High baseline C-reactive protein levels predict partial type 2 diabetes mellitus remission after biliopancreatic diversion.

BACKGROUND AND AIMS: Several studies demonstrated that surgery can improve inflammation parameters, such as C-reactive protein (CRP). Few biomarkers have been investigated to potentially predict type 2 diabetes mellitus (T2DM) remission. We aimed at determining whether pre-surgery serum CRP levels could predict T2DM remission after 3 years in patients undergoing bariatric surgery, especially biliopancreatic diversion (BPD). METHODS AND RESULTS: This study was conducted from 2007 to 2009 at the Surgical Department of the University of Genoa, Italy. Forty-four patients with T2DM undergoing BPD (n = 38) or Roux-en-Y gastric bypass (n = 6) were enrolled. The primary endpoint was to evaluate whether pre-surgery CRP levels could predict T2DM partial remission at 3-year follow-up. Secondary endpoints were to assess whether glycaemic, lipid, and inflammatory parameters modified during the follow-up. At baseline, patients with T2DM ranged from overweight to morbid obesity, had mild dyslipidaemia, and a low-grade inflammation. Bariatric surgery improved body weight, lipid and glycaemic profile both at 1- and 3-year follow-up. Pre-surgery CRP levels progressively decreased at 1- and 3-year follow-up. Among inflammatory pre-surgery parameters, only high CRP levels were shown to predict T2DM partial remission after 3 years. Multivariate analysis confirmed the predictive value of pre-surgery CRP levels independently of age, gender, type of surgery, and body mass index. CONCLUSION: Bariatric surgery, in particular BPD, improved both metabolic and inflammatory biomarkers at 1- and 3-year follow-up. Pre-surgery high CRP levels predicted 3-year T2DM partial remission, indicating a promising target population to be especially treated with BPD.

Effects of obesity on posture and walking: study prior to and following surgically induced weight loss.

BACKGROUND: We investigate whether in severely obese people a marked weight loss may influence individual postural control and motor activities and then reverse the alterations caused by the extra load of body mass. Recent studies have shown that most severely obese patients have various degrees of impairment of postural control, but only a few studies considered those subjects before and after a marked weight loss. METHODS: Ten obese and ten subjects of average weight took part in our experiment. The subjects were requested to perform four different tasks. All obese patients repeated the tasks 1 year after undergoing bariatric surgery. RESULTS: We have found differences between obese and normal-weight people in the execution of all four work tasks. However, a year after surgery, obese patients showed a change in the execution of only two tasks, keeping the same performance in the other two. CONCLUSIONS: The excess of fat mass alters the execution of some tasks, as confirmed by the improvement obtained after weight loss. For other work tasks, we can hypothesize that the neurophysiological plasticity of the neuro-muscular system would require more time to adapt.

Do clinical and behavioural correlates of obese patients seeking bariatric surgery differ from those of individuals involved in conservative weight loss programme?

BACKGROUND: Clinical practice has suggested that, in severely obese patients seeking bariatric surgery, clinical conditions, behavioural characteristics and psychological status might all differ from those of their counterparts starting conventional conservative therapy. METHODS: Two groups of obese patients with closely similar body mass values were considered. The first group included individuals voluntarily and spontaneously seeking biliopancreatic diversion and the second group comprised patients at the beginning of a weight loss programme. After anthropometric and metabolic evaluation, the patients underwent an alimentary interview; eating behaviour and psychological status were assessed by Three Factor Eating Questionnaire and by Toronto Alexithymia Scale (TAS). RESULTS: Among bariatric candidates, a greater number of individuals with type 2 diabetes and dyslipidaemia and high tendency to disinhibition and susceptibility to hunger scores was observed, whereas the other aspects of eating pattern were essentially similar. In the two groups, no difference in TAS score and or number of patients with alexithymic traits was observed. Finally, a logistic regression model showed that only age and metabolic derangement predicted the bariatric option, whereas eating behaviour or psychological status did not influence individual therapeutic choice. CONCLUSIONS: Independently of the degree of obesity, bariatric surgery was requested by the more metabolically deranged patients, whereas, in the surgical candidates, the eating pattern and psychological conditions were very similar to those of obese persons at the beginning of a conservative weight loss programme. These results suggest a highly realistic and practical attitude in severely obese patients towards obesity and bariatric surgery.

