycerides were also ”strongly associated” with NAFLD at year 25.

“Importantly,” he noted, the measure of the association between GDM and NAFLD remained statistically significant, after adjusting for these covariates (OR, 2.29). At the start of the study, women who went on to develop GDM had significantly higher body mass index (BMI), HOMA-IR, waist circumference, and triglycerides than those who did not develop GDM, but the magnitude of those differences was small.

Additionally, after adjustment for a diagnosis of diabetes at year 25, the association between a history of GDM and NAFLD was stronger (OR, 1.99) than the association between a diagnosis of diabetes at year 25 and NAFLD (OR, 1.5), he said.

The researchers added BMI to their multivariate analysis to determine whether women with a gestational diabetes history gained more weight, and whether that weight explained the increased prevalence of NAFLD, “and found that the association between gestational diabetes and non-alcoholic fatty liver disease remained,” Dr. Ajmera added.

Evaluations of race, baseline BMI, and baseline HOMA-IR as effect modifiers of the relationship between GDM and NAFLD were not significant.

“Gestational diabetes represents insulin resistance unmasked by the stress of pregnancy, and offers the unique opportunity to identify those at risk of NAFLD at a young age,” Dr. Ajmera concluded.

Limitations of the study included not being able to determine if the women had NAFLD before they were diagnosed with GDM. However, based on the participants’ young age at enrollment, that is unlikely, he said. In addition, the researchers had no information on liver biochemistry tests, which, however, are not sensitive or specific for diagnosing NAFLD. The strengths of the study include the length of follow-up of a large biracial population, with measurement of well-characterized metabolic covariates measured, he added.

Dr. Ajmera reported having no relevant financial disclosures. The CARDIA study is supported by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.

[email protected]

WASHINGTON – Gestational diabetes was identified as a significant, independent risk factor for developing non-alcoholic fatty liver disease later in life, according to a study of more than 1,000 women followed for 25 years.

This study “is the first to show a strong association between gestational diabetes in young adulthood and non-alcoholic fatty liver disease in middle-age,” Dr. Veeral Ajmera of the department of gastroenterology at the University of California, San Francisco, reported at the annual Digestive Disease Week.

The study evaluated 1,115 women from the Coronary Artery Risk Development in Young Adults (CARDIA) study, who had at least one delivery, did not have a diabetes diagnosis before pregnancy, and had a CT evaluation for hepatic steatosis at the 25-year visit, in 2010 and 2011. Women were excluded if they did not have a complete CT scan at that time, they had more than 14 drinks of alcohol per week, used medications associated with steatosis, or had chronic viral hepatitis or HIV infections.

At baseline the median age was 25-26 years, about 55%-56% were black, and the prevalence of hypertension (2%-3%) and dyslipidemia were similar. The CARDIA study enrolled about 5,100 men and women aged 18-30 years at four U.S. medical centers in the mid 1980s. Patients had 7 study visits over a 25-year follow-up period.

Of the 1,115 women evaluated, 124 (11%) went on to develop GDM and 75 (7%) met the CT definition for NAFLD (liver attenuation less than or equal to 40 Hounsfield units on CT scan) by the 25-year follow-up, when they were a median age of 50-51 years.

At 25 years, 14% of those with a history of GDM had NAFLD, compared with 5.8% of those who did not have GDM, for an unadjusted odds ratio of 2.56 (p <0.01), Dr. Ajmera said.

In the statistical analysis, the researchers determined that baseline homeostatic model assessment of insulin resistance (HOMA-IR) and baseline triglycerides were also ”strongly associated” with NAFLD at year 25.

“Importantly,” he noted, the measure of the association between GDM and NAFLD remained statistically significant, after adjusting for these covariates (OR, 2.29). At the start of the study, women who went on to develop GDM had significantly higher body mass index (BMI), HOMA-IR, waist circumference, and triglycerides than those who did not develop GDM, but the magnitude of those differences was small.

Additionally, after adjustment for a diagnosis of diabetes at year 25, the association between a history of GDM and NAFLD was stronger (OR, 1.99) than the association between a diagnosis of diabetes at year 25 and NAFLD (OR, 1.5), he said.

The researchers added BMI to their multivariate analysis to determine whether women with a gestational diabetes history gained more weight, and whether that weight explained the increased prevalence of NAFLD, “and found that the association between gestational diabetes and non-alcoholic fatty liver disease remained,” Dr. Ajmera added.

Evaluations of race, baseline BMI, and baseline HOMA-IR as effect modifiers of the relationship between GDM and NAFLD were not significant.

“Gestational diabetes represents insulin resistance unmasked by the stress of pregnancy, and offers the unique opportunity to identify those at risk of NAFLD at a young age,” Dr. Ajmera concluded.

Limitations of the study included not being able to determine if the women had NAFLD before they were diagnosed with GDM. However, based on the participants’ young age at enrollment, that is unlikely, he said. In addition, the researchers had no information on liver biochemistry tests, which, however, are not sensitive or specific for diagnosing NAFLD. The strengths of the study include the length of follow-up of a large biracial population, with measurement of well-characterized metabolic covariates measured, he added.

Dr. Ajmera reported having no relevant financial disclosures. The CARDIA study is supported by the National Heart, Lung, and Blood Institute, part of the National Institutes of Health.

[email protected]

While a third of the U.S. population in 2012 had metabolic syndrome, that number is no longer growing and may be declining in some populations, judging from NHANES data discussed in a research letter from Dr. Maria Aguilar, of the department of medicine in the Alameda Health System–Highland Hospital, Oakland, Calif., and her associates.

