Therapy and prevention of obesity: nutrition, physical activity and medical treatment / Az elhízás kezelése és megelozése: táplálkozás, testmozgás, orvosi lehetoségek.

Összefoglaló. Az elhízás és következményes megbetegedései fontos népegészségügyi problémát jelentenek hazánkban is. Kezelése komoly szakmai kihívás, ugyanakkor prevenciója eredményesebb lehet. Az elhízott betegekkel leggyakrabban találkozó háziorvosok, más szakorvosok és egészségügyi szakemberek részérol nagy igény van egy viszonylag rövid, áttekintheto, naprakész gyakorlatias útmutatóra. A különbözo orvosszakmai társaságokban tevékenykedo, évtizedes szakmai tapasztalatokkal rendelkezo szerzok összefoglalják tudományosan megalapozott, bizonyítékokon alapuló ismereteiket. Az elhízás kezelését lépcsozetesen célszeru megkezdeni, elotte felmérve a beteg motivációját, általános állapotát, lehetoségeit. A szerzok leírják az energiaszükséglet meghatározásával, az étrenddel és a fizikai aktivitás megtervezésével kapcsolatos alapveto szempontokat. Felsorolják a hazánkban elérheto gyógyszereket és metabolikus sebészeti beavatkozásokat, az életmódi támogatás igényét. Az elhízás megelozésében az élet elso 1000 napjának táplálkozása, a késobbiekben a szüloi minta a meghatározó. Sok kihasználatlan lehetosége van a háziorvosok, a lakóközösségek, az állami szervek koordinált együttmuködésének, helyi kezdeményezéseknek. Az elhízás betegségként való meghatározása egyaránt igényel egészségpolitikai és kormányzati támogatást, az elhízottak ellátására szakosodott multidiszciplináris centrumok számának és kompetenciájának növelését. Orv Hetil. 2021; 162(9): 323-335. Summary. Obesity and related morbidities have a high public health impact in Hungary. The treatment is a challenge, but prevention seems more effective. General practitioners, other specialists and health care professionals who are treating obese persons require short, summarized, updated and practical guideline. Hungarian medical professionals of different scientific societies, having decennial practices, are summarizing their evidence-based knowledge. Obesity management requires step by step approach, evaluating previously the general health condition, motivation and options of the patients. The measurement of energy requirement, planning of diet and physical activities, available surgical methods and medications are described in detail with life style and mental support needed. The most important period in the prevention of obesity is the first 1000 days from conception. Other significant factors are the life style habits of the parents. Proper obesity prevention requires better coordination of primary health care, community and governmental activities. Obesity should be defined as morbidity, therefore stronger governmental support and more health-policy initiatives are needed, beside increasing number and developing of multidisciplinary centres. Orv Hetil. 2021; 162(9): 323-335.

How can we further improve the LDL-cholesterol target level achievement rate based on the Hungarian MULTI GAP 2011 study results and considering the new European dyslipidemia guidelines?

INTRODUCTION: Despite the continuous improvement of the quality of lipid lowering therapy the achievement of target values is still not satisfactory, mainly in the very high cardiovascular risk category patients, where the goal of low density lipoprotein cholesterol (LDL-C) is 1.80 mmol/l. MATERIAL AND METHODS: The trends in lipid lowering treatment of 17420 patients from different studies conducted between 2004 and 2010 were compared to that of 1626 patients of MULTI GAP (MULTI Goal Attainment Problem) 2011 treated by general practitioners (GPs) and specialists. RESULTS: In MULTI GAP 2011 the mean LDL-C level ± SD) of patients treated by GPs was found to be 2.87 ±1.01 mmol/l, the target value of 2.50 was achieved by 40% of them, in the specialists' patients the mean LDL-C level proved to be 2.77 ±1.10 mmol/l and the achievement rate was 45%. In the 2.50 mmol/l achievement rate of GPs' patients a satisfactory improvement was observed in the studied years, but the 1.80 mmol/l LDL-C goal in 2011 was attained only in 11% of very high risk cases. There was a linear correlation between the patient compliance estimated by the physicians and the LDL-C achievement rate. CONCLUSIONS: As the number of very high risk category patients has been increased according to the new European dyslipidemia guidelines, growing attention needs to be placed on attainment of the 1.80 mmol/l LDL-C level. Based on the results of the MULTI GAP studies, improving patients' adherence and the continuous training of physicians are necessary.

