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Challenges and Opportunities in Obesity

Challenges and Opportunities in Obesity

Laya Rajan, Alaina L Pearce, Xiaozhen You, Eleanor Mackey, Evan P Nadler, and Chandan J Vaidya


Obesity is associated with altered food-related reward processing, but its impact on non-food reward remains unclear. This question is both timely due to rising rates of severe obesity and important because adolescence is a period of heightened reward seeking behavior. We used computational modeling and functional magnetic resonance imaging to examine monetary reward processing using classic experimental tasks in 35 adolescents (14-18 years-old, 13 male) with severe obesity (n=18) and without obesity (n=17). Participants completed the Balloon Analog Risk Taking Task to assess reward-related decision-making and the Monetary Incentive Delay task to assess neural correlates of reward anticipation. Reward-related decision-making model parameters revealed no differences in reward sensitivity but less adaptive decision-making (response consistency) in those with obesity compared to without obesity. Other metrics (e.g., number of balloons popped, number of pumps, and total points) did not differ between groups. During reward anticipation, those with obesity had lower activation than without obesity in ventral tegmental area and prefrontal cortex, canonical regions for reward and cognitive control, respectively. Weight status moderated associations between ventral tegmental area activation and reward-related decision-making metrics such that higher ventral tegmental area activation was associated with more risky decision-making (more popped balloons) in those with but not without obesity. Functional connectivity of ventral tegmental area with right inferior frontal gyrus and left superior temporal gyrus was greater higher in OB than nonOB. Associations between value-related ventral tegmental area-superior temporal gyrus connectivity and reward-related decision-making metrics were moderated by weight status such that higher connectivity was associated with greater number of pumps and points for without obesity and less risky decision-making for those with obesity. Therefore, differences in activation and connectivity between groups may suggest differences in decision-making strategies. Together, findings reveal that ventral tegmental area, prefrontal, and temporal engagement during monetary reward anticipation differs between adolescents with and without obesity and may contribute to individual differences in reward-related decision-making. Such domain-general alteration of reward processing may have far reaching consequences, not only for food intake but also functions central to motivational behavior such as learning and socialization during adolescence, a sensitive period in development. These findings highlight the importance of considering reward more broadly when designing and tailoring behavioral interventions in adolescent obesity.

Tassalapa Daengsuwan, MD and Thitaya Sangsawang, MD


Background: Monitoring of lung function is necessary to detect irreversible airway obstruction in both asthma and obesity. Impulse oscillometry (IOS), a novo non-invasive equipment, is increasing popularity to measure airway resistance in young children worldwide.

Aims:  To compare IOS parameters among Thai asthmatic children and Thai obese children with and without asthma.

Methods: A cross-sectional study was conducted in 120 participants, aged 4-15 years old. Forty children were in each group (asthma, obesity, and obesity with asthma). All volunteers were consented to measure airway resistance by IOS technique (Jaeger, Germany).

Results: Seventy-three percent of patients were male with the mean age at 8.8 + 2.61 years old. Mean X5 was found normal in childhood obesity (-0.13) when compared to children with asthma (-0.23) and obesity with asthma (-0.19) (p < 0.001 and 0.013 respectively). The cut-off value of X5, according to ROC curve, for predicting asthma in obese patients was -0.16 kPa/L/s with 70% sensitivity, 70% specificity and 70% accuracy (AUC= 0.69). However, with the bronchodilator effect (adjusted by duration of asthma control), we found significant higher percentage change of IOS parameters, including resonant frequency, area of reactance and R5-R20, in asthma (Fres -24.57 + 15.82, AX -58.28 + 13.37, R5-R20 -51.32 + 20.13) than in asthma with obesity (Fres -13.77 + 16.42, AX -43.35 + 21.4, R5-R20 -34.72 + 18.21), (p = 0.014, 0.004, 0.002 respectively).

Conclusions: X5 and percentage changes after bronchodilator of Fres, AX, and R5-R20 are useful parameters to differentiate airway dysfunction in asthmatic children from obese children.