From 2003 to 2012, overall prevalence of the metabolic syndrome in the United States was 33%. From 2003-2004 to 2011-2012, overall prevalence of the metabolic syndrome increased from 32.9% to 34.7%. During this period, metabolic syndrome prevalence trends among men and all race/ethnic groups remained stable, while decreasing among women from 39.4% in 2007-2008 to 36.6% in 2011-2012.

Increasing metabolic syndrome prevalence was seen with increasing age in all groups.

“Greater awareness of the metabolic syndrome and its health consequences may have contributed to improvements in optimizing treatment of risk factors such as hypertension and diabetes. Furthermore, recent NHANES data demonstrate that obesity prevalence in the United States also appears to have stabilized, which also may contribute to the stabilizing prevalence of the metabolic syndrome,” the investigators noted.

Find the full research letter in JAMA (doi:10.1001/jama.2015.4260).

[email protected]

While a third of the U.S. population in 2012 had metabolic syndrome, that number is no longer growing and may be declining in some populations, judging from NHANES data discussed in a research letter from Dr. Maria Aguilar, of the department of medicine in the Alameda Health System–Highland Hospital, Oakland, Calif., and her associates.

From 2003 to 2012, overall prevalence of the metabolic syndrome in the United States was 33%. From 2003-2004 to 2011-2012, overall prevalence of the metabolic syndrome increased from 32.9% to 34.7%. During this period, metabolic syndrome prevalence trends among men and all race/ethnic groups remained stable, while decreasing among women from 39.4% in 2007-2008 to 36.6% in 2011-2012.

Increasing metabolic syndrome prevalence was seen with increasing age in all groups.

“Greater awareness of the metabolic syndrome and its health consequences may have contributed to improvements in optimizing treatment of risk factors such as hypertension and diabetes. Furthermore, recent NHANES data demonstrate that obesity prevalence in the United States also appears to have stabilized, which also may contribute to the stabilizing prevalence of the metabolic syndrome,” the investigators noted.

Find the full research letter in JAMA (doi:10.1001/jama.2015.4260).

[email protected]

While a third of the U.S. population in 2012 had metabolic syndrome, that number is no longer growing and may be declining in some populations, judging from NHANES data discussed in a research letter from Dr. Maria Aguilar, of the department of medicine in the Alameda Health System–Highland Hospital, Oakland, Calif., and her associates.

From 2003 to 2012, overall prevalence of the metabolic syndrome in the United States was 33%. From 2003-2004 to 2011-2012, overall prevalence of the metabolic syndrome increased from 32.9% to 34.7%. During this period, metabolic syndrome prevalence trends among men and all race/ethnic groups remained stable, while decreasing among women from 39.4% in 2007-2008 to 36.6% in 2011-2012.

Increasing metabolic syndrome prevalence was seen with increasing age in all groups.

“Greater awareness of the metabolic syndrome and its health consequences may have contributed to improvements in optimizing treatment of risk factors such as hypertension and diabetes. Furthermore, recent NHANES data demonstrate that obesity prevalence in the United States also appears to have stabilized, which also may contribute to the stabilizing prevalence of the metabolic syndrome,” the investigators noted.

Find the full research letter in JAMA (doi:10.1001/jama.2015.4260).

[email protected]

SEATTLE – New data presented at the World Congress on Osteoarthritis further suggest that hand osteoarthritis and cardiometabolic disease may have a shared etiology or pathophysiology.

In a study of 869 patients with hand osteoarthritis, those with ischemic cardiac disease were more than three times as likely to have joint symptoms and had greater clinical progression. In addition, obese patients had more extensive radiographic disease in their hands.

The results add to previous data showing higher rates of ischemic cardiac events in patients with symptomatic hand osteoarthritis (Ann. Rheum. Dis. 2013;74:74-81), according to Dr. Alice Courties, a rheumatologist at Saint-Antoine Hospital, Université Paris 6, Assistance Publique–Hôpitaux de Paris.

“One hypothesis is that symptomatic hand osteoarthritis and cardiometabolic disease share a common background based on chronic low-grade inflammation,” she proposed.

In an interview, Dr. Lisa Mandl, a rheumatologist at the Hospital for Special Surgery, New York, and one of the session’s comoderators, said, “I think this study is confirmatory that inflammation may play a role in non–weight-bearing joints.” She noted that analyses stratified by anatomic subtype of hand osteoarthritis would have been additionally informative.

Dr. Nigel Arden, the other session comoderator and director of both Musculoskeletal Epidemiology and the Oxford Musculoskeletal BioBank at the University of Oxford (England) said, “I think the whole association of cardiovascular risk, metabolic syndrome, and osteoarthritis is very important, and very important in treating patients or intervention. And this [study] is an integral part of that work.”

Giving some background to the research, Dr. Courties noted that risk factors for the development of hand osteoarthritis have been identified, but factors associated with clinical and radiographic severity of disease and with progression remain poorly defined.

The investigators performed an ancillary study of patients enrolled in the phase III, randomized Strontium Ranelate in Knee Osteoarthritis (SEKOIA) trial, in which assessments included hand x-rays and hand symptoms. The trial was conducted by Servier, but the ancillary analysis was fully independent.

Cross-sectional analyses were based on 869 patients with hand osteoarthritis, defined as presence of at least two joints with a Kellgren-Lawrence score of 2 or higher. In terms of clinical severity, 26% of patients had symptomatic hand joints, defined as a Functional Index for Hand Osteoarthritis (FIHOA) score of 5 or greater; in terms of radiographic severity, the average summary Kellgren-Lawrence hand score was 21 out of 128 points.

Results of multivariate analyses showed that patients with ischemic heart disease were more likely to have symptomatic hand joints (odds ratio, 3.59), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Odds were also higher for postmenopausal women, and for patients who had depression, a higher Kellgren-Lawrence hand score, or more joints showing erosion.

