Patterns of eating behavior in people with severe obesity seeking weight loss treatment: An exploratory study.

Although subjects with severe obesity need specific interventions, knowledge about their eating behavior, physical and mental health profiles remains insufficient. This cross-sectional study aimed to identify profiles of individuals with severe obesity based on clinical, psychological and eating behavior characteristics. We included 126 participants (103 women; mean age: 47.2 ± 13.9 years; mean BMI: 41.0 ± 5.7 kg/m2). Cluster analyses were performed to identify profiles based on age, waist circumference, eating behavior, depressive symptoms, food-related quality of life and physical activity. Metabolic syndrome components and type 2 diabetes prevalence were compared between the clusters. Three clusters were identified. Cluster 1 labeled struggling with food (48% of the population) had high scores on both emotional eating and uncontrolled eating, low score on comfort with food and they had depressive symptoms. Cluster 2, low loss of eating control (29%), had low scores on emotional eating and uncontrolled eating, and high quality of life in the psychosocial dimension. Cluster 3, pleasure from eating (22%), had the greatest score on comfort with food, the highest physical activity level, and depressive symptoms. In cluster 2, prevalence of type 2 diabetes was higher, although not statistically significant. Otherwise, no differences were found between clusters. Conclusion: Subjects with severe obesity have different profiles, partly explained by their eating behavior, associated with clinical and behavioral patterns. Further studies should confirm this cluster structure and assess how these profiles impact the evolution of obesity and whether they can help to improve the personalization of care programs.

Medication errors at hospital admission and discharge in Type 1 and 2 diabetes.

AIMS: To assess the prevalence and characteristics of medication errors at hospital admission and discharge in people with Type 1 and Type 2 diabetes, and identify potential risk factors for these errors. METHODS: This prospective observational study included all people with Type 1 (n = 163) and Type 2 diabetes (n = 508) admitted to the Diabetology-Department of the University Hospital of Montpellier, France, between 2013 and 2015. Pharmacists conducted medication reconciliation within 24 h of admission and at hospital discharge. Medication history collected from different sources (patient/family interviews, prescriptions/medical records, contact with community pharmacies/general practitioners/nurses) was compared with admission and discharge prescriptions to detect unintentional discrepancies in medication indicating involuntary medication changes. Medication errors were defined as unintentional medication discrepancies corrected by physicians. Risk factors for medication errors and serious errors (i.e. errors that may cause harm) were assessed using logistic regression. RESULTS: A total of 322 medication errors were identified and were mainly omissions. Prevalence of medication errors in Type 1 and Type 2 diabetes was 21.5% and 22.2% respectively at admission, and 9.0% and 12.2% at discharge. After adjusting for age and number of treatments, people with Type 1 diabetes had nearly a twofold higher odds of having medication errors (odds ratio (OR) 1.72, 95% confidence interval (CI) 1.02-2.94) and serious errors (OR 2.17, 95% CI 1.02-4.76) at admission compared with those with Type 2 diabetes. CONCLUSIONS: Medication reconciliation identified medication errors in one third of individuals. Clinical pharmacists should focus on poly-medicated individuals, but also on other high-risk people, for example, those with Type 1 diabetes.

Evolution of silent myocardial ischaemia prevalence and cardiovascular disease risk factor management in Type 2 diabetes over a 10-year period: an observational study.

AIMS: To assess the evolution of silent myocardial ischaemia prevalence and of cardiovascular disease risk factor management over 10 years in people with Type 2 diabetes. METHODS: This repeated cross-sectional study prospectively included 770 people with Type 2 diabetes who presented at our centre in the period 1999-2009. All had at least one additional cardiovascular disease risk factor, no history of coronary disease and were screened for silent myocardial ischaemia using myocardial perfusion imaging. The prevalence of silent myocardial ischaemia, clinical and biological variables and treatments were collected and compared among participants screened in three periods: 1999 to 2002; 2003 to 2005; and 2006 to 2009. We also identified predictive factors for silent myocardial ischaemia. RESULTS: Participants had a mean ± sd age of 62.3 ± 9.3 years, 57.4% were men and the mean time from diagnosis of diabetes was 13.4 ± 9.3 years. Overall, silent myocardial ischaemia screening was positive in 13.9% of participants. This prevalence decreased sharply over the 10-year study period (22.6% in 1999-2002, 13.7% in 2003-2005 and 5.9% in 2006-2009; P<0.0001). In parallel, diastolic and systolic blood pressure, HbA1c and LDL cholesterol significantly decreased and glitazone and statin use increased (all P<0.001). Male gender, peripheral artery disease, diastolic blood pressure >80 mmHg and LDL cholesterol >2.6 mmol/l were independently associated with silent myocardial ischaemia. Further adjustment showed the screening period had a significant effect, which erased the effects of diastolic blood pressure and LDL cholesterol. CONCLUSIONS: The prevalence of silent myocardial ischaemia decreased sharply over time, and control of the main cardiovascular disease risk factors improved. Although the causality link cannot be established, the present study supports current recommendations advocating glycaemic control and intensive management of cardiovascular factors instead of systematic screening.