[The pharmacological treatment of obesity: past, present and future]. / Az elhízás gyógyszeres kezelése: múlt, jelen, jövo

Currently, obesity presents one of the biggest health problems. Management strategies for weight reduction in obese individuals include changes in life style such as exercise and diet, behavioral therapy, and pharmacological treatment, and in certain cases surgical intervention. Diet and exercise are best for both prevention and treatment, but both require much discipline and are difficult to maintain. Drug treatment of obesity offer a possible adjunct, but it may only have modest results, limited by side effects; furthermore, the weight lowering effects last only as long as the drug is being taken and, unfortunately, as soon as the administration is stopped, the weight is regained. These strategies should be used in a combination for higher efficacy. Drugs used to induce weight loss have various effects: they increase satiety, reduce the absorption of nutrients or make metabolism faster; but their effect is usually moderate. In the past, several drugs were used in the pharmacological therapy of weight reduction including thyroid hormone, dinitrophenol, amphetamines and their analogues, e.g. fenfluramine, At present, only orlistat is available in the long term treatment (≥ 24 weeks) of obesity as sibutramine and rimonabant were withdrawn form the market. Several new anti-obesity drugs are being tested at present, and liraglutide, a GLP-1 analogue (incretin mimetic), is the most promising one.

[Becoming more "goal-oriented" in therapy of dyslipidemias: results of the Hungarian MULTI GAP 2010]. / Egyre "célratörobb" lipidterápiás szokásaink - A Magyar MULTI GAP 2010 eredményei.

UNLABELLED: Previous studies have found that many high-risk patients are not achieving their LDL-cholesterol goals, and many patients, despite being treated with lipid-lowering therapy, also have elevated triglycerides and/or low levels of HDL-cholesterol. AIMS: Authors analyzed the treatment strategies for dyslipidemic subjects following cardiovascular events similarly to their former survey from 2008 and 2009. METHODS: In the MULTI GAP (MULTI Goal Attainment Problem) 2010 trial data from standard and structured questionnaires of 2332 patients were processed. Authors analyzed the proportion of the patients reaching target levels for total cholesterol, LDL-C, HDL-C, A-C (atherogen cholesterol) and triglyceride. RESULTS: 15% (n = 355) of the patients did not receive any lipid lowering treatment. 44% of the patients treated by specialists reached the target LDL-C level of 2.5 mmol/l. In "high risk" group target levels for HDL-C were reached by 61% of the patients, and for triglyceride by 43% of the subjects. 43% of the patients with the best compliance (>90%) reached the target LDL-C level of 2.5 mmol/l. CONCLUSION: There is a need for more effective lipid lowering therapy with more frequent use of higher doses of statins or combinations of lipid lowering drugs.

An attempt to make lipid-lowering therapy more effective in Hungary. The results of MULTI GAP 2010 and the PLUS Program.

INTRODUCTION: The primary goal of lipid-lowering therapy is the attainment of low-density lipoprotein cholesterol (LDL-C) target levels. MATERIAL AND METHODS: The MULTI GAP (MULTI Goal Attainment Problem) 2010 is a part of surveys started a few years ago, in which the lipid results of 1540 patients treated by general practitioners (GPs) and specialists were measured. The data were compared to the results of similar studies involving 15,580 patients between 2004 and 2009. RESULTS: In 2010 the mean LDL-C level (± SD) of patients treated by GPs was found to be 3.01 ±1.0 mmol/l. The target of 2.50 mmol/l was achieved by 32%, with a mean LDL-C level of 2.84 ±1.0 mmol/l and an achievement rate of 39% in patients treated by specialists. The results of comparisons starting from 2004 showed a marked improvement every year in the beginning, but in the last 3 years stagnation was observed. In 2010 in addition to the MULTI GAP main study, a group of physicians took part in special training called the Plus Program. As a result of this, the LDL-C level was 0.18 mmol/l lower in 114 of the GPs' patients (p = 0.088) and 0.27 mmol/l (p < 0.0001) lower in 313 of the specialists' patients, with a significantly better, 42% (p = 0.045) and 50% (p = 0.001), goal attainment rate, respectively. CONCLUSIONS: The 2010 MULTI GAP study shows that the quality of lipid-lowering therapy in Hungary seems to be in stagnation. The results of the PLUS Program suggest that continuous training of doctors is the key to further improvement.