Patients who were obese (a body-mass index of 30 kg/m² or greater) had more severe radiographic disease assessed with the hand score (beta, 2.88 points). Severity was also greater for those who had symptomatic hand joints or a higher Kellgren-Lawrence knee score.

Longitudinal analyses were based on the 307 patients who were in the trial’s placebo group and had a mean follow-up of 2.6 years. Overall, 23% experienced clinical progression of their hand osteoarthritis, defined as a worsening of their FIHOA, and 72% experienced radiographic progression, defined as a worsening of their Kellgren-Lawrence hand score, reported Dr. Courties, who disclosed that she has received congress invitations from Pfizer, Biogaran, and Expanscience. Multivariate analysis here showed that patients with ischemic cardiac disease had greater clinical progression (beta, 2.31 points), while those with a higher hand score at baseline had greater radiographic progression.

SEATTLE – New data presented at the World Congress on Osteoarthritis further suggest that hand osteoarthritis and cardiometabolic disease may have a shared etiology or pathophysiology.

In a study of 869 patients with hand osteoarthritis, those with ischemic cardiac disease were more than three times as likely to have joint symptoms and had greater clinical progression. In addition, obese patients had more extensive radiographic disease in their hands.

The results add to previous data showing higher rates of ischemic cardiac events in patients with symptomatic hand osteoarthritis (Ann. Rheum. Dis. 2013;74:74-81), according to Dr. Alice Courties, a rheumatologist at Saint-Antoine Hospital, Université Paris 6, Assistance Publique–Hôpitaux de Paris.

“One hypothesis is that symptomatic hand osteoarthritis and cardiometabolic disease share a common background based on chronic low-grade inflammation,” she proposed.

In an interview, Dr. Lisa Mandl, a rheumatologist at the Hospital for Special Surgery, New York, and one of the session’s comoderators, said, “I think this study is confirmatory that inflammation may play a role in non–weight-bearing joints.” She noted that analyses stratified by anatomic subtype of hand osteoarthritis would have been additionally informative.

Dr. Nigel Arden, the other session comoderator and director of both Musculoskeletal Epidemiology and the Oxford Musculoskeletal BioBank at the University of Oxford (England) said, “I think the whole association of cardiovascular risk, metabolic syndrome, and osteoarthritis is very important, and very important in treating patients or intervention. And this [study] is an integral part of that work.”

Giving some background to the research, Dr. Courties noted that risk factors for the development of hand osteoarthritis have been identified, but factors associated with clinical and radiographic severity of disease and with progression remain poorly defined.

The investigators performed an ancillary study of patients enrolled in the phase III, randomized Strontium Ranelate in Knee Osteoarthritis (SEKOIA) trial, in which assessments included hand x-rays and hand symptoms. The trial was conducted by Servier, but the ancillary analysis was fully independent.

Cross-sectional analyses were based on 869 patients with hand osteoarthritis, defined as presence of at least two joints with a Kellgren-Lawrence score of 2 or higher. In terms of clinical severity, 26% of patients had symptomatic hand joints, defined as a Functional Index for Hand Osteoarthritis (FIHOA) score of 5 or greater; in terms of radiographic severity, the average summary Kellgren-Lawrence hand score was 21 out of 128 points.

Results of multivariate analyses showed that patients with ischemic heart disease were more likely to have symptomatic hand joints (odds ratio, 3.59), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Odds were also higher for postmenopausal women, and for patients who had depression, a higher Kellgren-Lawrence hand score, or more joints showing erosion.

Patients who were obese (a body-mass index of 30 kg/m² or greater) had more severe radiographic disease assessed with the hand score (beta, 2.88 points). Severity was also greater for those who had symptomatic hand joints or a higher Kellgren-Lawrence knee score.

Longitudinal analyses were based on the 307 patients who were in the trial’s placebo group and had a mean follow-up of 2.6 years. Overall, 23% experienced clinical progression of their hand osteoarthritis, defined as a worsening of their FIHOA, and 72% experienced radiographic progression, defined as a worsening of their Kellgren-Lawrence hand score, reported Dr. Courties, who disclosed that she has received congress invitations from Pfizer, Biogaran, and Expanscience. Multivariate analysis here showed that patients with ischemic cardiac disease had greater clinical progression (beta, 2.31 points), while those with a higher hand score at baseline had greater radiographic progression.

SEATTLE – New data presented at the World Congress on Osteoarthritis further suggest that hand osteoarthritis and cardiometabolic disease may have a shared etiology or pathophysiology.

In a study of 869 patients with hand osteoarthritis, those with ischemic cardiac disease were more than three times as likely to have joint symptoms and had greater clinical progression. In addition, obese patients had more extensive radiographic disease in their hands.

The results add to previous data showing higher rates of ischemic cardiac events in patients with symptomatic hand osteoarthritis (Ann. Rheum. Dis. 2013;74:74-81), according to Dr. Alice Courties, a rheumatologist at Saint-Antoine Hospital, Université Paris 6, Assistance Publique–Hôpitaux de Paris.

“One hypothesis is that symptomatic hand osteoarthritis and cardiometabolic disease share a common background based on chronic low-grade inflammation,” she proposed.

In an interview, Dr. Lisa Mandl, a rheumatologist at the Hospital for Special Surgery, New York, and one of the session’s comoderators, said, “I think this study is confirmatory that inflammation may play a role in non–weight-bearing joints.” She noted that analyses stratified by anatomic subtype of hand osteoarthritis would have been additionally informative.

Dr. Nigel Arden, the other session comoderator and director of both Musculoskeletal Epidemiology and the Oxford Musculoskeletal BioBank at the University of Oxford (England) said, “I think the whole association of cardiovascular risk, metabolic syndrome, and osteoarthritis is very important, and very important in treating patients or intervention. And this [study] is an integral part of that work.”