Experiential or behavioral processes: which one is prominent in physical activity? Examining the processes of change 1 year after an intervention of therapeutic education among adults with obesity.

OBJECTIVE: Although physical activity (PA) is essential, most obese people will not engage in its practice. The transtheoretical model (TTM) and its processes of change (POC) contribute to the understanding of behavior change regarding PA. The present study aimed to test how POC are associated with a progression through the stages of change (SOC) and whether they predict BMI change. METHODS: Interventional study. A total of 134 subjects participated in an education program, were called at 1 year and 62 of them provided follow-up data. Participants completed the SOC and POC questionnaires at baseline, at 1 year and were classified according to their SOC progression. RESULTS: Participants who progressed through SOC lost more weight (p<0.001). Significant interactions were found for three out of five POC (p<0.05). Progression through SOC was associated with an increased use of POC. Weight loss was predicted by two behavioral POC. CONCLUSION: Results support the previous cross-sectional studies showing that physically active people use more frequently POC. PRACTICE IMPLICATIONS: The present findings support the development of TTM-grounded behavioral interventions targeted to obese patients. Identifying methods to promote POC use to improve adherence to weight guidelines may lead to improved clinical outcomes and quality of life.

Regulation of oxidative stress by glycaemic control: evidence for an independent inhibitory effect of insulin therapy.

AIMS/HYPOTHESIS: We examined whether type of diabetes and/or insulin treatment can modulate the impact of sustained hyperglycaemia and glycaemic variability as activators of oxidative stress. METHODS: This was an observational study in 139 patients with diabetes, 48 with type 1, 60 with type 2 treated by oral hypoglycaemic agents (OHAs) alone and 31 with type 2 treated with insulin plus OHAs. In addition, two groups of ten patients with type 2 diabetes were investigated either before and after introducing insulin treatment (add-on insulin group) or before and after add-on OHA therapy to metformin (add-on OHA group). Oxidative stress was estimated from 24 h urinary excretion rates of 8-isoprostaglandin F2alpha (8-iso-PGF2alpha). HbA(1c) was assessed and mean amplitude of glycaemic excursions (MAGE) was estimated by continuous monitoring. RESULTS: The 24 h excretion rate of 8-iso-PGF2alpha (median [range] picomoles per millimole of creatinine) was much higher (p < 0.0001) in type 2 diabetes patients treated with OHAs alone (112 [26-329]) than in the type 1 diabetes group (65 [29-193]) and the type 2 diabetes group treated with insulin (69 [30-198]). It was associated with HbA(1c) (F = 12.9, p = 0.0008) and MAGE (F = 7.7, p = 0.008) in non-insulin-treated, but not in insulin-treated patients. A significant reduction in 24 h excretion rate of 8-iso-PGF2alpha from 126 (47-248) to 62 (35-111] pmol/mmol of creatinine was observed in the add-on insulin group (p = 0.005) but not in the add-on OHA group. CONCLUSIONS/INTERPRETATION: In type 1 and type 2 diabetes, insulin exerts an inhibitory effect on oxidative stress, a metabolic disorder that is significantly activated by sustained hyperglycaemia and glucose variability in non-insulin-treated type 2 diabetes.

Evaluation of a structured educational programme for type 2 diabetes patients seen in private practice.

