Optimization of Care for Adult Outpatients With Type 2 Diabetes Through the Diabetes Self-Management Multidisciplinary Program: A Randomized Clinical Trial.

OBJECTIVES: Our aim in this study was to evaluate the efficacy of a Self-Management Multidisciplinary Program (MP) on glycemic management, quality of life and diabetes self-care activities. METHODS: People with type 2 diabetes and glycated hemoglobin (A1C) of >7.5% were randomized to participate in the MP or to usual care (UC). The MP consisted of face-to-face meetings with each health-care provider (nurse, pharmacist, dietitian, physical educator and social worker) to approach diabetes self-management issues. MP topics were tailored toward local habits and culture. Three different modules were offered over 12 weeks. The primary outcome was change in A1C from baseline to 12 months. Diabetes Quality of Life and Summary of Diabetes Self-Care Activities questionnaires were assessed at baseline and at 6 and 12 months. RESULTS: Ninety-six participants were included (mean 59 years of age, 60% women, diabetes duration 16±10 years, 62% of lower middle/low socioeconomic status). Change in A1C at 12 months (UC: 0.52% [95% confidence interval, -1.07 to 0.04]; MP: -0.30% [95% confidence interval, -1.05 to 0.44]; p=0.33) was not different between the groups. There was an increase in satisfaction and a reduction in worry about future effects of diabetes in the MP group, which was not found in the UC group. CONCLUSIONS: A short-term self-management multidisciplinary program improved diabetes-related quality of life but failed to reduce A1C in individuals with longstanding type 2 diabetes and a low socioeconomic status.

Polysomnography in pre-operative screening for obstructive sleep apnea in patients undergoing bariatric surgery: a retrospective cohort study.

BACKGROUND/OBJECTIVES: To assess the impact of obstructive sleep apnea (OSA) screening with polysomnography on preventing cardiovascular and pulmonary complications in the postoperative period of bariatric surgery. SUBJECTS/METHODS: This was a single-center retrospective cohort study, including 522 adults who underwent bariatric surgery between August 2010 and May 2019. Electronic medical records were accessed to obtain variables of interest. Screening for OSA was performed as a medical indication and registered as positive if apnea-hypopnea index was ≥5 events/hour in patients who did not have previous OSA diagnosis. The primary outcome was the presence of cardiac or pulmonary events in the 30-day postoperative period. Secondary outcomes included length of stay (days), need for an intensive care unit (ICU) after surgery, length of mechanical ventilation, and time from mechanical ventilation withdrawal. Statistical analyses were performed with χ2, Fisher's exact test, Student's t-test, Mann-Whitney U test, and Poisson regression. RESULTS: Most participants (n = 326) did not have OSA screening with polysomnography, while 196 had performed this screening. There was no difference in cardiopulmonary events between the screening and non-screening groups (4.2% vs. 2.8%; P = 0.45). Polysomnography screening could not reduce cardiovascular or pulmonary complications in the postoperative period, RR = 1.73 (95% CI: 0.68-4.14). There was no difference in ICU admission, length of stay, and time from mechanical ventilation between groups in secondary outcomes. CONCLUSIONS: Our study suggests that OSA screening with polysomnography in the pre-operative care of bariatric surgery is a dispensable procedure, as it does not change postoperative cardiopulmonary outcomes. Indications for polysomnography should be made at the individual level.

Accuracy of ultrasound diagnosis of nonalcoholic fatty liver disease in patients with classes II and III obesity: A pathological image study.