Giving some background to the research, Dr. Courties noted that risk factors for the development of hand osteoarthritis have been identified, but factors associated with clinical and radiographic severity of disease and with progression remain poorly defined.

The investigators performed an ancillary study of patients enrolled in the phase III, randomized Strontium Ranelate in Knee Osteoarthritis (SEKOIA) trial, in which assessments included hand x-rays and hand symptoms. The trial was conducted by Servier, but the ancillary analysis was fully independent.

Cross-sectional analyses were based on 869 patients with hand osteoarthritis, defined as presence of at least two joints with a Kellgren-Lawrence score of 2 or higher. In terms of clinical severity, 26% of patients had symptomatic hand joints, defined as a Functional Index for Hand Osteoarthritis (FIHOA) score of 5 or greater; in terms of radiographic severity, the average summary Kellgren-Lawrence hand score was 21 out of 128 points.

Results of multivariate analyses showed that patients with ischemic heart disease were more likely to have symptomatic hand joints (odds ratio, 3.59), according to data reported at the meeting, which was sponsored by the Osteoarthritis Research Society International. Odds were also higher for postmenopausal women, and for patients who had depression, a higher Kellgren-Lawrence hand score, or more joints showing erosion.

Patients who were obese (a body-mass index of 30 kg/m² or greater) had more severe radiographic disease assessed with the hand score (beta, 2.88 points). Severity was also greater for those who had symptomatic hand joints or a higher Kellgren-Lawrence knee score.

Longitudinal analyses were based on the 307 patients who were in the trial’s placebo group and had a mean follow-up of 2.6 years. Overall, 23% experienced clinical progression of their hand osteoarthritis, defined as a worsening of their FIHOA, and 72% experienced radiographic progression, defined as a worsening of their Kellgren-Lawrence hand score, reported Dr. Courties, who disclosed that she has received congress invitations from Pfizer, Biogaran, and Expanscience. Multivariate analysis here showed that patients with ischemic cardiac disease had greater clinical progression (beta, 2.31 points), while those with a higher hand score at baseline had greater radiographic progression.

SAN DIEGO – Treating gut failure after bariatric surgery involves meeting patients’ nutritional needs while avoiding a recurrence of morbid obesity, according to Dr. Kareem Abu-Elmagd of the Cleveland Clinic.

Surgeons must be flexible, and should be familiar with a variety of reconstructive techniques to restore patients to nutritional autonomy while minimizing the need for visceral transplantation, he said.

Gut failure is a rare but serious and potentially life-threatening complication of bariatric surgery. When it occurs, the patient can no longer meet nutritional needs autonomously, but rather requires total parenteral nutrition (TPN). Although comprehensive medical management including TPN is necessary when gut failure occurs, reconstructive surgery or visceral transplantation is the only means to allow patients to regain nutritional autonomy.

Dr. Abu-Elmagd reported the results of 2 decades of experience with post–bariatric surgery gut failure at the Cleveland Clinic and the University of Pittsburgh Medical Center at the annual meeting of the American Surgical Association. He and his coinvestigators at the two facilities assessed a total of 131 patients who were referred for gut failure from 1995 to 2015. The number of referrals, said Dr. Abu-Elmagd, has been increasing sharply, with nearly two-thirds of patients referred over the past 5 years.

The study sought to identify the types and causes of gut failures seen, to describe surgical techniques used for repair or transplant, and to track outcomes for patients after surgical repair for gut failure. Of the 131 patients in the study, 100 had a Roux-en-Y or similar combined malabsorptive and restrictive surgery as their primary bariatric procedure. Overall, 85% of patients were female.

Dr. Abu-Elmagd classified gut failure into three major groups: 55 patients (42%) had type I or catastrophic gut loss, which included strangulation and vascular occlusion; 43 patients (33%) had type II gut failure, caused by technical complications such as loss of gut continuity, strictures, and fistulae; and 33 patients (25%) had type III gut failure, caused by dysfunctional syndromes such as dysmotility, restriction, or absorption.

Of the 131 patients referred, 116 went on to have a total of 317 restorative procedures. Most (n = 84, 72%) needed reversal of their primary bariatric procedure. Patients received a total of 198 autologous reconstruction procedures, while 10 intestinal-lengthening procedures and 25 visceral transplantations were performed.

Dr. Abu-Elmagd and his colleagues characterized the reconstruction procedures according to the embryonic origins of the structures repaired. Seventy-eight patients had major reconstruction of the foregut, “the most tedious and technically challenging procedure … to restore normal gut anatomy and physiology,” said Dr. Abu-Elmagd. Three other patients had gastroplasty to restore the foregut, and seven needed to have an alimentary conduit interposed in order to restore normal alimentary flow. Mid- and hindgut reconstructions (n = 110) were essential to maximize absorption and restore nutritional autonomy, he said.

If patients had less than 100 cm of small bowel remaining, they received serial transverse enteroplasty, an intestinal-lengthening procedure. The few patients who needed intestinal, liver-intestine, or multivisceral transplantations had ultrashort gut syndrome and could not be maintained on TPN.

Five-year cumulative survival for those receiving reconstruction or transplantation was 84%, and plateaued at 72% at 10 and 15 years post restoration. For the subset who received transplantation, the 5-year survival was 69%. Among the first 100 surviving surgical patients, 83% retained full nutritional autonomy.

Bariatric surgery, noted discussant Dr. Debra Sudan of Duke University, “is clearly the most effective treatment for obesity and has tremendous impact on comorbidities,” but, since it is an elective procedure, “it’s devastating when complications develop.” She asked what considerations were specific to the bariatric population when dealing with gut failure.