AIM: Structured education is necessary in the management of a chronic disease such as diabetes and should be readily offered to patients in different settings. Our aim was to demonstrate the feasibility and advantages of a group education programme for type 2 diabetic patients in a private setting in France. METHODS: A programme of group education for patients with type 2 diabetes was initiated by a multidisciplinary group of volunteer healthcare providers, including general practitioners, specialists in diabetology and non-medical members. All volunteers received one day of training, and physicians were instructed to organize several sessions of group education for the type 2 diabetic patients who regularly attended their practice. The first 427 patients entering the programme were included in the study, and asked to fill in a questionnaire to assess their knowledge, beliefs and behaviours with regard to diabetes. Their physician filled in a medical form. Six months later, the same questionnaire and form were sent for follow-up information. RESULTS: At six months versus baseline, patients exhibited small, but consistent, improvements: (i) fasting glucose 142+/-42 mg/dL (P<0.04) vs 146+/-44 mg/dL (P<0.04); (ii) HbA(1c) 7.41+/-1.26% vs 7.57+/-1.33% (P<0.01); and (iii) all of the main parameters of diabetes self-management recorded in the study. The percentage of patients who inspected their feet at least once a week increased from 67 to 77% (P<0.001). Patients improved their knowledge of the disease and developed a more positive attitude towards their diabetes. CONCLUSION: Our study demonstrates that it is possible to organize educational sessions for diabetic patients in a private-practice setting. At six months, patients receiving these sessions showed benefits in terms of blood glucose control and other important markers of self-management of their disease.

Continuous glucose monitoring in patients with type 2 diabetes: Why? When? Whom?

The overall assessment of glycaemic control in patients with type 2 diabetes should normally include the monitoring of three parameters that are usually depicted as the 'glucose triad': HbA(1c), fasting plasma glucose (FPG) and postprandial glucose (PPG) excursions. However one additional marker, the so-called 'glucose variability' might be as important as the three others since it has been demonstrated that both upward and downward glucose fluctuations are potent activators of oxidative stress. Even though many methods have been proposed for assessing glucose fluctuations, the 'mean amplitude glucose excursions' (MAGE) index remains the 'gold standard'. However MAGE estimation requires the use of continuous glucose sensors. Despite the debate on the reliability and cost of the devices that permit glucose monitoring, we suggest that interventional trials designed to evaluate the effects of glucose fluctuations on diabetic complications should benefit from the use of continuous glucose monitoring systems (CGMSs). More prosaically, the use of these technologies could be extended to current clinical care of type 2 diabetic patients especially for motivating them to accept earlier insulin treatments in case of 'oral antidiabetic drug secondary failure', and further for choosing the most appropriate insulin regimen.

An overview of the rationale for pharmacological strategies in type 2 diabetes: from the evidence to new perspectives.

Therapeutic strategies in type 2 diabetic patients should not only integrate both the targets and indications of the different therapies but should be also a compromise between the patient's and physician's goals and willingnesses. The rationale for therapeutic targets is based on recommendations that differ from one country to another. Even though HbA1c remains the "gold standard", monitoring of blood glucose at fasting and postprandial time-points is a complementary tool for estimating both the quality and safety of diabetic control. Despite the lack of available strong evidence-based data it seems that achieving glucose levels < 130 mg/dl at fasting and < 180 mg/dl or < 140 mg/dl over postbreakfast or postlunch periods, respectively, might be a reasonable goal in most countries. The choice of appropriate strategies for treating type 2 diabetic patients should ideally be based on pathophysiological considerations. However for practical reasons, decisions for initiating or completing antidiabetic treatments are usually made by using such simple parameters as HbA1c and plasma glucose levels. The bridge between pathophysiological and clinical rationales can be obtained from the analysis of the relative contributions of fasting and postprandial glucose to the overall hyperglycaemia. In patients with HbA1c < 7.3%, postprandial glucose makes the major contribution to the overall hyperglycaemia, whereas the contribution of fasting glucose becomes progressively predominant in patients with HbA1c > 7.3%. As a consequence of these observations, initiation of antidiabetic treatments or implementation of second-line therapies should be aimed at reducing either postprandial excursions or fasting hyperglycaemia according to whether HbA1c levels are found respectively below or above a cut-off value of 7.3%.

Dichotomous responses of inter and postprandial hyperglycaemia to short-term calorie restriction in patients with type 2 diabetes.

