Exploration of barriers to treatment for patients with eating disorders in Chile.

BACKGROUND: Eating disorders (EDs) are associated with high morbidity and mortality, affecting predominantly young people and women. A delay in starting treatment is associated with chronic and more severe clinical courses; however, evidence on barriers and facilitators of access to care in Latin America is scarce. We aimed to identify barriers and facilitators of ED treatment in Chile from the perspective of patients, relatives, and health professionals. METHODS: Qualitative approach through semi-structured interviews with patients, their relatives, and health professionals. Participants were recruited from two ED centers in Santiago, Chile (one public and one private). Analysis was mainly based on Grounded Theory, using MAXQDA software. RESULTS: 40 interviews were conducted (n = 22 patients, 10 relatives, and 8 health professionals). The mean age of patients was 21.8 years, while the mean duration of untreated ED was 91.4 months (median 70 months). Five categories emerged with intersections between them: patient (P), family and social environment (FSE), health professionals (HP), healthcare system (HCS), and social and cultural context (SCC). Relevant barriers appeared within these categories and their intersections, highlighting a lack of professional knowledge or expertise, cultural ignorance or misinformation regarding EDs, and patient's ego-syntonic behaviors. The main facilitators were patients' and relatives' psychoeducation, recognition of symptoms by family members, and parents taking the initiative to seek treatment. CONCLUSIONS: This study provides information regarding access to treatment for patients living with EDs in Chile. A practical public health approach should consider the multi-causality of delay in treatment and promoting early interventions. Eating disorders (EDs) may severely affect the daily functioning of people enduring them. A delay in starting treatment is associated with a disease that is more difficult to treat. To our knowledge, there are no published studies carried out in Latin America exploring factors influencing treatment initiation in EDs patients. This study aimed to identify facilitators of and barriers to treating patients with EDs in Chile. We interviewed patients (n = 22), their relatives (n = 10), and health professionals (n = 8) from a private and a public center in Santiago, Chile. Our analysis showed that the main barriers to starting treatment were the lack of professional knowledge in ED, the monetary cost of illness, and cultural misinformation. Facilitators were related to the role of the family in recognizing and addressing the disease while being educated in EDs by professionals. This study helps to provide data about treatment access in developing countries. While facilitators and barriers were similar to others reported in the literature, the untreated ED's duration was longer. It is essential to address these barriers to provide access to treatment more efficiently and prevent severe and enduring forms of disease.

Virtually Accompanied Eating in the Outpatient Therapy of Anorexia Nervosa.

BACKGROUND: Normalizing the eating pattern and weight recovery are the main objectives in treating anorexia nervosa (AN). Eating accompaniment through shared mealtimes is a common strategy in eating disorder management programs. This study aims to examine the impact on weight gain of an internet-delivered meal support group on patients with AN who were under ambulatory treatment with the Eating Disorders Unit of the UC Christus Health Network, Chile. METHODS: An observational study of 54 female patients with AN diagnosis who participated in Online Meal Support Groups (OMSGs) three times a week was performed. Their weight, BMI and BMI%, was reviewed at the beginning of the sessions and at 45- and 90-day follow-up. RESULTS: Patients showed significant weight gain during follow-up. At the 90-day follow-up, patients had gained 4.41 (SD ± 2.82) kg with an effect size of -1.563. CONCLUSIONS: Statistically significant differences were found between the weight at the beginning of the intervention and at the 45- and 90-day follow-up, meaning that eating support online groups may be an effective intervention for weight gain and maintenance in patients with AN. These findings highlight the viability of developing cost-effective and more accessible interventions for AN and thus help reduce the duration of untreated disease and its consequences.

Bile acids synthesis decreases after laparoscopic sleeve gastrectomy.

