One of the dreaded complications of chronic hepatitis B and C viral infection is the development of liver cirrhosis. As the cirrhosis progress, the hardened liver would no longer be able to sustain life, thus, precipitating the need for a liver transplant. Will the fact that one is under-weight or over-weight at the time of liver transplantation influence patient outcome?

Researchers at the University of Washington examined the United Network for Organ Sharing (UNOS) database from 1987 to 2007 in order to determine the morbidity and mortality of patients undergoing liver transplantation at the extremes of the body mass index (BMI). The 73,538 recipients were stratified into 6 BMI categories: underweight (< 18.5 kg/m²), normal weight (18.5 - < 25 kg/m²), overweight (25 - < 30 kg/m²), obese (30 - < 35 kg/m²), severely obese (35 - < 40 kg/m²) and very severely obese (≥ 40 kg/m²). There were 1827 patients in the underweight group, 1447 patients in the very severely obese group and 68,172 patients in the other groups, which became the control (Liver Transpl 2009; 15: 968 – 977). Groups at the extreme ends of BMI (<18.5 and ≥ 40) were compared to control. The analysis showed that underweight patients are more likely to die from haemorrhagic complications and cerebrovascular accidents. The very severely obese patients were more likely to die from infectious complications and cancers. Thus, underweight and very severe obesity were significant predictors of death in those who had liver transplantation.

Is this poorer outcome also evident in other organ transplantation, such as kidney transplantation? Not much information is available for under-weight recipients. What about over-weight recipients? A study from University Hospital of Wales analysed the outcomes of 114 obese kidney recipients, allocated into Group A (BMI 30 – 34.9, moderate obesity) and Group B (BMI ≥ 35, morbid obesity). The 1 year and 5 year patient survival rates in Group A were 98.9% and 95.6% respectively, compared to 87.5% and 79.2% respectively in Group B patients. The degree of obesity also influenced kidney graft survival. The 5 year graft survival rate in Group A was 94.5% compared to only 63% in Group B (Transplant Proc 2008; 40: 3408 – 3412). Morbidly obese kidney recipients have a significantly poorer outcome.

It is easy to become over-weight. It is more difficult to become under-weight. Obesity has become a global health issue and will become a major health problem in the 21^st century. You have a big say in whether you become too fat or just right. Choose wisely!

The worldwide incidence for obesity is increasing. Apart from being associated with increased risks of developing diabetes mellitus, ischaemic heart disease, back problems and joint diseases, obesity is also a risk factor for the development of cancer.

A study from the University of Texas M D Anderson Cancer Center compared 841 patients with pancreatic adenocarcinoma with 754 healthy individuals to see if there is an association between obesity and increased risk of pancreatic cancer (JAMA 2009; 301: 2553 – 2562). Overweight individuals (BMI 25 – 29.9), aged 14 to 39 years, and obese individuals (BMI ≥ 30), aged 20 to 49 years, respectively had a 67% and 158% increased risk of pancreatic cancer. The association was stronger in men than in women. Those who were overweight or obese from the ages of 20 to 49 years had an earlier onset of pancreatic cancer by 2 – 6 years. When non-obese individuals with pancreatic cancer were compared to obese individuals with pancreatic cancer, aged 30 to 79 years, the non-obese individuals had longer overall survival irrespective of the cancer disease stage and tumour resection status.

Once you have become overweight or obese, would losing weight reverse the increased risk of cancer? The Swedish Obese Subjects (SOS) study recently published its study involving 2010 obese patients (BMI ≥ 34 in men and ≥ 38 in women) who underwent weight reduction surgery (bariatric surgery) and 2037 contemporaneously matched obese controls (Lancet Oncol 2009; 10: 653 – 662). The median follow-up time was 10.9 years. Over 10 years, bariatric surgery led to a sustained weight reduction of 19.9 kg while in controls there was a weight gain of 1.3 kg. The risk of developing cancer was reduced by 33% in those who underwent bariatric surgery. However, the risk reduction by bariatric surgery was only seen in women but not in men.

These two studies demonstrate that being overweight or obese will increase your risk of developing cancer. While surgery to help you lose weight can reduce your risk of developing cancer, the goal in life surely is not to become overweight or obese in the first place.

Watch your weight. Keep fit and keep trim.

Recently, a lady from Malaysia consulted me for a second opinion as she had been diagnosed with stage IV pancreatic cancer. Apart from a history of epigastric discomfort, early satiety and slight loss of weight, she felt fine. The CT scan showed a locally advanced pancreatic cancer with metastases to the liver. The family wanted to know why she developed the cancer. Was it something she had eaten, drunk or something she had come into contact with?

Researchers from the National Cancer Institute, USA, studied the link between 5 lifestyle factors and the risk of pancreatic cancer in 450,416 participants in the National Institutes of Health-AARP Diet and Health Study (Arch Intern Med 2009; 169: 764 – 770). During 1995 – 1996, these participants completed a baseline frequency questionnaire eliciting diet and lifestyle information and were followed up through 31^st December 2003. The participants were scored on 5 modifiable lifestyle factors as unhealthy (0 points) or healthy (1 point), receiving 1 point each for non-smoking, limited alcohol use, adherence to the Mediterranean dietary pattern, body mass index (BMI, ≥ 18 and < 25) and regular physical activity. A combined score of 5 meant most healthy and a score of 0 meant least healthy.

The distribution of lifestyle scores was 1.5%, 10.7%, 27.8%, 31.3%, 21.1% and 7.6% for scores of 0, 1, 2, 3, 4 and 5, respectively. Those with higher scores tended to be older, were less likely to be African-American and had a higher educational level. Having a combined lifestyle score of 5 was associated with a 58% risk reduction for pancreatic cancer. Non-smoking and normal BMI were associated with a statistically significant reduction of pancreatic cancer risk. Among the 5 risk factors, non-smoking had the higher population-attributable risk of 14%; that is 14% of cases would have been prevented if all participants were non-smokers.

Among cancers, pancreatic cancer incidence among men and women is 9^th and 10^th respectively. However, the mortality rate is worse compared to other more common cancers and it ranks 4^th among men and women. It carries a much poorer prognosis because the pancreas lies deep at the back of the abdominal cavity. It tends to grow to a more advanced stage before giving symptoms. In order to reduce the burden of this disease we should think more in terms of prevention. The simplest preventative measures should start with what we do and what we eat / drink. We need to modify our lifestyle habits in order to reduce our risk for pancreatic cancer.

As the saying goes - you reap what you sow!