Italian guidelines for the management of adult individuals with overweight and obesity and metabolic comorbidities that are resistant to behavioral treatment.

AIM: This guideline (GL) is aimed at providing a clinical practice reference for the management of adult patients with overweight or obesity associated with metabolic complications who are resistant to lifestyle modification. METHODS: Surgeons, endocrinologists, gastroenterologists, psychologists, pharmacologists, a general practitioner, a nutritionist, a nurse and a patients' representative acted as multi-disciplinary panel. This GL has been developed following the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. A systematic review and network meta-analysis was performed by a methodologic group. For each question, the panel identified potentially relevant outcomes, which were then rated for their impact on therapeutic choices. Only outcomes classified as "critical" and "important" were considered in the systematic review of evidence. Those classified as "critical" were considered for clinical practice recommendations. Consensus on the direction (for or against) and strength (strong or conditional) of recommendations was reached through a majority vote. RESULTS: The present GL provides recommendations about the role of both pharmacological and surgical treatment for the clinical management of the adult patient population with BMI > 27 kg/m2 and < 40 kg/m2 associated with weight-related metabolic comorbidities, resistant to lifestyle changes. The panel: suggests the timely implementation of therapeutic interventions in addition to diet and physical activity; recommends the use of semaglutide 2.4 mg/week and suggests liraglutide 3 mg/day in patients with obesity or overweight also affected by diabetes or pre-diabetes; recommends semaglutide 2.4 mg/week in patients with obesity or overweight also affected by non-alcoholic fatty liver disease; recommends semaglutide 2.4 mg/week as first-line drug in patients with obesity or overweight that require a larger weight loss to reduce comorbidities; suggests the use of orlistat in patients with obesity or overweight also affected by hypertriglyceridemia that assume high-calorie and high-fat diet; suggests the use of naltrexone/bupropion combination in patients with obesity or overweight, with emotional eating; recommends surgical intervention (sleeve gastrectomy, Roux-en-Y gastric bypass, or metabolic gastric bypass/gastric bypass with single anastomosis/gastric mini bypass in patients with BMI ≥ 35 kg/m2 who are suitable for metabolic surgery; and suggests gastric banding as a possible, though less effective, surgical alternative. CONCLUSION: The present GL is directed to all physicians addressing people with obesity-working in hospitals, territorial services or private practice-and to general practitioners and patients. The recommendations should also consider the patient's preferences and the available resources and expertise.

Body composition changes after laparoscopic adjustable gastric banding: what is the role of -174G>C interleukin-6 promoter gene polymorphism in the therapeutic strategy?

BACKGROUND: There is growing evidence that interleukin-6 (IL-6) is linked to the regulation of fat mass (FM). Our previous data define the common -174G>C IL-6 polymorphism as a marker for 'vulnerable' individuals at risk of age- and obesity-related diseases. An association between -174G>C IL-6 polymorphism and weight loss after bariatric surgery has been demonstrated. OBJECTIVE: We investigated the impact of -174G>C IL-6 polymorphism on weight loss, body composition, fluid distribution and cardiometabolic changes in obese subjects, after laparoscopic adjustable gastric banding (LAGB) surgery. DESIGN AND OUTCOME MEASURES: A total of 40 obese subjects were studied at baseline and at 6 months follow-up after LAGB surgery. Cardiometabolic and genetic assessment of -174G>C IL-6 polymorphism, anthropometric, body composition and fluid distribution analysis were performed. RESULTS: After LAGB surgery, significant reductions in weight (Δ%=-11.66 ± 7.78, P<0.001), body mass index (P<0.001), total and trunk FM (kg, %) (Δ% of total FM=-22.22 ± 12.15, P<0.01), bone mineral density (T-score) (P<0.001), resting metabolic rate (RMR) (P<0.01), and total body water and intracellular water (TBW, ICW) (P<0.05) were observed. At baseline, C(-) carriers of IL-6 polymorphism had a significantly higher RMR (P<0.05), free FM (kg), but less total and trunk FM (%), higher body cell mass (BCM), content of TBW (L) and ECW (extracellular water)/ICW ratio compared with C(+) carriers (P<0.001). After LAGB, C(+) carriers had a significantly stronger reduction of total FM (kg), but lower bone density, compared with C(-) carriers (P<0.05). CONCLUSIONS: Beyond the relationship between -174G>C IL-6 polymorphism and body composition, this study provides first evidence about the association of IL-6 variant with fluid distribution, at baseline, and FM and bone density loss in obese subjects at 6 months follow-up after LAGB surgery. LAGB was less effective if the subjects were carrying risk genotypes, C(-) carriers, for obesity, suggesting a role of genetic variations on bariatric surgery outcomes.