BACKGROUND: Bariatric surgery is the most effective treatment alternative in morbid obesity. The mechanisms contributing to these benefits remain poorly understood. Bile acids (BAs) are mediators of different regulatory functions in glucose and cholesterol homeostasis and energy expenditure. Recent evidence suggests that BAs are critically important for the beneficial effects of sleeve gastrectomy (SG). OBJECTIVES: The aim of this study was to evaluate the effect of SG on BA synthesis. SETTING: University Hospital. Santiago, Chile. METHODS: Obese patients were evaluated before and after SG (1, 3, 6, and 12 months). BA synthesis was evaluated through the serum marker, 7 α-hydroxy-4-cholesten-3-one (C4). Primary and secondary BA and C4 were determined by high performance liquid chromatography coupled with tandem mass spectrometry detection (HPLC-MS/MS). RESULTS: From June 2013 to January 2014, 19 patients (age 37.6±7.8 years; BMI 35.8±3.5 kg/m(2); 79% female) were included in this study. Mean weight loss at 1, 3, 6, and 12 months was 11.3, 17.5, 23.6, and 25.4 kg, respectively, equivalent to 11.8, 18.6, 24.8, and 26.9 of total body water percentage (%TBW) (P<.0001), respectively and 43.2, 68.2, 91, and 98.8 of percentage of excess weight loss (%EWL), respectively (P<.001). Serum C4 levels at baseline, 1, 3, 6, and 12 months were 23.4±21.1, 4.9±8.2, 8.7±12.1, 13.8±12.9, and 18.8±16.8 ng/mL (P<.0001), respectively. Fibroblast growth factor 19 (FGF19) levels at baseline, 1, 3, 6, and 12 months were 71±33.3, 130.5±66.2, 117.8±57.2, 134.6±91.7, and 124.3±85.9 pg/mL (P = .019), respectively. CONCLUSION: Serum levels of C4 decrease after SG, indicating a reduction in the synthesis of BA. FGF19 may play a role in decreasing BA synthesis. Further studies are necessary to characterize the effect of bariatric surgery on BA homeostasis.

Vivir sin gluten: percepción sobre alimentación, calidad de vida y socialización en adultos celiacos / GLUTEN-FREE LIFE: FOOD PERCEPTION- QUALITY OF LIFE AND SOCIALIZATION IN CELIAC ADULTS

La enfermedad celiaca es la intolerancia alimentaria más común del mundo, alcanzando a un 1% de la población y su único tratamiento es una dieta libre de gluten. El objetivo del estudio, de tipo exploratorio y diseño descriptivo, es conocer la percepción que los adultos celiacos tienen sobre su alimentación, calidad de vida y socialización después de empezar el tratamiento. Se entrevistó a 8 celiacos entre 24 y 37 años. Los entrevistados describen una respuesta emocional ante su nueva alimentación, que abarca frustración, cansancio, alivio, tranquilidad, no siendo excluyentes entre sí. El tratamiento nutricional hace ganar habilidades como la cocina, lo que genera mayor consciencia sobre lo que se come. Extrañar la comida con gluten es transversal; hay quienes pueden manejarlo, otros quienes rompen el tratamiento. La calidad de vida se ve afectada por el mayor costo económico de alimentacion sin gluten, las enfermedades asociadas y los factores que facilitan la adherencia a la dieta. La socialización con el entorno es facilitada cuando al celiaco se le apoya en su tratamiento; el ocio se vuelve más escaso y difícil, llevando a la restricción social

Celiac disease is the most common food intolerance in the world, reaching a prealenve of 1% of the population and its only treatment is a gluten-free diet. The aim of the study, exploratory and descriptive design, is to know the perception that celiac adults have about their diet, quality of life and socialization after starting treatment. Eight celiacs between the ages of 24 and 37 were interviewed. The interviewees describe an emotional response to their new diet, encompassing frustration, tiredness, relief and calm. Nutritional treatment makes them gain skills like cooking, which raises awareness about what you eat. Missing gluten-food is cross-cutting, some can handle it, others break treatment. Quality of life is affected by the higher economic cost of gluten-free nutrition, associated diseases and factors that facilitate diet adherence. Socialization with the environment is facilitated when celiac people is supported in its treatment; leisure becomes scarcer and more difficult, leading to social restrictions

Effects of sleeve gastrectomy and medical treatment for obesity on glucagon-like peptide 1 levels and glucose homeostasis in non-diabetic subjects.