Bariatric patients, said Dr. Abu-Elmegd, have the advantage that they do not have an underlying disease process, and overall they have the ability to adapt and return to more normal gut function very quickly. From a surgical perspective, the solutions must be flexible and tailored to the patient. He said, “Whatever the patient has, you fix it.”

The authors reported no relevant financial disclosures.

SAN DIEGO – Treating gut failure after bariatric surgery involves meeting patients’ nutritional needs while avoiding a recurrence of morbid obesity, according to Dr. Kareem Abu-Elmagd of the Cleveland Clinic.

Surgeons must be flexible, and should be familiar with a variety of reconstructive techniques to restore patients to nutritional autonomy while minimizing the need for visceral transplantation, he said.

Gut failure is a rare but serious and potentially life-threatening complication of bariatric surgery. When it occurs, the patient can no longer meet nutritional needs autonomously, but rather requires total parenteral nutrition (TPN). Although comprehensive medical management including TPN is necessary when gut failure occurs, reconstructive surgery or visceral transplantation is the only means to allow patients to regain nutritional autonomy.

Dr. Abu-Elmagd reported the results of 2 decades of experience with post–bariatric surgery gut failure at the Cleveland Clinic and the University of Pittsburgh Medical Center at the annual meeting of the American Surgical Association. He and his coinvestigators at the two facilities assessed a total of 131 patients who were referred for gut failure from 1995 to 2015. The number of referrals, said Dr. Abu-Elmagd, has been increasing sharply, with nearly two-thirds of patients referred over the past 5 years.

The study sought to identify the types and causes of gut failures seen, to describe surgical techniques used for repair or transplant, and to track outcomes for patients after surgical repair for gut failure. Of the 131 patients in the study, 100 had a Roux-en-Y or similar combined malabsorptive and restrictive surgery as their primary bariatric procedure. Overall, 85% of patients were female.

Dr. Abu-Elmagd classified gut failure into three major groups: 55 patients (42%) had type I or catastrophic gut loss, which included strangulation and vascular occlusion; 43 patients (33%) had type II gut failure, caused by technical complications such as loss of gut continuity, strictures, and fistulae; and 33 patients (25%) had type III gut failure, caused by dysfunctional syndromes such as dysmotility, restriction, or absorption.

Of the 131 patients referred, 116 went on to have a total of 317 restorative procedures. Most (n = 84, 72%) needed reversal of their primary bariatric procedure. Patients received a total of 198 autologous reconstruction procedures, while 10 intestinal-lengthening procedures and 25 visceral transplantations were performed.

Dr. Abu-Elmagd and his colleagues characterized the reconstruction procedures according to the embryonic origins of the structures repaired. Seventy-eight patients had major reconstruction of the foregut, “the most tedious and technically challenging procedure … to restore normal gut anatomy and physiology,” said Dr. Abu-Elmagd. Three other patients had gastroplasty to restore the foregut, and seven needed to have an alimentary conduit interposed in order to restore normal alimentary flow. Mid- and hindgut reconstructions (n = 110) were essential to maximize absorption and restore nutritional autonomy, he said.

If patients had less than 100 cm of small bowel remaining, they received serial transverse enteroplasty, an intestinal-lengthening procedure. The few patients who needed intestinal, liver-intestine, or multivisceral transplantations had ultrashort gut syndrome and could not be maintained on TPN.

Five-year cumulative survival for those receiving reconstruction or transplantation was 84%, and plateaued at 72% at 10 and 15 years post restoration. For the subset who received transplantation, the 5-year survival was 69%. Among the first 100 surviving surgical patients, 83% retained full nutritional autonomy.

Bariatric surgery, noted discussant Dr. Debra Sudan of Duke University, “is clearly the most effective treatment for obesity and has tremendous impact on comorbidities,” but, since it is an elective procedure, “it’s devastating when complications develop.” She asked what considerations were specific to the bariatric population when dealing with gut failure.

Bariatric patients, said Dr. Abu-Elmegd, have the advantage that they do not have an underlying disease process, and overall they have the ability to adapt and return to more normal gut function very quickly. From a surgical perspective, the solutions must be flexible and tailored to the patient. He said, “Whatever the patient has, you fix it.”

The authors reported no relevant financial disclosures.

SAN DIEGO – Treating gut failure after bariatric surgery involves meeting patients’ nutritional needs while avoiding a recurrence of morbid obesity, according to Dr. Kareem Abu-Elmagd of the Cleveland Clinic.

Surgeons must be flexible, and should be familiar with a variety of reconstructive techniques to restore patients to nutritional autonomy while minimizing the need for visceral transplantation, he said.

Gut failure is a rare but serious and potentially life-threatening complication of bariatric surgery. When it occurs, the patient can no longer meet nutritional needs autonomously, but rather requires total parenteral nutrition (TPN). Although comprehensive medical management including TPN is necessary when gut failure occurs, reconstructive surgery or visceral transplantation is the only means to allow patients to regain nutritional autonomy.

Dr. Abu-Elmagd reported the results of 2 decades of experience with post–bariatric surgery gut failure at the Cleveland Clinic and the University of Pittsburgh Medical Center at the annual meeting of the American Surgical Association. He and his coinvestigators at the two facilities assessed a total of 131 patients who were referred for gut failure from 1995 to 2015. The number of referrals, said Dr. Abu-Elmagd, has been increasing sharply, with nearly two-thirds of patients referred over the past 5 years.

The study sought to identify the types and causes of gut failures seen, to describe surgical techniques used for repair or transplant, and to track outcomes for patients after surgical repair for gut failure. Of the 131 patients in the study, 100 had a Roux-en-Y or similar combined malabsorptive and restrictive surgery as their primary bariatric procedure. Overall, 85% of patients were female.

