A psycho-educational intervention for the prevention of foot lesions in people with diabetes: Report of a clinical audit.

BACKGROUND AND AIMS: Motivational approaches may help target the psychological aspects of self-care, improving adherence to good practices in individuals with diabetes. The present study was designed to test the feasibility and effectiveness of a psychoeducational program for diabetic foot prevention or disease progression. METHODS AND RESULTS: Eighty-one subjects with or at high risk of foot ulcer development entered a program consisting of six 120-min group sessions, conducted by a podiatrist and an expert in psycho-education. Occurrence/recurrence of lesions in a 3-year follow-up was compared with 172 cases with similar risk score (IWGDF score 2019), receiving education at any 6-month podiatric visit (standard-of-care). Motivation to self-care and competence were assessed by specific questionnaires. The experimental program increased adherence to follow-up. The prevalence of foot lesions was higher at baseline and was remarkably reduced at any time-point in patients attending the psychoeducational program, whereas it remained relatively stable in standard care (around 10% of cases). The cumulative incidence was lower in the psychoeducational program (13.2, 95% CI 9.2-18.0 per 100 patient-year vs. 26.1; 95% CI 22.1-30.2); time to new lesions was increased (P = 0.022). Cox proportional hazard analysis confirmed an overall reduction of lesions in the psychoeducational program (HR 0.34; 95% CI 0.18-0.66; P < 0.001), after adjustment for confounders. The program was associated with significant changes in competence and motivation to self-care. CONCLUSION: A psychoeducational approach is both feasible and effective to support patients with diabetes at high risk of first or recurrent foot lesions, increasing their adherence to self-care practices.

Management of Diabetes in Candidates for Liver Transplantation and in Transplant Recipients.

Diabetes is common in patients waitlisted for liver transplantation because of end-stage liver disease or hepatocellular cancer as well as in posttransplant phase (posttransplantation diabetes mellitus). In both conditions, the presence of diabetes severely affects disease burden and long-term clinical outcomes; careful monitoring and appropriate treatment are pivotal to reduce cardiovascular events and graft and recipients' death. We thoroughly reviewed the epidemiology of diabetes in the transplant setting and the different therapeutic options, from lifestyle intervention to antidiabetic drug use-including the most recent drug classes available-and to the inclusion of bariatric surgery in the treatment cascade. In waitlisted patients, the old paradigm that insulin should be the treatment of choice in the presence of severe liver dysfunction is no longer valid; novel antidiabetic agents may provide adequate glucose control without the risk of hypoglycemia, also offering cardiovascular protection. The same evidence applies to the posttransplant phase, where oral or injectable noninsulin agents should be considered to treat patients to target, limiting the impact of disease on daily living, without interaction with immunosuppressive regimens. The increasing prevalence of liver disease of metabolic origin (nonalcoholic fatty liver) among liver transplant candidates, also having a higher risk of noncirrhotic hepatocellular cancer, is likely to accelerate the acceptance of new drugs and invasive procedures, as suggested by international guidelines. Intensive lifestyle intervention programs remain however mandatory, both before and after transplantation. Achievement of adequate control is mandatory to increase candidacy, to prevent delisting, and to improve long-term outcomes.

Effects of antidiabetic agents on steatosis and fibrosis biomarkers in type 2 diabetes: A real-world data analysis.