Liver biopsy is the gold standard method to diagnose nonalcoholic fatty liver disease (NAFLD). However, ultrasound is widely recommended as the first-line imaging test for individuals with suspected NAFLD. This study aimed to estimate the accuracy of ultrasound as a screening test for NAFLD compared to liver biopsy in a cohort of patients with class II and III obesity undergoing bariatric surgery. This retrospective study included patients undergoing Roux-en-Y gastric bypass in southern Brazil between 2010 and 2019 who were screened for NAFLD with both ultrasound and liver biopsy. All samples were collected by a core biopsy needle and were analyzed by the same pathologist. Sensitivity, specificity, and positive and negative predictive values of ultrasound were estimated. The final database included 227 patients, mostly female (84%) and white (83.6%), with a mean age of 42.5 ± 10.2 years and a mean preoperative body mass index of 49.5 ± 8.4 kg/m2. A total of 153 subjects (67.4%) were diagnosed with NAFLD through liver biopsies: 41 (18%) had fatty liver and 112 (49.3%) had nonalcoholic steatohepatitis. Ultrasound sensitivity was 88.9% and specificity was 44.6%. Positive and negative predictive values were 76.8% and 66.0%, respectively. Positive likelihood ratio was 1.6 (95% CI 1.30-1.98), and negative likelihood ratio was 0.25 (95% CI 0.15-0.42). Therefore, approximately three every four subjects with an ultrasound suggesting NAFLD were true positives. Ultrasound showed a good sensitivity in detecting NAFLD in patients with class II and III obesity.

Association between diet quality index and cardiometabolic risk factors in adolescents: Study of Cardiovascular Risks in Adolescents (ERICA).

OBJECTIVE: This study evaluated the association between diet quality, assessed by the Diet Quality Index for Adolescents adapted for Brazilians (DQIA-BR), and cardiometabolic markers in adolescents. METHODS: The DQIA-BR and cardiometabolic markers were assessed in 36 956 Brazilian adolescents (12-17 y old) enrolled in the Study of Cardiovascular Risks in Adolescents (ERICA), a national school-based cross-sectional multicenter study in Brazil. For analyses, the sample was stratified by sex and nutritional status. Multiple linear regressions were used to investigate the association between DQIA-BR and cardiometabolic markers (total cholesterol, HDL-c, LDL-c, triglycerides, fasting glucose and HOMA-IR). Adjusted models were constructed with two input levels of covariates. The first model was adjusted for sex, age, and socioeconomic status; in the second model, total energy intake, physical activity, and sedentary behavior were included. RESULTS: A higher DQIA-BR score was associated with a better cardiometabolic profile in girls with normal weight; however, no association was observed in those with overweight/obesity. In boys with overweight/obesity, a better quality of diet was associated with lower concentrations of total cholesterol (ß = -0.338, 95% confidence interval [CI]: -0.611 to -0.066) and LDL-c (ß = -0.227, 95% CI: -0.448 to -0.005), but only LDL-c remained significant in those with normal weight (ß = -0.115, 95% CI: -0.224 to 0.005). CONCLUSION: The effects of diet quality on cardiometabolic risk factors differ according to sex and the presence of overweight/obesity. Overall, DQIA-BR is a suitable tool to evaluate the association between diet quality and cardiometabolic markers in normal-weight adolescents, but not for adolescents, especially girls, with overweight/obesity.

Development and Validation of a Predictive Model of Success in Bariatric Surgery.

PURPOSE: There are no criteria to establish priority for bariatric surgery candidates in the public health system in several countries. The aim of this study is to identify preoperative characteristics that allow predicting the success after bariatric surgery. MATERIALS AND METHODS: Four hundred and sixty-one patients submitted to Roux-en-Y gastric bypass were included. Success of the surgery was defined as the sum of five outcome variables, assessed at baseline and 12 months after the surgery: excess weight loss, use of continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) as a treatment for obstructive sleep apnea (OSA), daily number of antidiabetics, daily number of antihypertensive drugs, and all-cause mortality. Partial least squares (PLS) regression and multiple linear regression were performed to identify preoperative predictors. We performed a 90/10 split of the dataset in train and test sets and ran a leave-one-out cross-validation on the train set and the best PLS model was chosen based on goodness-of-fit criteria. RESULTS: The preoperative predictors of success after bariatric surgery included lower age, presence of non-alcoholic fatty liver disease and OSA, more years of CPAP/BiPAP use, negative history of cardiovascular disease, and lower number of antihypertensive drugs. The PLS model displayed a mean absolute percent error of 0.1121 in the test portion of the dataset, leading to accurate predictions of postoperative outcomes. CONCLUSION: This success index allows prioritizing patients with the best indication for the procedure and could be incorporated in the public health system as a support tool in the decision-making process.