Dr. Abu-Elmagd classified gut failure into three major groups: 55 patients (42%) had type I or catastrophic gut loss, which included strangulation and vascular occlusion; 43 patients (33%) had type II gut failure, caused by technical complications such as loss of gut continuity, strictures, and fistulae; and 33 patients (25%) had type III gut failure, caused by dysfunctional syndromes such as dysmotility, restriction, or absorption.

Of the 131 patients referred, 116 went on to have a total of 317 restorative procedures. Most (n = 84, 72%) needed reversal of their primary bariatric procedure. Patients received a total of 198 autologous reconstruction procedures, while 10 intestinal-lengthening procedures and 25 visceral transplantations were performed.

Dr. Abu-Elmagd and his colleagues characterized the reconstruction procedures according to the embryonic origins of the structures repaired. Seventy-eight patients had major reconstruction of the foregut, “the most tedious and technically challenging procedure … to restore normal gut anatomy and physiology,” said Dr. Abu-Elmagd. Three other patients had gastroplasty to restore the foregut, and seven needed to have an alimentary conduit interposed in order to restore normal alimentary flow. Mid- and hindgut reconstructions (n = 110) were essential to maximize absorption and restore nutritional autonomy, he said.

If patients had less than 100 cm of small bowel remaining, they received serial transverse enteroplasty, an intestinal-lengthening procedure. The few patients who needed intestinal, liver-intestine, or multivisceral transplantations had ultrashort gut syndrome and could not be maintained on TPN.

Five-year cumulative survival for those receiving reconstruction or transplantation was 84%, and plateaued at 72% at 10 and 15 years post restoration. For the subset who received transplantation, the 5-year survival was 69%. Among the first 100 surviving surgical patients, 83% retained full nutritional autonomy.

Bariatric surgery, noted discussant Dr. Debra Sudan of Duke University, “is clearly the most effective treatment for obesity and has tremendous impact on comorbidities,” but, since it is an elective procedure, “it’s devastating when complications develop.” She asked what considerations were specific to the bariatric population when dealing with gut failure.

Bariatric patients, said Dr. Abu-Elmegd, have the advantage that they do not have an underlying disease process, and overall they have the ability to adapt and return to more normal gut function very quickly. From a surgical perspective, the solutions must be flexible and tailored to the patient. He said, “Whatever the patient has, you fix it.”

The authors reported no relevant financial disclosures.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors may lead to ketoacidosis, and patients taking these medications should seek immediate medical attention if they experience symptoms, the Food and Drug Administration warned in an announcement May 15.

Medications in the SGLT2 inhibitor class include canagliflozin, dapagliflozin, and empagliflozin, and are used to treat type 2 diabetes. Ketoacidosis occurs when the body produces high levels of ketones, and may include symptoms such as difficulty breathing, nausea, vomiting, abdominal pain, confusion, and fatigue, the FDA said in the statement.

“Health care professionals should evaluate for the presence of acidosis, including ketoacidosis, in patients experiencing these signs or symptoms; discontinue SGLT2 inhibitors if acidosis is confirmed; and take appropriate measures to correct the acidosis and monitor sugar levels,” the statement said.

The FDA’s Adverse Event Reporting System database contains 20 recorded cases of diabetic ketoacidosis, ketoacidosis, or ketosis in patients receiving treatment with SGLT2 inhibitors, reported between March 2013 and June 2014, all of which required hospitalization or emergency department visits. The agency has since continued to receive reports of additional cases, they said.

The FDA is evaluating whether changes are needed in the prescribing information for SGLT2 inhibitor drugs. Health care providers should report adverse side effects to the FDA MedWatch program.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors may lead to ketoacidosis, and patients taking these medications should seek immediate medical attention if they experience symptoms, the Food and Drug Administration warned in an announcement May 15.

Medications in the SGLT2 inhibitor class include canagliflozin, dapagliflozin, and empagliflozin, and are used to treat type 2 diabetes. Ketoacidosis occurs when the body produces high levels of ketones, and may include symptoms such as difficulty breathing, nausea, vomiting, abdominal pain, confusion, and fatigue, the FDA said in the statement.

“Health care professionals should evaluate for the presence of acidosis, including ketoacidosis, in patients experiencing these signs or symptoms; discontinue SGLT2 inhibitors if acidosis is confirmed; and take appropriate measures to correct the acidosis and monitor sugar levels,” the statement said.

The FDA’s Adverse Event Reporting System database contains 20 recorded cases of diabetic ketoacidosis, ketoacidosis, or ketosis in patients receiving treatment with SGLT2 inhibitors, reported between March 2013 and June 2014, all of which required hospitalization or emergency department visits. The agency has since continued to receive reports of additional cases, they said.

The FDA is evaluating whether changes are needed in the prescribing information for SGLT2 inhibitor drugs. Health care providers should report adverse side effects to the FDA MedWatch program.

Sodium-glucose cotransporter-2 (SGLT2) inhibitors may lead to ketoacidosis, and patients taking these medications should seek immediate medical attention if they experience symptoms, the Food and Drug Administration warned in an announcement May 15.

Medications in the SGLT2 inhibitor class include canagliflozin, dapagliflozin, and empagliflozin, and are used to treat type 2 diabetes. Ketoacidosis occurs when the body produces high levels of ketones, and may include symptoms such as difficulty breathing, nausea, vomiting, abdominal pain, confusion, and fatigue, the FDA said in the statement.

“Health care professionals should evaluate for the presence of acidosis, including ketoacidosis, in patients experiencing these signs or symptoms; discontinue SGLT2 inhibitors if acidosis is confirmed; and take appropriate measures to correct the acidosis and monitor sugar levels,” the statement said.

