January 29, 2010 | 10:03 pm

Normal Weight Obesity:  Why Losing Weight Is Not Always the Answer

Posted by Albert Fuchs, M.D.

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Weight loss is one of the most common recommendations that doctors make.  How do we know if a patient should lose weight?  We usually use the Body Mass Index (BMI) which is a way to compare a patient’s weight to her height.  (For all you math geeks, it’s the weight in kilograms divided by the height in meters squared.  For all you physicists, I know the units make no sense.)  A BMI of 18.5 to 25 is considered normal.  A BMI of 25 to 30 is considered overweight, and over 30 is considered obese.  (See the link below to calculate your BMI.)

An article in the health section of Tuesday’s Wall Street Journal reminds us that BMI may not be telling us the whole story.  The article cites a study published in the European Heart Journal last year which followed over 6,000 adults with a normal BMI.  They all had their body fat percentage measured and were followed for about 9 years.

Surprisingly, even in these adults with a “normal” weight, those with a high body fat content had a higher likelihood of high blood pressure, high cholesterol and cardiovascular disease.

This study is too small to be definitive, and it’s observational, not randomized.  So we don’t know whether lowering body fat reverses any of these risk factors.  I’m not suggesting we all run out to measure our body fat content.  Still the article suggests a few tantalizing possibilities.

First, dieting may not be enough in improving cardiovascular health.  It may decrease overall weight without decreasing percent body fat.  Exercise is critical to burn fat and build muscle, thereby decreasing percent body fat.

Second, thin people who are inactive may have a high body fat percentage and may be falsely reassured by their “normal” weight.  This is what the authors call “normal weight obesity”.

Finally, for those of you who are exercising and not losing weight, don’t despair.  You may be losing inches from your waist, burning fat and building muscle, muscle while your weight stays the same.  Going by the weight alone is a recipe for frustration when in reality your health is improving.

Learn more:

The Centers for Disease Control BMI calculator

Wall Street Journal article:  The Scales Can Lie: Hidden Fat (only by subscription)

European Heart Journal article:  Normal weight obesity: a risk factor for cardiometabolic dysregulation and cardiovascular mortality

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

January 22, 2010 | 6:12 pm

A New Treatment for Clostridium difficile

Posted by Albert Fuchs, M.D.

You may not yet have heard of the bacterium Clostridium difficile (C. dif.), but in the next few years it will likely become a household name, as well known as Staph and Strep.  C. dif. causes a severe infection of the colon leading to severe diarrhea.  It frequently results as a consequence of antibiotic use.  Antibiotics can kill the normal intestinal bacteria and allow harmful bacteria like C. dif. to proliferate.

Decades ago, C. dif. infection was a minor nuisance, but in the last decade, due perhaps to increasing use of broad-spectrum antibiotics, C. dif. has become more common and more severe.  Many patients, especially older patients, require hospitalization for C. dif. diarrhea.  Besides causing severe dehydration, C. dif. can cause systemic infection and sometimes death.

Ironically, the typical treatment for C. dif. colitis is antibiotics.  But since antibiotics don’t allow the normal gut bacteria to return, recurrence of C. dif. diarrhea after treatment is completed is a frequent problem.  In hospitals and nursing homes spread of C. dif. has become a menace.

A study published in this issue of the New England Journal of Medicine offers hope against this worsening problem.  The study randomized 200 patients with C. dif. diarrhea.  All patients received conventional antibiotic treatment.  Half the patients also received a new intravenous antibody directed at C. dif. toxin; the other half received intravenous placebo.  The results were encouraging.  Only 7% of the patients that received the intravenous antibody developed another episode of C. dif. infection, compared to 25% receiving placebo.  That means that for every about six patients that receive the antibody, one recurrent infection is prevented.

This new treatment will have to undergo larger trials before it is approved.  In the meantime the cornerstones of C. dif. prevention remain judicious antibiotic use and preventing spread between patients in hospitals and nursing homes.

Learn more:

New England Journal of Medicine article:  Treatment with Monoclonal Antibodies against Clostridium difficile Toxins

New England Journal of Medicine editorial:  Clostridium difficile — Beyond Antibiotics

Forbes post on The Science Business:  Why You Should Care About Treatment with Monoclonal Antibodies against Clostridium difficile Toxins

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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January 15, 2010 | 7:56 pm

To Clot or to Bleed?

Posted by Albert Fuchs, M.D.

Aspirin has long been known to prevent strokes and heart attacks in patients with a previous stroke or heart attack.  But aspirin has potentially serious side-effects.  Aspirin can cause stomach ulcers, and it inhibits blood clotting raising the risk of life-threatening bleeding.