Neonatal Outcomes of Pregnancy Following Roux-en-Y Gastric Bypass: a Matched Case-Control Study.

PURPOSE: To compare perinatal outcomes and to assess the predictors of birth weight (BW) after Roux-en-Y gastric bypass (RYGB) to those women unexposed to bariatric surgery. MATERIALS AND METHODS: Singleton births from women submitted to RYGB (BSG) were matched to two control births by maternal age, delivery year, and gender. Control group 1 (CG1) and control group 2 (CG2) were selected according to the prepregnancy body mass index (BMI) < 35 kg/m2 and ≥ 35 kg/m2, respectively, without previous bariatric surgery. RESULTS: Fifty-eight pregnancies were evaluated in each group (n = 174). Neonates born after RYGB presented lower BW compared to CG1 (mean difference - 182.3 g; 95% CI - 333; - 31, P = 0.018) and CG2 (mean difference - 306.6 g, 95% CI - 502; - 111, P = 0.02). Although gestational age (GA) was similar (P = 0.219), fetal growth rate (in grams) per gestational week was higher in CG2 (ß = 196.27, P < 0.001) vs. BSG (ß = 127.65, P < 0.001), irrespective of gestational weight gain (GWG). Pregnancies post-RYGB showed lower GWG, lower BW, and higher prevalence of cesarean section than CG1 and were associated with lower BW, smaller cephalic perimeter, lower prevalence of macrosomia, hypertension, and gestational diabetes than CG2. CONCLUSION: Birth weight was higher in neonates from women with higher prepregnancy BMI, as compared to births from women submitted to RYGB, irrespective of GWG. Although nearly half of the RYGB mothers were classified with obesity at conception, those pregnancies were associated with better obstetric and neonatal outcomes than among women with prepregnancy BMI ≥ 35 kg/m2 who had never undergone RYGB.

Self-perceived body image, dissatisfaction with body weight and nutritional status of Brazilian adolescents: a nationwide study / Auto-imagem corporal, insatisfação com o peso corporal e estado nutricional deadolescentes brasileiros: um estudo nacional

Abstract Objectives The purpose of this study was to evaluate the agreement and risk factors for underestimation and overestimation between nutritional status and self-perceived body image and to assess the prevalence and associated factors for dissatisfaction with body weight among Brazilian adolescents. Methods Students aged 12-17 years participating in the Study of Cardiovascular Risk in Adolescents ("ERICA"), a multicenter, cross-sectional, school-based country-wide study, were included (n = 71,740). Variables assessed as covariates were sex, age, skin color, socioeconomic status, and common mental disorders (screened by the General Health Questionnaire, GHQ-12). Multinomial logistic regression was used to explore the association between covariates and combinations between self-perceived body image and body mass index (agreement, underestimation and overestimation). The associations between dissatisfaction with body weight and exposure variables were investigated using multivariable Poisson regression models. Results Approximately 66% students rightly matched their body mass index with self-perceived weight (kappa coefficient was 0.38 for boys and 0.35 for girls). Agreement was higher among younger students and adolescents from low income households. Male sex, older age, and GHQ-12 score ≥3 were associated with weight overestimation. Prevalence of dissatisfaction with body weight was 45.0% (95% CI: 44.0-46.0), and higher among girls, older adolescents, those with underweight or overweight/obesity, as well as those who were physically inactive and with GHQ-12 ≥3. Conclusions Most of the sample rightly self-perceived their body image according to body mass index. Students with body image misperception and those dissatisfied with their weight were more likely to present a positive screening for common mental disorders.

