Lifestyle mediators of associations among siestas, obesity, and metabolic health.

OBJECTIVE: The aim of this study was to determine the association between siestas/no siestas and obesity, considering siesta duration (long: >30 minutes, short: ≤30 minutes), and test whether siesta traits and/or lifestyle factors mediate the association of siestas with obesity and metabolic syndrome (MetS). METHODS: This was a cross-sectional study of 3275 adults from a Mediterranean population (the Obesity, Nutrigenetics, TIming, and MEditerranean [ONTIME] study) who had the opportunity of taking siestas because it is culturally embedded. RESULTS: Thirty-five percent of participants usually took siestas (16% long siestas). Compared with the no-siesta group, long siestas were associated with higher values of BMI, waist circumference, fasting glucose, systolic blood pressure, and diastolic blood pressure, as well as with a higher prevalence of MetS (41%; p = 0.015). In contrast, the probability of having elevated SBP was lower in the short-siesta group (21%; p = 0.044) than in the no-siesta group. Smoking a higher number of cigarettes per day mediated the association of long siestas with higher BMI (by 12%, percentage of association mediated by smoking; p < 0.05). Similarly, delays in nighttime sleep and eating schedules and higher energy intake at lunch (the meal preceding siestas) mediated the association between higher BMI and long siestas by 8%, 4%, and 5% (all p < 0.05). Napping in bed (vs. sofa/armchair) showed a trend to mediate the association between long siestas and higher SBP (by 6%; p = 0.055). CONCLUSIONS: Siesta duration is relevant in obesity/MetS. Timing of nighttime sleep and eating, energy intake at lunch, cigarette smoking, and siesta location mediated this association.

Flexible treatment of gestational diabetes mellitus adjusted according to intrauterine fetal growth versus treatment according to strict maternal glycemic parameters: a randomized clinical trial.

INTRODUCTION: To compare the conventional treatment of gestational diabetes mellitus (GDM) with flexible treatment according to the measurement of fetal abdominal circumference (AC) in daily clinical practice. RESEARCH DESIGN AND METHODS: Two hundred and sixty pregnant women diagnosed with GDM before week 34 were randomly placed in two groups: a control group, treated according to maternal capillary glycemia, and an experimental group, treated according to ultrasound parameters of fetal growth. The glycemic targets in the control group were blood glucose levels when fasting and 1 hour postprandial (<95/140 mg/dL). In the experimental group, glycemic targets depended on the percentile (p) of fetal AC: if AC p <75th, then blood glucose targets when fasting and at 1 hour postprandial were <120/180 mg/dL; and if AC p ≥75th, then the glycemic targets were <80/120 mg/dL. The follow-up of both groups was scheduled according to the GDM protocol of our diabetes and gestation unit. RESULTS: The study was completed by 246 pregnant women, 125 in the control group and 121 in the experimental group. In the experimental group, insulin treatment and neonatal hypoglycemia were significantly lower (p=0.018 and p 0.035, respectively). No differences were observed in large and small infants according to gestational age. However, macrosomic infants were less frequent in the experimental group, although this difference did not reach statistical significance. In terms of gestation complications, the type of delivery and its complications and the rest of the neonatal complications analyzed, no significant differences were observed. CONCLUSIONS: The treatment of flexible GDM according to the measurement of fetal AC is safe for the mother and the fetus and almost halves the number of pregnant women who require insulin treatment, without increasing the number of ultrasound checks or medical visits.

Obesity, endothelial function and inflammation: the effects of weight loss after bariatric surgery.

OBJECTIVE: Obesity is associated with a high risk for atherosclerotic cardiovascular disease. There is a causal association between obesity, inflammation, insulin resistance (IR) and endothelial dysfunction. The aim of this study was to evaluate changes in IR, proinflammatory state and markers of endothelial dysfunction in morbidly obese patients after weight loss following bariatric surgery. METHODS: In this study, we measured the levels of soluble intracellular adhesion molecule-1 (sICAM1), plasminogen activator inhibitor 1 (PAI-1), high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6) in 79 morbidly obese patients at baseline and 3, 6 and 12 months after gastric bypass. Also, we evaluated changes in IR. RESULTS: Twelve months after surgery, there was a significant decrease in plasma levels of sICAM1 (p < 0.001), PAI-1 (p < 0.05), hs-CRP (p < 0.001), IL-6 (p < 0.001) and homeostasis model assessment (HOMA) (p < 0.001) and a significant increase of McAuley index (McAuley) (p < 0.001). Baseline levels of hs-PCR were positively correlated with sICAM-1 (r = 0.450, p < 0.01) and IL-6 (r = 0.451, p < 0.01). Significant correlations were also found between the decrease of PAI-1 and the decrease of hs-PCR (r = 0.425, p < 0.01) and tryglicerides (r = 0.351, p < 0.01). CONCLUSIONS: In patients with morbid obesity, substantial surgically induced weight loss is followed by a significant improvement in the endothelial function, inflammatory state and insulin sensitivity, that may reduce their cardiovascular risk. A relationship exists between improved inflammatory profile and endothelial function.

