A Vital Role Played By Primary Care Physicians In The Care Of Diabetes Patients

Main Category: Diabetes
Also Included In: Primary Care / General Practice
Article Date: 14 Dec 2012 - 1:00 PST Current ratings for:
A Vital Role Played By Primary Care Physicians In The Care Of Diabetes Patients

Previous research has shown that patients without a consistent primary care physician (PCP) have worse outcomes than those who do, but little is known about why this is true. New research from Brigham and Women's Hospital (BWH) has brought to light the importance of the role of a primary care physician in a population of diabetes patients. Their findings are published in Diabetes Care.

"We found that primary care physicians provide better care to diabetes patients when compared to other providers in a primary care setting because they were more likely to alter medications and consistently provide lifestyle counseling," said Alexander Turchin, MD, a physician and researcher in the Division of Endocrinology at BWH and the senior author of the paper.

Dr. Turchin and his research colleagues designed a study to evaluate whether PCP's provide higher quality care to their patients by paying more attention to prescribed medications, offering lifestyle counseling more frequently or have a higher number of patient encounters when compared to other providers in a primary care setting including a covering physician or another provider such as a nurse practitioner or physician assistant.

Researchers evaluated more than 27,000 patients with diabetes who were cared for in a primary care setting at two academic medical centers. Among these patients, there were nearly 585,000 primary care encounters over an average of five years and five months. Researchers report that 83 percent of those encounters were with a primary care provider.

Additionally researchers report that covering physicians were the next most likely provider to see a patient, accounting for 13 percent of interactions, and they were also more likely to see a patient for an acute issue defined as a complaint of pain or infection.

Across all patient encounters, medication intensification, defined as either adding a new medication or increasing the dose of an existing medication, happened approximately 10 percent of the time and lifestyle counseling, as measured by documentation in the electronic health record, happened 40 percent of the time. The overall mean time between encounters was 1.6 months.

However, the odds of medication intensification were 49 and 26 percent higher respectively when a patient had an encounter with a PCP compared with a covering physician or mid-level provider. Additionally, the odds that lifestyle counseling occurred were 91 and 21 percent higher during an encounter with the PCP compared to a covering physician or another provider.

"Access to care is important and covering physicians and other providers play an important role in increasing access, especially in patients with acute complaints. With growing focus on a team based approach to practicing medicine, this finding should help guide the development of new models of primary care, especially in the care of diabetes patients. Based on this finding, we would suggest better documentation and communication of the treatment plan through the electronic medical record to other care providers in efforts to help to bridge the gaps that we observed in this study," Dr. Turchin said.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our diabetes section for the latest news on this subject. This study was funded by the Agency for Healthcare Research and Quality (5R18HS017030), National Library of Medicine (5RC1LM010460) and Diabetes Action Research and Education Foundation.
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posted by Yeming on 18 Dec 2012 at 3:08 pm

More attention should be given to primary care physicians in order to prevent and treat diabetes.

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'A Vital Role Played By Primary Care Physicians In The Care Of Diabetes Patients'

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Good Response From Pre-Diabetic Patients For Self-Directed Lifestyle Interventions

Main Category: Diabetes
Also Included In: Obesity / Weight Loss / Fitness;  Primary Care / General Practice
Article Date: 12 Dec 2012 - 1:00 PST Current ratings for:
Good Response From Pre-Diabetic Patients For Self-Directed Lifestyle Interventions

Efforts to help overweight patients avoid diabetes through lifestyle changes need not rely on intensive, one-on-one focused programs, a new clinical study from the Stanford University School of Medicine and the Palo Alto Medical Foundation Research Institute has found.

The study, published in the Archives of Internal Medicine, opens up a practical way for primary care physicians to help their patients at high risk for developing diabetes.

Researchers have known for 10 years that intensive intervention programs led by lifestyle coaches to encourage weight loss through healthier diet and exercise help reduce type-2 diabetes incidence. The Diabetes Prevention Program clinical research study, the results of which were published in 2002, found this strategy led to a 58 percent decrease in the incidence of type-2 diabetes, a result that surpassed the benefit of drug treatment.