Preoperative assessment of respiratory function in severely obese patients undergoing biliopancreatic diversion.

Since severe obesity is often associated with a pulmonary function defect and abdominal surgery increases the risks of respiratory postoperative complications (RPC), an increased incidence of RPC might occur after bariatric operations. A cohort of 146 severely obese patients undergoing biliopancreatic diversion (BPD) was retrospectively evaluated for the occurrence of RPC. Respiratory function was evaluated prior to BPD from the quotient between measured and predicted values of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV(1)) and the Tiffeneau index (TI: FEV(1)/FVC). In this cohort of obese individuals the BMI degree prior to the operation was totally unrelated to the standardized values of TI and to the presence of restrictive or obstructive pulmonary disease. Globally, a very low rate of RPC (7.5%) was found; in patients with suspected restrictive pulmonary impairment, a high occurrence of RPC was observed (p < 0.05). When data are controlled for preoperative BMI values, smoking status and presence of sleep apnoea, a logistic regression model indicates that respiratory function data cannot predict the occurrence of RPC after bariatric surgery.

Sub-clinical organ damage in hypertension and obesity.

BACKGROUND: The development of sub-clinical organ damage precedes and predicts the occurrence of cardiovascular (CV) events in hypertensive as well as in obese patients. AIM AND METHODS: We investigated the prevalence and clinical correlates of organ damage (OD), namely carotid atherosclerosis (US scan) and urine albumin to creatinine ratio (three non-consecutive first morning samples) in a group of 164 obese patients and in an age- and gender-matched group of non-obese hypertensive patients. RESULTS: There was a significantly greater prevalence and severity of OD in obese patients as compared to non-obese hypertensive patients. In particular obese patients more frequently had microalbuminuria (16 vs 7%, χ(2) 5.8, P=0.0157) and carotid abnormalities (53 vs 10%, χ(2) 69.5, P<0.0001) as well as higher urinary albumin excretion rate (-0.05 ± 0.52 vs -0.28 ± 0.43log ACR, P<0.0001) and carotid intima-media thickness (0.955 ± 0.224 vs 0.681 ± 0.171, <0.0001). Notably, the coexistence of hypertension and obesity did not entail a greater prevalence and severity of OD. Moreover, after adjusting for potentially confounding factors including blood pressure levels, diagnosis of diabetes, and lipid profile, morbidly obese patients showed a 5-fold, and 22-fold higher risk of having microalbuminuria, and carotid atherosclerosis, respectively. CONCLUSIONS: Sub-clinical OD is highly prevalent in obese patients, even in the absence of high blood pressure. Hypertension and obesity seem to exert an independent, possibly non-additive role on the occurrence of organ damage.

Alexithymia and eating behaviour in severely obese patients.

BACKGROUND: Alexithymia is the inability to express feelings with words and comprises a psychological construct frequently found in obese individuals. In eating disordered patients who show a tendency to lose control over food intake, personality traits with alexithymic characteristics have been demonstrated. The present cross-sectional study investigated the relationships between alexithymia and eating behaviour in severely obese patients. METHODS: This study analysed 150 obese patients undergoing bariatric surgery and 132 subjects at more than 1 year after biliopancreatic diversion (BPD), when body weight has steadily normalised and any preoccupation with weight, food and diet has been completely abandoned. Obese and operated subjects completed the Toronto Alexithymia Scale (TAS), and eating behaviour was assessed via a semi-structured interview exploring binge eating disorder (BED), night eating and emotional eating, as well as by utilisation of the Three Factor Eating Questionnaire (TFEQ). RESULTS: Although alexithymic patients showed deranged eating behaviour, as evaluated by the TFEQ scores, the frequency of BED, night eating and emotional eating was similar in alexithymic (TAS > 60) and non-alexithymic patients. However, the prevalence of alexithymia was similar in obese and BPD subjects, whereas, in the operated subjects, TFEQ scores were lower (P < 0.005) than those in obese patients. CONCLUSIONS: These data suggest that, in severely obese patients, alexithymia does not influence eating behaviour; in severely obese patients, the tendency to lose control over food intake apparently represents a psychological construct that is substantially independent from alexithymia.