BACKGROUND: In type 2 diabetes the effects of short-term calorie restrictions on glycaemia are usually judged on fasting plasma glucose. As fasting duration rarely exceeds 2-3 h, we determined the effects of calorie restriction over different daytime periods using a continuous glucose monitoring system (CGMS) in noninsulin-using patients with type 2 diabetes. DESIGN: Fourteen poorly controlled (mean HbA1c = 9.3%) overweight or obese patients (mean body mass index = 30.1 +/- 0.7 kg m(-2)) with type 2 diabetes were investigated twice with a CGMS, at baseline and at the end of a 18-day calorie-restricted diet (1490 kcal day(-1)). Areas under curves (AUCs) of 24-h glucose monitoring were measured and divided into postprandial and interprandial AUCs according to meal times. RESULTS: Areas under curves of 24-h glucose monitoring were significantly decreased after dieting: -37%, P = 0.0047. Both post and interprandial AUCs were significantly diminished (-26%, P = 0.0186 and -48%, P = 0.0037, respectively), but changes in interprandial AUCs were more marked than changes in postprandial AUCs (P = 0.0060). Nycthemeral peaks of glucose were observed at mid-morning times and were not significantly different before (242 +/- 15 mg dL(-1)) and after dieting (227 +/- 16 mg dL(-1)). CONCLUSIONS: Short-term calorie restriction in overweight or obese patients with type 2 diabetes resulted in dichotomous responses between interprandial and postprandial glycaemic excursions. The resistance of mid-morning glucose peaking to calorie restriction should result in additional dietary or pharmacological measures at breakfast.

Obesity and pregnancy: complications and cost.

The prevalence of obesity is currently rising in developed countries, making pregravid overweight one of the most common high-risk obstetric situations. Although the designs and populations of published studies vary widely, most authors agree that pregravid overweight increases maternal and fetal morbidity. Even moderate overweight is a risk factor for gestational diabetes and hypertensive disorders of pregnancy, and the risk is higher in subjects with overt obesity. Compared with normal weight, maternal overweight is related to a higher risk of cesarean deliveries and a higher incidence of anesthetic and postoperative complications in these deliveries. Low Apgar scores, macrosomia, and neural tube defects are more frequent in infants of obese mothers than in infants of normal-weight mothers. The regional distribution of fat modulates the effects of weight on carbohydrate tolerance, hemodynamic adaptation, and fetal size. Maternal obesity increases perinatal mortality. Long-term complications include worsening of maternal obesity and development of obesity in the infant. The average cost of hospital prenatal and postnatal care is higher for overweight mothers than for normal-weight mothers, and infants of overweight mothers require admission to neonatal intensive care units more often than do infants of normal-weight mothers. Preconception counseling, careful prenatal management, tight monitoring of weight gain, and long-term follow-up could minimize the social and economic consequences of pregnancies in overweight women.

Assessment of insulin sensitivity from plasma insulin and glucose in the fasting or post oral glucose-load state.

OBJECTIVE: To compare insulin sensitivity indexes derived from plasma insulin (I) and glucose (G) in the basal state (Sib) and at the second hour (I2h and G2h) of an oral glucose tolerance test (OGTT, Si2h) (i) with measurements of insulin sensitivity using the insulin modified frequently sampled intravenous glucose tolerance test (FSIVGTT) [Si(IVGTT)] and (ii) with modelling of fasting glucose and insulin by the homeostasis model assessment (HOMA). SUBJECTS: 47 subjects entered the study. 31 subjects were classified as having normal glucose tolerance (NGT), 10 as having impaired tolerance to glucose (IGT) and six as type 2 diabetes mellitus according to the World Health Organisation (WHO) criteria. MEASUREMENTS: Sib and Si2h were calculated as follows. Sib = 10(8)/(I x G x VD), Si2h = 10(8)/(I2hr x G2hr x VD) where VD is an estimate of the apparent glucose distribution volume. A third insulin sensitivity index (SiM) was calculated by averaging Sib and Si2h. HOMA was calculated as follows: I/(22.5 x e(-lnG)) RESULTS: Si(IVGTT), Sib, SI2h and SiM were all significantly higher in subjects with NGT than in those with IGT or type 2 diabetes. Si(IVGTT) was highly correlated (P < or = 0.0001) with the three insulin sensitivity indexes found in the total population, in subjects with NGT and in those with IGT. In type 2 diabetic patients, a significant correlation was only noted when SiM was tested against Si(IVGTT) (P < or = 0.05). In most circumstances, the associations of Si(IVGTT) with Sib, SI2h and SiM were stronger than the corresponding associations with Ib, I2h or HOMA. SiM was the index that correlated best with Si(IVGTT) in the whole group (r = 0.92, P < 0.0001) as well as in NGT (r = 0.86, P < 0.0001), IGT (r = 0.96; P < 0.0001) and type 2 diabetes (r = 0.83, P < or = 0.05) subgroups. CONCLUSIONS: Calculations of sensitivity indexes from G and I concentrations in the basal state and during a conventional 2 h OGTT appear to be useful for coupling in the same simple and single test both a determination of glucose tolerance and an estimate of insulin sensitivity.

