Press Release

August 2003

The Management of Obesity

Criticism of obese individuals is the last socially acceptable form of prejudice in the United States, according to an article on the management of obesity in the first issue for August of the American Thoracic Society’s peer-reviewed journal.

Writing in the American Journal of Respiratory and Critical Care Medicine, Gary D. Foster, Ph.D., of the Weight and Eating Disorders Program, University of Pennsylvania School of Medicine, Philadelphia, points out that one study showed that 63 percent of family practice physicians attributed obesity to a lack of will power, and more than one-third described their obese patients as “lazy.”

“Such experiences need to be remedied because they lead to interactions that, at best, provide medical care at the expense of a patient’s self-esteem, or at worst, prevent obese patients from seeking health care altogether,” said Dr. Foster.

According to the author, overweight and obesity are very serious problems in the U.S. A recent Centers for Disease Control and Prevention report indicated that 65 percent of all American are either overweight or obese. The number of obese Americans has more than doubled in the last 20 years. And, as studies have shown, the problem can lead to type 2 diabetes, hypertension, cardiovascular disease, and sleep apnea, among other illnesses.

In his article, Dr. Foster suggests the following approaches for physicians to use in their management of overweight in their practice. First, assume that obese individuals know they are overweight because many people have already told them. Ask simple questions such as “What do you think about your weight?” The answer will provide the patient’s perspective on a sensitive issue. Secondly, either listen carefully to the patient about the problem they want to discuss or focus on pertinent test results. Few patients consider weight to be their main problem. It could be high lipid levels, for example. Encouraging that patient to reduce saturated fats in their diet and to increase activity will influence both weight and lipids. Finally, provide the same care to obese patients as to non-obese patients. Encourage these patients to lose weight but also provide appropriate pharmacologic care in a timely fashion.

He points out that the use of pharmacotherapy to treat obesity has been compromised by a history of inappropriate practices. These approaches have reflected such approaches as the use of thyroid supplementation in patients who do not need it, as well as the suggestion of other unsafe agents. To date, only two medications have been approved by the U.S. Food and Drug Administration for patients with a high body mass index of 30 or more (27 with other related problems.) The first is Sibutramine, which facilitates a feeling of fullness rather than suppressing appetite. Side effects, which affect 20 to 30 percent of the patients, are headache and dry mouth. Both are mild and well tolerated, according to Dr. Foster. However, approximately 2 percent of patients on this medication may experience a significant increase in blood pressure and heart rate. The second drug Orlistat selectively prevents the absorption of fat, reducing it by approximately 30 percent. In dozens of randomized, placebo-controlled trials, these two drugs have been shown to be safe and effective in properly selected patients, producing weight loss of from 8 to 10 percent over 2 years.

Dr. Foster outlines guidelines to help patients improve their adherence to the behaviors necessary for effective weight loss. These include: the establishment of a specific plan for weight loss that goes into detail such as walking 20 minutes after dinner three or four times per week; the identification of either facilitators and/or barriers to success in achieving weight loss goals; urging the patient to make a written record of his or her plan, including its specific steps to implementation; at the next visit, discussing the patient’s progress with the plan, helping the individual to identify any problem areas, discussing ways to overcome the difficulties, and assuring that he or she takes responsibility for addressing these issues; remembering that patients benefit more from examining how either behavior does or does not change rather than why things did not go as originally planned; finally, if the physician questions motivation, it does little to improve adherence.

“Physicians can provide a great service to their obese patients by reminding them that their worth is not measured on the scale,” added Dr. Foster. “Reaffirming a patient’s self-worth, independent of body weight, is perhaps one of the most powerful interventions a physician can provide to an obese patient.”

The First Evidence of “Chimerism” in the Human Lung

Based on the results of studies with the tissues of two out of three patients, investigators have provided the first evidence of chimerism in the human lung after human stem cell transplantation, according to an article in the first issue for August 2003 of the American Thoracic Society’s peer-reviewed journal.

Benjamin T. Suratt, M.D., of the Division of Pulmonary Sciences and Critical Care Medicine, University of Vermont Health Sciences Research Facility, Burlington, along with seven associates, in a report in the American Journal of Respiratory and Critical Care Medicine, found significant rates of epithelial (2.5 to 8 percent) and endothelial (37.5 to 42.3 percent) chimerism in lung tissue samples from two of three patients who had undergone either lung biopsy or autopsy.