Changes in attainment of lipid goals by general practitioners and specialists in patients at high cardiovascular risk in Hungary during 2004-2008.

INTRODUCTION: Lipid-lowering therapy should achieve target levels. We assessed the change of the achievement of targets and the mean low-density lipoprotein cholesterol (LDL-C) levels in high-risk Hungarian patients. MATERIAL AND METHODS: Six studies performed with patients of general practitioners (GPs) and specialists between 2004 and 2008 were evaluated: 9,508 patients from GPs and 2809 from specialist practices (total 12,317). RESULTS: During this 4-year period the LDL-C level decreased by 0.73 mmol/l and the LDL-C goal achievement rate increased from 14 to 32% in patients treated by GPs. LDL-C showed a decrease of 0.48 mmol/l and the goal achievement rate changed from 20 to 43% in patients treated by specialists. In the majority of the patients not achieving the LDL-C goal (57% for specialists and 89% for GPs) there was no modification in the current therapy. In addition to emphasizing the priority of LDL-C lowering, we should also strive for residual risk reduction, which means raising high-density lipoprotein cholesterol (HDL-C) and lowering triglyceride levels. There was no significant improvement in HDL-C or triglyceride levels during the examined period. CONCLUSION: More attention needs to be paid to changing treatment of patients to achieve target levels.

Lipid-modifying therapy and attainment of cholesterol goals in Hungary: the return on expenditure achieved for lipid therapy (REALITY) study.

BACKGROUND AND OBJECTIVE: Cardiovascular disease is a leading cause of death in Eastern Europe. Few studies on cholesterol goal achievement have been conducted in Hungarian clinical settings. This study set out to evaluate lipid-modifying therapy practices and their effects on total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) goal attainment in Hungarian patients with coronary heart disease (CHD), CHD risk equivalents, or >or=2 coronary risk factors. METHODS: This multicentre observational study involved patients receiving lipid-modifying therapy who were under the care of general practitioners (n = 300) or specialists (n = 140). Physician questionnaires were used to collect data on baseline patient characteristics, including laboratory parameters. Using validated cardiovascular risk assessment measures, patients were stratified into high-risk (10-year absolute coronary risk >20%; n = 367) and lower risk groups (n = 73). Cholesterol goals were TC <4.5 mmol/L (<175 mg/dL) and LDL-C <2.5 mmol/L (<100 mg/dL) for the high-risk group and TC <5.0 mmol/L (<193 mg/dL) and LDL-C <3.0 mmol/L (<117 mg/dL) for those at lower risk. RESULTS: Among 440 patients (n = 312 with CHD or CHD risk equivalents), 374 (85%) were initiated on HMG-CoA reductase inhibitors (statin monotherapy), 44 (10%) received fibric acid derivatives and 22 (5%) received combination regimens. Although >50% of patients needed >35% TC lowering to reach goal, <10% of patients received high or very high potency lipid-modifying regimens or combination regimens initially. A total of 116 (26.4%) patients achieved their TC goals after >/=1 year of treatment, including 27.9% of patients with CHD/risk equivalents and 22.7% of those with risk factors only. Sixty-six (15%) patients achieved goal on initial lipid-modifying regimens, while a further 50 (11.4%) achieved goal following treatment changes, including upward dosage adjustments. CONCLUSION: Approximately 74% of Hungarian patients receiving lipid-modifying therapy in our study did not achieve cholesterol goals. The proportion of patients realising their TC goals was higher in those treated by specialists but still did not exceed one-third.

Orlistat increases serum paraoxonase activity in obese patients.