The new study - headed by Jun Ma, MD, PhD, an associate investigator at the research institute and an affiliate member of the Stanford Prevention Research Center - builds off the DPP's strategy but makes full use of online resources and, in one group, a take-home DVD. If implemented, the new interventions could increase the accessibility and reach of existing educational, coach-based diabetes prevention programs, and free up time for primary care doctors, who are often frustrated with high patient loads that prevent them from providing the individualized care these patients need.

"The big issue in diabetes prevention is how to take what clearly worked for DPP - which was very intensive and one-on-one focused - and get it to the point where it could be established as a program in large group practices," said Randall Stafford, MD, PhD, professor of medicine at the Stanford Prevention Research Center and a senior investigator on the study.

Diabetes currently affects 25.8 million people in the United States, or 8.3 percent of the population. The disease is a major cause of heart disease and stroke, and is the leading cause of kidney failure, nontraumatic lower-limb amputation and new cases of blindness among adults. In 2007, diabetes-related medical costs in the United States were estimated at $174 billion. Effective health interventions that reach a maximum amount of pre-diabetic patients - those at the highest risk for developing diabetes - are urgently needed to curb the burden of the disease.

What the DPP sported in effectiveness, it lacked in its ability to broadly reach patients at the level of primary care. In the new study, Ma and Stafford set out to determine whether restructuring the DPP to take advantage of online connectivity and health monitoring could be achieved without sacrificing the benefits seen in the original program.

Pre-diabetic patients were recruited from Palo Alto Medical Foundation and randomized into three groups: a coach-led group intervention, a self-directed DVD intervention or usual care. In addition to offering practical ways to start eating healthier foods and exercising more, the curriculum in both the coach-led and DVD-based interventions also focused on the mental and behavioral strategies necessary to make the changes stick. This lifestyle instruction was delivered over a three-month intensive intervention phase.

Following the first three months of intervention, the participants regularly received encouraging messages to help them follow through with what they had learned in the initial intervention phase. During this 12-month maintenance phase, participants received supportive emails within an electronic health-record system, and monitored their health goals through the publicly available American Heart Association's Heart360 website. The primary outcome tested in the study was a change in body mass index (a calculation based on a person's height and weight), although other factors, including weight loss, waist circumference, blood pressure and blood glucose, were also measured.

The results show that participants responded to both the coach-led and self-directed interventions, although the coach-led group fared slightly better. At the beginning of the study, the participants had an average BMI of 32; a BMI of 30 or more is considered obese. After the 15-month trial, the average drop in BMI was 2.2 for the coach-led group, 1.6 for the self-directed group and 0.9 for the group that received usual care. The average weight loss was 13.9 pounds for the coach-led group, 9.9 pounds for the self-directed group and 5.3 pounds for usual care. Both interventions also led to a dip in waistline circumference as compared to the usual-care group.

Though the study was too small to generate statistically significant findings along gender lines, they turned up a hint of a gender difference: While men responded with equal success to both the coach-led and self-directed interventions, women responded better to the coach-led approach.

Stafford points out that the suggested differences between genders highlights the need for options when it comes to lifestyle interventions. "It suggests that a one-size-fits-all program isn't necessarily what we need. We need some way to offer people different styles of intervention," said Stafford.

Narrow demographics were a primary limitation of the study. Participants were all from a single clinic in Silicon Valley, and a large majority were white (78 percent), college-educated (97 percent) and earned more than $75,000 per year (88 percent). Stafford acknowledged the limited demographics of the study, but said he hopes that similar lifestyle interventions will work in more diverse populations. His group is currently conducting a National Institutes of Health-funded study testing the effectiveness of weight-loss interventions in a low-income, Latino population.

If implemented, the approaches - especially the self-directed DVD - could extend the reach and lower the cost of lifestyle intervention programs. In addition to the cost-benefit of the intervention programs themselves, the real savings will come from diabetes prevention. "Diabetes is an expensive disease to treat and its complications are both personally devastating and societally costly," said Stafford. If patients respond to self-directed programs by losing a modest amount of weight, this could be enough to prevent or significantly delay the onset of type-2 diabetes in high-risk populations, ultimately reducing the burden of this chronic disease.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our diabetes section for the latest news on this subject.
Other Stanford co-authors were instructors Veronica Yank, MD, and Lisa Rosas, PhD. They also collaborated with other researchers at the Palo Alto Medical Foundation Research Institute.

The study was supported by grants from the National Institute of Diabetes and Digestive and Kidney Diseases and the American Heart Association, as well as internal funding from the Palo Alto Medical Foundation Research Institute.