Resumo Objetivos A finalidade deste estudo foi avaliar a concordância e os fatores de risco para subestimação e superestimação entre o estado nutricional e a autoimagem corporal e para avaliar a prevalência e os fatores associados à insatisfação com o peso corporal entre adolescentes brasileiros. Métodos Foram incluídos estudantes entre 12 e 17 anos que participavam do Estudo de Riscos Cardiovasculares em Adolescentes ("ERICA"), um estudo multicêntrico, transversal, nacional e de base escolar (n = 71.740). As variáveis analisadas como covariáveis foram sexo, idade, cor da pele, situação socioeconômica e transtornos mentais comuns (triados pelo Questionário de Saúde Geral, QSG-12). A regressão logística multinomial foi usada para explorar a associação entre as covariáveis e as combinações entre a autoimagem corporal e o índice de massa corporal (concordância, subestimação e superestimação). As associações entre a insatisfação com o peso corporal e as variáveis de exposição foram investigadas com os modelos multivariáveis de regressão de Poisson. Resultados Aproximadamente 66% dos estudantes associaram corretamente seu índice de massa corporal com o peso autopercebido (o coeficiente kappa foi 0,38 para meninos e 0,35 para meninas). A concordância foi maior entre jovens e adolescentes de baixa renda. Sexo masculino, adolescentes mais velhos e um escore QSG 12 ≥ 3 foram associados à superestimação do peso. A prevalência de insatisfação com o peso corporal foi 45,0% (IC de 95%: 44,0-46,0), maior entre meninas, adolescentes mais velhos, aqueles abaixo do peso ou com sobrepeso/obesidade, fisicamente inativos e com QSG-12 ≥ 3. Conclusões A maior parte da amostra associou corretamente sua imagem corporal de acordo com o índice de massa corporal. Estudantes com distorção da autoimagem corporal e aqueles insatisfeitos com seu peso foram mais propensos a apresentar rastreamento positivo para transtornos mentais comuns.

Diet quality index for Brazilian adolescents: the ERICA study.

PURPOSE: This study aimed to assess the dietary patterns of adolescents using a food-based diet quality index and their compliance with a healthy dietary guideline METHODS: Participants included 71,553 Brazilian adolescents (12-17 years old) from the Study of Cardiovascular Risks in Adolescents (ERICA), a cross-sectional school-based multicenter study.. Dietary intake was measured by one 24-h recall. A second recall was collected in a random subsample (~ 10%) to correct within-person variability. The Diet Quality Index for Adolescents adapted for Brazilians (DQIA-BR) was used to measure the overall quality of the dietary intake. The National Cancer Institute method was applied to estimate usual dietary intake. The DQIA-BR and the distribution of its components (quality, diversity, and equilibrium) were analyzed according to sex, geographical area, and type of school RESULTS: The mean (SD) DQIA-BR scores were 14.8% (6.1%) for females and 19.0% (6.3%) for males. All analyzed strata revealed low scores of DQIA-BR and its components. The median usual intake was five to sevenfold below the recommendations for vegetables and fruits and approximately twofold below the recommendations for dairy. The highest DQIA-BR mean scores were found in the northern region [17.0% (6.4%), females; 20.7% (6.3%), males]. Adolescents in both types of schools had relatively similar median intakes of snacks (~ 85 g) and sugared drinks (~ 600 ml) CONCLUSIONS: The overall diet quality of Brazilian adolescents is inadequate based on evaluated parameters in all regions and socioeconomic backgrounds.

Self-perceived body image, dissatisfaction with body weight and nutritional status of Brazilian adolescents: a nationwide study.

OBJECTIVES: The purpose of this study was to evaluate the agreement and risk factors for underestimation and overestimation between nutritional status and self-perceived body image and to assess the prevalence and associated factors for dissatisfaction with body weight among Brazilian adolescents. METHODS: Students aged 12-17 years participating in the Study of Cardiovascular Risk in Adolescents ("ERICA"), a multicenter, cross-sectional, school-based country-wide study, were included (n=71,740). Variables assessed as covariates were sex, age, skin color, socioeconomic status, and common mental disorders (screened by the General Health Questionnaire, GHQ-12). Multinomial logistic regression was used to explore the association between covariates and combinations between self-perceived body image and body mass index (agreement, underestimation and overestimation). The associations between dissatisfaction with body weight and exposure variables were investigated using multivariable Poisson regression models. RESULTS: Approximately 66% students rightly matched their body mass index with self-perceived weight (kappa coefficient was 0.38 for boys and 0.35 for girls). Agreement was higher among younger students and adolescents from low income households. Male sex, older age, and GHQ-12 score ≥3 were associated with weight overestimation. Prevalence of dissatisfaction with body weight was 45.0% (95% CI: 44.0-46.0), and higher among girls, older adolescents, those with underweight or overweight/obesity, as well as those who were physically inactive and with GHQ-12 ≥3. CONCLUSIONS: Most of the sample rightly self-perceived their body image according to body mass index. Students with body image misperception and those dissatisfied with their weight were more likely to present a positive screening for common mental disorders.