If we knew in advance that a patient was going to be in a car accident or have a bleeding stomach ulcer, we would discontinue the aspirin a week before the event and minimize the bleeding risk.  (This is exactly what we do in anticipation of routine surgery.)  But of course such events don’t herald themselves, so doctors are left reacting to adverse events after they occur.  If a patient has life-threatening bleeding we stop the aspirin and consider that the risk may outweigh the benefits.  If the patient months or years later has a stroke we reconsider restarting the aspirin.  But this strategy is irrational.  What is needed is a way to balance risks and benefits of aspirin based on the likelihood of future events, regardless of which event happened most recently.

A study published in this issue of Annals of Internal Medicine examines the wisdom of the current practice of discontinuing aspirin after bleeding from stomach ulcers.  The study followed 156 patients who had been taking aspirin for stroke or heart attack prevention and developed bleeding stomach ulcers.  All patients had endoscopy to determine the site of bleeding and to stop the bleeding.  They were all then started on acid suppressing medication to decrease the risk of future bleeding.  Half the patients were randomized to continue 80 mg of aspirin daily and the other half to placebo.

The patients were followed for 8 weeks to test whether the patients on aspirin had more recurrent bleeding than those on placebo.  The hope was that the acid blocking medication would make the aspirin safe.  It didn’t.  Significantly more patients had bleeding on aspirin than on placebo.  But surprisingly, more patients died on placebo than on aspirin.  The reason was that more patients had strokes and heart attacks on placebo.

This study is too small to reach definitive conclusions, but its results should rattle our current thinking.  Rather than stop aspirin because an adverse effect occurs, the right course may be to remember why we recommended aspirin in the first place.  After all, strokes and heart attacks are much harder to fix than bleeding ulcers.

Learn more:

Annals of Internal Medicine article:  Continuation of Low-Dose Aspirin Therapy in Peptic Ulcer Bleeding

Annals of Internal Medicine editorial:  Aspirin Withdrawal in Acute Peptic Ulcer Bleeding: Are We Harming Patients?

Tangential miscellany:

My post last week, Antidepressants for Mild Depression May Not Help Much, generated many interesting comments, some from the handful of psychiatrists and psychologists who are my patients.  Many comments pointed out important limitations of the study I wrote about.  Two psychiatrists pointed me to the following New York Times articles which make the case that antidepressants are more beneficial than the study I cited suggests.  I’m grateful to all who wrote to me.

New York Times article:  Before You Quit Antidepressants ...

New York Times Op-Ed:  The Wrong Story About Depression

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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January 8, 2010 | 8:10 pm

Antidepressants for Mild Depression May Not Help Much

Posted by Albert Fuchs, M.D.

Treatments for depression are difficult to study.  First, depression is a condition that can improve without treatment.  So any treatment must be compared to placebo to see if the treatment is responsible for the improvement or if the depression improved on its own.  Also, depression can not be measured objectively.  There is no objective test like an X ray or a blood test that can diagnose depression.  (At least not yet.  As our understanding of brain function improves, such a test is certainly conceivable.)  For now, the most reliable measures of depression used in research are standardized questionnaires.  Another difficulty is that depression has a high response rate to placebo, so demonstrating that a treatment is better than placebo isn’t easy.

Because of these difficulties, most randomized trials testing antidepressants tend to study severely depressed patients, and they clearly show that antidepressants are beneficial.  But is the benefit the same in patients with milder depression?  A study in this issue of the Journal of the American Medical Association answers that question.

The study collected the data from six trials which randomized a total of 718 patients with depression to an antidepressant or to placebo.  It then compared how much more improvement antidepressants offered over placebo in patients with different levels of depression severity.  Surprisingly, for patients with mild or moderate initial symptoms, the difference between antidepressant and placebo was not significant.  The benefit of antidepressants over placebo grew in those with more severe symptoms.

The authors conclude:

The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.

What does that mean in practical terms?  First, it’s another reminder that antidepressants help patients with severe depression.  But for patients with mild symptoms it suggests that the visit with an attentive doctor, the anticipation that the medication may work, and the simple passage of time help more than the medicine itself.

Learn more:

Wall Street Journal article:  Effectiveness of Antidepressants Varies Widely

LA Times article:  Study finds medication of little help to patients with mild, moderate depression

Journal of the American Medical Association article:  Antidepressant Drug Effects and Depression Severity

Important legal mumbo jumbo:
Anything you read on the web should be used to supplement, not replace, your doctor’s advice.  Anything that I write is no exception.  I’m a doctor, but I’m not your doctor despite the fact that you read or comment on my posts.  Leaving a comment on a post is a wonderful way to enter into a discussion with other readers, but I will not respond to comments (just because of time constraints).

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