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STUDY OBJECTIVES: To determine the prevalence of obstructive sleep apnea (OSA) in a cohort of women with class III obesity, and a comparator lean group, in the second and third trimesters of pregnancy. Secondary objectives were to compare characteristics of women with obesity with and without OSA and to assess factors that were predictive of OSA. METHODS: We performed a prospective cohort study involving 33 women with class III obesity (mean body mass index 43.5 ± 3.9 kg/m(2)) and 39 lean women (body mass index 22.0 ± 1.7 kg/m(2)) with singleton pregnancies. Participants completed 2 level 3 sleep studies between 12–22 weeks and 32–38 weeks gestation. OSA was defined as a respiratory event index ≥ 5 events/h (≥ 3% desaturation criteria). Levels of interleukin-6, glucose, and C-peptide were quantified in maternal blood. Logistic regression analysis was performed to determine predictors of OSA. RESULTS: OSA was identified in 12 (37.5%) and 14 (50.0%) women with obesity and in 1 (2.6%) and 3 (9.1%) lean women in the second and third trimesters, respectively. Women with obesity with OSA were older than those with no OSA but otherwise had similar characteristics. In unadjusted analysis of women with obesity, increased age, body mass index, homeostatic model assessment of insulin resistance, and history of nonsmoking were associated with increased odds of OSA. In multivariable analysis, only increased age remained significantly associated with OSA. CONCLUSIONS: OSA is highly prevalent in pregnant women with class III obesity. Further research is required to establish effective management strategies for the growing number of women in this high-risk group. CITATION: Johns EC, Hill EA, Williams S, et al. High prevalence of obstructive sleep apnea in pregnant women with class III obesity: a prospective cohort study. J Clin Sleep Med. 2022;18(2):423–432.

Background: Concern exists regarding adequacy of visualization of stress echocardiograms performed without intravenous contrast in persons with Class III obesity (body mass index ≥ 40 kg/m2). Methods: Dobutamine stress echocardiography (DSE) was performed on 128 candidates for bariatric surgery with class III obesity without chest pain or pre-existent coronary artery disease (CAD). DSE without intravenous contrast was initially performed on 62 patients with class III obesity, then was subsequently was performed with intravenous contrast on 66 patients with class III obesity. Left ventricular (LV) regional wall motion was assessed at baseline and peak stress using the 16-segment model. Results: In the intravenous contrast group 1046 of 1056 LV segments studied (99.1%) were well-visualized and interpretable at baseline and 1044 of 1056 LV segments studied (98.9%) were well-visualized and interpretable at peak stress. In the non-contrast group 905 of 992 segments studied (91.2%) were well-visualized and interpretable at baseline and 886 of 992 segments studied (89.3%) were well-visualized and interpretable at peak stress. A significantly greater number of LV segments were well-visualized and interpretable in the intravenous contrast group than in the group compared to the non-contrast group, at baseline and at peak stress (p < 0.00001 for both). DSE was positive for ischemia in 1 patient. All patients underwent bariatric surgery without cardiovascular complications. Six months after surgery, all patients were alive; none developed cardiovascular events. Conclusion: The use of intravenous contrast during DSE significantly improves visualization and interpretability of LV segments in patients with class III obesity.

Objective Women with obesity and other comorbidities such as hypertension and diabetes are at an increased risk of preeclampsia and perinatal morbidity. This study evaluates whether screening echocardiogram can identify women with obesity at a higher risk of preeclampsia. Methods We conducted a retrospective cohort study of women with class III obesity (body mass index [BMI] ≥40 kg/m2) and one or more medical comorbidities associated with an increased risk of preeclampsia (such as diabetes, hypertension, and rheumatologic disease) undergoing screening echocardiogram. Abnormal findings were defined as the presence of one or more of the following: diastolic dysfunction, ejection fraction of ≤45%, or cardiac chamber enlargement or hypertrophy. Multivariable logistic regression was used to estimate the odds ratio (OR) of gestational hypertension/mild preeclampsia, severe preeclampsia, and any preterm delivery Results Of 267 eligible women, 174 (64%) underwent screening echocardiograms. Sixty-nine women (40%) had abnormal echocardiograms. Maternal clinical characteristics were similar between women with normal echocardiographic findings and women with abnormal findings. Women with abnormal echocardiograms were more likely to have chronic hypertension (78 vs. 62%, p = 0.04) and a history of preeclampsia (27 vs. 10%, p = 0.02). After controlling for confounders, women with abnormal echocardiogram were at an increased risk of hypertensive disorders of pregnancy, OR 6.80 (95% confidence interval [CI] 3.32–13.93, p = 0.01), and in particular severe preeclampsia, OR 8.77 (95% CI 3.90–19.74, p = 0.01). Conclusion Among pregnant women with class III obesity and medical comorbidities, screening echocardiogram may help identify a subset of women at the highest risk of developing preeclampsia. Key Points

Elevated body mass index is a risk factor for gallstone disease and cholecystectomy, but outcomes for low body mass index patients remain uncharacterized. We examined the association of body mass index with morbidity, mortality, and resource use after cholecystectomy.The 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program was retrospectively analyzed for adult patients undergoing laparoscopic and open cholecystectomy. Patients were stratified into 5 groups: body mass index18.5 (underweight), body mass index 18.5 to 24.9 (normal weight), body mass index 25 to 29.9 (overweight), body mass index 30 to 34.9 (class I obesity), body mass index 35 to 39.9 (class II obesity), and body mass index ≥40 (class III obesity). Multivariable regressions identified independent associations of covariates with 30-day mortality, complications, and resource use.Of 327,473 cholecystectomy patients, 1.0% were underweight, 19.5% normal weight, 30.3% overweight, 24.0% class I obesity, 13.5% class II obesity, and 11.7% class III obesity. After multivariable analysis, underweight patients had a higher risk of mortality (adjusted odds ratio = 1.53; P = .029) and postoperative bleeding (adjusted odds ratio = 1.45; P = .011) relative to normal weight patients. Conversely, class III obesity patients had lower mortality (adjusted odds ratio = 0.66; P = .005) but increased operative time (β = 10.2 minutes; P.001), wound infection (adjusted odds ratio = 1.38; P.001), and wound dehiscence (adjusted odds ratio = 2.20; P.001). Hospital duration of stay and readmission rates were highest for underweight patients.Underweight patients experience increased risk of mortality and readmission, while class III obesity patients have higher rates of wound infection and dehiscence as well as prolonged operative time. These findings may guide choice of intervention.

Background Obesity has reached epidemic proportions worldwide, affecting life quality and span. Susceptibility to obesity is partly mediated by genetic differences. Indeed, several genes from the clock gene family have already been shown to be intimately associated with obesity in diverse ethnic groups. In the present study, an association between BMI and the rs707467, rs228697 and rs228729 PER3 (Period Circadian Clock 3) polymorphisms in subjects with class II (BMI ≥ 35.0–39.9 kg/m2) and class III obesity (>40 kg/m2, extreme obesity) were carried out using TaqMan real-time PCR. Overall, 259 Brazilian adults were genotyped, of whom 122 had class II or III obesity (BMI ≥ 35.0 kg/m2) and 137 were controls having normal weight (BMI > 18.5 and Results PER3 tag SNP (rs228729) shows a significant association with extreme obesity (1000 permutation p = 0.03 and p = 0.04), for genotype and allele frequency respectively) and a haplotype among the three assessed SNPs (alleles G/T/A, rs228697, rs228729, and rs707467, respectively, 1000 permutation p = 0.03) was significantly more prevalent in the group with obesity. Conclusion This exploratory association study suggests that PER3 rs228729 may be associated with extreme obesity in Brazilian adults, however, replication is needed.