Stanford University Medical Center

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Diabetic Patients May Benefit From The Antidepressant Paroxetine

Main Category: Diabetes
Also Included In: Vascular;  Depression
Article Date: 20 Dec 2012 - 0:00 PST Current ratings for:
Diabetic Patients May Benefit From The Antidepressant Paroxetine

University of Texas Medical Branch at Galveston researchers have discovered that the commonly used antidepressant drug paroxetine could also become a therapy for the vascular complications of diabetes.

The scientists made their discovery after screening 6,766 clinically used drugs and pharmacologically active substances.

"We developed this assay and used it to test literally every single existing drug and a good selection of other biologically active compounds," said UTMB professor Csaba Szabo, senior author of a paper on the research published online by Diabetes. "We were quite surprised when paroxetine came out as an active compound - a result, we later determined, of what seems to be a completely new effect unrelated to its antidepressant actions and not shared by any other known antidepressant drug."

The initial screening process tested the ability of different compounds to protect the cells that make up the inner linings of blood vessels from the destructive effects of the high sugar levels produced by diabetes, known as hyperglycemia. In people with diabetes, hyperglycemia causes these endothelial cells to generate toxic molecules known as reactive oxygen species (ROS), which ravage blood-vessel linings and lead to diabetic endothelial dysfunction, the key factor in such destructive diabetic complications as heart attacks, strokes, retinopathy, nephropathy and neuropathy.

In subsequent test-tube studies, researchers found that paroxetine - which is sold as an antidepressant under the trade name "Paxil" - prevents hyperglycemia-initiated ROS damage to endothelial cells in two ways. First, it directly reduces concentrations of superoxide, a powerful ROS. Second, it suppresses superoxide production by mitochondria, tiny structures whose real job is making the energy-transfer molecules needed for most cellular processes. In a hyperglycemic environment, mitochondria are cells' biggest source of superoxide. According to the researchers' findings, paroxetine inhibits this activity without interfering with the mitochondria's vital normal function.

Further experiments yielded still more evidence that paroxetine protects endothelial cells under hyperglycemic conditions. Reactive oxygen species cause significant damage to DNA, RNA and proteins, but cell-culture experiments showed that paroxetine significantly reduced this effect. The drug had similarly beneficial results when tested on rat "aortic rings" - small pieces of blood vessel kept alive with tissue-culture techniques. When treated with the vasodilator acetylcholine, these rings dilated just as if they were still part of a functioning circulatory system; endothelial dysfunction caused by diabetic hyperglycemia normally interferes with this function, but paroxetine restored it.

Finally, the researchers tested paroxetine in rats that had been injected with streptozotocin, a chemical that induces diabetes. The animals given paroxetine developed hypoglycemia, but like the aortic rings, their arteries retained the ability to dilate - an indication that the drug had prevented damage to their epitheliums.

"The future potential of this study is that we may be able to 're-purpose' paroxetine for the experimental therapy of diabetic cardiac complications," Szabo said. "We'll need to carefully characterize its safety profile in diabetic patients, but I think there's definite potential here."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our diabetes section for the latest news on this subject. Other authors of the Diabetes paper include instructor Dr. Domokos Gerö, research fellow Petra Szoleczy, postdoctoral fellow Kunihiro Suzuki, postdoctoral fellow Katalin Módis, faculty associate Dr. Gabor Oláh and postdoctoral fellow Ciro Colletta. This research was supported by the Juvenile Diabetes Foundation, the American Heart Association and the James W. McLaughlin Endowment.
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Obese Patients Face Increased Risk Of Kidney Damage After Heart Surgery

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our cardiovascular / cardiology section for the latest news on this subject. Study co-authors include Mias Pretorius, MD, Jonathan Schildcrout, PhD, Nathaniel Mercaldo, John Byrne, MD, T. Alp Ikizler, MD, Nancy J. Brown, MD (Vanderbilt University School of Medicine).

Disclosures: The authors reported no financial disclosures.

The article, entitled "Obesity and Oxidative Stress Predict Acute Kidney Injury Following Cardiac Surgery," will appear online at http://jasn.asnjournals.org/ on May 24, 2012, doi: 10.1681/ASN.2011090940.