Therapist characteristics that predict the outcome of multipatient psychotherapy: systematic review of empirical studies.

We defined multipatient psychotherapy as the set of psychotherapeutic techniques applied with more than one patient in the room. Assumptions of what makes a psychotherapist effective guide training programmes but may not be supported by evidence. We need to identify the empirical data on what makes a multipatient psychotherapist effective. We undertook the systematic review of empirical studies which correlate therapist characteristics with measurable patient outcome in multipatient psychotherapy. We found that the scientific literature on the topic is broad and heterogeneous in scope, studying demographic, professional and psychosocial characteristics of the therapists, but is poor in quality. The most solid results are that ethnic matching improves the outcome of family therapy with drug abusing adolescents in some ethnic minorities and that therapist knowledge patterns affect patient satisfaction. We concluded that the therapist characteristics that affect clinical outcome seem to be internal to the therapist and depend on the patient treated.

A paradigm shift in the monitoring of patients with acromegaly: last available growth hormone may overestimate risk.

CONTEXT: Acromegaly is associated with reduced life expectancy, which has been reported to be normalized if treatment is successful in controlling GH/IGF-I levels. OBJECTIVE: Most previous studies have invariably used the last available GH/IGF-I, which may be biased as it only assesses exposure at a single point in time. We compared the last available GH/IGF-I analysis to a "time-dependent" and cumulative method, during follow-up to assess risk of mortality in the West Midlands Acromegaly study (n = 501). RESULTS: Using the last available GH, there was a statistically significant increase in mortality comparing groups as low as GH ≤ 1 µg/L vs >1 µg/L (relative risks [RR] 1.8, P = .03). This was not the case when using the "time-dependent method," where only comparisons of GH values of GH ≤5 µg/L vs >5 µg/L were suggestive of being associated with an increased risk of mortality (RR = 1.5, P = .08). When the time-dependent GH method of analysis was used, the RR of mortality at each level was lower and the associated P value was less significant. Irrespective of using the last available or time-dependent method, when IGF-I was divided into levels according to quartile or arbitrary cutoffs, there was no significant increase in mortality with higher levels. CONCLUSIONS: This study emphasizes the potential bias of using the latest available GH/IGF-I levels to predict mortality. Our study again highlights the limitations of IGF-I in predicting mortality.

Obesity and inflammation: change in adiponectin, C-reactive protein, tumour necrosis factor-alpha and interleukin-6 after bariatric surgery.

BACKGROUND: Obesity is associated with a low-grade inflammatory state. A causal association between inflammation and atherosclerosis has been suggested. The aim of this study was to evaluate changes in the proinflammatory profile of morbidly obese patients after weight loss following bariatric surgery. METHODS: In this study, we measured levels of adiponectin, high-sensitivity C-reactive protein (hs-CRP), tumour necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) and their relation to insulin resistance and lipid parameters in 60 morbidly obese women at baseline and 3, 6 and 12 months after gastric bypass. RESULTS: Twelve months after surgery, there was a significant increase in plasma levels of adiponectin (p < 0.001) and high-density lipoprotein cholesterol (p < 0.01) and a significant decrease in levels of IL-6 (p < 0.001), hs-CRP (p < 0.001), cholesterol (p < 0.001), triglycerides (p < 0.001), low-density lipoprotein cholesterol (p < 0.001), glucose (p < 0.001), insulin (p < 0.001) and homeostasis model assessment (HOMA; p < 0.001). At 12 months, correlations were seen between IL-6 levels and the following: body mass index (BMI) (r = 0.53, p < 0.001), insulin (r = 0.51, p < 0.001) and HOMA (r = 0.55, p < 0.001). Also, hs-CRP levels correlated with BMI (r = 0.40, p = 0. 004), triglycerides (r = 0.34, p = 0.017), insulin (r = 0.50, p = 0.001) and HOMA (r = 0.46, p = 0.002). CONCLUSIONS: In patients with morbid obesity, significant weight loss is followed by a significant improvement in the inflammatory state, insulin sensitivity and lipid profile. A relationship exists between improved inflammatory profile and insulin sensitivity.