Association of Maternal Roux-en-Y Gastric Bypass with Obstetric Outcomes and Fluid Intelligence in Offspring.

PURPOSE: The purpose of the study is to assess whether Roux-en-Y gastric bypass (RYGB) prior to pregnancy is associated with fluid intelligence in offspring. Additionally, perinatal and obstetric outcomes, and children nutritional status were evaluated. MATERIAL AND METHODS: Singleton births of women who underwent RYGB between 2000 and 2010 (BS) were matched to two control births by maternal age, delivery year, and gender. Control group 1 (CG1) and control group 2 (CG2) included women with a pre-pregnancy body mass index (BMI) < 35 kg/m2 and ≥ 35 kg/m2, respectively, who had never undergone bariatric surgery. RESULTS: Thirty-two children from each group (n = 96) were analyzed, mostly female (59%) and Caucasian (82%), with a mean age of 7 ± 2 years. Their general intelligence scores were similar after adjusting for sociodemographic confounders; family economic class was the strongest predictor (low: ß = - 20.57; p < 0.001; middle: ß = - 9.34; p = 0.019). Gestational diabetes mellitus (OR 0.06; 95% CI 0.03; 0.35) and hypertensive disorders (OR 0.09; 95% CI 0.01; 0.40) were less frequent in BS than CG2. Post-RYGB pregnancies were associated with lower birth weight (P = 0.021) than controls. Child overweight and obesity was higher (OR 4.59; 95% CI 1.55; 13.61; p = 0.006) in CG2 (78%) than CG1 (44%) and similar to BS (65%). CONCLUSIONS: RYGB prior to pregnancy was not associated with fluid intelligence in offspring. Prior RYGB was associated with a lower frequency of gestational diabetes mellitus and hypertensive disorders than in women with a pre-pregnancy BMI ≥ 35 kg/m2, as well as with lower birth weight than both control groups.

Early reduction of resting energy expenditure and successful weight loss after Roux-en-Y gastric bypass.

BACKGROUND: Weight loss and body composition changes after Roux-en-Y gastric bypass (RYGB) may influence resting energy expenditure (REE). The effect of lower REE after the procedure on long-term weight remains to be elucidated. OBJECTIVE: To evaluate the effects of RYGB on REE and body composition 6 months after RYGB and to find out whether postsurgery REE affects weight at 12 and 18 months SETTING: Tertiary referral hospital, southern Brazil METHOD: A prospective study involving 30 RYGB patients aged>18 years was performed. Body composition was evaluated by X-ray absorptiometry and REE by indirect calorimetry. All patients were assessed before RYGB and 6 months postoperatively. Further analysis of weight was carried out at 12 and 18 months. RESULTS: Baseline body mass index was 49±9 kg/m² and mean weight was 128±19 kg, half of which comprised fat mass (50±5%). Baseline mean REE was 2297±182 kcal/d. The percent total weight loss was 26±7%, 32±9%, and 34±9% at 6, 12, and 18 months, respectively. The percent excess weight loss gradually increased from 54 ± 12% at 6 months, to 67 ± 18% at 12 months, and 71 ± 19% at 18 months. REE was significantly lower at follow-up (-405±108 kcal/d; P<.001). Furthermore, an inverse correlation between REE at 6 months and percent excess weight loss at 18 months (r =-.612; P = .035) was observed in the subgroup of patients whose REE decreased>405 kcal/d at 6 months. CONCLUSION: Patients undergoing RYGB who had a substantial drop in REE at 6 months may exhibit less long-term weight loss.