BACKGROUND & AIMS: There is intense research for drugs able to reduce disease progression in nonalcoholic fatty liver disease. We aimed to test the impact of novel antidiabetic drugs (dipeptidyl-peptidase-4 inhibitors - DPP-4Is, glucagon-like peptide-1 receptor agonists - GLP-1RAs, sodium-glucose cotransporter-2 inhibitors - SGLT-2Is) on non-invasive biomarkers of steatosis (fatty liver index, FLI) and fibrosis (Fibrosis-4 score, FIB-4) in patients with type 2 diabetes (T2D). METHODS: Clinical, anthropometric and biochemical parameters were retrospectively analysed in 637 consecutive T2D patients switched from metformin w/wo sulfonylureas and/or pioglitazone to DPP-4Is, GLP-1RAs and SGLT-2Is in a tertiary care setting. 165 patients maintained on original treatments served as controls. The effects on FLI and FIB-4 at 6- and 12-month follow-up were analysed by logistic regression after adjustment for baseline differences, computed by propensity scores, and additional adjustment for changes in glycosylated hemoglobin (HbA1c) and body mass index. RESULTS: Body mass index, HbA1c and aminotrasferases significantly decreased following switching to GLP-1RAs and SGLT2-Is, compared with both controls and DPP-4Is, whereas only HbA1c was reduced on DPP-4Is. FLI and FIB-4 were reduced on GLP-1RA and SGLT-2I; logistic regression analysis confirmed a significant improvement of both biomarkers after adjustment for propensity score. The shift of FIB-4 values towards the category ruling out advanced fibrosis was maintained after additional adjustment for confounders. These effects were confirmed in a sensitivity analysis on effect size. CONCLUSIONS: Glucagon-like peptide-1 receptor agonists and SGLT-2Is improve biomarkers of steatosis and fibrosis, in keeping with beneficial effects on liver disease progression, and should be considered the treatment of choice in T2D.

Motivational Interviewing Adapted to Group Setting for the Treatment of Relapse in the Behavioral Therapy of Obesity. A Clinical Audit.

Motivational interviewing (MI) is devised to change unhealthy behaviors by increasing motivation. We adapted MI to a group format for the treatment of relapse during the behavioral treatment of obesity and performed a clinical audit to evaluate its effectiveness in stopping weight regain. The program was structured in seven weekly sessions, plus a 6-month follow-up. Patients (n = 86) completed a questionnaire on motivation to change in both healthy diet and physical activity, and a self-reported measurement of calorie intake and physical activity at baseline, at program end and at 6-month follow-up. The attendance to the program was high, with only 13 patients (15%) not completing the program and 24% not attending the 6-month follow-up. By the end of follow up, the prevalence of patients in either precontemplation or contemplation was reduced from over 60% at enrollment to approximately 20%, whereas the sum of patients in action or maintenance stages was increased from 9.5% in healthy diet and 14% in physical activity to 39.7% and 41.3%, respectively. These changes translated into significant behavioral changes (mean calorie intake, -13%; total physical activity, +125%; sedentary time, -8%) and finally into reduced body weight ( -3%). We conclude that MI programs adapted for groups may be used to stop relapse in individuals following a behavioral intervention for obesity.

Maternal PKU: Defining phenylalanine tolerance and its variation during pregnancy, according to genetic background.

BACKGROUND AND AIMS: Phenylketonuria (PKU)-affected women may become pregnant, and dietary phenylalanine (Phe) intake must be adjusted according to Phe tolerance. We report our experience with maternal PKU in relation to genotype PKU heterogeneity. METHODS AND RESULTS: A total of 10 pregnancies in 7 PKU women (7 different genotypes) were followed up as part of personalized care. Phe tolerance during preconception and pregnancy was assessed by strict dietary control and weekly Phe measurement (blood spots) in relation to genotype. Most women had stopped PKU diet during childhood or adolescence and six pregnancies were unplanned; a phenylalanine-restricted diet was reinstituted soon after conception. Women were classified according to their Phe levels at birth screening and genotype. Phe tolerance increased systematically in the course of pregnancy in all cases, but the increase was different in subjects with classic PKU (cPKU) when compared with cases with mild hyperphenylalaninemia (mHPA), both on average (+297 mg/day in cPKU vs. 597 in mHPA; P = 0.017) and as percentage (+107% in cPKU vs. +17% in mHPA). Notably, Phe tolerance also varied in the same women in the course of different pregnancies, when body weight gain was also different. Two newborns from the same cPKU mother (unplanned pregnancies on free diet) were affected by congenital alterations. CONCLUSIONS: Several factors influence metabolic phenotype in maternal PKU, to an unpredictable extent even in the same woman. The number of maternal PKU cases is growing in dedicated Nutrition Units, and the burden associated with careful management of this condition for the health care system should be adequately considered.