The FDA’s Adverse Event Reporting System database contains 20 recorded cases of diabetic ketoacidosis, ketoacidosis, or ketosis in patients receiving treatment with SGLT2 inhibitors, reported between March 2013 and June 2014, all of which required hospitalization or emergency department visits. The agency has since continued to receive reports of additional cases, they said.

The FDA is evaluating whether changes are needed in the prescribing information for SGLT2 inhibitor drugs. Health care providers should report adverse side effects to the FDA MedWatch program.

SAN DIEGO – Teens with chronic illnesses who participated in a program that consisted of mind-body principles and peer support demonstrated statistically significant positive changes in physical and mental well-being, anger, tension, and stress, in a pilot study.

“Young people living with serious chronic illnesses must deal not only with the physical effects and uncomfortable symptoms of their conditions, but must also endure significant psychosocial effects,” Dr. Brittany Blockman said in an interview in advance of the annual meeting of the Pediatric Academic Societies. “As we learn more about the impact of stress not only on mental health but also physical health, it will be important to design interventions and programs that address this vital, yet sometimes intangible area of health.”

Mind-body medicine focuses on the ways in which emotional, mental, social, and spiritual factors can directly impact health, said Dr. Blockman, a resident physician for the University of California, San Francisco’s Pediatric Leadership for the Underserved program. “Mind-body skills can enhance an individual’s sense of control and have been demonstrated to lower sympathetic arousal, decrease anxiety, and improve mood. Some examples of these modalities include meditation, mindfulness practices, breath work, yoga, biofeedback, and guided imagery. There is a growing body of literature reporting the positive physical and psychological health benefits of mind-body group interventions in various adult populations living with chronic illnesses, including improvements in quality of life, mood, pain, stress, coping skills, disease progression, and mortality. However, there is limited research exploring similar mind-body and group support interventions in pediatric and adolescent populations.”

Dr. Blockman and her associates enrolled 10 teens aged 13-18 years with chronic illnesses, and their parents, to study the impact of Communitas, a novel program that provides mind-body skills and peer support. Teens and parents met in separate groups 10 times for 2 hours at a time. Each session consisted of meditation, a lesson on guided imagery or some other mind-body technique, an exercise, and group sharing. The National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale, the Profile of Mood States (POMS), the Brief COPE scale, the Mindfulness Attention Awareness Scale (MAAS), the Perceived Stress Scale, and the Resilience Scale were administered before and after the 10 sessions.

The majority of teens (80%) were female; they attended an average of 7.3 sessions. Illnesses represented included juvenile idiopathic arthritis, cerebral palsy, type 1 diabetes, cancer, muscular dystrophy, cystic fibrosis, lung disease, spinal cord injury, and Wegener’s granulomatosis. Of the nine parents who participated, 75% were female; they completed an average of 7.5 sessions.

When Dr. Blockman and her associates compared baseline teen responses with those immediately after the 10-session intervention, they observed statistically significant effects on a number of scales, including the physical well-being subscale of the NIH PROMIS Global Health Scale (a mean increase of 1.56; P = .047); the mental well-being subscale of the NIH PROMIS Global Health Scale (a mean increase of 2.33; P = .025); the anger subscale of the POMS (a mean decrease of .54; P = .039); the tension subscale of the POMS (a mean decrease of .78; P = .006); the distraction/disengagement subscale of the Brief Cope (a mean decrease of .84; P = .035); and the Perceived Stress Scale (a mean decrease of 3.89; P = .005). The results for adults are still being analyzed.

“I was surprised at how willing the adolescents were to participate in the intervention and how engaged they were in the practices that were taught,” Dr. Blockman said. “It is our hope that the results of this study are helpful in thinking about the types of innovative interventions that may be useful in treating, healing, and supporting adolescents living with chronic illness, as well as their family members.”

She acknowledged certain limitations of the study, including the small sample size and the fact that there was no comparison group. “In the future, we plan to test our intervention further in a controlled trial design study, with a larger sample size. Another limitation is we cannot easily evaluate whether our positive results were attributable to the intervention content or the supportive nature of the intervention group. Our qualitative data may help us in teasing this apart.”

Dr. Blockman reported having no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – Teens with chronic illnesses who participated in a program that consisted of mind-body principles and peer support demonstrated statistically significant positive changes in physical and mental well-being, anger, tension, and stress, in a pilot study.

“Young people living with serious chronic illnesses must deal not only with the physical effects and uncomfortable symptoms of their conditions, but must also endure significant psychosocial effects,” Dr. Brittany Blockman said in an interview in advance of the annual meeting of the Pediatric Academic Societies. “As we learn more about the impact of stress not only on mental health but also physical health, it will be important to design interventions and programs that address this vital, yet sometimes intangible area of health.”

Mind-body medicine focuses on the ways in which emotional, mental, social, and spiritual factors can directly impact health, said Dr. Blockman, a resident physician for the University of California, San Francisco’s Pediatric Leadership for the Underserved program. “Mind-body skills can enhance an individual’s sense of control and have been demonstrated to lower sympathetic arousal, decrease anxiety, and improve mood. Some examples of these modalities include meditation, mindfulness practices, breath work, yoga, biofeedback, and guided imagery. There is a growing body of literature reporting the positive physical and psychological health benefits of mind-body group interventions in various adult populations living with chronic illnesses, including improvements in quality of life, mood, pain, stress, coping skills, disease progression, and mortality. However, there is limited research exploring similar mind-body and group support interventions in pediatric and adolescent populations.”

Dr. Blockman and her associates enrolled 10 teens aged 13-18 years with chronic illnesses, and their parents, to study the impact of Communitas, a novel program that provides mind-body skills and peer support. Teens and parents met in separate groups 10 times for 2 hours at a time. Each session consisted of meditation, a lesson on guided imagery or some other mind-body technique, an exercise, and group sharing. The National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale, the Profile of Mood States (POMS), the Brief COPE scale, the Mindfulness Attention Awareness Scale (MAAS), the Perceived Stress Scale, and the Resilience Scale were administered before and after the 10 sessions.

