WASHINGTON—Recent months have seen a reinvigorated commitment to research targeted at curbing the obesity epidemic in the United States, including a number of completed studies from VA and DoD and the release of a new strategic plan from NIH.
Plan for Obesity
The Strategic Plan for NIH Obesity Research, released last month, provides a coordinated plan for how to invest the substantial amount of resources the agency devotes to obesity-related efforts each year. In 2010, NIH invested $824 million of its budget, along with an additional $147 million through the Recovery Act, in research to reduce the prevalence of obesity and its health consequences.
Developed by a task force co-chaired by the leaders of the National Institute of Diabetes and Digestive and Kidney Diseases, National Heart, Lung and Blood Institute and the National Institute of Child Health and Human Development, the new plan will help bring obesity-related research efforts contained within NIH’s various institutes into alignment.
“The prospects of what [the obesity epidemic] will do in terms of health care and longevity is a very deep concern,” said Francis Collins, MD, PhD, director of NIH in a statement following the plan’s release. “If the NIH has its mission to try and promote human health, obesity is right in the middle of that. There’s a very short list of organizations aimed at trying to tackle this problem, and NIH is at the top of that list, and we embrace that. We aim to live up to that responsibility by promoting excellent science that gives rigorous results.”
The strategic plan, Collins said, incorporates everything from basic science to environmental factors to interventions. “What are the signals that trigger satiety and hunger? And what are the genetic influences that play a role in the tendency towards obesity?” Collins said. “And then how do you design trials with creative new ideas about how to prevent or treat obesity? Then how do you develop an approach to discover how they work in the real world?”
Research recommendations in the plan include: discovering the processes that regulate body weight and eating behavior; understanding other factors that contribute to obesity; designing new approaches for achieving and maintaining weight loss; evaluating strategies to treat obesity in the real world; and using new technology to advance research and improve health-care delivery.
Like any large health-care system, VA finds obesity a continuing challenge among its patient population, and each year sees several new studies released that touch on the epidemic.
VA researchers in Tennessee have been studying the occurrence of senescent gynecomastia—enlarged mammary glands in men—among veteran patients in an attempt to understand VA’s management of the disease. The condition is not uncommon in the population, researchers noted, because of obesity and the use of numerous drugs that list the condition as a side effect.
The researchers looked at patients treated in the VA Tennessee Valley Healthcare System between 2003 and 2007. Of 670 patient charts addressing breast complaints, 454 cases of senescent gynecomastia were identified. Of those, 92% were using multiple medications associated with gynecomastia, and in 79.% of cases that was determined to be the cause of the condition. Medication conditions were found to cause the condition in 13.7% of patients.
Researchers found that more than 50% of patients underwent diagnostic imaging studies, with 20% being tested for etiologic endocrine tumors. This testing found tumors in only 1.1% of patients. Most of the patients (94%) had their condition managed without surgery.
While researchers determined that the management of these conditions was generally correct, they did suggest that there was excessive use of imaging and invasive diagnostic procedures at the Tennessee VA. The condition, they noted, is a benign disease that can usually be diagnosed without any kind of imaging and can almost always be treated nonoperatively.
Breast J. 2011 Mar;17(2):160-6. doi:10.1111 /j. 1524-4741.2010.01050.x
Insulin Resistance and Obesity
Science does not yet understand the pathology of heightened cardiovascular risk among patients with systemic insulin resistance and whether myocardial insulin resistance accompanies systemic insulin resistance.
Researchers at the Denver VA Medical Center developed a porcine model of diet-induced obesity to help determine if myocardial insulin resistance develops in parallel with systemic insulin resistance and investigated what mechanisms could be responsible for those changes.
Control subjects were fed a diet low in fat with no added sugars over a period of seven months, while the
intervention group was fed either a diet of coconut oil or high-fructose corn syrup. Those pigs in the intervention diet developed obesity, hypertension and dyslipidemia. They also developed systemic insulin resistance, manifested by elevated fasting glucose and insulin, abnormal response to intravenous glucose tolerance testing and the blunting of insulin-receptor response.
In the myocardium, insulin-stimulated glucose uptake and the activation of insulin receptors were also blunted. This showed that in a porcine model of diet-induced obesity, myocardial insulin resistance develops at the same time as systemic insulin resistance and is
associated with multiple abnormalities in
Am. J. Physiol. Heart Circ. Physiol. December 1, 2010:H1917-H1927
Extreme Weight Dosing
While injectable medications always have dosing instructions, few provide details for how to dose patients with extremes in weight, according to researchers at the VA Sierra Nevada Health Care System.
The researchers reviewed product information and pivotal studies on newly marketed injectable medications approved by FDA between 2004 and 2009. They noted any information related to weight descriptors or dosing of patients with extremes of weight, which was defined as a body mass index less than 18.5 or greater than 40. If pivotal studies on the medication had not been published, researchers contacted the pharmaceutical company to acquire the information.
The information on each drug provided was scored on a scale of 1 to 3, with a score of 2 or 3 considered minimally adequate for dosing patients with extreme weight. Of the 84 medications evaluated, only 27% had any reference to weight descriptors, and none had a score of 2 or above.
The researchers concluded that instructions provided for new injectable medications are currently inadequate for dosing patients with extremes in weight.
Am J Health Sits Pharm. 2010 Nov 15;67(22):1948-1950.
Finding Fit Servicemembers
Obesity is also a concern in the active military. Musculoskeletal injuries are a major cause of injury during training, and those injuries are more common in overweight and obese individuals. According to researchers, the military can be challenged during strong economic times to recruit enough qualified personnel, resulting in a relaxing of physical standards.
Researchers at the Walter Reed Army Institute of Research compared the incidence of outpatient utilization of health services for training-related injuries among men who were over body fat (OBF) with those who were weight qualified (WQ) and met military standards.
Of the 812 OBF and 6,511 WQ participants, the OBF were 47% more likely to experience a musculoskeletal injury and had a 49% higher health- care utilization.
The researchers noted that, since the economy has taken a downturn, recruitment standards have improved in recent years. However, if the economy should improve, the military may be challenged again to find physically fit recruits in adequate numbers.
Occup Med (Lond). (2011) doi: 10.1093/occmed/kqr028 First published online: April 11, 2011.