“Many of the body’s tissues once thought to be only locally regenerative may, in fact, be actively replaced by circulating stem cells after hematopoietic stem cell transplantation,” said Dr. Suratt.

He noted that localization of donor-derived cells or chimerism had recently been shown to occur in the cells of mice after either hematopoietic stem cell transplantation or infusion of cultured marrow.

Dr. Suratt said that his team’s results suggest that significant chimerism of the human lung may follow hematopoietic stem cell transplantation and that adult human stem cells could potentially play a therapeutic role in treatment of the damaged lung.

According to the authors, donor-derived epithelial and endothelial cells were predominately found in the alveoli, although donor-derived epithelial cells were occasionally found in the bronchial lining. (The bronchioles are the smaller airways with dozens of bubble-shaped, air-filled cavities at their end called alveoli.)

The tissue specimens were obtained from patients at time periods ranging from 50 to 463 days after transplantation.

“Although the small sample size of this study limits definitive conclusions,” said Dr. Suratt, “the lack of chimerism in the second patient is of interest. Given the patient’s relatively brief engraftment period at the time of biopsy at 50 days, compared with the first patient at 200 days and the third patient at 462 days, this might reflect a requirement for long-term engraftment before circulating stem cells incorporation or differentiation in the lung.”

The authors note that given current limitations in the field, detailed analysis of the true incidence and degree of pulmonary chimerism after a transplant, as well as factors that may influence its appearance, must await the development of better techniques and the examination of large numbers of human stem cell transplant recipients.

First Sarcoidosis Patient Quality of Life Outcome Measure Developed

Researchers have developed the first validated outcome measure, the Sarcoidosis Health Questionnaire, to determine health-related quality of life in patients with this disease.

Writing in the first issue for August 2003 of the American Thoracic Society’s peer-reviewed American Journal of Respiratory and Critical Care Medicine, Christopher E. Cox, M.D., M.P.H., of the Division of Pulmonary and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, along with four associates, created the questionnaire in the hope that it could improve communication between clinicians and patients by facilitating discussion about issues not usually discussed, such as depression, or easily measured, such as pain and fatigue.

In sarcoidosis, which develops usually between the ages of 20 and 40, patients suffer from abnormal collections of inflammatory cells called granulomas that can occur in the lung, liver, lymph nodes, eyes, spleen, and other organs. The disease is more common in northern Europeans and American black persons. Its cause is unknown, and there is no cure. The lung is the organ that is often most affected by the disease. Sarcoidosis produces inflammation in the lung that can lead to scarring and cyst formation. These problems can result in coughing and shortness of breath; however, the illness is rarely fatal.

The Sarcoidosis Health Questionnaire was arranged in three domains based on the development team’s belief in their importance to patients. The areas are: Daily Functioning (13 items); Physical Functioning (6 items), and Emotional Functioning (10 items). The items, written at a sixth grade reading level, are scored using responses ranging from 1 (“all the time”) to 7 (“none of the time”).

The questionnaire underwent developmental testing using 149 patients whose median age was 44. The majority were African-Americans (80 percent) and female (69 percent). The characteristics of the 111 validation study patients were nearly identical to those in the development group, except the number being treated currently was greater (70 percent versus 52 percent).

During the development phase, patients identified common problems such as low energy level (84 percent), worrying about sarcoidosis worsening (83 percent), having the sensation of breathing uncomfortably (79 percent), and feeling bodily pain (79 percent).

“The Sarcoidosis Health Questionnaire requires no investigator supervision, can be scored easily, requires only about 10 minutes to complete, and appears more sensitive than other health-related quality of life questionnaires to the extent of sarcoidosis organ system involvement,” said Dr. Cox. “Importantly, the questionnaire includes only items that patients with sarcoidosis felt were needed.”

Habitual Snoring in Children Associated with Poor Academic Performance

Habitual snoring in third-grade children was associated with poor academic performance on mathematics, science, and spelling in a large study of 1,129 German primary students, according to research published in the American Thoracic Society’s peer-reviewed journal.

Writing in the second issue for August 2003 of the American Journal of Respiratory and Critical Care Medicine, Christian F. Poets, Ph.D., of the Department of Neonatology, University Hospital of Tuebingen, Tuebingen, Germany, along with six associates, reported that the study was the first to show a clear biological relationship between snoring frequency and the risk of poor academic performance. Information on snoring was available for 1,129 children. Of that number, 410 (36.3 percent) never snored and 605 (53.6 percent) snored occasionally. Eighty-nine youngsters (7.9 percent) snored frequently and 25 (2.2 percent) always snored.