BACKGROUND AND AIM: Previous studies have demonstrated that oxidative stress is increased in obese patients. The high-density lipoprotein (HDL) associated human paraoxonase 1 (PON1) can inhibit low-density lipoprotein oxidation and has an antiatherogenic effect. Our objective was to assess the effects of orlistat therapy combined with diet on body mass index (BMI), waist circumference, lipid parameters, blood pressure, serum glucose level and PON1 activity. METHODS AND RESULTS: A longitudinal, multicenter, randomized study with and without orlistat treatment was performed. One hundred thirty nine otherwise healthy, obese subjects were divided in to two groups: 78 persons received orlistat (120 mg three times a day) combined with diet while 61 persons were kept on diet only. Anthropometrical parameters, serum lipid levels and PON1 activity were measured at baseline and after 6 months of treatment. BMI and waist circumference were reduced more pronouncedly in the orlistat group than in the control group. Patients receiving orlistat also had significantly greater improvements in fasting blood glucose levels and blood pressure. The orlistat-treated group showed a greater reduction in total cholesterol and triglyceride levels. In addition, the serum PON1 activity in these patients was significantly increased compared to the diet-only group. CONCLUSIONS: The 6-month treatment with orlistat had a beneficial effect on the lipid profile and improved the antioxidant status by increasing serum PON1 activity. However, because of the limited therapeutic effectiveness, obese patients with hypercholesterolemia should receive additional lipid lowering medications.

[New features in the recommendations of the Second Hungarian Therapeutic Consensus Conference]. / Aktualitások a cardiovascularis kockázat ertékelésében es a preventív terápián a II. Magyar Terápiás Konszenzus konferencia ajánlásaiban.

The First Hungarian Therapeutic Consensus Conference took place on 3rd Nov. 2003 with the participation of 9 medical societies. Over the past 2 years the results of new major studies have been published and the American ATP III has also updated its guidelines issued in 2004. Based on the above proposals, the Second Hungarian Therapeutic Consensus Conference held on 3rd Nov. 2005 partly confirmed its earlier suggestions, but made some changes as well. Within the high risk category the Conference optionally created a very high risk group from those patients who - in addition to their cardiovascular disease--have either diabetes or metabolic syndrome or acut coronaria syndrome or who are chain smokers. We have included - as a complement - into the asymptomatic high risk category such newly emerging risk factors, one of which already in itself means high risk: ankle/arm index < or = 0.9, GFR <60 ml/min, microalbuminuria (30-300 mg), preclinical atherosclerosis (plaque). Besides, 4 other risk factors were also categorised such as Lp/a (> or = 30 mg/dl), CRP (> or = 3mg/l), homocysteine (> or = 12 micromol), familiarity--atherogenic gene constellation, but only the presence of at least two of these verify high risk. In very high risk group the goals of 3.5 mmol/l and 1.8 mmol/l were determined as therapeutic option. The goal in obese patients--expressed earlier only in BMI--can now be equally determined by the abdominal circumference (94 cm for men, 80 cm for women respectively). ACE inhibitors were recommended earlier as a preventive therapy in case of dysfunction of the left ventricle, while at present they are suggested for all patients with cardiovascular disease. In the recent recommendations guidelines related to nutrition, smoking, exercise have also been included.

Ciprofibrate increases paraoxonase activity in patients with metabolic syndrome.