James A. Koziol and Jan E. Schnitzer


Objectives. Obesity and old age are commonly assumed to be risk factors for COVID-19 mortality. On a worldwide basis, we examine quantitative measures of obesity and elderly in the populations of individual countries and territories, and investigate whether these measures are predictive of COVID-19 mortality in those countries. In particular, we highlight regional differences relative to obesity and elderly metrics, and how these relate to COVID-19 mortality.

Methods. In this retrospective, population-based study, we obtained data relating to percentages of obese or elderly individuals in 199 countries, as well as COVID-19 mortality rates in these countries. We used negative binomial regression analyses to assess associations between COVID-19 mortality rates and the putative risk factors, in six regions – Africa, Asia, Europe, North America, Oceania, and South America.

Results. We found significant differences between regions relative to COVID-19 mortality, as well as obesity and elderly population proportions. There were also substantial differences between countries within regions relative to proportions of obesity and elderly individuals, and COVID-19 mortality.

Conclusions. There are significant differences both between regions and within regions relative to COVID-19 mortality rates, as well as proportions of obese or elderly individuals. A global pronouncement that obesity and elderly constitute definitive risk factors for COVID-19 mortality masks the subtleties engendered by these intra- and inter-regional differences.

Franchell Richard Hamilton


Obesity continues to be on the rise despite all of its advances in medications and surgeries, not to mention the invasiveness of the diet and fitness industry in this area. More than 72% of the U.S population is overweight or obese, and obesity is now rising in the pediatric population affecting our next generation. (1) Obesity on its own occupies a large part of health expenditures in the globe and has been the catalyst for over 200 other diseases identified. This chronic relapsing disease over time has been one of the most invasive to our nation and the most difficult to treat.

We have seen relapse rates from diet and medication over 90% and post bariatric surgery recurrence rates long  term have been more than 70%. (3) The World Health Organization states that 2.8 million people die of obesity each year, a preventable disease. (4) Even when the name was changed several years ago by  the American College of Endocrinology the epidemic continued to rise. At what point will the overseeing bodies decide that this is no longer good enough? As a bariatric surgeon, also board certified in obesity medicine, I am familiar with all the treatment algorithms for obesity and have practiced those for years. After seeing surgeries require 2 and 3 revisions due to weight recurrence I had to ask what was missing in the algorithm? After years of watching my patients struggle they answered that question for me. The addition of neurobehavioral science is what was missing.

Raj Lele, Sheryl Haller, Kate David, Gaby Gutierrez, Shurouk Kattan Rahmani, and M Rami Bailony


This paper examines disparities in obesity treatment and their implications for health equity. A comprehensive literature review was performed using Pubmed, Medline, and Google Scholar to identify studies examining obesity treatment options that reported data on African Americans, Asians, Hispanics, and Caucasians. These studies, published from 2000 to 2022, revealed disparities in behavioral/lifestyle, surgical, and pharmacological interventions for obesity. While a majority of behavioral/lifestyle and surgical treatment studies found disparities in weight loss and clinical outcomes, pharmacological studies found minimal to no evidence of disparities or favorable outcomes for racial and ethnic minorities for weight and cardiometabolic outcomes. All treatment pathways showed disparities in referral rates, access, and engagement/retention. These findings underscore the urgent need to incorporate obesity treatment as a central component in strategies addressing health inequities. By understanding and addressing these disparities, healthcare equity can be improved, ensuring a more inclusive approach to obesity management.

Ananda Vigneswari Anebarassou, MD, MPH  and Sujatha Kambhatla, MD


Several studies have shown that people with obesity are more likely to experience worse outcomes with COVID 19 infection, regardless of the severity of illness and the presence of other comorbidities. The same population also experiences numerous disparities while accessing health care. From obesity related stigma embedded in thought processes of healthcare personnels to lack of widespread availability of equipment/personnel to handle patients with obesity delay appropriate care reception. As described in this article, these systemic disparities become more evident amongst critically ill COVID 19 patients by directly contributing to severe morbidity and mortality. The pandemic highlighted the unmet need amongst this population in reception of acute and subacute medical care. Also, it shed light on the opportunities to improve the status quo in healthcare delivery. Therefore, it is of utmost importance that the health care system works toward eliminating systemic biases associated with acute care for patients with obesity. As the proportion of obese population is continually growing in the United States without the necessary reformation in the health care system, this article is intended to inform policy makers of the urgent need for reformation of the acute and subacute health care systems in order to accommodate the changing needs of the population.