[Profession: dietician]. / Professione dietista.

This editorial deals with the specific professional competences of the registered dietician. The dietician might play an essential role in catering and agro-alimentary industry and in large retailers. Furthermore, the dietician has specific qualification in alimentary education in different fields. In the clinical practice, in any case the dietician cannot substitute the physician in diagnosis and in prescribing therapy. His/her role is to promote building the physicians alimentary and lifestyle indications into the individual current habits and behavior, so that the physician prescriptions become actually useful for restoring and maintaining a satisfactory healthy status.

Long-term normalization of insulin sensitivity following biliopancreatic diversion for obesity.

OBJECTIVE: Assess insulin sensitivity and metabolic status of obese patients with stable weight loss at long term following biliopancreatic diversion (BPD). MATERIAL AND METHODS: The study was carried out in 36 nondiabetic severely obese patients undergoing BPD. Serum concentration of glucose, insulin and leptin were determined prior to and at 2 y following the operation. Insulin sensitivity was calculated according to the homeostatic model assessment (HOMA IR). RESULTS: At 2 y following BPD, weight loss in all subjects corresponded to a marked drop in serum leptin concentration and improvement of insulin sensitivity within physiological range. Following the operation, HOMA IR values were positively correlated with serum leptin concentration independently of body mass index values. DISCUSSION: The stable weight loss following BPD at long term is accompanied by a complete reversal of the preoperative insulin resistance. Serum leptin concentration and HOMA IR data were positively related only postoperatively, suggesting that the action of factors that could influence the relation between leptin and insulin action in the obese status can be reverted.

Satiety after vertical banded gastroplasty.

Early satiety following gastroplasty is due to the new anatomic conditions created by the operation and refers to a distressing or painful epigastric sensation after food consumption. Early satiation may act as an aversive stimulus, shaping eating habits and behaviour in such a way as to promote satisfactory weight loss and maintenance. This hypothesis was tested in patients who had undergone vertical banded gastroplasty (VBG). The duration of the sensation of early satiety was associated with the scores of questionnaires assessing eating behaviour, but seemed to be completely unrelated to the radiologically measured proximal pouch volume, energy intake and weight loss data. These findings suggest that cognitive factors play a substantial role in determining food intake and therefore in achieving weight goals following gastric restriction.

Serum leptin concentration in obese patients with binge eating disorder.

BACKGROUND: In steady-state conditions serum leptin concentration is directly related to body fat stores, but is also affected by changes in energy balance. This cross-sectional study investigated the serum leptin concentrations of severely obese patients with binge eating disorder (BED), in whom body fat was greater than normal and, because of eating pattern, rapid and repeated changes in energy balances took place. METHODS: A group of BED obese patients was compared to a group of obese patients with a regular eating pattern with the same body weight, body composition and resting energy expenditure. Serum leptin was measured and the eating attitudes were evaluated by Eating Inventory and Eating Disorder Inventory. RESULTS: In these patients serum leptin concentrations were only weakly correlated to body mass. Furthermore, in BED obese patients serum leptin concentration was higher than in their non binging counterparts. CONCLUSIONS: In obese patients both body fat size and eating behavior influence serum leptin concentration, but BED patients binge eating is not triggered by a low leptin value.

Metabolic syndrome in severely obese patients.

BACKGROUND: The authors assessed the prevalence of diabetes, hypertension, dyslipidemia and metabolic syndrome in patients with a high degree of obesity. METHODS: A retrospective investigation was planned in a cohort of obese patients with a wide range of body mass index (BMI) referred to a large University Hospital for weight loss. RESULTS: An increase in prevalence of diabetes and hypertension with increase in the degree of obesity was observed, while the prevalence of dyslipidemia and metabolic syndrome appeared to be independent of the BMI values. CONCLUSION: In severely obese patients a still unknown factor which affects differently glucose and lipid metabolism cannot be excluded.

Failure of preoperative resting energy expenditure in predicting weight loss after gastroplasty.