Introduction Class III obesity (BMI≥40kg/m2) during pregnancy predisposes mother and offspring to a range of adverse pregnancy complications and outcomes. Risk profiles vary between pregnancies and are affected by interpregnancy weight gain. We evaluated the risk of adverse outcomes in women with BMI≥40kg/m2 in first and second pregnancies, and the impact of interpregnancy weight change on this risk. Materials and methods Data were extracted for all women with BMI≥40kg/m2 at first antenatal visit, who completed antenatal and delivery care for first and second pregnancies in NHS Lothian between 1/1/2009–31/12/2018. Multiple pregnancies and recipients of bariatric surgery were excluded. Results 442 pregnancies among 221 women were included. In first pregnancy, median (interquartile range) weight was 117kg (108.5-126.7), age 28 years (24-31) and BMI 42kg/m2 (41.0-44.5), 14.4% had gestational diabetes (GDM), 11.3% had pregnancy-induced hypertension and 44.6% had a post-partum haemorrhage (PPH). 20.8% of babies were large for gestational age (LGA, ≥97% centile at birth). In second pregnancy, women were heavier with a median weight of 119.9kg (109.0-130.0, p=0.00) with 19.9% gaining over 10kg. Women were more likely to develop GDM (21.6%, p=0.02). Babies were heavier with 40% of babies LGA(p

Background Childhood obesity increases the risk of non-alcoholic fatty liver disease marked by elevated alanine aminotransferase (ALT). This study investigated the prevalence of increased ALT in children and adolescents with obesity, and its associations with sex, age, degree of obesity, and metabolic parameters. Methods Individuals between 5 and 17.99 years of age enrolled in the Swedish Childhood Obesity Treatment Register (BORIS) before March 2020 were included. Mildly increased ALT was defined by ALT 27–51 U/L (males) and 23–43 U/L (females), while markedly increased ALT by levels above. Multiple logistic regression models were used for statistical analysis. Results Among 11,776 individuals (age 11.0 ± 3.3 years, 53.5% males), the prevalence of mildly and markedly increased ALT were 37.9 and 10.6%, respectively. A sex-age interaction was found, where increasing age strengthened the odds of markedly increased ALT in males (OR, 99% CI: 1.34, 1.29–1.4 for each year) while the corresponding pattern in females with was minuscule (1.09, 1.02–1.10). Compared to class I obesity, class II and III obesity had greater odds ratios for mildly increased ALT (class II obesity OR, 99% CI: 1.51, 1.35–1.70; class III obesity OR, 99% CI: 2.17, 1.66–2.61) and for markedly increased ALT (class II obesity OR, 99% CI: 1.82, 1.51–2.20; class III obesity OR, 99% CI 3.38, 2.71–4.23). Dyslipidemia was associated with both mildly and markedly increased ALT, all p Conclusions The risk of markedly increased ALT increased exponentially with age among boys, but not among girls. Higher degree of obesity was observed in individuals with mildly and markedly increased ALT. Further, metabolic derangements were more prevalent among individuals with mildly and markedly increased ALT.

Obesity is a major global health problem, and it has reached epidemic proportions worldwide. Therefore, surgeons will confront an increasingly larger proportion of obese candidates for pancreatoduodenectomy (PD) in the future. Several small retrospective studies have been conducted to evaluate the role of Body Mass Index (BMI) in postoperative surgical complications after PD, with conflicting results. The aim of this study was to use a large multi-institutional database to clarify the impact of different levels of obesity after PD.The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was queried for patients who underwent PD from 2014 to 2016. Patients were categorized in the following six BMI groups:18.5 (Underweight), 18.5-24.9 (Normal Weight), 25-29.9 (Overweight), 30-34.9 (Class I obesity), 35-39.9 (Class II Obesity) and40 (Class III Obesity). The primary outcomes of interest were 30-day mortality and morbidity after PD among the six BMI groups.The final population consists of 10,316 patients. Class III is associated with higher risk of 30-day mortality (OR 2.56, 95% CI 1.25-5.25, p = 0.011), major complications (OR 2.23, 95% CI 1.54-3.22, p 0.001), clinically relevant postoperative pancreatic fistula (OR 2.48, 95% CI 1.89-3.24, p 0.001), surgical site infections (OR 2.06, 95% CI 1.61-2.65, p 0.001) and wound dehiscence (OR 3.47, 95% CI 1.7-7.1, p 0.001) in multivariable analysis.In conclusion, our study shows that obesity is significantly associated with higher risk of postoperative complications in patients undergoing PD and patients with BMI≥40 have increased risk of mortality after PD.

Background From both a medical and surgical perspective, obese breast cancer patients are considered to possess higher risk when undergoing autologous breast reconstruction relative to nonobese patients. However, few studies have evaluated the continuum of risk across the full range of obesity. This study sought to compare surgical risk between the three World Health Organization (WHO) classes of obesity in patients undergoing deep inferior epigastric perforator (DIEP) flap breast reconstruction. Methods A retrospective review of 219 obese patients receiving 306 individual DIEP flaps was performed. Subjects were stratified into WHO obesity classes I (body mass index [BMI]: 30–34), II (BMI: 35–39), and III (BMI: ≥ 40) and assessed for risk factors and postoperative donor and recipient site complications. Results When examined together, the rate of any complication between the three groups only trended toward significance (p = 0.07), and there were no significant differences among rates of specific individual complications. However, logistic regression analysis showed that class III obesity was an independent risk factor for both flap (odds ratio [OR]: 1.71, 95% confidence interval [CI]: 0.91–3.20, p = 0.03) and donor site (OR: 2.34, 95% CI: 1.09–5.05, p = 0.03) complications. Conclusion DIEP breast reconstruction in the obese patient is more complex for both the patient and the surgeon. Although not a contraindication to undergoing surgery, obese patients should be diligently counseled regarding potential complications and undergo preoperative optimization of health parameters. Morbidly obese (class III) patients should be approached with additional caution, and perhaps even delay major reconstruction until specific BMI goals are met.

Aims The association between hyperglycemia at hospital admission and relevant short- and long-term outcomes in elderly population is known. We assessed the effects on mortality of hyperglycemia, disability, and multimorbidity at admission in internal medicine ward in patients aged ≥ 65 years. Methods Data were collected from an active register of 102 internal medicine and geriatric wards in Italy (RePoSi project). Patients were recruited during four index weeks of a year. Socio-demographic data, reason for hospitalization, diagnoses, treatment, severity and comorbidity indexes (Cumulative Illness rating Scale CIRS-SI and CIRS-CI), renal function, functional (Barthel Index), and cognitive status (Short Blessed Test) and mood disorders (Geriatric Depression Scale) were recorded. Mortality rates were assessed in hospital 3 and 12 months after discharge. Results Of the 4714 elderly patients hospitalized, 361 had a glycemia level ≥ 250 mg/dL at admission. Compared to subjects with lower glycemia level, patients with glycemia ≥ 250 mg/dL showed higher rates of male sex, smoke and class III obesity. These patients had a significantly lower Barthel Index (p = 0.0249), higher CIRS-SI and CIRS-CI scores (p = 0.0025 and p = 0.0013, respectively), and took more drugs. In-hospital mortality rate was 9.2% and 5.1% in subjects with glycemia ≥ 250 and p = 0.0010). Regression analysis showed a strong association between in-hospital death and glycemia ≥ 250 mg/dL (OR 2.07; [95% CI 1.34–3.19]), Barthel Index ≤ 40 (3.28[2.44–4.42]), CIRS-SI (1.87[1.27–2.77]), and male sex (1.54[1.16–2.03]). Conclusions The stronger predictors of in-hospital mortality for older patients admitted in general wards were glycemia level ≥ 250 mg/dL, Barthel Index ≤ 40, CIRS-SI, and male sex.

Backgraund: obesity/overweight in women are often the causes of menstrual dysfunction and infertility.Aims: To identify the association between overweight/obesity and IVF outcomes.Materials and methods: retrospective study — data of 1874 patients undergoing IVF in the Endocrinology Research Centre (2012–2019) was analyzed. Exclusion criteria: BMI Results: Patients were divided into 5 groups (gr.): normal body weight (NBW) - 1061 people (ppl.) (gr. 1), overweight — 368 (gr. 2), class I obesity — 117 (gr. 3), class II obesity — 36 (gr. 4), class III obesity — 1 (gr. 5). In each group, the estimated pregnancy rate (PR) and its outcomes, the frequency of lightweight newborns (body weight at birth Conclusions: Correlation analysis of the dependence of PR and its outcomes on the BMI was not revealed (p=0.975 and p=0.469, respectively). Large fetus births were more often detected in obese patients (p=0.0016). A large prospective group is needed to expand the estimated body parameters to the IVF outcomes.