Lifestyle Changes for the Treatment of Nonalcoholic Fatty Liver Disease - A 2015-19 Update.

BACKGROUND: Lifestyle interventions aimed at weight loss have been associated with improved liver enzymes, reduced intrahepatic triglyceride content, and improved histology (including reduced fibrosis stage). OBJECTIVE: To revise the evidence on the beneficial effects of lifestyle changes accumulated since 2015, following the publication of the pivotal Cuban experience with histologic outcome. METHODS: A PubMed search covering the period 2015 to July 2019 was carried out. All retrieved references were analyzed and double-checked by authors. RESULTS: 20 new studies were identified; in addition, two relevant studies provided new evidence. Thirteen studies were classified as randomized, controlled studies, three as proof-of-concept/pilot studies, four as cohort observational studies. In an attempt to maintain a closer contact between participants and the treatment center, a study implemented regular phone calls, another an e-mail service, a third was based on text messages, and finally, a study was totally web-based. Notably, the web-based treatment, accessed following intense motivational interviewing, was not less effective than a standard group-based behavior program. CONCLUSION: Lifestyle changes should form the basis of any NAFLD intervention. Information technology provides the opportunity to expand treatment, bypassing job and time constraints in younger patients, and to maintain long-term contact between patients and therapists in the NAFLD population.

Moderate Alcohol Intake in Non-Alcoholic Fatty Liver Disease: To Drink or Not to Drink?

Nonalcoholic fatty liver disease (NAFLD) is defined by hepatic steatosis in the presence of alcohol intake within safe limits, defined by guidelines of scientific associations (usually 20 g or 2 units/day in women, 30 g or 3 units in men). The diagnosis is usually followed by medical counseling of total abstinence, in order to prevent disease progression. This policy has been challenged by epidemiological studies, suggesting that the risk of liver disease and disease progression is lower in modest drinkers than in total abstainers. We revised the literature on the effects of modest alcohol intake on disease burden. Epidemiological data may suffer from several potential biases (recall bias for retrospective analyses, difficulties in the calculation of g/day), limiting their validity. Prospective data suggest that NAFLD patients with regular alcohol intake, although within the safe thresholds, are at higher risk of liver disease progression, including hepatocellular carcinoma; a detrimental effect of modest alcohol drinking is similarly observed in liver disease of viral etiology. Alcohol intake is also a risk factor for extrahepatic cancers, particularly breast, oral, and pharyngeal cancers, with gender difference and no floor effect, which outweigh the possible beneficial effects on cardiovascular system, also derived from retrospective studies. Finally, the negative effects of the calorie content of alcohol on dietary restriction and weight loss, the pivotal intervention to reduce NAFLD burden, should be considered. In summary, the policy of counseling NAFLD patients for alcohol abstinence should be maintained.

Dysfunctional eating in type 2 diabetes mellitus: A multicenter Italian study of socio-demographic and clinical associations.

BACKGROUND AND AIMS: Dysfunctional eating might impact on the management and metabolic control of type 2 diabetes (T2DM), modifying adherence to healthy diet and food choices. METHODS AND RESULTS: In a multicenter study, we assessed the prevalence of dysfunctional eating in 895 adult outpatients with T2DM (51% males, median age 67, median BMI 30.3 kg/m2). Socio-demographic and clinical characteristics were recorded; dysfunctional eating was tested by validated questionnaires (Eating Attitude Test-EAT-26, Binge Eating Scale-BES; Night Eating Questionnaire-NEQ); food intake and adherence to Mediterranean diet were also measured (in-house developed questionnaire and Mediterranean Diet Score-MDS). Obesity was present in 52% of cases (10% obesity class III), with higher rates in women; 22% had HbA1c ≥ 8%. The EAT-26 was positive in 19.6% of women vs. 10.2% of men; BES scores outside the normal range were recorded in 9.4% of women and 4.4% of men, with 3.0% and 1.5% suggestive of binge eating disorder, respectively. Night eating (NEQ) was only present in 3.2% of women and 0.4% of men. Critical EAT and BES values were associated with higher BMI, and all NEQ + ve cases, but one, were clustered among BES + ve individuals. Calorie intake increased with BES, NEQ, and BMI, and decreased with age and with higher adherence to Mediterranean diet. In multivariable logistic regression analysis, female sex, and younger age were associated with increase risk of dysfunctional eating. CONCLUSION: Dysfunctional eating is present across the whole spectrum of T2DM and significantly impacts on adherence to dietary restriction and food choices.