[Obesity and Eating Disorders. Indications for the different levels of care. An Italian Expert Consensus Document]. / Documento di Consensus. Obesità e Disturbi dell'Alimentazione Indicazioni per i diversi livelli di trattamento.

This paper is an Italian Expert Consensus Document on multidimensional treatment of obesity and eating disorders. The Document is based on a wide survey of expert opinion. It presents, in particular, considerations regarding how clinicians go about choosing the most appropriate site of treatment for a given patient suffering from obesity and/or eating disorders: outpatient, partial hospitalization, residential rehabilitation centre, inpatient hospitalization. In a majority of instances obesity and eating disorders are long-term diseases and require a multiprofessional team-approach. In determining an initial level of care or a change to a different level of care, it is essential to consider together the overall physical condition, medical complications, disabilities, psychiatric comorbidity, psychology, behaviour, family, social resources, environment, and available services. We first created a review manuscript, a skeleton algorithm and two rating scales, based on the published guidelines and the existing research literature. As the second point we highlighted a number of clinical questions that had to be addressed in the specific context of our National Health Service and available specialized care units. Then we submitted eleven progressive revisions of the Document to the experts up to the final synthesis that was approved by the group. Of course, from point to point, some of the individual experts would differ with the consensus view. The document can be viewed as an expert consultation and the clinical judgement must always be tailored to the particular needs of each clinical situation. We will continue to revise the Document periodically based on new research information and on reassessment of expert opinion to keep it up-to-date. The Document was not financially sponsored.

Alpha-lipoic acid supplementation: a tool for obesity therapy?

Lipid peroxidation has supposed as the major biochemical alteration underling oxidant-induced cell injury in stress including numerous diseases. One of the natural molecules know to prevent or retard oxidation is alpha-lipoic acid (LA) and, therefore, the lipoic acid/dihydrolipoic acid (LA/DHLA) redox couple has received considerable attention. Recent studies have highlighted the potential of free LA and DHLA as powerful metabolic antioxidants that are able to scavenge the reactive oxygen species, to recycle other antioxidants. Our aim was to investigate the beneficial effects of LA in the treatment of Italian pre-obese and obese subjects. We screened 1612 subjects for enrollment; of these, 1127 subjects (445 men and 682 women, 18-60 age) met enrolment criteria and were enrolled in the study. According to body mass index (BMI) the 53% was obese and the 43% was pre-obese. The subjects were treated for 4 month with 800 mg/day of LA. In pre-obese subject significant reduction (p<0.001) of weight (8%, both gender), BMI (2 points), blood pressure, and abdominal circumference (female 6 cm, male 7 cm) were observed. In obese subjects significant reductions (p<0.001) of weight (9%, both gender), BMI (female 3 point, male 4 point), blood pressure and abdominal circumference (female 9 cm, male 11 cm) were observed. Our study indicated that LA is an ideal antioxidant candidate for the therapy of obesity related diseases. Further clinical studies should be considered to highlight the role and efficacy of LA treatment.

Resting metabolic rate incremented by pulsating electrostatic field (PESF) therapy.

Pulsating electrostatic field (PESF) therapy was investigated to assess the possibility of increasing the resting metabolic rate (RMR) in 14 adult females. The pumping effect of positive calcium and hydrogen ions was obtained by 30 min daily exposure to negative PESF, adjusted individually between 2 and 9 kV. This treatment could result in a buffering effect on blood pH and reduction of the rouleaux formation of erythrocytes, thus ameliorating the oxygen exchange potential and the red cell circulation in the capillary system. After PESF therapy, the average RMR (measured by indirect calorimetry) of 1255 kcal was increased on average by 323 kilocalories, indicating a possible role of PESF in the obesity treatment.