TSH suppression combined with carbimazole for Graves' disease: effect on remission and relapse rates.

OBJECTIVE: We studied the influence of TSH suppressive therapy combined with carbimazole (CBZ) on treatment outcome in Graves' disease. DESIGN: Open non-randomized prospective study. SETTING: University Hospital of Montpellier, France. SUBJECTS: Sixty-six consecutive patients without prior treatment were included. All the patients were treated initially with 30 mg of CBZ. After 1 month of treatment, one group continued CBZ alone (n = 23), another group received a combination of CBZ plus T3 (n = 19) and a third group received CBZ and 3,5,3'-triiodothyroacetic acid (Triac, n = 24). Therapy was stopped when remission was obtained based on clinical euthyroidism, normalization of FT4 and of early radioiodine uptake. Nine patients with medical treatment failure or major side effects requiring to stop antithyroid drugs underwent surgery or radioiodine therapy. Nine patients were lost to follow-up. The remaining 48 patients were available for analysis of both remission and relapse. RESULTS: The median duration of therapy was 18 months (range, 4-41 months). Based on clinical examination, goitre size at 4 months decreased more in the CBZ + T3 and CBZ + Triac groups than in the CBZ group (P = 0.02). The overall remission rate tended to be higher in the groups treated with CBZ + T3 and CBZ + Triac than in the group treated with CBZ alone, but the difference did not reach statistical significance (P = 0.17). No difference in the relapse rate was observed between the three groups. CONCLUSION: TSH suppression combined with CBZ has little or no effect on remission and relapse rates in Graves' disease patients.

Influence of short-term submaximal exercise on parameters of glucose assimilation analyzed with the minimal model.

After exercise, glucose uptake in tissues increases by insulin-dependent and -independent mechanisms. We evaluated whether these two effects of exercise on glucose disposal can be detected with the minimal model technique. Seven healthy volunteers were submitted at random order to two frequently sampled intravenous glucose tolerance test (FSIVGTTs), one at rest and the other 25 minutes after a 15-minute exercise test. This exercise included 5 minutes of increasing workload on a cycloergometer followed by 10 minutes at 85% of the maximal theoretic heart rate. Bergman's minimal model of insulin action was used to analyze the two FSIVGTTs and produced the following parameters: coefficient of glucose tolerance (Kg), ie, the slope of the exponential decrease in glycemia between 4 and 19 minutes after intravenous glucose; insulin sensitivity (Sl); and glucose effectiveness at basal insulin (Sg). Sg was divided into its two components: basal insulin effectiveness ([BIE] Sl x basal insulin) and glucose effectiveness at zero insulin ([GEZI] Sg-BIE). After the exercise bout, subjects had an increased Kg (3.44 +/- 0.44 v 2.06 +/- 0.28 x 10(-2).min-1, P < .02), Sl (11.43 +/- 1.27 v 6.23 +/- 0.97 x 10(-4) microU/mL.min-1, P < .01), and Sg (4.40 +/- 0.55 v 2.81 +/- 0.36 x 10(-2).min-1, P < .02). The increase in Sg was mainly explained by a 60% increase in GEZI (3.6 +/- 0.57 v 2.25 +/- 0.36 x 10(-2).min-1, P < .02), but also by an increase in BIE (0.80 +/- 0.12 v 0.47 +/- 0.08 x 10(-2).min-1, P < .05).(ABSTRACT TRUNCATED AT 250 WORDS)