BACKGROUND: The effects of medical and surgical treatments for obesity on glucose metabolism and glucagon-like peptide 1 (GLP-1) levels independent of weight loss remain unclear. This study aims to assess plasma glucose levels, insulin sensitivity and secretion, and GLP-1 levels before and after sleeve gastrectomy (SG) or medical treatment (MED) for obesity. METHODS: This study is a prospective, controlled, non-randomised study. Two groups of non-diabetic obese patients with similar BMIs, including a SG group (BMI, 35.5 ± 0.9 kg/m(2); n = 6) and a MED group (BMI, 37.7 ± 1.9 kg/m(2); n = 6) and a group of lean subjects (BMI, 21.7 ± 0.7 kg/m(2); n = 8). RESULTS: Plasma glucose, insulin, and total GLP-1 levels at fasting and after the intake of a standard liquid meal at baseline and at 2 months post-intervention. At baseline, total GLP-1 levels were similar, but obese patients had lower insulin sensitivity and higher insulin secretion than lean subjects. At 2 months post-intervention, SG and MED patients achieved similar weight loss (14.4 ± 0.8%, 15.3 ± 0.9%, respectively). Insulin sensitivity increased in SG and MED patients; however, postprandial insulin secretion decreased after MED, but not after SG. The incremental area under the curve of GLP-1 increased after SG (P = 0.04), but not after MED. CONCLUSIONS: Weight loss by medical or surgical treatment improved insulin sensitivity. However, only MED corrected the hyperinsulinemic postprandial state associated to obesity. Postprandial GLP-1 levels increased significantly after SG without duodenal exclusion, which may explain why insulin secretion did not decrease following this surgery.

Medical and surgical treatments for obesity have opposite effects on peptide YY and appetite: a prospective study controlled for weight loss.

CONTEXT: The effects of medical and surgical treatments for obesity on peptide YY (PYY) levels, in patients with similar weight loss, remain unclear. OBJECTIVE: The objective of the study was to assess PYY and appetite before and after Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and medical treatment (MED). DESIGN: This was a prospective, controlled, nonrandomized study. SETTING: The study was conducted at the Departments of Nutrition and Digestive Surgery at a university hospital. PARTICIPANTS: PARTICIPANTS included three groups of eight patients with similar body mass indexes (RYGB 37.8 +/- 0.8, SG 35.3 +/- 0.7, and MED 39.1 +/- 1.7 kg/m(2), P = NS) and eight lean controls (body mass index 21.7 +/- 0.7 kg/m(2)). MAIN OUTCOME MEASURES: Total plasma PYY, hunger, and satiety visual analog scales in fasting and after ingestion of a standard test meal were measured. RESULTS: At baseline there were no differences in the area under the curve (AUC) of PYY, hunger, or satiety in obese groups. Two months after the interventions, RYGB, SG, and MED groups achieved similar weight loss (17.7 +/- 3, 14.9 +/- 2.4, 16.6 +/- 4%, respectively, P = NS). PYY AUC increased in RYGB (P < 0.001) and SG (P < 0.05) and did not change in MED. PYY levels decreased at fasting, 30 min, and 180 min after a standard test meal in MED (P < 0.05). Hunger AUC decreased in RYGB (P < 0.05). Satiety AUC increased in RYGB (P < 0.05) and SG (P < 0.05). Appetite did not change in MED. PYY AUC correlated with satiety AUC (r = 0.35, P < 0.05). CONCLUSION: RYGB and SG increased PYY and reduced appetite. MED failed to produce changes. Different effects occur despite similar weight loss. This suggests that the weight-loss effects of these procedures are enhanced by an increase in PYY and satiety.

[Pathophysiology of diabetic retinopathy and nephropathy]. / Fisiopatología de la retinopatía y nefropatía diabéticas.