The majority of teens (80%) were female; they attended an average of 7.3 sessions. Illnesses represented included juvenile idiopathic arthritis, cerebral palsy, type 1 diabetes, cancer, muscular dystrophy, cystic fibrosis, lung disease, spinal cord injury, and Wegener’s granulomatosis. Of the nine parents who participated, 75% were female; they completed an average of 7.5 sessions.

When Dr. Blockman and her associates compared baseline teen responses with those immediately after the 10-session intervention, they observed statistically significant effects on a number of scales, including the physical well-being subscale of the NIH PROMIS Global Health Scale (a mean increase of 1.56; P = .047); the mental well-being subscale of the NIH PROMIS Global Health Scale (a mean increase of 2.33; P = .025); the anger subscale of the POMS (a mean decrease of .54; P = .039); the tension subscale of the POMS (a mean decrease of .78; P = .006); the distraction/disengagement subscale of the Brief Cope (a mean decrease of .84; P = .035); and the Perceived Stress Scale (a mean decrease of 3.89; P = .005). The results for adults are still being analyzed.

“I was surprised at how willing the adolescents were to participate in the intervention and how engaged they were in the practices that were taught,” Dr. Blockman said. “It is our hope that the results of this study are helpful in thinking about the types of innovative interventions that may be useful in treating, healing, and supporting adolescents living with chronic illness, as well as their family members.”

She acknowledged certain limitations of the study, including the small sample size and the fact that there was no comparison group. “In the future, we plan to test our intervention further in a controlled trial design study, with a larger sample size. Another limitation is we cannot easily evaluate whether our positive results were attributable to the intervention content or the supportive nature of the intervention group. Our qualitative data may help us in teasing this apart.”

Dr. Blockman reported having no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk

SAN DIEGO – Teens with chronic illnesses who participated in a program that consisted of mind-body principles and peer support demonstrated statistically significant positive changes in physical and mental well-being, anger, tension, and stress, in a pilot study.

“Young people living with serious chronic illnesses must deal not only with the physical effects and uncomfortable symptoms of their conditions, but must also endure significant psychosocial effects,” Dr. Brittany Blockman said in an interview in advance of the annual meeting of the Pediatric Academic Societies. “As we learn more about the impact of stress not only on mental health but also physical health, it will be important to design interventions and programs that address this vital, yet sometimes intangible area of health.”

Mind-body medicine focuses on the ways in which emotional, mental, social, and spiritual factors can directly impact health, said Dr. Blockman, a resident physician for the University of California, San Francisco’s Pediatric Leadership for the Underserved program. “Mind-body skills can enhance an individual’s sense of control and have been demonstrated to lower sympathetic arousal, decrease anxiety, and improve mood. Some examples of these modalities include meditation, mindfulness practices, breath work, yoga, biofeedback, and guided imagery. There is a growing body of literature reporting the positive physical and psychological health benefits of mind-body group interventions in various adult populations living with chronic illnesses, including improvements in quality of life, mood, pain, stress, coping skills, disease progression, and mortality. However, there is limited research exploring similar mind-body and group support interventions in pediatric and adolescent populations.”

Dr. Blockman and her associates enrolled 10 teens aged 13-18 years with chronic illnesses, and their parents, to study the impact of Communitas, a novel program that provides mind-body skills and peer support. Teens and parents met in separate groups 10 times for 2 hours at a time. Each session consisted of meditation, a lesson on guided imagery or some other mind-body technique, an exercise, and group sharing. The National Institutes of Health (NIH) Patient Reported Outcomes Measurement Information System (PROMIS) Global Health Scale, the Profile of Mood States (POMS), the Brief COPE scale, the Mindfulness Attention Awareness Scale (MAAS), the Perceived Stress Scale, and the Resilience Scale were administered before and after the 10 sessions.

The majority of teens (80%) were female; they attended an average of 7.3 sessions. Illnesses represented included juvenile idiopathic arthritis, cerebral palsy, type 1 diabetes, cancer, muscular dystrophy, cystic fibrosis, lung disease, spinal cord injury, and Wegener’s granulomatosis. Of the nine parents who participated, 75% were female; they completed an average of 7.5 sessions.

When Dr. Blockman and her associates compared baseline teen responses with those immediately after the 10-session intervention, they observed statistically significant effects on a number of scales, including the physical well-being subscale of the NIH PROMIS Global Health Scale (a mean increase of 1.56; P = .047); the mental well-being subscale of the NIH PROMIS Global Health Scale (a mean increase of 2.33; P = .025); the anger subscale of the POMS (a mean decrease of .54; P = .039); the tension subscale of the POMS (a mean decrease of .78; P = .006); the distraction/disengagement subscale of the Brief Cope (a mean decrease of .84; P = .035); and the Perceived Stress Scale (a mean decrease of 3.89; P = .005). The results for adults are still being analyzed.

“I was surprised at how willing the adolescents were to participate in the intervention and how engaged they were in the practices that were taught,” Dr. Blockman said. “It is our hope that the results of this study are helpful in thinking about the types of innovative interventions that may be useful in treating, healing, and supporting adolescents living with chronic illness, as well as their family members.”

She acknowledged certain limitations of the study, including the small sample size and the fact that there was no comparison group. “In the future, we plan to test our intervention further in a controlled trial design study, with a larger sample size. Another limitation is we cannot easily evaluate whether our positive results were attributable to the intervention content or the supportive nature of the intervention group. Our qualitative data may help us in teasing this apart.”

Dr. Blockman reported having no relevant financial conflicts.

[email protected]

On Twitter @dougbrunk