Prevention and Treatment of Sarcopenic Obesity in Women.

Sarcopenic obesity (SO) is referred to as the combination of obesity with low skeletal muscle mass and function. However, its definition and diagnosis is debated. SO represents a sizable risk factor for the development of disability, possibly with a worse prognosis in women. The present narrative review summarizes the current evidence on pharmacological, nutrition and exercise strategies on the prevention and/or treatment of SO in middle-aged and older-aged women. A literature search was carried out in Medline and Google Scholar between 29th January and 14th March 2019. Only controlled intervention studies on mid-age and older women whose focus was on the prevention and/or treatment of sarcopenia associated with obesity were included. Resistance training (RT) appears effective in the prevention of all components of SO in women, resulting in significant improvements in muscular mass, strength, and functional capacity plus loss of fat mass, especially when coupled with hypocaloric diets containing at least 0.8 g/kg body weight protein. Correction of vitamin D deficit has a favorable effect on muscle mass. Treatment of SO already established is yet unsatisfactory, although intense and prolonged RT, diets with higher (1.2 g/kg body weight) protein content, and soy isoflavones all look promising. However, further confirmatory research and trials combining different approaches are required.

Dietary habits in Parkinson's disease: Adherence to Mediterranean diet.

INTRODUCTION: Our objective is to describe the dietary habits, food preferences and adherence to Mediterranean diet (MeDi) of a large sample of Italian Parkinson's Disease (PD) patients compared to a group of controls. METHODS: Dietary habits of 600 PD patients from throughout Italy and 600 controls matched by gender, age, education, physical activity level and geographical residence, were collected using the ON-GP Food Frequency Questionnaire. Then, we compared patients by disease duration and the presence of swallowing disturbances. RESULTS: Overall, adherence of PD patients (males, 53.8%; mean disease duration, 9.2 ± 7.0 years) to MeDi was similar to controls (score, 4.8 ± 1.7 vs. 4.9 ± 1.6; P = 0.294). Patients consumed less alcohol and fish and drank significantly less water, coffee, and milk which resulted also in lower total fluids intake. On the contrary, they ate more fruit, cooked vegetables, cereals and baked items, more dressings and more sweets in general. Disease duration was associated with increased intake of several food groups but it was not associated with changes in MeDi score (P = 0.721). Patients with swallowing disturbances (n = 72) preferred softer and more viscous food but preferences did not result in differences in dietary pattern. However, patients with dysphagia drank less fluids (P = 0.043). DISCUSSION: PD patients presented different dietary habits and food preferences compared to the general population and adherence to MeDi was not associated with disease duration. Self-reported dysphagia was associated with reduced intake of fluids. These aspects may be amenable to change in order to improve the management of nutritional issues in this patient population.

Dietary habits and neurological features of Parkinson's disease patients: Implications for practice.

BACKGROUND & AIMS: Parkinson's disease (PD) patients can benefit considerably from appropriate nutritional care, particularly from diet. However, there is limited evidence on the eating habits of PD patients and their relationship with the features of the disease. METHODS: We conducted a large case-control study. Consecutive PD patients (N = 600) receiving systematic nutritional care and healthy controls (N = 600) matched (1:1) for age, gender, education, physical activity level and residence were studied using a 66-item food frequency questionnaire. The relationship between dietary habits and the following features of PD were investigated in patients: body weight, energy balance, constipation, and levodopa therapy (dose) and its related motor complications. RESULTS: PD patients had lower BMI and reported higher food intake than controls. BMI was found to be inversely associated with disease duration and severity, and levodopa-related motor complications, whereas energy intake was positively associated with these variables. An increase in protein intake by 10 g over physiological requirements (0.8 g/kg/day) corresponded to a mean increase in levodopa dose of 0.7 mg/kg/day. Constipation was also associated with higher levodopa requirements. Finally, protein intake and its distribution throughout the day influenced levodopa-related motor complications. CONCLUSION: The management of protein intake and the treatment of constipation should be considered to be an integral part of the care of PD patients. Attention should always be focused on energy intake also. This would result in the maintenance of nutritional status, the optimization of levodopa-therapy and the minimization of its related motor complications.