The content of this article does not reflect the views or opinions of The American Society of Nephrology (ASN). Responsibility for the information and views expressed therein lies entirely with the author(s). ASN does not offer medical advice. All content in ASN publications is for informational purposes only, and is not intended to cover all possible uses, directions, precautions, drug interactions, or adverse effects. This content should not be used during a medical emergency or for the diagnosis or treatment of any medical condition. Please consult your doctor or other qualified health care provider if you have any questions about a medical condition, or before taking any drug, changing your diet or commencing or discontinuing any course of treatment. Do not ignore or delay obtaining professional medical advice because of information accessed through ASN. Call 911 or your doctor for all medical emergencies.

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Lipoprotein Levels In Obese Patients With NAFLD Do Not Improve With Exercise

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Main Category: Liver Disease / Hepatitis
Also Included In: Obesity / Weight Loss / Fitness;  Sports Medicine / Fitness
Article Date: 29 May 2012 - 10:00 PDT Current ratings for:
'Lipoprotein Levels In Obese Patients With NAFLD Do Not Improve With Exercise'

Moderate physical activity does not improve lipoprotein concentrations in obese patients with non-alcoholic fatty liver disease (NAFLD), say researchers. The team found that in these patients, exercise only decreases triglyceride and alanine transaminase (ALT) levels by a small amount.

The study is published in Hepatology, a journal of the American Association for the Study of Liver Diseases.

According to the World Health Organization (WHO), in 2008, 1.5 billion individuals aged 20+ were overweight, and of these, 500 million were considered obese.

NAFLD is a common complication of obesity and can cause inflammation and scarring in the liver as well as liver failure. Earlier studies revealed that regular exercise and weight loss improved metabolic disturbances linked with NALFD.

In this study, Dr. Samuel Klein and his team from the Washington University School of Medicine in St. Louis, Mo., set out to determine how physical activity programs recommended by the Department of Health and Human Services impacted cholesterol, ALT, and triglyceride levels in obese patients with NALFD.

The researchers enrolled 18 obese patients with NAFLD to participate in the study. 12 participants were randomly assigned to the physical activity group and 6 were assigned to the control group. Those in the physical activity group engaged in 30-60 minutes of moderate exercise 5 days per week for 16 weeks.

The team evaluated how much physical exercise affected very low density lipoproteins (VLDL), intrahepatic triglyceride (IHTG), and apolipoprotein B-100 (apoB-100).

The researchers found that physical activity reduced IHTG content by 10%, but did not change body fat percentage or total body weight. Before the exercise program began, total body weight was 103.1 kg vs. 102.9 kg after, and total body fat was 38.9 vs. 39.2 after the exercise program.

No change in liver lipoprotein levels (VLDL or apoB-100) was found among participants in the physical activity group.

Dr. Klein concludes:

"Our data demonstrate that a moderate intensity exercise program followed by obese patients with NALFD causes a small decrease in IHTG content, even when body weight and total body fat mass are maintained.

Current exercise recommendations seem to have only a modest effect on triglycerides and ALT levels, suggesting that improvement in lipoprotein metabolism and fatty liver (steatosis) may be due to weight loss and not increased physical activity."

The researchers note that further research is required in order to assess the impact of moderate physical activity on IHTF content in individuals with NAFLD.

Written By Grace Rattue
Copyright: Medical News Today
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'Lipoprotein Levels In Obese Patients With NAFLD Do Not Improve With Exercise'

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Better Outcomes In Obese Heart Failure Patients

Main Category: Heart Disease
Also Included In: Obesity / Weight Loss / Fitness
Article Date: 05 Jul 2012 - 1:00 PDT Current ratings for:
Better Outcomes In Obese Heart Failure Patients

A slim waist and normal weight are usually associated with better health outcomes, but that's not always the case with heart failure patients, according to a new UCLA study.

Researchers found that in both men and women with advanced heart failure, obesity - as indicated by a high body mass index (BMI) - and a higher waist circumference were factors that put them at significantly less risk for adverse outcomes.

The study findings are published in the July 1 online issue of the American Journal of Cardiology.

Heart failure affects 5.8 million people, including 2.5 million women. Approximately one-half to two-thirds of heart failure patients are overweight or obese.

Women and men are known to have differences in body composition and body-fat distribution, and this study is one of the first to specifically assess the impact of BMI and waist circumference on women and compare it with men.