AIMS: Diabetic dyslipidaemia with decreased high-density lipoprotein-cholesterol (HDL-C) concentration plays a key role in enhanced atherosclerosis. The antioxidant effect of HDL is due to the influence of human paraoxonase 1 (PON1) and several authors have described decreased activity of this enzyme in Type 2 diabetics and subjects with metabolic syndrome. The goal of this study was to examine the effect of daily ciprofibrate on serum PON1 and lipoprotein concentrations in patients with metabolic syndrome. METHODS: Fifty-one patients with metabolic syndrome were enrolled into the study. We examined the effect of 100 mg day(-1) ciprofibrate treatment on lipid concentrations, oxidized low-density lipoprotein (LDL), PON1 concentrations and activity. We also investigated the calculated size of LDL-cholesterol (LDL-C). RESULTS: During the 3-month study, it was observed that following treatment with ciprofibrate, the serum triglyceride concentration decreased significantly (from 2.76 +/- 0.9 mmol l(-1) to 2.27 +/- 1.6 mmol l(-1); -18%; P < 0.001), while HDL-C increased significantly (from 0.95 +/- 0.2 mmol l(-1) to 1.2 +/- 0.3 mmol l(-1); 26%; P < 0.001). The oxidatively modified LDL-C concentration decreased significantly (from 137 +/- 19 U l(-1) to 117 +/- 20 U l(-1); P < 0.001), while HDL-associated apolipoprotein A1 significantly increased (from 1.35 +/- 0.2 g l(-1) to 1.75 +/- 0.3 g l(-1); P < 0.001). The LDL-C/LDL-apoB ratio, which reflects the size of LDL, increased significantly (from 0.96 +/- 0.05 to 1.05 +/- 0.06; P < 0.05). Serum PON1 activity was significantly elevated (from 108 +/- 34 U l(-1) to 129 +/- 31 U l(-1); P < 0.05), while standardized values for HDL-C remained significantly unchanged (PON1/HDL-C) (from 114 +/- 21 to 107 +/- 20; NS). CONCLUSION: Three months of treatment with ciprofibrate favourably affected the lipid profile, increased LDL resistance to oxidation and improved antioxidant status by increasing serum paraoxonase activity in these patients.

[Achieving the target lipid levels in Hungary, 2004]. / Célértékek elérése lipidcsökkento kezelés során--Magyarország 2004.

INTRODUCTION: Recent European and Hungarian guidelines of cardiovascular prevention have clearly defined the target levels in lipid lowering therapy. OBJECTIVE: To analyze the risk status of patients receiving long term lipid lowering therapy and the rate of achievement of target level in a Hungarian multicenter trial. METHOD: The investigation was performed in January and February of 2004 involving general practitioners and specialists (cardiologists, lipidologists). Applying a questionnaire the authors asked for risk factors and the further implementations in the knowledge of results of each doctors' 10 consecutive patients receiving lipid lowering therapy for at least one year. RESULTS: LDL target levels accepted by the Hungarian Therapic Consensus Conference was achieved in 22% of GP's patients and 27% of specialists' patients, in 24% of patients, in average. According to risk stratification, the 83% of patients receiving lipid lowering therapy were at high risk, and 79% of these did not reach the suggested target level of serum total cholesterol. In 54% of patients not achieving target level the doctors continue the therapy without any modification. Considering therapy modification in the rest of patients, a dose increase was intended in 61%, change of drug in 31% of cases, and rarely the combination therapy. CONCLUSION: While only a quarter of patients receiving lipid lowering treatment achieved the target levels, along with wide spreading of this kind of therapy further efforts should be made in order to achieve the levels defined in guidelines with dose increase or combination of appropriate drugs.

[Lipid-lowering therapy in patients with type-2 diabetes mellitus]. / Lipidszintcsökkentó terápia 2-es típusú diabetes mellitusban.

Diabetic dyslipidemia is mainly characterised by hypertriglyceridaemia, low HDL-cholesterol level, an increased small dense HDL concentration, i.e. by atherogenic dyslipidemia. Dyslipidaemia occurs in some two third of the type 2 diabetes cases. In the treatment of dyslipidaemia it is essential to control the diabetes, to reduce the intake of saturated fat and supplement it with monounsatured fat ty acid or complex carbohydrates. Based on the latest studies diabetes is considered the same risk as coronary heart disease and, therefore, diabetic dyslipidaemia should be treated in the same aggressive way. According to the simplified guidelines, after the diet--above 5.2 mmol/l cholesterol level--antilipaemic drugs, i.e. statin should be administered in order to achieve the primary goal of the therapy, namely the 2.6 mmol/l LDL-cholesterol level. In patients with combined II/b type hyperlipoproteinaemia statins are the drugs of first choice, fibric acid derivates being only considered in case of normal LDL-cholesterol level (< 3.4 mmol/l), if the HDL-cholesterol level is also low. Fibrate therapy is the first choice in the isolated hypertriglyceridaemia (> 2.3 mmol/l) as well as in type V. hyperlipoproteinaemia. On the basis of the guidelines far more patients with diabetes should be treated with lipid lowering therapy than before.