Background The relationship between obesity and failure to achieve a minimal clinically important difference (MCID) following total hip arthroplasty (THA) has not been well defined. The aims of this study are to determine whether increasing body mass index (BMI) is associated with failure to achieve the 1-year Hip Disability and Osteoarthritis Outcome Score-Physical Function Short Form (HOOS-PS) MCID and to determine a threshold BMI beyond which this risk is significantly increased. Methods A multi-institutional arthroplasty registry was queried for THA patients from 2016 to 2018 with completion of preoperative and 1-year postoperative HOOS-PS. A previously defined anchor-based MCID threshold of 23 was used. Variables collected included demographics and patient-reported outcome measures. BMI was analyzed continuously and categorically. The association was analyzed via logistic regression. A BMI threshold was determined using the Youden index and receiver operating characteristic curve. Results A total of 1256 THAs were included. The average HOOS-PS improvement was 27.6 ± 18 points. The area under the receiver operating characteristic curve for BMI and risk of failure to achieve HOOS-PS MCID was 0.54 (95% confidence interval [CI], 0.50-0.57). Increasing BMI assessed continuously was a significant risk factor (odds ratio [OR], 1.03; 95% CI, 1.01-1.05; P value = .010). When BMI was analyzed categorically, this association was only observed for obese class III patients (>40 kg/m2) (OR, 2.5; 95% CI, 1.21-5.3; P value = .010). Conclusion This study found an association between increasing BMI and failure to achieve the 1-year HOOS-PS MCID. Obese class III patients (>40 kg/m2) face a near 3-fold increased risk of suffering this adverse outcome.

INTRODUCTION The US population has witnessed an epidemic expansion of obesity in the past several decades; nearly 50% of the population is projected to be obese by 2030 and 25% morbidly obese. This study examined trends, characteristics and outcomes of morbidly obese women who underwent benign hysterectomy. MATERIAL AND METHODS This is a population-based retrospective observational study querying the National Inpatient Sample from January 2012 to September 2015. The study population included 509 395 women who underwent hysterectomy for benign gynecological disease: 430 865 (84.6%) non-obese women, 50 435 (9.9%) women with class I-II obesity and 28 095 (5.5%) women with class III obesity. Main outcome measures were (i) cohort-level trends of obesity and perioperative complications assessed by piecewise linear regression with log transformation and (ii) patient-level perioperative complication risk by body habitus assessed with a generalized estimating equation after using a multiple-group generalized boosted model. RESULTS The rate of class III obesity increased by 40.4%, higher than the rate of class I-II obesity (22.2%) (both, P

OBJECTIVE: Assess the effect of class III (body mass index [BMI, kg/m(2)] 40–49.9) and class IV obesity (≥ 50) on clinical pregnancy and live birth outcomes after first oocyte retrieval and fresh embryo transfer cycle. DESIGN: Cohort study SETTING: Academic center PATIENTS: Patients undergoing their first oocyte retrieval with planned fresh embryo transfer in our clinic between 01/01/2012 and 12/31/2018. Patients were stratified by BMI: 18.5–24.9 (n = 4913), 25–29.9 (n = 1566) 30–34.9 (n = 559), 35–39.9 (n = 218), and ≥ 40 (n = 114). INTERVENTION: None MAIN OUTCOME MEASURE: Live birth rate RESULTS: Following embryo transfer, there were no differences in pregnancy rates across all BMI groups (p value, linear trend = 0.86). However among pregnant patients, as BMI increased, a significant trend of a decreased live birth rate was observed (p value, test for linear trend = 0.004). Additionally, as BMI increased, a significant trend of an increased miscarriage rate was observed (p value, linear trend = < 0.001). Compared to the normal-weight cohort, women with a BMI ≥ 40 had a significantly higher rate of cancelled fresh transfers after retrieval (18.4% vs. 8.2%, OR 2.51; 95%CI 1.55–4.08). Among singleton deliveries, a significant trend of an increased c-section rate was identified as the BMI increased (p value, linear trend = 40 have worse IVF treatment outcomes compared to normal-weight patients. After embryo transfer, their pregnancy rate is comparable to normal-weight women; however, their miscarriage rate is higher, leading to a lower live birth rate for pregnant women in this population. Patients with a BMI > 40 have a c-section rate that is 50% higher than normal-weight patients. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s10815-020-02011-1.

Background Telomere length (TL) is one biomarker of cell aging used to explore the effects of the environment on age-related pathologies. Obesity and high body mass index have been identified as a risk factors for shortened TL. Objective To evaluate TL in different subtypes of obese patients, and to examine changes in TL in relation to weight loss after bariatric surgery. Setting University Hospital in Spain. Methods A cohort of 94 patients submitted to bariatric surgery were followed-up during 24 months (t24m: lost to follow-up = 0%). All patients were evaluated before surgery (t0) and during the postoperative period (t6m, t12m, and t24m) for body mass index and metabolic variables. We assessed TL at each timepoint using quantitative polymerase chain reactions and the telomere sequence to single-copy gene sequence ratio method. Results Patients with class III obesity showed significantly shorter TL at baseline than those patients with class II obesity (P = .027). No differences in TL were found between patients with or without type 2 diabetes or metabolic syndrome. Longitudinal analysis did not show an effect of time, type of surgery, age, or sex on TL. However, a generalized estimating equation model showed that TL was shorter amongst class III obesity patients across the time course (P = .008). Comparison between patients with obesity class II and class III showed differences in TL at t6m (adjusted P = .024), whereby class II patients had longer TL. However, no difference was observed at the other evaluated times. Conclusion Obesity severity may have negative effects on TL independently of type 2 diabetes or metabolic syndrome. Although TL is significantly longer in class II obesity patients relative to class III 6 months after bariatric surgery. This difference is not apparent after 24 months.

Objectives The incidence rates of acute pancreatitis (AP) and the prevalence of class III obesity, and metabolic syndrome (MetS) are increasing in the US. Since class III obesity was associated with adverse clinical outcomes of AP, we sought to understand if the presence of metabolic comorbidities collectively recognized, as MetS were associated with worse clinical outcomes and increased health-care utilization. Methods The Nationwide Readmissions Database (NRD) (2010–2014) was reviewed to identify all adult subjects with a principal discharge diagnosis of AP. Inpatient mortality, severe AP (SAP), and 30-day readmissions were the primary outcomes analyzed. Propensity score weighted analyses were used to compare AP subjects with and without MetS and were further stratified by class III obesity status. Results MetS was associated with 12.91% (139,165/1,078,183) of all admissions with AP. Propensity score weighted analyses showed that MetS was associated with an increased proportion of SAP (OR 1.21, 95% CI 1.17, 1.25), but decreased mortality (OR 0.62, 95% CI 0.54, 0.70) and 30-day readmissions (OR 0.86, 95% CI 0.83, 0.89). Propensity score weighted analyses also revealed that class III obesity was independently associated with increased mortality in AP subjects with (OR 1.92, 95% CI 1.41, 2.61) and without MetS (OR 1.55, 95% CI 1.26, 1.92), and increased SAP in subjects with and without MetS. Conclusions Class III obesity appears to be the primary factor associated with adverse clinical outcomes in subjects with MetS admitted with AP. This has significant implications for patient management and future research targeting AP.

Objective Population-based data on perioperative complications among women with endometrial cancer and severe obesity are lacking. We evaluated 30-day complication rates among women with and without class III obesity (body mass index ≥ 40 kg/m2) undergoing primary surgical management for endometrioid endometrial cancer (EEC), and how outcomes differed according to surgical approach (open vs. minimally invasive). Methods We performed a retrospective population-based cohort study of women with EEC undergoing hysterectomy in Ontario, Canada, between 2006 and 2015. We evaluated perioperative complications in the whole cohort, and in a 1:1 matched analysis using hard and propensity score matching to ensure similar distributions of patient, tumour, provider and institution-level factors between women with and without class III obesity (identified using a surgical billing code). The primary outcome of interest was the 30-day perioperative complication rate. Results 12,112 women met inclusion criteria; 2697 (22.3%) had class III obesity. We matched 2320 (86%) women with class III obesity to those without. The composite complication rate was significantly higher among women with class III obesity (23.2% vs. 18.4%, standardized mean difference [SMD] = 0.12), primarily due to wound infection/disruption (12.1% vs. 6.2%). There was no difference in outcomes for women with and without class III obesity when a minimally invasive approach was used. Conclusions Wound infection/disruption was increased for women with class III obesity compared to women without. Otherwise, perioperative complications were similar between the matched pairs. When minimally invasive approaches were used, women with class III obesity had a similar risk of complications as women without obesity.

This study evaluated the influence of early gestational weight gain (GWG) on neonatal outcomes among women with class III obesity.Retrospective cohort of women with class III obesity who gained more than the Institute of Medicine (IOM) guidelines (20lbs). Women gaining ≥75% of total gestational weight prior to 28 weeks (EWG) were compared to women gaining75% of their total weight prior to 28 weeks (SWG). The primary outcome was a neonatal composite morbidity and mortality. Secondary outcomes included individual components of composite and LGA.Of 144 women identified, 42 (29.2%) had EWG and 102 (70.8%) had SWG. Though 11% of the total population had composite neonatal morbidity, this did not differ between groups (Though adverse neonatal outcomes were common in this population, timing of gestational weight gain was not correlated. Increased rates of LGA and higher median birth weight in the SWG group suggests excessive GWG continuing in the third trimester of pregnancy may be of import for neonatal size.