Obesity, endothelial function and inflammation: the effects of weight loss after bariatric surgery / Obesidad, inflamación y función endotelial: efectos de la pérdida de peso tras cirugía bariatrica

Objective: Obesity is associated with a high risk for atherosclerotic cardiovascular disease. There is a causal association between obesity, inflammation, insulin resistance (IR) and endothelial dysfunction. The aim of this study was to evaluate changes in IR, proinflammatory state and markers of endothelial dysfunction in morbidly obese patients after weight loss following bariatric surgery. Methods: In this study, we measured the levels of soluble intracellular adhesion molecule-1 (sICAM1), plasminogen activator inhibitor 1 (PAI-1), high-sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6) in 79 morbidly obese patients at baseline and 3, 6 and 12 months after gastric bypass. Also, we evaluated changes in IR. Results: Twelve months after surgery, there was a significant decrease in plasma levels of sICAM1 (p < 0.001), PAI-1 (p < 0.05), hs-CRP (p < 0.001), IL-6 (p < 0.001) and homeostasis model assessment (HOMA) (p < 0.001) and a significant increase of McAuley index (McAuley) (p < 0.001). Baseline levels of hs-PCR were positively correlated with sICAM-1 (r = 0.450, p < 0.01) and IL-6 (r = 0.451, p < 0.01). Significant correlations were also found between the decrease of PAI-1 and the decrease of hs-PCR (r = 0.425, p < 0.01) and tryglicerides (r = 0.351, p < 0.01). Conclusions: In patients with morbid obesity, substantial surgically induced weight loss is followed by a significant improvement in the endothelial function, inflammatory state and insulin sensitivity, that may reduce their cardiovascular risk. A relationship exists between improved inflammatory profile and endothelial function (AU)

Objetivo: la obesidad está asociada con un aumento del riesgo de enfermedad cardiovascular. Se ha propuesto una relación causal entre obesidad, inflamación, resistencia a la insulina, y disfunción endotelial. El objetivo de este estudio fue valorar marcadores de insulinorresistencia, infl amación y disfunción endotelial en pacientes con obesidad mórbida antes y después de la pérdida de peso por cirugía bariátrica. Métodos: se midieron las concentraciones séricas de moléculas solubles de adhesión intercelular tipo 1 (sICAM-1), inhibidor del activador del plasminógeno tipo 1 (PAI-1), proteína C reactiva de alta sensibilidad (hs-PCR) e interleucina 6 (IL-6) en 79 pacientes con obesidad mórbida antes y a los 3, 6 y 12 meses de la realización de un by-pass gástrico. También se evaluaron índices de resistencia a la insulina. Resultados: a los 12 meses de la cirugía disminuyeron los niveles de sICAM1 (p < 0,001), PAI-1 (p < 0,05), hs-CRP (p < 0,001), IL-6 (p < 0,001) y el índice homeostasis model assessment (HOMA) (p < 0,001) y aumentó el índice McAuley (p < 0,001). Los niveles basales de hs-PCR estaban correlacionados con los de sICAM-1 (r = 0,450, p < 0,01) y de IL-6 (r = 0,451, p < 0,01). También existía correlación entre el descenso de los niveles de PAI-1 y el descenso de hs-PCR (r = 0,425, p < 0,01) y triglicéridos (r = 0,351, p < 0,01). Conclusiones: en pacientes con obesidad mórbida una importante pérdida de peso por cirugía bariátrica se acompaña de una mejora significativa de marcadores inflamatorios, de función endotelial e insulinorresistencia, lo que puede suponer una disminución del riesgo cardiovascular. Existe una relación entre mejora del perfil inflamatorio y función endotelial (AU)

Mortality in patients with pituitary disease.

Pituitary disease is associated with increased mortality predominantly due to vascular disease. Control of cortisol secretion and GH hypersecretion (and cardiovascular risk factor reduction) is key in the reduction of mortality in patients with Cushing's disease and acromegaly, retrospectively. For patients with acromegaly, the role of IGF-I is less clear-cut. Confounding pituitary hormone deficiencies such as gonadotropins and particularly ACTH deficiency (with higher doses of hydrocortisone replacement) may have a detrimental effect on outcome in patients with pituitary disease. Pituitary radiotherapy is a further factor that has been associated with increased mortality (particularly cerebrovascular). Although standardized mortality ratios in pituitary disease are falling due to improved treatment, mortality for many conditions are still elevated above that of the general population, and therefore further measures are needed. Craniopharyngioma patients have a particularly increased risk of mortality as a result of the tumor itself and treatment to control tumor growth; this is a key area for future research in order to optimize the outcome for these patients.