The findings also offer further insight into an observed phenomenon in chronic heart failure known as the "obesity paradox": Obesity is a known risk factor for developing heart disease and heart failure, but once heart failure has manifested, being overweight may provide some protective benefits.

"The study provides us with more insight about how both genders of heart failure patients may be impacted by the obesity paradox," said senior author Dr. Tamara Horwich, an assistant professor of cardiology at the David Geffen School of Medicine at UCLA. "Heart failure may prove to be one of the few health conditions where extra weight may prove to be protective."

For the study, researchers analyzed data on advanced heart failure patients treated at UCLA Medical Center from 1983 to 2011. The team assessed 2,718 patients who had their BMI measured at the beginning of heart failure treatment and 469 patients who had their waist circumference measured at the beginning of treatment.

Using standardized measures, the researchers identified men or women as having a high BMI if they were greater or equal to 25 kg/m² - this included both overweight patients (25 to 29.9 kg/m²) and obese patients (30 kg/m² or greater).

For men, a high waist circumference was considered 40 inches (102 cm) or greater, and for women, 37 inches (88 cm) or greater. This assessment also included patients who were either overweight or obese.

At the two-year follow-up, researchers used statistical analysis and found that in men, a high waist circumference and high BMI were associated with event-free survival from adverse outcomes like death, the need for a heart transplant, or the need for ventricular assist device placement.

Women with a higher BMI also had better outcomes than their normal-weight counterparts, and women with a high waist circumference also trended toward improved outcomes.

Both men and women with a normal BMI and waist circumference were at a substantially higher risk for these adverse outcomes. In fact, a normal BMI was associated with significantly worse outcomes - a 34 percent higher risk in men and a 38 percent higher risk in women - than a high BMI.

Normal waist circumference was also associated with an increased risk of adverse outcomes in both genders, with men's risk doubling and women's risk tripling.

"We knew that obesity might provide a protective benefit for heart failure patients, but we didn't know whether this obesity paradox applied specifically to women with heart failure, as well as men - and it does," Horwich said.

BMI measurement has been used for years as a surrogate measure of body fat. Since it measures all mass - including lean muscle, which weighs more than fat - the measurement may not be specific for total body fat. Waist circumference is a newer addition that may provide a more direct connection to body fat, since it measures the fat accumulated around the belly.

"The study also demonstrates how BMI and waist circumference can be used together to provide a more accurate measure of fat in the body to help determine obesity and assess risk," said the study's first author, Adrienne L. Clark, a resident in the department of medicine at the Geffen School of Medicine.

According to Horwich, no one knows exactly why the obesity paradox exists for heart failure patients, but there are several possible explanations.

Being underweight is traditionally associated with a poorer prognosis in heart failure patients. Obesity may be at the other end of the spectrum, and patients may thereby benefit from increased muscle mass, as well as metabolic reserves in the form of fatty tissue. In addition, increased levels of serum lipoproteins that are associated with increased body fat may play an anti-inflammatory role, neutralizing circulating toxins and inflammation-related proteins.

Obese patients also present at an earlier stage of heart failure due to increased symptoms and functional impairment caused by excess body weight, so they may be getting help sooner, which also could improve outcomes, the researchers said.

The next steps in research will include larger studies with longer follow-up times, as well as a closer look at the physiology behind the obesity paradox.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our heart disease section for the latest news on this subject. The study was funded by the National Heart, Lung and Blood Institute, part of the National Institutes of Health (grant 1K23HL085097).
Jennifer Chyu of the UCLA Department of Molecular, Cell and Developmental Biology, was also a study author.
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Minimally Invasive Operations Lead To Fewer Complications For Obese Appendectomy Patients

Main Category: GastroIntestinal / Gastroenterology
Also Included In: Obesity / Weight Loss / Fitness
Article Date: 28 Jun 2012 - 1:00 PDT Current ratings for:
Minimally Invasive Operations Lead To Fewer Complications For Obese Appendectomy Patients

Obese patients who need to have their appendixes removed fare better after a minimally invasive surgical procedure rather than an open operation, according to a new study published in the July issue of the Journal of the American College of Surgeons.