This study aimed to investigate the effects of obesity on the internal mechanical work, and its influence on the total mechanical work, energy cost, and mechanical efficiency in obese and nonobese adults while walking at different speeds. Body composition and anthropometrical characteristics were obtained for eleven obese [O; 39.9 ± 7.9 yr; body mass index (BMI): 43.0 ± 4.2 kg/m 2 ] and thirteen lean adults (L; 29.6 ± 5.7 yr; BMI: 22.0 ± 1.5 kg/m 2 ). Participants walked at five speeds (0.56, 0.83, 1.11, 1.39, 1.67 m/s) while oxygen consumption was measured to obtain net energy cost of walking (NC w ). A motion analysis system and instrumented treadmill were combined to obtain external (W ext ), internal (W int ), and total (W tot ) mechanical work, and pendular energy recovery. Mechanical efficiency was calculated as the ratio of W tot to NC w . Relative NC w (per unit body mass) was significantly higher in O than L (P ≤ 0.001). Relative W ext was significantly lower in O compared with L (P = 0.002), whereas no significant difference was found in relative W int (P = 0.16) and W tot (P = 0.6). Recovery was significantly higher (P ≤ 0.001), while mechanical efficiency was significantly lower in O than in L (P ≤ 0.001). These results suggest that individuals with obesity class III have similar mass-normalized W int and W tot compared with their lean counterparts, along with a higher relative NC w . Consequently, the efficiency of walking was reduced in this population. These results suggest that mass-normalized W int is unaffected by obesity and is not responsible for the higher relative NC w and lower efficiency of walking in these individuals.NEW & NOTEWORTHY It has been suggested that internal mechanical work (i.e., the work required to move the limbs with respect to the center of mass, W int ) may be responsible for the higher net cost of walking in obese adults, but this variable has not yet been studied in individuals with obesity. The main finding of the present study is that individuals with class III obesity exhibit a similar amount of mass-normalized W int to that of adults with a normal body weight, suggesting that body mass-relative W int is not affected by obesity and is not responsible for the higher energy cost and the lower efficiency of walking in this population.

Introduction Prior studies have identified associations between obesity and numerous conditions that increase risks for chronic pain. However, the impact of obesity on prescription opioid use is not well known. This study investigates the association between obesity and incidence of long-term prescription opioid use. Methods Fifteen panels of the Medical Expenditure Panel Survey from 2000 to 2015 were pooled to generate a sample of civilian non-institutionalized adults aged 30–84 years who were prescription opioid–naive for approximately 9 months. Incident long-term prescription opioid use was defined as reporting use at 2 of 3 interviews during a 15-month follow-up. BMI was reported at baseline. Analyses were completed in 2019. Results Among opioid–naive adults (n=89,629), obesity was strongly associated with incident long-term prescription opioid use. The association increased at progressively higher BMI values, with 24% elevated odds (95% CI=7%, 44%) in adults with overweight (25–29.9 kg/m2) and 158% increased odds (95% CI=106%, 224%) among adults with Class III obesity (40–49.9 kg/m2). These associations grew with higher-dosage opioids. Of the reasons for opioid use, joint pain, back pain, injury, and muscle/nerve pain contributed the most to the excess use observed among adults with obesity. At the population level, 27.0% of incident long-term prescription opioid use (95% CI=19.0%, 34.8%) was attributable to adults having a BMI above normal weight (25–49.9 kg/m2). Conclusions These findings suggest that obesity has contributed to prescription opioid use in the U.S. Future investments in chronic pain reduction may benefit from increased integration with obesity prevention and treatment.

Objective The recommendation for conventional body weight loss (BWL) treatment in obesity is 5-10%. It is not clear whether BWL is similar across the three different body mass index (BMI) obesity classes. The aim was to provide an overview on BWL across these classes in moderate lifestyle/diet intervention programs. Method A systematic literature search was conducted and the evidence of randomized controlled trials (RCTs) and pre-post design studies synthesized. The outcome was BWL. Results For RCTs, mean BWL in the intervention group was 3.6 kg (class I) and 5.3 kg (class II), which equates to 4 and 5% BWL, respectively. None of the assessed class III obesity studies met the inclusion criteria. For pre-post design studies, mean BWL was 5.4 kg (class I), 5.5 kg (class II) and 7.9 kg (class III), with high variation within and across studies in the latter. This equates to 6, 5 and, 6% BWL, respectively. Conclusions BWL of moderate BWL programs are similar across the different obesity classes. For class I obesity, the results differ between RCT and pre-post design studies by 2% BWL. The high variation of BWL in class III obesity might reflect different states of motivation such as the attitude towards bariatric surgery.

Objective To assess the risk factors associated with cesarean delivery in women with class III obesity (body mass index [BMI, calculated as weight in kilograms divided by height in meters squared] 40 or higher) who are undergoing induction of labor. Methods This was a retrospective cohort of obese women with a BMI of 40 or higher and singleton pregnancy of 34 weeks of gestation or longer who underwent induction of labor at two large teaching institutions from January 2013 to December 2015. The primary outcome was cesarean delivery. Secondary outcomes included maternal and neonatal composite morbidity. We then assessed the applicability of using a previously developed calculator to predict the risk of cesarean delivery. The area under the receiver operating characteristic (ROC) curve was used as a measure of the ability of the calculator to discriminate between women who underwent cesarean compared with vaginal delivery. Results There were 485 women with class III obesity who underwent induction during the study period. Of the 428 women who met inclusion criteria, 81.8% had a BMI of 40-50, 14.5% had a BMI of 50-60, and 3.7% had a BMI higher than 60. The overall cesarean delivery rate was 49.1% (46% with BMI 40-50, 63% with BMI 50-60, and 69% with BMI higher than 60, P=.012). Of the 428 women studied, 77.6% were black and 55% were nulliparous. Nulliparity, height, initial cervical dilation, and modified Bishop score were associated with a higher rate of cesarean delivery in multivariable models. Maternal and neonatal composite morbidity was higher in obese women who underwent cesarean delivery, compared with those who delivered vaginally. The performance of a previously developed induction calculator applied to this cohort had an area under the ROC curve of 75% (95% CI 0.70-0.79). Conclusions In women with class III obesity who underwent labor induction, the cesarean delivery rate approaches 50%. Nulliparity, height, and unfavorable cervical examination were the most significant risk factors for cesarean delivery. This information can be used to augment counseling for the obese patient who is undergoing induction.

Sleeve gastrectomy is one of the most common bariatric procedures because of its simplicity and effectiveness. Gastro-esophageal reflux disease (GERD) symptoms and weight regain after SG are common issues. Roux-en-Y gastric bypass (RYGB) is currently the most promising approach to achieve satisfying weight loss and GERD remission; however, remnant gastric cancer is still a major concern for patients. We present a video case that individualized procedure of Nissen fundoplication, and SASI bypass (N-SASI) was designed and applied to the patient with class III obesity and severe GERD. This is a 37-year-old man with obesity (BMI: 41.8 kg/m2, categorized as class III obesity) and associated disease of stage 1 hypertension, hyperlipidemia, obstructive sleep apnea syndrome, and non-alcoholic steatohepatitis as well as severe symptoms of GERD. Esophageal-gastro-duodenal scope revealed GERD grade C, hiatal hernia, and duodenal ulcer. He refused RYGB recommended initially due to serious concern about remnant gastric cancer. We therefore performed Nissen fundoplication for his GERD symptoms and adapted SASI bypass instead of RYGB as the individualized bariatric surgery to achieve the optimal surgical outcome. The postoperative course was smooth, and the patient was discharged on postoperative day 8.

BACKGROUND: Patients who are obese are at risk for developing high pleural pressure, which leads to alveolar collapse. Esophageal pressure (P(es)) can be used as a surrogate for pleural pressure and can be used to guide PEEP titration. Although recent clinical data on P(es)-guided PEEP has shown no benefit, its utility in the subgroup of patients who are obese has not been studied. METHODS: The Medical Information Mart for Intensive Care-III critical care database was queried to gather data on P(es) in subjects on mechanical ventilation. P(es) in obese and non-obese groups were compared, and a subgroup analysis was performed in subjects with class III obesity. Thereafter, empirical and P(es)-guided PEEP protocols of a recently published trial were theoretically applied to the obese group and ventilator outcomes were compared. RESULTS: A total of 105 subjects were included in the study. The average end-expiratory P(es) in the obese group was 18.8 ± 5 cm H(2)O compared with 16.8 ± 4.8 cm H(2)O in the non-obese group (P < .05). If P(es)-guided PEEP protocol was to be applied to those in the obese group, then the PEEP setting would be significantly higher than empirical PEEP setting. These findings were accentuated in the subgroup of subjects with class III obesity. CONCLUSIONS: Individualization of PEEP with P(es) guidance may have a role in patients who are obese.