OBJECTIVE: To evaluate the predictive efficacy of preoperative resting energy expenditure (REE) on weight loss after vertical banded gastroplasty (VBG). When subjected to a gastric restriction procedure of similar extent, the patients with higher energy expenditure should experience a greater negative energy balance than those with lower-energy expenditure, and thus, lose more weight, thereby making REE a reliable predictor of weight loss after VBG. RESEARCH METHODS AND PROCEDURES: This was a prospective investigation after VBG, taking into account the relationship between preoperative REE values and the results at 1-year follow-up in terms of weight loss and success of the procedure. The correlations were evaluated by multiple and logistic regression analysis. RESULTS: The weight loss and the outcome at 1 year after VBG seemed to be completely independent of preoperative energy expenditure. DISCUSSION: These findings suggest that, despite gastric restriction, patients may voluntarily adjust their energy intake, and that the weight outcome after VBG is influenced more by behavioral and cognitive variables than by biological or surgical factors.

Outcome of biliopancreatic diversion in subjects with Prader-Willi Syndrome.

BACKGROUND: In Prader-Willi Syndrome (PWS), mental retardation and compulsive hyperphagia cause early obesity, the co-morbidities of which lead to short life-expectancy, with death usually occurring in their 20s. Long-term weight loss is mandatory to lengthen the survival; therefore, the lack of compliance in voluntary food restriction requires a surgical malabsorptive approach. METHODS: 15 PWS subjects were submitted to biliopancreatic diversion (BPD) and followed (100%) for a mean period of 8.5 (4-13) years. BPD consists of a distal gastrectomy with a long Roux-en-Y reconstruction which, by delaying the meeting between food and biliopancreatic juices, causes an intestinal malabsorption. Indication for BPD was BMI > 40 or > 35 with metabolic complications. Preoperative mean age was 21 +/- 5 years, mean weight 127 +/- 26 kg, and mean Body Mass Index (BMI, kg/m2) 53 +/- 10. According to Holm's criteria, all of the subjects had a total score > or = 8. IQ assessment was performed in each subject, with a mean score of 72 +/- 10. An arbitrary lifestyle score was given to each subject. RESULTS: No perioperative complications were observed. Percent excess weight loss (%EWL) was 59 +/- 15 at 2 years and 56 +/- 16 at 3 years, and then progressive regain occurred; at 5 years %EWL was 46 +/- 22 and at 10 years 40 +/- 27. Spearman rank test failed to demonstrate any correlation between weight loss at 5 years and patient data, except with lifestyle score (Spearman r = 0.8548, p < .0001). Current mean age is 31 +/- 7 years. CONCLUSION: BPD has to be considered for its value in prolonging and qualitatively improving the PWS patient's life.

Leptin and HDL-cholesterol in non-diabetic normotensive subjects.

BACKGROUND: We investigated the relationships between body mass index (BMI), serum leptin and serum HDL-cholesterol. MATERIAL AND METHODS: A retrospective study was carried out in 80 patients who did not have type 2 diabetes mellitus and/or high blood pressure. RESULTS: Both serum leptin and HDL-cholesterol serum levels correlated with BMI (r = 0.616 and r = -0.269, respectively), but when the BMI values were kept constant no correlation was found between serum leptin and HDL-cholesterol both in simple and in multiple regression. CONCLUSION: The findings suggest that serum leptin concentration is completely independent of lipid metabolism.

The influence of body weight on food and shape attitudes in severely obese patients.

BACKGROUND: Cognitive restraint, binge eating, night eating, body image disparagement and shape overconcern describe the food and weight related attitudes of obese patients. POSTOPERATIVE FINDINGS: At long term follow-up after biliopancreatic diversion, body weight is steadily at normal or nearly normal levels regardless of food intake: any preoccupation for food, weight and diet are thereafter completely abandoned. The normalization of body shape corresponds to a sharp improvement in eating behavior, body image and psychological conditions. CONCLUSION: These results suggest that the dissatisfaction of one's somatic morphology and the consequent dieting account for most of the aberrant eating patterns in obese patients.

Alexithymia and body weight in obese patients.