Cirurgia para tratamento da obesidade mórbida: princípios básicos / Surgical treatment of morbid obesity: basic principles

A obesidade é uma doença caracterizada pelo excesso de gordura corporal. Esse acúmulo ocorre quando a oferta de calorias é constantemente maior do que o gasto de energia corporal e resulta frequentemente em sérios prejuízos à saúde.Atualmente, atinge 600 milhões de pessoas no mundo, 30 milhões somente no Brasil.Estudos da Organização Mundial da Saúde (OMS) projetam um cenário ainda pior para os próximos anos. Estima-se que, em 2015, existirão 2,3 bilhões de pessoas com excesso de peso e 700 milhões de obesos no mundo inteiro. Com o aumento do uso de procedimentos cirúrgicos como opções de tratamento para obesidade mórbida, o conhecimento da cirurgia bariátrica se tornou essencial. Durante a última década, o número de procedimentos bariátricos aumentou e os refinamentos desses procedimentos fizeram-nos mais seguros e mais eficazes. Todos os médicos devem saber como identificar candidatos adequados e estar familiarizados com os procedimentos cirúrgicos disponíveis, cientes de possíveis complicações e benefícios. A cirurgia bariátrica reúne técnicas com respaldo científico, destinadas ao tratamento da obesidade mórbida e das doenças associadas ao excesso de gordura corporal ou agravadas por ele. O objetivo deste artigo de revisão é analisar os dados da literatura acerca do tratamento da obesidade mórbida.

Obesity is a disease characterized by excessive body fat. This accumulation occurs when the supply of calories is consistently greater than the body’s energy expenditure and often results in serious harm to health. Currently, obesity reaches 600 million people worldwide, 30 million in Brazil. Studies of the World Health Organization (WHO) project an even worse scenario for the upcoming years. It is estimated that by 2015 there will be 2.3 billion people overweight and 700 million obese worldwide. With the increased use of surgical procedures as treatment options for obesity, knowledge of bariatric surgery has become essential. During the last decade, the number of bariatric procedures increased and refinements of these procedures have made them safer and more effective. All doctors should know how to identify suitable candidates, be familiar with the surgical procedures available, and be aware of possible complications and benefits. Bariatric surgery gathers techniques with scientific support for the treatment of obesity and the diseases associated with excessive body fat or aggravated by it. This report aimed to review the literature on the treatment of morbid obesity.

Nutritional profile of patients before and after Roux-en-Y gastric bypass: 3-year follow-up.

BACKGROUND: Bariatric surgery is considered the most effective treatment for obesity class II and III. However, postoperative side effects may occur, such as nutritional deficiencies resulting from reduced gastric capacity and alterations in nutrient absorption along the gastrointestinal tract. METHODS: A total of 170 patients (136 women and 34 men) submitted to Roux-en-Y gastric bypass (RYGB) between 2000 and 2005 were retrospectively assessed. Anthropometric and laboratory data were evaluated and the use of vitamin and mineral supplements, before and 1, 6, 12, 24, and 36 months following surgery, was assessed, as well. RESULTS: Mean excess weight loss at 24 and 36 months was 81.5 ± 19.2 and 78.5 ± 20.8 %, respectively. Anemia was present in 6.5 % of subjects prior to the surgery and increased to 33.5 % at 36 months. The levels of total cholesterol, low-density lipoprotein cholesterol, triglycerides, and glycemia were reduced, while high-density lipoprotein cholesterol was increased. Albumin and vitamin B12 levels showed no significant differences at the end of the study compared to the preoperative evaluation. Folic acid levels increased significantly during the follow-up. Almost 6 % of the patients had used standard vitamin and mineral supplements in the preoperative period and 72.4, 85.3, 74.7, 77.1, and 72.4 % at 1, 6, 12, 24, and 36 months following RYGB, respectively. CONCLUSIONS: Bariatric surgery is an effective treatment for long-term weight loss. However, nutritional deficiency is one of its side effects and should be properly diagnosed and handled, aimed at improving the patient's quality of life and preventing severe complications.