BACKGROUND: There are limited data comparing the relative associations of various BMI metrics with adiposity and cardiometabolic risk factors in youth. OBJECTIVE: Examine correlations of 7 different BMI metrics with adiposity, cardiometabolic risk factors, and biomarkers (i.e. blood pressure, waist circumference, cholesterol, leptin, insulin, high molecular weight adiponectin, high-sensitivity c-reactive protein (hsCRP)). METHODS: This was a cross-sectional analysis of youth in all BMI categories. BMI metrics: BMI z-score (BMIz), extended BMIz (ext. BMIz), BMI percentile (BMIp), percent of the BMI 95th percentile (%BMI(p95)), percent of the BMI median (%BMI(p50)), triponderal mass index (TMI), and BMI (BMI). Correlations between these BMI metrics and adiposity, visceral adiposity, cardiometabolic risk factors and biomarkers were summarized using Pearson’s correlations. RESULTS: Data from 371 children and adolescents ages 8–21 years old were included in our analysis: 52% were female; 20.2% with Class I obesity, 20.5% with Class II, and 14.3% with Class III obesity. BMIp consistently demonstrated lower correlations with adiposity, risk factors, and biomarkers (r = 0.190–0.768) than other BMI metrics. The %BMI(p95) and %BMI(p50) were marginally more strongly correlated with measures of adiposity as compared to other BMI metrics. The ext.BMIz did not meaningfully outperform BMIz. CONCLUSION: Out of all the BMI metrics evaluated, %BMI(p95) and %BMI(p50) were the most strongly correlated with measures of adiposity. %BMI(p95) has the benefit of being used currently to define obesity and severe obesity in both clinical and research settings. BMIp consistently had the lowest correlations. Future research should evaluate the longitudinal stability of various BMI metrics and their relative associations with medium to long-term changes in adiposity and cardiometabolic outcomes in the context of intervention trials.

BACKGROUND An increasing number of clinical practice guidelines recommend screening children with obesity for non-alcoholic fatty liver disease (NAFLD). However, there is limited evidence regarding what parameters should be used to initiate the screening. OBJECTIVE The objective of this study was to determine whether obesity class rather than age group can identify a higher percent of children at risk of NAFLD as assessed by abnormal alanine aminotransferase (ALT). METHODS This is a cross-sectional study in a regional referral clinic for evaluation of obesity. Children were stratified by age group or by obesity class, and data obtained at first visit were analysed. RESULTS Of the 784 children, 482 were ≥10, 209 were 6 to 9 and 93 were 2 to 5 years of age. Abnormal ALT was observed in 32.1%, 46.9% and 61.0% of children with class I, II or III obesity, respectively (p

Background Rates of adherence to available recommendations for dose adjustments in patients with severe obesity are generally low. Hence, antimicrobials are often underdosed in these patients. Antimicrobial stewardship programmes can improve the use of antimicrobials in hospitalised patients. The aim of the study was to analyse the impact of an antimicrobial stewardship programme based on a computerised clinical decision support system for optimal dosing and antimicrobial use in inpatients with severe obesity. Methods This quasi-experimental retrospective study using interrupted time series was conducted in an academic centre in Canada from August 2008 to June 2018. The Antimicrobial Prescription Surveillance System was implemented in August 2010 (intervention 1) and specific rules targeting patients with class III obesity (body mass index ≥ 40 kg/m2) were added in June 2014 (intervention 2). Data were collected from all hospitalised adults receiving antimicrobials which required dose adjustment for severe obesity and were stratified by body mass index. Segmented regression analysis of interrupted time series was used to evaluate the impact of the Antimicrobial Prescription Surveillance System on the proportion of inappropriate days of therapy according to posology and on antimicrobial consumption. Results Overall, 65 205 antimicrobial prescriptions (68% non-obese, 25% class I-II obesity, and 7% class III obesity) were analysed. In patients with class III obesity, the intervention was associated with a decrease in the proportion of inappropriate days of therapy (trend after the first intervention, −0.8% per 2-month period [95% CI −1.1 to −0.5], p p Conclusions Antimicrobial Prescription Surveillance System had a positive impact on dosing optimisation and antimicrobial consumption in patients with class III obesity. Improving antimicrobial prescriptions in these patients is important because suboptimal dosing could be associated with unfavourable outcomes.

Objective The aim of this study was to evaluate the effect of a policy to deliver at 39 weeks for class III obesity. Methods This was a retrospective cohort study of women with class III obesity delivering at ≥ 37 weeks before (May 2012 to April 2014) and after the policy (September 2014 to August 2016). The primary outcome was the cesarean rate. Secondary outcomes included maternal morbidities and a neonatal morbidity composite. Modified Poisson regression was used to adjust for demographic differences between groups. Results The study included a total of 1,210 patients, 580 before the policy and 630 after the policy. Before and after the policy, cesarean rates were similar (41.6% vs. 47.1%; risk ratio [RR]: 1.13 [95% CI: 1.00-1.29]; adjusted RR [aRR]: 1.03 [95% CI: 0.92-1.14]). In adjusted comparisons of women undergoing labor induction, parous women had lower cesarean rates (aRR: 0.62; 95% CI: 0.41-0.94) but nulliparous women had higher cesarean rates (aRR: 1.32; 95% CI: 1.04-1.68) after the policy (P for interaction = 0.01). Rates of chorioamnionitis, endometritis, and cesarean wound infection were not different between groups. Composite neonatal morbidity was not different between pre- and postpolicy groups. Conclusions A policy of delivery at 39 weeks for class III obesity did not affect overall cesarean rate or rates of maternal or neonatal morbidity. Further investigation should evaluate subsets of women who may have a higher cesarean rate with this policy.

Objective The obesity paradox is the association of increased survival for overweight and obese patients compared to normal and underweight patients, despite an increased risk of morbidity. The obesity paradox has been demonstrated in many disease states but has yet to be studied in trauma. The objective of this study is to elucidate the presence of the obesity paradox in trauma patients by evaluating the association between BMI and outcomes. Methods Using the 2014–2015 National Trauma Database (NTDB), adults were categorized by WHO BMI category. Logistic regression was used to assess the odds of mortality associated with each category, adjusting for statistically significant covariables. Length of stay (LOS), ICU LOS and ventilator days were also analyzed, adjusting for statistically significant covariables. Results A total of 415,807 patients were identified. Underweight patients had increased odds of mortality (OR 1.378, p

INTRODUCTION Our aim was to identify risk factors for failed induction in morbidly obese patients undergoing the induction of labor at term. MATERIAL AND METHODS This was a retrospective multicenter study on a cohort of 235 patients with a body mass index greater than 40 kg/m2 and giving birth to a singleton in cephalic presentation, who had an induction of labor from 38 weeks of amenorrhea. Scheduled cesareans and spontaneous vaginal deliveries were excluded. Maternal, peri-partum and neonatal characteristics were analyzed according to the delivery route. RESULTS In all, 235 patients were included. Of these, 62.5% patients delivered vaginally and 37.5% by cesarean section. The frequency of nulliparity was greater in patients who had a cesarean section (56 [interquartile range, IQR, 38.1] vs 56 [IQR 63.6], P

Objective Obese women have higher cervical cancer incidence and mortality than their counterparts, possibly related to nonadherence to screening recommendations. We assessed the association of body mass index with adherence to cervical cancer screening recommendations in Hispanic women living in Puerto Rico, a minority population with the highest incidence of cervical cancer in the United States. Materials and methods We included 536 Hispanic women aged 21 to 64 years enrolled in a population-based study of human papillomavirus (HPV) infection. Demographic and clinical characteristics and risky behaviors were collected using structured interviews. Weight and height were measured to classify body mass index as underweight, normal, overweight, and obesity (class I, class II, class III). Adherence to cervical cancer screening recommendations was self-reported. Logistic regression models were fit to estimate the odds ratio with 95% CI after adjusting for covariates. Results Nearly one third (29.7%) of women were overweight and 43.5% were obese (class I: 22.6%, class II: 11.0%, class III: 9.9%). Overall adherence to cervical cancer screening within the past 3 years was 78.5%, being lowest among women with class III obesity (60.4%). After multivariable adjustment, only women with class III obesity had significantly higher odds (odds ratio = 2.5, 95% CI: 1.2-5.1) of reporting nonadherence to cervical cancer screening compared with normal weight women. Conclusions Adherence to cervical cancer screening in this population was below the Healthy People 2020 target of 93%, especially for women with morbid obesity. These findings highlight the importance of adequate interventions to decrease cervical cancer screening disparities in these women.