The authors evaluated severely obese patients to determine whether being far different in body shape from the accepted standard may cause obese people to develop alexithymic personality traits. They evaluated the food- and weight-related attitudes in obesity surgery patients and in long-term follow-up of those who had previously had biliopancreatic diversion (BPD) for obesity. One quarter of the obese patients had alexithymic characteristics without any modification following stable weight loss, a rate of alexithymia similar to that observed in the nonclinical population. Furthermore, the frequency of alexithymia and the patients' scores on the Toronto Alexithymia Scale were similar in obese and post-BPD individuals. The authors concluded that being obese by itself does not influence the presence of alexithymic personality traits. However, they suggest that the improvement in food-related and weight-related attitudes following stable weight loss may be different in alexithymic and in nonalexithymic obese patients.

Energy and nitrogen absorption after biliopancreatic diversion.

BACKGROUND: The strict long-term weight maintenance in good nutritional conditions observed after biliopancreatic diversion (BPD) needs to be explained. MATERIALS AND METHODS: 15 operated subjects were maintained at an isoenergetic and isonitrogenic diet as similar as possible to their usual diet. Apparent absorption (AA) of energy, fat, nitrogen and calcium was calculated subtracting the fecal content, measured directly, from the oral intake, derived from tables. The alimentary protein absorption was directly determined by I125 albumin oral administration. RESULTS: Mean AA for energy and fat was 57% and 32%, respectively; AAs were unrelated as absolute value and negatively associated as percent of the intake with the energy and fat intake. I125 intestinal absorption was 73%, while nitrogen percent AA was 57%, indicating higher than normal loss of endogenous nitrogen. Calcium AA was 551 mEq/day, 26% of the intake. A positive correlation between nitrogen and calcium AA as absolute values and alimentary intake was observed, while there was no correlation when AA were considered as per cent of the intake. CONCLUSIONS: For energy and fat, an increase in intake corresponds to an increase in percent malabsorption, so that the absolute amount absorbed tends to remain constant, accounting for the excellent weight maintenance observed following BPD. This was confirmed by a long-term hypernutrition study after BPD. On the contrary, for nitrogen and calcium, the percent absorption tends to remain constant when intake varies, so that an increase in alimentary intake results in an increased absolute amount absorbed.

Short-term changes in serum leptin concentration following biliopancreatic diversion.

BACKGROUND: The influence of the new anatomico-functional structure created by biliopancreatic diversion (BPD) in the postoperative fall of serum leptin concentration was evaluated. METHODS: Serum leptin concentration was determined in obese women before and immediately after BPD, before the usual postoperative intestinal rest. The measurements were repeated at the second postoperative month, when oral intake had nearly totally resumed and the patients had lost the first amount of weight. RESULTS: 5 days following BPD, a sharp reduction of serum leptin concentration was observed. At the second postoperative month the values remained nearly unchanged and were indistinguishable from those observed in a group of obese non-operated patients with a closely similar body weight. CONCLUSIONS: Changes in the upper gastrointestinal tract due to BPD appear to have no influence in the postoperative reduction of serum leptin concentration, which appears to be substantially related only to the patientís adiposity.

Weight loss after dieting with behavioral modification for obesity: the predicting efficiency of some psychometric data.

The aim of the study was to identify the predicting efficiency of some psychometric data on weight loss after behavior modification in moderately obese patients. A group of patients on a weight loss program with a moderately hypoenergetic diet plus behavior modification therapy for 24 weeks completed the Eating Inventory (EI), the Eating Disorder Inventory (EDI), the Body Shape Questionnaire (BSQ) and the Body Attitude Questionnaire (BAQ). Correlations between the pre-diet and post-treatment scores were evaluated by stepwise regression analysis. The weight loss percentage was positively correlated with the EDI Bulimia scale and the BAQ Feeling Fat, and negatively with the EDI Body Dissatisfaction and Interpersonal Distrust scores. These findings indicate the true effectiveness of the behavior modification technique employed to extinguish bulimic behaviors. Furthermore, it can be suggested that realistic attitudes towards own fatness with a strong motivation and a good relationship with the therapist guarantee a greater weight loss.