While the traditional open operation (appendectomy) and minimally invasive procedure (laparoscopic appendectomy) are known to have similar outcomes for people of normal weight, surgeons at the University of Southern California's Keck School of Medicine found that obese patients had fewer complications 30 days after a minimally invasive laparoscopic operation, in which surgeons make one to three small incisions in the abdomen and remove the appendix through one of the small openings. The obese patients had longer hospital stays and higher rates of infectious complications if they underwent the open procedure, whereby a surgeon removes the appendix through a 2-to-4-inch incision in the right side of the abdomen.

"There are early studies that suggest the laparoscopic approach may be less risky in obese patients, but there's not much recent information available to strongly prove it," said lead study author Rodney J. Mason, MBBCh, FACS, associate professor of surgery at Keck School of Medicine. Appendectomies are among the most common types of operations in the United States.1 Meanwhile, more than 35 percent of U.S. adults and 17 percent of youth are obese, according to the U.S. Centers for Disease Control and Prevention.2 "We expect to see more and more obese people with medical conditions that require general surgical intervention" Dr. Mason said. "We need to know what approach works best for these patients."

Dr. Mason and colleagues did two analyses in the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP®) database of patients who had appendectomy procedures between 2005 and 2009. Approximately 13,330 patients in the database were considered obese, based on a body mass index (BMI) of 30 or higher.

In the first analysis, Mason and his team of surgeons compared how all the obese patients in the database fared after having either an open or laparoscopic appendectomy. Results showed that patients who had the open procedure were significantly more likely to have complications, including wound infections, pneumonia, heart attacks, and septic shock. For example, 8 percent of the open appendectomy patients had non-wound related complications like heart attacks, compared with 4 percent of laparoscopy patients. Additionally, open appendectomy patients stayed in the hospital a mean of 2.3 days longer than patients who had the laparoscopic appendectomy. Overall, the laparoscopic procedure was associated with a 57 percent reduction in morbidity compared with the open procedure in obese patients.

The second analysis matched 1,114 of the laparoscopic appendectomy patients with an open operation patient group who had the same demographics and comorbid conditions. Results again showed that complications were more likely for patients who had open appendectomies. They spent more than a day longer in the hospital, and their procedures took longer than the time required for patients who had the laparoscopic procedure, which was associated with a 53 percent reduction in the risk of morbidity. Also, the more patients weighed, the worse their outcomes were with open procedures. In contrast, all the patients who underwent the laparoscopic procedure had similar outcomes, regardless of how obese they were.

Despite the noted improved outcomes for the laparoscopic surgical approach in patients with complicated appendicitis, over 40 percent of these patients in the database had undergone an open operation. With national expenditures already estimated at about $147 billion for obesity-related conditions,3 the study's results have implications for health care costs, particularly at hospitals that say open procedures cost less because they do not require the expensive equipment needed for laparoscopy.

"We've shown a shorter length of stay. There's the cost savings right there," Dr. Mason said. "Also if you can prevent a patient's wound infection, which stops him or her from having to come see the doctor four times after a procedure, reducing that complication will reduce costs. And if someone doesn't get pneumonia after an operation, that result will be cost-effective as well."

Dr. Mason noted that because laparoscopic appendectomy is still relatively new, especially for obese patients, some surgeons and hospitals default to the tried-and-true open procedure. But that approach is changing. "It depends on the surgeons' training and whether they were trained to perform laparoscopy or not," he explained. "Many surgeons are more inclined to perform laparoscopic procedures because that's how they were trained."

Moreover, the move toward laparoscopic appendectomy is to some extent patient driven, Dr. Mason pointed out. "Most of my patients seem to prefer laparoscopic operations nowadays" he concluded.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our gastrointestinal / gastroenterology section for the latest news on this subject. 1 Owings MF, Kozak LJ. "Ambulatory and in-patient procedures in the United States, 1996." In: Vital and Health Statistics, Series 13, No. 139 [DHHS publication no. (PHS) 99-1710.] Hyattsville, MD: National Center for Health Statistics, 1998:26
2 Ogden, CL, et al. "Prevalence of Obesity in the United States, 2009-2010." NCHS Data Brief 82: Jan. 2012: http://www.cdc.gov/nchs/data/databriefs/db82.pdf
3 Finkelstein, EA, et al. "Annual medical spending attributable to obesity: Payer- and service-specific estimates." Health Affairs 28(5): w822-w831; Sept-Oct. 2009.
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'Minimally Invasive Operations Lead To Fewer Complications For Obese Appendectomy Patients'

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