Objective The aim of this study is to describe the impact of maternal weight gain on infant birth weight among women with Class III obesity. Study Design Retrospective cohort of women with body mass index (BMI) ≥40 kg/m2 at initial prenatal visit, delivered from July 2013 to December 2017. Women presenting 14/0 weeks of gestational age (GA), delivering preterm, or had multiples or major fetal anomalies excluded. Maternal demographics and complications, intrapartum events, and neonatal outcomes abstracted. Primary outcomes were delivery of large for gestational age or small for gestational age (SGA) infant. Bivariate statistics used to compare women gaining less than Institute of Medicine (IOM) recommendations (LTR) and women gaining within recommendations (11–20 pounds/5–9.1 kg) (at recommended [AR]). Regression models used to estimate odds of primary outcomes. Results Of included women (n = 230), 129 (56%) gained LTR and 101 (44%) gained AR. In sum, 71 (31%) infants were LGA and 2 (0.8%) were SGA. Women gaining LTR had higher median entry BMI (46 vs. 43, p 0.99). After controlling for confounders, the AOR of an LGA baby for LTR women was 0.79 (95% CI: 0.4–1.4). Conclusion In this cohort of morbidly obese women, gaining less than IOM recommendations did not impact risk of having an LGA infant, without increasing risk of an SGA infant.

Childhood obesity has increased dramatically in the United States. Most available research has followed obesity prevalence with little attention to medical comorbidities, which could guide prevention and intervention.A retrospective chart review examined 2038 children referred to a Pediatric Weight Management Clinic providing low intensity (26 contact hours) intervention. Linear regression examined associations between obesity severity level (I, II, III) and blood pressure percentile scores (systolic, diastolic) while controlling for gender, age group, and ethnicity. Logistical regression examined associations between obesity severity level and five medical diagnoses (hypertension, type 2 diabetes, elevated ALT, hyperlipidemia, obstructive sleep apnea), again controlling for demographics.Results revealed that children with Class III obesity severity had significantly greater risk for five of the seven medical conditions examined, with higher systolic and diastolic blood pressure scores, and higher odds for hypertension, type 2 diabetes, and obstructive sleep apnea.The US Preventive Services Task Force has documented the effectiveness of intensive behavioral interventions (26 contact hours for changes in diet, exercise, screen time) for reducing obesity severity in children. Additional research is required to determine whether more intensive behavioral approaches should be added before a child's obesity reaches the Class III level of severity in order to prevent medical comorbidities.

To evaluate the efficacy of incisional negative pressure wound therapy in the prevention of postoperative wound morbidity in women with class III obesity undergoing cesarean delivery.In an open label randomized controlled trial, women admitted for delivery with class III obesity (body mass index 40 or higher) measured within 2 weeks of admission for delivery were offered participation in the study. They were consented either in the outpatient maternal-fetal medicine specialty clinic, during admission to labor and delivery and before a decision to perform cesarean delivery, or in the preoperative area of the hospital before scheduled cesarean delivery. Exclusion criteria included anticoagulation therapy, human immunodeficiency virus infection, and silver or acrylic allergy. Those who ultimately underwent cesarean delivery were randomized to standard surgical dressing or incisional negative pressure wound therapy dressing. The primary outcome was wound morbidity. Preplanned secondary outcomes included characteristics of composite wound morbidity, and hospital, emergency room, and clinic utilization. The sample size estimate required randomization of 440 women to detect a 50% decrease in composite outcome.Between January 1, 2015, and July 31, 2016, 850 women were screened and 677 women with class III obesity were enrolled. Of these, 441 underwent cesarean delivery and were subsequently randomized (219 to standard dressing and 222 to incisional negative pressure wound therapy). The primary outcome, overall composite wound morbidity rate, was 18%. This was not different between the two cohorts (incisional negative pressure wound therapy 17% vs standard dressing 19%, relative risk 0.9 [95% CI 0.5-1.4]).Prophylactic incisional negative pressure wound therapy use did not reduce postoperative wound morbidity when compared with a standard surgical dressing in women with class III obesity.ClinicalTrials.gov, NCT02289157.

Behavioral treatment strategies improve adherence to lifestyle intervention for adults with obesity, but can be time and resource intensive when delivered via traditional face-to-face care. This study aimed to investigate the efficacy and optimal timing of using telephone calls and text message as adjunctive tools to support a community-based obesity management program. This 8-month randomized controlled crossover trial recruited 61 adults with class III obesity (BMI > 40 kg/m2) enrolled in a publicly funded obesity management service (OMS). Participants were randomly assigned to receive telephone and text message support in addition to standard OMS care, or standard OMS care alone. After 4 months, participants crossed over to the alternative sequence. The technological support was based on self-determination theory. Outcome measures included diet, physical activity, anthropometry, self-efficacy, and treatment self-regulation. Telephone and text message support improved lifestyle intervention adherence and clinical outcomes when compared with standard care. Participants who received the intervention in the first 4-month period lost 4.87 kg, compared with no weight loss (+ 0.38 kg) in the standard care only group. There was no evidence to indicate an optimal timing of the intervention, with both groups achieving significant results by the end of the intervention. These results suggest a high degree of promise for the incorporation of telephone and text message support into community-based obesity management services. The findings have the potential to improve existing practices and reduce the burden on the health care system by demonstrating a resource-effective improvement to obesity management service delivery.

Background Obesity is an in independent risk factor for cardiovascular disease. Goal To describe the early LV remodelling pattern in patients with overweight and obesity and structurally normal hearts. Methods Consecutive patients (n = 2374), with structurally normal hearts and BMI ≥ 18.5 kg/m2, undergoing prospective mid-diastolic ECG gated CTCA were selected. Left ventricular mass (LVM) and Left ventricular mid-diastolic volume (LVMDV) were measured. The concentricity index (LVM/LVMDV) were calculated. According to the definitions of the World Health Organization (WHO), the patients were divided into weight categories. Results The mean LVM ± Std. deviation in the subgroups according to WHO classification was 101.68 ± 28.99 g (normal weight), 115.79 ± 29.14 g (overweight), 123.8 ± 33.44 g (class I obesity), 125.85 ± 32.89 g (class II obesity) and 132.45 ± 37.85 g (class III obesity). (p The mean LVMDV progressed with increasing WHO weight category from 112.37 ± 36.46 in patients with normal BMI to 140.26 ± 43.78 in patients with class III obesity. (p The concentricity index was 0.935 ± 0.216 g/ml in patients with normal BMI, 0.979 ± 0.253 g/ml, 1.058 ± 0.635 g/ml, 0.996 ± 0.284 g/ml and 0.9768 ± 0.244 g/ml in patients with BMI categories 25–29.99, 30–34.99, 35–39.99 and ≥40 kg/m2, respectively. Conclusions Our study demonstrates a non-linear (inverse U-shape) relationship between increasing BMI class and concentricity index, reaching its maximum at a BMI of 30–34.99 kg/m2. Further increase in BMI results in LV dilation.

Objective We investigated the association between gestational weight gain (GWG) and postpartum depression (PPD) in women with class III obesity. Study Design This is a retrospective cohort of women with body mass index (BMI) ≥ 40 kg/m2 at entry to care, first prenatal visit ≤14 weeks gestation, with singleton, nonanomalous pregnancies who delivered at term from July 2013 to December 2017. Women missing data regarding PPD were excluded. Primary outcome was PPD; classified as Edinburgh Postnatal Depression Scale (EPDS) score >13/30 or provider's report of depression. Participants were classified, according to Institute of Medicine GWG guidelines (11–20 pounds), as either less than 11 pounds (LT11) or at/more than 11 pounds (GT11). Bivariate statistics compared demographics and pregnancy characteristics. Logistic regression used to estimate odds of primary outcome. Results Of 275 women, 96 (34.9%) gained LT11 and 179 (65.1%) gained GT11 during pregnancy. The rate of PPD was 8.7% (n = 24), 9 (9.4%) in the LT11 group and 15 (8.4%) in the GT11 group (p = 0.82, odds ratio: 1.13, 95% confidence interval [CI]: 0.48, 2.69). When controlling for entry BMI and multiparity, adjusted odds of PPD was 1.07 (95% CI: 0.44, 2.63). No correlation was found between GWG and EPDS. Conclusion A relationship between GWG and PPD in class III obese women was not found in this cohort.