Clinical and psychological correlates of health-related quality of life in obese patients.

BACKGROUND: Health-related quality of life (HRQL) is poor in obese subjects and is a relevant outcome in intervention studies. We aimed to determine factors associated with poor HRQL in obese patients seeking weight loss in medical units, outside specific research projects. METHODS: HRQL, together with a number of demographic and clinical parameters, was studied with generic (SF-36, PGWB) and disease-specific (ORWELL-97) questionnaires in an unselected sample of 1,886 (1,494 women; 392 men) obese (BMI > 30 kg/m2) patients aged 20-65 years attending 25 medical units scattered throughout Italy. The clinics provide weight loss treatment using different programs. General psychopathology (SCL-90 questionnaire), the presence of binge eating (Binge Eating scale), previous weight cycling and somatic comorbidity (Charlson's index) were also determined. Scores on SF-36 and PGWB were compared with Italian population norms, and their association with putative determinants of HRQL after adjustment for confounders was assessed through logistic regression analysis. RESULTS: HRQL scores were significantly lower in women than in men. A greater impairment of quality of life was observed in relation to increasing BMI class, concurrent psychopathology, associated somatic diseases, binge eating, and weight cycling. In multivariate analysis, psychopathology (presence of previously-diagnosed mental disorders and/or elevated scores on SCL-90) was associated with lower HRQL scores on both psychosocial and somatic domains; somatic diseases and higher BMI, after adjustment for confounders, were associated with impairment of physical domains, while binge eating and weight cycling appeared to affect psychosocial domains only. CONCLUSIONS: Psychopathological disturbances are the most relevant factors associated with poor HRQL in obese patients, affecting not only psychosocial, but also physical domains, largely independent of the severity of obesity. Psychological/psychiatric interventions are essential for a comprehensive treatment of obesity, and to improve treatment outcome and to reduce the burden of disease.

Long-term mortality in a cohort of severely obese persons in Italy.

Few large studies on Northern European or US populations reported on mortality of severely obese individuals (BMI > or = 40 kg/m(2)). We studied a historical cohort in Italy to compare its mortality with previous findings, to investigate its relationship with BMI in the >40 range, and to provide evidence useful for clinical decision-making on treatment. The cohort comprised 4,837 persons with a BMI > or =40 kg/m(2) and aged > or =18 at first consultation, referred to six centers for obesity treatment between 1975 and 1996. After exclusion of persons with missing personal identification data or those untraceable, 4,498 (972 men, 3,526 women) remained for analyses. We calculated standardized mortality ratios (SMRs) and carried out Cox proportional hazards modeling. General mortality (484 deaths: 153 men, 331 women) was in excess, with SMRs (95% confidence intervals) of 2.78 (2.36-3.26) for men and 2.10 (1.88-2.34) for women. Excess mortality (i) was observed in all BMI categories, except among women weighing 40-42.4 kg/m(2); (ii) increased with increasing BMI; (iii) increased less among persons recruited in recent calendar periods; (iv) was inversely related to age attained at follow-up; and (v) was due to cardiovascular and respiratory diseases and violent deaths but not malignant neoplasms. Excess mortality was similar to that observed in Northern European and US cohorts. Its steady increase with BMI levels > or =40 suggests that benefits proportional to weight reduction are expected and that even limited control may be beneficial. The smaller excess among persons recruited most recently might reflect better treatment.