Body composition and respiratory function.

Although the effects of sex, ageing, height, race, and current and past health on pulmonary function tests have been described, only non-significant associations have been observed between body weight and lung function among healthy persons after having accounted for the effects of age and height. However, few studies have considered the influence of body compartments (e. g. lean and fat masses and their distribution) on lung function and respiratory gas exchange. The present work consists of a review of the literature on the effects of body weight components and body composition measurements on lung function. One of the important findings of this review was that the central (or upper body) pattern of fat distribution is negatively associated with airway function and that increases in body muscular mass result in linear increases for all spirometric variables in healthy persons. Nonetheless, the role that body composition plays in lung function still needs to be clarified.

Predicting fat-free mass in children using bioimpedance analysis.

Body composition assessment is a useful procedure for the study of nutritional status and water distribution. In adults, it is a predictor of morbidity and mortality, since body fatness is associated with risk factors for cardiovascular disease. Bioelectric impedance analysis (BIA) is a simple, safe, and inexpensive method for assessment of body composition both in pediatric and adult subjects. The aim of our study was to validate the impedance index, ZI (H(2)/Z, height in cm(2)/impedance), as a predictor factor of fatfree mass (FFM) and fat mass (FM) in a sample ( n=75) of normal children. Dual-energy X-ray absorptiometry (DXA) was chosen as reference method. Despite some minor bias, DXAis considerably less expensive and easier to administer in pediatric subjects than other established gold standard reference methods for assessing body composition. ZI values were highly correlated with FFM measured with DXA. The following equations were obtained from the regression analysis: (a). male subjects, FFM(DXA)=0.6375 (ZI)+5.9913, r(2)=0.897, p<0.0001; (b). female subjects, FFM(DXA)=0.7597 (ZI)+ 3.5853, r(2)=0.903, p<0.0001. These data support the notion that BIA alone can be used as a surrogate to measure FFM in a pediatric sample.

Body composition modification in obese patients treated with intragastric balloon.

At the Centre for the Therapy of Morbid Obesity, a multidisciplinary team attends severely obese patients in a day-care hospital setting. The patients' psychological and nutritional profiles are studied and their body composition investigated with bioelectrical impedance. After the diagnosis, several approaches are proposed; among them, the insertion of a Bioenterics Intragastric Balloon (BIB). For 6 months after insertion, patients were periodically examined and followed a strict personal regimen, behaviour schedule and physical activity programme compatible with the BIB. The results obtained from the first 20 subjects are encouraging. No severe complications have been reported, and after the BIB removal, subjects are maintaining the obtained results with some of them continuing to lose weight.

Effects of weight loss on body composition and pulmonary function.

BACKGROUND: The relationship between obesity, impaired respiratory function and weight loss is established. OBJECTIVE: Some aspects need further elucidation: the different impact of the pathological modifications of body compartments (total and regional fat mass and lean body mass) on respiratory function, the choice of a restricted diet, the relationship between the modifications of body compartments and the variations in respiratory parameters after weight loss. METHODS: The restricted diet was elaborated according to the traditional Mediterranean diet. In a series of 16 obese patients, respiratory function was assessed by spirometry; body composition was assessed by dual-energy X-ray absorptiometry, allowing the direct estimation of total and segmental body fat and lean body mass. RESULTS: Weight loss was sustained mainly by fat mass decrease, mostly upper body fat. Total and truncal lean body mass were not affected. Lung volumes and function were improved. A correlation was observed between lean body mass and respiratory parameters, and was unmodified after weight loss. CONCLUSIONS: Mediterranean-style restricted diet was well accepted and enabled a selective decrease in fat mass, with a good improvement in lung function. Truncal fat (as well as abdominal fat) was decreased, while truncal lean body mass (i.e. respiratory muscles) were not affected, as expected in obese subjects with respiration problems.