AIMS To assess the association of body mass index (BMI) with heart failure (HF) outcomes after cardiac resynchronization therapy with defibrillator (CRT-D) implantation. METHODS AND RESULTS Medicare beneficiaries with HF aged ≥ 65 years (n = 18 922) undergoing first-time CRT-D from the National Cardiovascular Data Registry (NCDR) Implantable Cardioverter-Defibrillator Registry between 2010 and 2013, were followed for 3 years post-implantation. Survival curves and covariate adjusted hazard ratio (aHR) or odds ratio were used to assess the risks for death, readmission, and device-related complications by BMI status. Of 18 922 HF patients receiving CRT-D, 5265 (27.8%) were normal weight, 6896 (37%) were overweight, 6318 (33.4%) were obese, and 353 (1.8%) were underweight. Compared to those of normal weight (BMI 18.5-24.9 kg/m2 ), underweight patients had a higher 3-year post-device implantation risk of death [aHR: 1.34 (95% confidence interval 1.09-1.65); P

Objective This study determines the differences in the distal gut and vaginal microbiome in African American (AA) women by prepregnancy body mass index and gestational weight gain (GWG) comparing women with and without obesity and by obesity class. Study Design We prospectively sampled the vaginal and distal gut microbiome in pregnant AA women at two time points during pregnancy. Samples were analyzed using high-throughput sequencing of the V4 region of the 16S ribosomal ribonucleic acid gene. Results Distinct differences in vaginal and distal gut α-diversity were observed at time point 1 between women with and without obesity by total GWG. Significant differences in distal gut β-diversity were also found at time point 1 in obese women by GWG. Within the Bacteroides genus, a significant association was observed by total GWG among obese women which was absent in nonobese women. Women with class III obesity who experienced low GWG had the lowest abundance of distal gut Bacteroides and appreciably higher relative abundance of a consortia of vaginal taxa including Atopobium, Gardnerella, Prevotella, and Sneathia. Conclusion These results contribute new evidence showing that GWG in combination with obesity and obesity class is associated with an altered distal gut and vaginal composition early in pregnancy among AA women.

Background This study sought to identify risk factors associated with wound disruption following Caesarean section (CS) in women with class III obesity and to determine the value of individualized perioperative care plans in reducing its incidence. Methods The study included women with class III obesity who underwent CS after 24 weeks of gestation at Mount Sinai Hospital, Toronto, Ontario between 2011 and 2015 and collected data on demographics, clinical history, and perioperative details. Multivariable logistic regression analysis was performed to identify factors likely to contribute to a higher incidence of wound disruption (level of evidence II-3B). Results Of the 334 identified cases, in women with a mean BMI of 48.20 ± 7.52 kg/m2, there were 60 cases of wound disruption (18%). The most common perioperative interventions involved Pfannenstiel skin incisions (75.6%), subcutaneous tissue closure (65.4%), use of pressure dressings (65%), and thromboprophylaxis (71.8%). On bivariable analysis, surgical time >1 hour (24.2% vs. 13.5%; OR 2.03; P = 0.017) and the use of thromboprophylaxis (20.1% vs. 10.6%; OR 2.22, P = 0.031) were associated with increased wound disruption, but these associations were attenuated on multivariable regression analysis. Conclusions No single risk factor or perioperative intervention was independently associated with wound disruption. However, the use of individualized perioperative care plans resulted in fewer wound disruptions in our cohort when compared with published literature.

Summary Background Disease severity in paediatric obesity is usually defined using the body-mass index (BMI). Although informative at the population level, its usefulness on an individual level has limitations. The use of a clinical staging system—Edmonton Obesity Staging System for Pediatrics (EOSS-P)—in identifying health risk has been proposed. This study aimed to examine the association between BMI class and EOSS-P stage. Methods This cross-sectional study was done in children with obesity aged 5–17 years who enrolled in the Canadian Pediatric Weight Management Registry (CANPWR) between May 31, 2013, and Oct 27, 2017, involving ten multidisciplinary paediatric weight management clinics in Canada. We classified participants into WHO BMI classes (class I as 2–3 SD scores, class II as >3 SD scores, and class III as >4 SD scores above the WHO growth standard median), and applied the EOSS-P staging system (stages 0, 1, and 2/3) based on the clinical assessment of coexisting metabolic, mechanical, mental health, and social milieu issues. Clinical information was extracted from medical records and reported using standardised case report forms. Associations of BMI class with EOSS-P stage were examined in children with complete data. Findings Of the 847 children with complete data, 546 (64%) had severe obesity based on BMI class (ie, class II or III) and 678 (80%) were EOSS-P stage 2/3. Stage 2/3 obesity-related health issues were common; mental health concerns were most common (520 [61%] of 847 children), followed by metabolic (349 [41%] of 847 children), social milieu (179 [21%] of 847 children), and mechanical (86 [10%] of 847 children) health issues. Mental health issues (eg, anxiety and attention-deficit hyperactivity disorder) were equally distributed across BMI classes, metabolic health issues were slightly more common in higher BMI classes, and mechanical (eg, musculoskeletal issues and sleep apnoea) and social milieu (eg, bullying and low household income) issues increased with increasing BMI class. Of children with class I obesity, 206 (76%) of 270 had overall EOSS-P stage 2/3, compared with 195 (85%) of 229 with class III obesity. Interpretation Physical and mental health issues were highly prevalent among children with obesity irrespective of BMI class. Participants with class III obesity carried the greatest health risk across subcategories of the EOSS-P. As BMI class increased, a concomitant increased disease burden in mechanical and social milieu issues was observed, whereas metabolic and mental health risks were high across BMI classes. Funding Canadian Institutes of Health Research, Ontario Ministry of Health, McMaster University, and McMaster Children's Hospital.

Background The obesity paradox has been recently demonstrated in trauma patients, where improved survival was associated with overweight and obese patients compared to patients with normal weight, despite increased morbidity. Little is known whether this effect is mediated by lower injury severity. We aim to explore the association between body mass index (BMI) and renal trauma injury grade, morbidity, and in-hospital mortality. Methods A retrospective cohort of adults with renal trauma was conducted using 2013–2016 National Trauma Data Bank. Multiple regression analyses were used to assess outcomes of interest across BMI categories with normal weight as reference, while adjusting for relevant covariates including kidney injury grade. Results We analyzed 15181 renal injuries. Increasing BMI above normal progressively decreased the risk of high-grade renal trauma (HGRT). Subgroup analysis showed that this relationship was maintained in blunt injury, but there was no association in penetrating injury. Overweight (OR 1.02, CI 0.83–1.25, p = 0.841), class I (OR 0.92, CI 0.71–1.19, p = 0.524), and class II (OR 1.38, CI 0.99–1.91, p = 0.053) obesity were not protective against mortality, whereas class III obesity (OR 1.46, CI 1.03–2.06, p = 0.034) increased mortality odds. Increasing BMI by category was associated with a stepwise increase in odds of acute kidney injury, cardiovascular events, total hospital length of stay (LOS), intensive care unit LOS, and ventilator days. Conclusions Increasing BMI was associated with decreased risk of HGRT in blunt trauma. Overweight and obesity were associated with increased morbidity but not with a protective effect on mortality. The obesity paradox does not exist in kidney trauma when injury grade is accounted for.

Introduction Although both obesity and coronavirus disease 2019 (COVID-19) independently induce inflammation and thrombosis, the association between obesity class and risk of thrombosis in patients with COVID-19 remains unclear. Methods This retrospective cohort study included consecutive patients hospitalized with COVID-19 at a single institution. Patients were categorized based on obesity class. The main outcomes were venous thromboembolism (VTE) and myocardial injury, a marker of microvascular thrombosis in COVID-19. Adjustments were made for sociodemographic variables, cardiovascular disease risk factors and comorbidities. Results 609 patients with COVID-19 were included. 351 (58%) patients were without obesity, 110 (18%) were patients with class I obesity, 76 (12%) were patients with class II obesity, and 72 (12%) were patients with class III obesity. Patients with class I and III obesity had significantly higher risk-adjusted odds of VTE compared to patients without obesity (OR = 2.54, 95% CI: 1.05–6.14 for class I obesity; and OR = 3.95, 95% CI: 1.40–11.14 for class III obesity). Patients with class III obesity had significantly higher risk-adjusted odds of myocardial injury compared to patients without obesity (OR = 2.15, 95% CI: 1.12–4.12). Both VTE and myocardial injury were significantly associated with greater risk-adjusted odds of mortality. Conclusion This study demonstrates that both macrovascular and microvascular thromboses may contribute to the elevated morbidity and mortality in patients with obesity and COVID-19.