Sebahattin Celik, İskan Çallı, Serpil Sevimli Deniz, M. Kadir Bartin, Öztekin Çıkman, Muharrem Duran, and Serhat Binici


World Health Organization defines obesity as “excessive fat accumulation at a level that may impair health”. Obesity is also officially defined as a “disease” by many surgical and endocrine societies (1,2), and also accepted as a risk factor for some cancers, cardiovascular diseases, chronic kidney disease, diabetes, metabolic syndrome, non-alcoholic fatty liver disease, as well as many chronic diseases (2). Although the degree of accuracy is debated, obesity is still defined as a body mass index (BMI) above 30 (1).

Obesity, which was alarming in western countries in the past, is currently a public health problem that concerns the whole world, except for a few southern African and Asian countries (1). Preventive measures are important in tackling the public health problem. In this context, an active life and low-calorie nutrition are accepted as basic preventive practices.

Amanda M. Delgado, Patrice Z. Collins, and Rodger D. MacArthur


The COVID-19 pandemic has impacted children from Kindergarten through 12th grade in numerous ways. Strategies aimed at mitigating the spread of the virus early on, predominately social distancing and isolation, negatively impacted children’s physical health by limiting access to physical education and facilitating sedentary lifestyles. These negative effects have longstanding implications on the physical health of pediatric patients, and it is especially pertinent to understand these effects during an already alarming pediatric obesity epidemic. As with obesity in adults, obesity in children is associated with numerous endocrine co-morbidities. Through a literature review, this paper aims to go beyond understanding how the COVID-19 pandemic negatively impacted the physical health of children and describe how the pandemic may have long-term effects on childhood obesity and endocrinopathies in pediatric patients. Additionally, it describes the direct impact COVID-19 may have on the increased incidence of endocrinopathies in pediatric patients.

George A Karpouzas, MD, Elizabeth Hernandez, MA, Matthew J Budoff, MD, and Sarah R Ormseth, PhD


Objectives. Underweight patients with rheumatoid arthritis incur greater total and cardiovascular mortality compared to overweight or obese. We explored whether obesity confounded cardiovascular risk estimates and the potential utility of noninvasive coronary atherosclerosis assessment and cardiac damage biomarkers in optimizing risk prediction in obese patients with rheumatoid arthritis. 

Methods. We evaluated 150 participants undergoing screening atherosclerosis evaluation with coronary computed tomography angiography and follow-up over 6.0±2.4 years. Framingham 2008 modified general cardiovascular risk score was computed at baseline. Obesity was defined as waist circumference >88 cm in females and >102 cm in males. Serum highly-sensitive cardiac troponin I (hs-cTnI) and leptin were measured at baseline.

Results. An interaction between the Framingham risk score and obesity on cardiovascular risk was observed (p=0.032); lower estimates were seen in obese (area under the curve-AUC 0.660, 95% CI 0.487-0.832) vs. non-obese patients (AUC 0.952, 95% CI 0.897-1.007, p=0.002). Likewise, risk estimates were inferior in patients with high (>22.1 ng/ml) vs. low leptin (AUC 0.618, 95% CI 0.393-0.842 vs. 0.874, 95% CI 0.772-0.976, p=0.042). In obese patients, sequential addition of the top highly-sensitive cardiac troponin I tertile values and extensive atherosclerotic plaque (>5 segments) information to a base model including the Framingham risk score alone significantly improved risk estimates, based on changes in net reclassification index (1.093 95% CI 0.517-1.574), integrated discrimination improvement (0.188, 95% CI 0.060-0.526), and AUC (0.179, 95% CI 0.058-0.378, p=0.02). The final, combined model accurately predicted 83.9% of incident cardiovascular events.

Conclusion. Obesity attenuated cardiovascular risk estimate accuracy in patients with rheumatoid arthritis. Risk optimization employing non-invasive assessment of coronary atherosclerosis burden and serum cardiac damage biomarkers may warrant further study.