“Snoring ‘always’ was significantly associated with poor academic performance in mathematics, science, and spelling,” said Dr. Poets. “Snoring ‘frequently’ was also significantly associated with poor academic performance in mathematics and spelling.”

The investigators assessed snoring and intermittent hypoxia (inadequate amounts of available oxygen in the blood) using a parental questionnaire and nocturnal home oximetry. (In its most fundamental form, oximetry is a process designed to measure oxygen concentrations in the blood using an electrode placed on the finger or an earlobe.)

The researchers found that children with signs of intermittent hypoxia showed no independent association with poor academic performance, whereas they did find a significant relationship between snoring and poor academic performance in children without intermittent hypoxia.

To account for the youngster’s health status at the time of the oximetry recording, all of the children with parentally reported signs of acute upper respiratory tract infection were excluded from the study.

The test involved third-grade students from 27 or 59 public primary schools within the city limits of Hannover, Germany. About 60 percent were 9 years old but over 18 percent were younger and over 21 percent older. Pupils were contacted in the classroom by two of the investigators between February and December 2001. The researchers handed out a cover letter explaining the study, an informed consent form, and sleep-disordered breathing questionnaire to be filled out by the parents. The investigators assessed snoring by directly questioning: “Does your child snore?” Responses were rated on a four-point scale from “never” and “occasionally” to “frequently” and “always.”

After a school nurse explained how to use the device, all children underwent nocturnal home pulse oximetry to record oxygen saturation, pulse rate, and signal quality. Children were instructed to start the recording at bedtime and end it in the morning.

“Considering that academic performance is a surrogate for neurocognitive functioning in children,” said Dr. Poets, “our findings suggest that mechanisms other than intermittent hypoxia may be more important in the relationship between snoring and neurocognitive deficits in most school children.”

The researchers note that their findings have direct public health impact since habitual snoring without hypoxia, previously considered benign, could impair neurocognitive functioning in children and adversely affect academic performance.

Exercise Reduces Decline in Pulmonary Function in Aging Men

In tests of male subjects over periods of up to 25 years, Finnish investigators found that higher levels of physical activity were associated with a slower rate of decline in pulmonary function with aging, along with lower mortality rates. The study’s results are published in the American Thoracic Society’s peer-reviewed journal.

Writing in the second issue for August 2003 of the American Journal of Respiratory and Critical Care Medicine, Margit Pelkonen, M.D., of the Department of Public Health and General Practice, University of Kuopio, Kuopio, Finland, together with five associates, found that the decline in a baseline lung function test was almost 10 ml per year less among men who were in the highest one-third (tertile) category for physical activity as compared with those in the lowest one-third.

Consequently, the authors point out that middle-aged and older people should be encouraged to enjoy exercise.

The Finnish investigators studied a group of men in southwestern rural Finland to examine the influence of physical activity on the longitudinal decline in pulmonary function among middle-aged men. They had complete data on physical activity, smoking habits, and decline in pulmonary function for 429 men for 10 years from 1964 to 1974, 275 men for 20 years until 1984, and 186 men for 25 years until 1989. From a questionnaire developed for another study, trained nurses gathered information on the men’s habitual walking, cycling, or cross-country skiing.

“Our results suggest that physical activity may delay the decline in pulmonary function occurring in middle and older age,” said Dr. Pelkonen. “The beneficial effect of physical activity on pulmonary function was independent of smoking and was similar in all smoking categories.”

The mean age of the men involved in the study at baseline in 1964 was 55 years. At the start of the study, the percentage of occupational activity listed for the men as heavy to very heavy was 70.9 percent in the lowest tertile of physical activity, 87.4 percent in the middle tertile, and 87.3 percent in the highest one-third. (Most of the men were farmers, and all had retired by 1984.) From 37.8 percent to 42.6 percent of the subjects were continuous smokers during the 25 years of the study.

The investigators said that a loss of lung elastic recoil, less chest wall compliance (the quality of yielding to pressure without disruption), and a decrease in the strength of respiratory muscles have been proposed as the most important factors contributing to the decline in pulmonary function during aging. They said that the loss of elastic recoil can lead to premature airway closure, resulting in air trapping during forced expiratory breathing. They believed it was possible that physical activity could counteract this stiffening tendency in the chest wall. They noted that older endurance athletes have been shown to suffer less aging-related effects on lung elastic recoil, and that claims have been made that physical activity can enhance inspiratory muscle endurance.