There is little documentation of the distribution of specific health conditions across obesity classes (I, II, III), especially for paediatric populations who are seen for routine care in large United States US healthcare systems. The aim of this study was to assess the odds of presenting ≥2 obesity-related comorbidities as well as assess the overall distribution of these co-morbidities in children by class I/II/III obesity status controlling for key sociodemographic characteristics. This retrospective (2015-2019) electronic health record review analysed 49 276 patients from the Children's Health System of Texas diagnosed with obesity-related health conditions by obesity status (no obesity, class I, II, III). Crude and adjusted logistic regression models examined the association between obesity class and the likelihood of ≥2 comorbidities as primary diagnoses. Patients with class I obesity were 22% more likely (OR 1.22, 95% CI, 1.16, 1.27), patients with class II obesity were almost 50% more likely (OR 1.44, 95% CI, 1.35, 1.53) and those with class III obesity twice as likely (OR 2.04, 95% CI 1.91, 2.18) to be diagnosed with ≥2 comorbidities as primary diagnoses, compared with patients classified with no obesity. Children with obesity, particularly severe obesity, should be monitored closely by paediatricians for possible diagnoses of risk factors that could lead to adult chronic disease.

Aims We aimed to determine the effect of increasing body weight upon right ventricular (RV) volumes, energetics, systolic function, and stress responses using cardiovascular magnetic resonance (CMR). Methods and results We first determined the effects of World Health Organization class III obesity [body mass index (BMI) > 40 kg/m2, n = 54] vs. healthy weight (BMI < 25 kg/m2, n = 49) upon RV volumes, energetics and systolic function using CMR. In less severe obesity (BMI 35 ± 5 kg/m2, n = 18) and healthy weight controls (BMI 21 ± 1 kg/m2, n = 9), we next performed CMR before and during dobutamine to evaluate RV stress response. A subgroup undergoing bariatric surgery (n = 37) were rescanned at median 1 year to determine the effects of weight loss. When compared with healthy weight, class III obesity was associated with adverse RV remodelling (17% RV end-diastolic volume increase, P < 0.0001), impaired cardiac energetics (19% phosphocreatine to adenosine triphosphate ratio reduction, P < 0.001), and reduction in RV ejection fraction (by 3%, P = 0.01), which was related to impaired energetics (R = 0.3, P = 0.04). Participants with less severe obesity had impaired RV diastolic filling at rest and blunted RV systolic and diastolic responses to dobutamine compared with healthy weight. Surgical weight loss (34 ± 15 kg weight loss) was associated with improvement in RV end-diastolic volume (by 8%, P = 0.006) and systolic function (by 2%, P = 0.03). Conclusion Increasing body weight is associated with significant alterations in RV volumes, energetic, systolic function, and stress responses. Adverse RV modelling is mitigated with weight loss. Randomized trials are needed to determine whether intentional weight loss improves symptoms and outcomes in patients with obesity and heart failure.

OBJECTIVES: Drug dosing recommendations for children with obesity remain limited. This may lead to variability in medication dosing among children with obesity. Therefore, our objective was to determine differences in the prevalence of guideline-nonadherent systemic corticosteroid orders by weight category in children hospitalized for asthma. METHODS: We performed a retrospective cross-sectional study of children aged 2 to 17 years hospitalized with asthma and prescribed systemic corticosteroids between January 1, 2010, and December 31, 2017, using the Cerner Health Facts deidentified database. Weight categories ranging from underweight to class III obesity were defined on the basis of BMI percentiles by using CDC guidelines. Corticosteroid orders were categorized as guideline adherent or nonadherent on the basis of total body weight–based dosing guidelines from the National Heart, Lung, and Blood Institute. χ2 test and multivariable logistic regression models were used to determine differences in guideline adherence between weight categories. RESULTS: We identified 21 488 children prescribed systemic corticosteroids during asthma hospitalizations. Most (54.2%) had a healthy weight, and 23.8% had obesity. Almost one-quarter received guideline-nonadherent orders (22.2%), with increasing prevalence among higher weight categories (19.4% of healthy weight children versus 36.0% of those with class III obesity; P < .001). After controlling for demographic and clinical covariates, weight category remained significantly associated with receiving a guideline-nonadherent order (P < .001). CONCLUSIONS: The prevalence of guideline-nonadherent corticosteroid orders for children hospitalized with asthma increases linearly with weight category, disproportionately affecting children with severe obesity. Standardization of drug dosing guidelines for children with obesity may help reduce variability in drug doses prescribed that may increase risk of harm.

We describe the case of a female infant born of a term pregnancy (38 weeks) with regular surveillance and course, despite the mother having class III obesity and gestational diabetes controlled with insulin. During pregnancy, the mother had three fetal ultrasounds, all with normal morphology and

Objective Adipose tissue distribution and glucose metabolism differ between men and women. Few studies have investigated sex differences in adipose tissue insulin resistance (adipose-IR). Herein, we investigated sex differences in adipose-IR in adults ranging from overweight to obese and the potential factors associated with sex differences in adipose-IR. Methods A total of 424 adults had their body mass index (BMI), adipose-IR, and sex hormones evaluated. Based on BMI, males and females were assigned to 4 groups. Results In total, males (n = 156) had higher adipose-IR than females with similar BMI levels (n = 268) (P Conclusions Adipose-IR reflects the progressive deterioration in adipose tissue insulin sensitivity from overweight to obesity in both males and females. Males with class III obesity have more severe adipose-IR than similarly obese females. The sex difference is associated with testosterone, and low testosterone levels may contribute to more severe adipose-IR in obese males.

Objective Obesity is associated with many cardiovascular risk factors (CVRF) in childhood. There is an ongoing discussion whether there is a linear relationship between degree of overweight and deterioration of CVRFs justifying body mass index (BMI) cut-offs for treatment decisions. Methods We studied the impact of BMI-SDS on blood pressure, lipids, and glucose metabolism in 76,660 children (aged 5–25 years) subdivided in five groups: overweight (BMI-SDS 1.3 to 2.8–3.3), and class IV (BMI-SDS > 3.3). Analyses were stratified by age and sex. Results We found a relationship between BMI-SDS and blood pressure, triglycerides, HDL cholesterol, liver enzymes, and the triglycerides–HDL-cholesterol ratio at any age and sex. Many of these associations lost significance when comparing children with obesity classes III and IV: In females Conclusions Since a BMI above the highest BMI cut-off was not associated consistently with dyslipidemia and disturbed glucose metabolism in every age group both in boys and girls, measurements of CVRFs instead of BMI cut-off seem preferable to guide different treatment approaches in obesity such as medications or bariatric surgery.

Exposure to maternal diabetes in utero increases the risk in the offspring for a range of metabolic disturbances. However, the timing and variability of in utero hyperglycemic exposure necessary to cause impairment have not been elucidated. The TEAM Study was initiated to evaluate young adult offspring of mothers with pregestational diabetes mellitus. This paper outlines the unique enrollment challenges of the TEAM Study and preliminary analysis of the association between exposure to diabetes in pregnancy and adverse metabolic outcomes. The TEAM Study enrolls offspring of women who participated in a Diabetes in Pregnancy (DiP) Program Project Grant between 1978 and 1995. The DiP Study collected medical and obstetric data across pregnancy. The first 96 eligible offspring of women with pregestational diabetes were age-, sex-, and race-matched to adults from the National Health and Nutrition Examination Survey (NHANES) 2015-2016 with an OGTT. Descriptive and regression analyses were employed to compare TEAM participants to NHANES participants. Among a subset of TEAM participants, we compared the metabolic outcomes across maternal glucose profiles using a longitudinal data clustering technique that characterizes level and variability, in maternal glucose across pregnancy. By comparing categories of BMI, TEAM Study participants had over 2.0 times the odds of being obese compared to matched NHANES participants (for class III obesity, OR = 2.81 ; 95% confidence interval (CI): 1.15, 6.87). Increasing levels of two-hour glucose were also associated with in utero exposure to pregestational diabetes in matched analyses. Exposure to pregestational diabetes in utero may be associated with an increased risk of metabolic impairment in the offspring with clinical implications.