Leonardo G Ribeiro, Vitor B Paravidino, Tatiana R Gonçalves, Alice P Duque, Luiz Fernando Rodrigues Junior, Jose Silvio O Brabosa, and Mauro F F Mediano


Purpose: Exercise has been documented as a critical strategy for improving physical and mental health. However, the impact of exercise training (ET) on quality of life (QoL) among obese is controversial. The present study aims to evaluate the impact of a 20-week ET program in women with obesity and the influence of baseline weight status on QoL responses to the ET program.

Methods: This secondary analysis from a quasi-experimental study included 40 obese women (BMI >30 kg/m2) aged between 18 and 65 years old (20 interventions and 20 controls). The intervention group participated in a moderate-to-vigorous intensity ET thrice a week, nutritional guidance, and psychological support. The control group received the same activities of nutritional guidance and psychological support but did not perform the ET. Measurements of QoL (WHOQOL-Bref) were performed at baseline and after 20- week follow-up.

Results: No significant impact of 20-week ET on QoL among obese women was observed. However, greater improvements in physical health, psychological, social relationship, and environment domains were observed for every increase in 1 unit of baseline BMI, except for the overall QoL score.

Conclusions/Recommendation: We can speculate that the better QoL responses to ET among those with higher BMI at baseline may be explained by the fact that individuals with more severe obesity are more impacted by functional limitations, stigmatization, discrimination, and social isolation; therefore, presenting worse QoL.


Moath AbdulAziz AlMasoud, Co Author



Globally there has been a surge in Physical fitness Centers and as we enter an era of obsession with “Six pack abdomen” never before has the world witnessed such a fascination for Rectus Abdominis muscles as we see today.

Diastasis of the rectus (DR) abdomen or divarication of recti muscle abdomen is the midline bulge caused by attenuation of the Linea alba. This attenuation of Diastasis recti (DR), is gradual and is characterized by thinning and widening of the Linea alba [1]. Diastasis recti (DR) is devoid of a true fascial defect, which is what differentiates it from a ventral hernia. Traditionally it has been associated with pregnancy. With the global epidemic of Obesity and the rise of Bariatric Surgery worldwise there is a surge in the prevalence of  Diastasis Recti (DR). Perhaps its time to revisit & Analyze the factors associated with this obsession of Diastasis recti (DR).

Heberth Moran, MD, Alfredo O. Labrada, MD, Bryan Grissett, MD, Monica C. Chiang, MD, and Gabriel I. Uwaifo, MD


Energy drinks (EDs) are a brand of non-alcoholic beverages that are typically distinguished from regular sweetened caloric beverages (SCBs) by their augmented carbohydrate and purine alkaloids/methylxanthines (usually either caffeine; 1,3,7 trimethylxanthine and/or theobromine; 3,7 dimethylxanthine) content touted as being able to boost energy levels. At initial inception they were dominantly consumed by young adults (with an initial strong male preponderance) but in the last few decades as their variety, main-stream acceptance and widespread marketing has increased their appeal and consumption has become widespread and virtually universal to the general population including virtually all age, gender and ethno-racial demographics. With increased widespread consumption concerns regarding their safety and potential impact on long term health have started being raised. This is particularly pertinent as their regulatory oversight and monitoring is often presently minimal.

Diabetes and Obesity represent two dominant halves of the global diabesity epidemic that afflicts over 650 million adults worldwide with over 40% of the adult population in the United States affected. The well documented cardiometabolic spectrum (CMS) of diseases that are associated comorbidities of diabesity are well documented and it is inevitable that the increasing consumption of EDs would involve these group of persons in adult, geriatric, adolescent and even pediatric populations.

This review summarizes and synthesizes the limited published data on the described and potential health impact of EDs use particularly in persons with and/or at risk for diabetes, obesity and other CMS diseases to make the case for need of more careful study, monitoring and scrutiny of the use of these beverages in these group of persons. After providing an overview of the history, epidemiology and major components of EDs we detail the major potential and reported systemic complications of their long-term intake especially in at risk populations discussing the modulating effects of genetics, present comorbidities and alcohol co-intake. The prominent roles of caffeine and carbohydrates in the potential poly-systemic effects of EDs and their reported toxidromes is also highlighted while acknowledging the limitations in the present body of published data in this area.