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Bone health in the context of two common maladies, osteoporosis and obesity, has spurred research in the area of physical activity (PA) and bariatric surgery (BarS). Objectives: To examine: 1) relationships between PA and the skeleton utilizing the peripheral Quantitative Computed Tomography (pQCT) and Dual-energy X-ray Absorptiometry (DXA) in pre-menopausal women; 2) effects of adjustable gastric banding (AGB) vs. Roux-en-Y gastric bypass (RYGB) surgeries on pQCT and DXA measures; 3) 6-month time course changes on serum biomarkers of bone turnover and associated adipokines induced by AGB vs. RYGB. Methods: Standard DXA and pQCT measurements were taken for all subjects. PA tertiles (PA-L, PA-M, PA-H) were based on a calculated average MET-min/day determined from 4-d self-reported PA and pedometer step counts. For BarS subjects, bone measurements were taken pre-surgery, 3- and 6-months post-surgery along with serum (or plasma) from fasting blood draws, with ELISA assays for total OC, undercarboxylated OC, CTx, adiponectin, and leptin. Results: Minimal DXA differences between the highest and lowest PA tertiles were seen, while pQCT tibial measures and polar strength-strain index (SSIp) indicated differences along the tibial shaft. Comparing the two instruments and adjusting for BMI, the DXA leg and hip BMD and BMC showed differences (p<0.05) between PA-M and PA-L as well as PA-H and PA-L. Similarly, the pQCT tibial cortical area, BMC, and SSIp were progressively greater for the different levels of PA (p<0.05). 3- and 6-months post-BarS weight, fat-free mass, fat mass, central body fat, tibial and radial subcutaneous fat, and radial MCSA decreased (p<0.05). Comparing the AGB and RYGB and adjusting for weight, DXA BMC showed decreases (p<0.01) at both time points for RYGB. RYGB demonstrated differences (p<0.05) in bone measures at 3- and 6-months post-surgery along the tibial shaft that are indicative of increases in bone strength, and at 6-months, total OC, undercarboxylated OC, and HMW adiponectin increased, while leptin decreased. Conclusions: PA is associated with increases in bone, but pQCT data are more discriminatory and sensitive. 6-months post-RYGB, pQCT measures indicate increases in bone strength parameters, and greater bone adaptation was evidenced by biomarkers of increased osteoblastic activity. / Ph. D.

Bakgrund: Fetma är ett folkhälsoproblem som har ökat dramatiskt de senaste två decennierna. För att behandla extrem fetma har magsäcksoperationer blivit en allt mer vanlig metod. De hälsoekonomiska aspekterna av operation har ännu inte studerats i Sverige. Syfte: Studiens syfte var att belysa hälsoekonomiska aspekter av magsäcksoperationer som intervention mot fetma. Metod: Metoden var en litteraturstudie. Elva vetenskapliga studier valdes ut, analyserades och sammanställdes utifrån hälsoekonomiska aspekter. Resultat: Magsäcksoperationer var kostnadseffektiva som intervention mot fetma i jämförelse med ingen intervention, traditionell intervention och medicinsk behandling. Studiernas resultat varierade i tid till break even och beräkning av inkrementell kostnadskvot. Troliga anledningar till dessa skillnader var studiernas olika ursprungsländer och tidsperspektiv. Slutsats: Ur ett hälsoekonomiskt perspektiv rekommenderas operationer som intervention mot fetma. Dock bör etiska aspekter beaktas när samhällets begränsade ekonomiska resurser ska fördelas mellan olika interventioner. / Background: Obesity has increased dramatically in the last 20 years and has become a major public health issue. Bariatric surgery has become a more commonly used method for treating morbid obesity. The health economic aspects of bariatric surgery have not yet been studied in Sweden. Aim: The study highlights the health economic aspects of bariatric surgery as an intervention to treat obesity. Method: The method used was a literature review. Eleven scientific studies were selected, analyzed and compiled using a health economic perspective. Results: Bariatric surgery was a cost effective intervention for treating obesity, compared with no interventions, traditional interventions and medical treatment. The results of the studies vary in time to break even and incremental cost ratio. The studies different countries of origin and time perspectives are possible reasons for these differences. Conclusion: From a health economic perspective bariatric surgery was recommended as an intervention for treating obesity. However, ethical issues should be considered when the society's limited financial resources are distributed between different interventions.

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Dans ce travail, nous décrivons les conséquences physiologiques et physiopathologiques de l'obésité, ainsi que les difficultés techniques et logistiques de la prise en charge clinique. Puis, nous étudions les caractéristiques de la prise en charge des patients obèses et obèses morbides aux urgences, au bloc opératoire et en réanimation, ainsi que les modifications de la fonction respiratoire liées à l'obésité morbide et à la perte de poids. Aux urgences, nous démontrons que les patients obèses (IMC et#8805; 30 kg/m²) ont un capital veineux moins accessible et sont plus difficiles à perfuser que les non obèses. En physiologie clinique, nous avons pu confirmer l'absence de variation de la CRF en position couchée et démontrer pour la première fois l'effet de la perte de poids et de la position couchée sur les variations de la CRF. Au bloc opératoire, nous montrons que la préoxygénation des obèses morbides est optimisée par la ventilation non invasive (VNI), qui permet une augmentation rapide et importante de la fraction expirée en oxygène (FEo2) que la préoxygénation classique. Nous montrons aussi que la position assise à 45° associée à la VNI n'améliore pas la préoxygénation chez l'obèse morbide comparé à la VNI seule. Enfin, nous rapportons que les patients obèses médicaux en réanimation se caractérisent par une surmortalité, qui persiste un an après la sortie de l'hôpital, alors que les patients obèses chirurgicaux bénéficient d'un effet protecteur qui persiste jusqu'à un an. Nos travaux proposent la mise en place de nouvelles techniques afin d'optimiser les conditions de prise en charge spécifiques des patients obèses aux urgences, au bloc opératoire et en réanimation. / To specifically address arising issues in managing obese patients, we have developed a physiological and a clinical approach. We first describe the physiological and pathophysiological consequences of obesity, as well as the technical and logistic difficulties in obese patient management. We then underline respiratory alterations in morbid obesity and study characteristics of obese and morbidly obese patients' care in the emergency department (ED), the operating room (OR) and the intensive care unit (ICU).In the ED, we demonstrate that obese patients (BMI ³ 30 kg/m2) are more difficult to perfuse than normal weight patients. In clinical physiology, as for alterations in respiratory function induced by obesity, we confirm the maintained functional residual capacity (FRC) in morbidly obese patients adopting a supine position and we further demonstrate for the first time, the effect of weight loss on postural changes in FRC, from the sitting to the supine position in a same individual.In the OR, we show that obese patient's pre-oxygenation can be optimized by using non-invasive ventilation (NIV), thus allowing a better and faster FeO2 increase than classical pre-oxygenation with spontaneous ventilation. We also demonstrate that combining a upright position at 45° to non invasive ventilation (NIV) does not improve pre-oxygenation in the morbidly obese patients. In the ICU, we show that medical obese patients show a higher mortality, whereas surgical obese patients benefit from a protective effect of obesity up to one year after hospital leave. In light of our data, we propose new techniques to specifically optimize obese patient management in the ED, OR and in the ICU.