Despite the availability of multiple therapeutic approaches, diabetes mellitus with chronic hyperglycemia remains as the main cause of new cases of blindness and chronic renal failure in the western hemisphere. We herein review the molecular mechanisms by which chronic hyperglycemia causes retinopathy and nephropathy in type I and type 2 diabetic patients. Diabetic retinopathy develops silently along years or decades, producing symptoms only in its very late stages. Its slow development starts with the activation of aldose reductase, shortly followed by the destruction of the retinal pericyte cells, and ends in sudden blindness when vitreous hemorrhage ensues. Nephropathy, on the other hand, centers its pathophysiology in the mesangial cell, that starts as a modified smooth-muscle cell, and turns itself into a myo-fibroblast, produces such amounts of cytoplasm and extracellular protein that strangulates the glomerular capillaries and causes renal failure. After a detailed review of the molecular mechanisms of the aforementioned complications, we conclude that, apart from directing our attention to the emerging medications that are being developed to block these molecular pathways, we should never abandon the struggle for improving the glycemic control of our diabetic patients.

Near-optimal glycemic control in Chilean women with pregestational type-2 diabetes: persistent macrosomia relates to maternal pre-pregnancy overweight.

UNLABELLED: After a 10-year program intending to improve glycemic control in diabetic pregnancies, we evaluated whether factors underlying macrosomia are similar for type-1 and -2 pregestational diabetic women. PATIENTS AND METHODS: Twenty-three pregnancies in type-1 diabetics (PDM1, age 28.3+/-1.1 years) and 51 pregnancies in type-2 diabetics (PDM2, age 32.8+/-0.6 years) were followed and treated with intensified insulin therapy. Several factors potentially influencing macrosomia were evaluated. STATISTICS: chi-square, Fisher's exact, Student's "t" and Mann-Whitney "U" tests, and ROC analysis. RESULTS: In PDM1 and PDM2, respectively, large-for-gestational-age (LGA) frequencies were 26.08% and 37.25% (NS), antepartum HbA1c values were 6.5+/-0.32 and 6.1+/-0.16 (NS), and pre-pregnancy body mass indexes (BMI) were 23.03+/-0.66 and 30.01+/-0.89 (p<0.0001). In PDM1 the main predictor of LGA was an antepartum HbA1c> or =6.8% (p=0.046), whereas in PDM2 pregestational BMI> or =24 the variable associated (p=0.032) with LGA newborns. CONCLUSIONS: PDM1 and PDM2 differ in the underlying factors related to macrosomia. Whereas in PDM1 the antepartum HbA1c emerged as the most significant variable, suggesting that glycemic control largely determines macrosomia, in PDM2 with near-optimal glycemic control, macrosomia related to pregestational BMI.

[Evaluation of a pilot intervention program for overweight and obese adults at risk of type 2 diabetes]. / Evaluación de un programa piloto de intervención en adultos con sobrepeso u obesidad, en riesgo de diabetes.

BACKGROUND: The Ministry of Health of Chile and selected obesity specialized centers implemented an interdisciplinary pilot program for overweight adults at risk of diabetes to decrease the risk of type 2 diabetes (T2D) and cardiovascular risk factors (CVRF). AIM: To assess the results of this program. PATIENTS AND METHODS: Beneficiaries of the public primary health system aged 18-45 years, with a body mass index (BMI) 25-38 kg/m(2) and fasting blood glucose 100-125 mg/dL or with any direct family member with T2D, were recruited. During the four months of the study, they were scheduled for three physician visits, four dietitian consultations, 14 physical activity sessions and four group workshops (two with a psychologist or therapist). In fasting blood samples, at the beginning and at the fourth month, glucose, insulin and lipids were determined. The Homeostasis model assessment (HOMA) index was calculated. RESULTS: Two hundred-seventy-six patients were recruited and 160 (141 women), completed the four months of follow up. In this subgroup, at the start and end of the intervention, a BMI equal to or greater than 30 kg/m(2) was observed in 69% and 52% of subjects respectively, a systolic blood pressure equal to or greater than 140 mm Hg was observed in 24% and 6% respectively, a diastolic blood pressure equal to or greater than 90 mm Hg was observed in 28% and 9% respectively, a blood glucose equal to or greater than 100 mg/dL was observed in 61% and 19% respectively, a plasma insulin equal to or greater than 12,5 microUl/ml was observed in 49% and 34% respectively and a HOMA equal to or greater than 2.5 was observed in 63% and 42% respectively (all these comparisons are significant with a p <0.05). CONCLUSIONS: In those patients that completed the follow up period, this intervention induced a significant decrease of some CVRF, such as BMI, fasting glucose levels and HOMA index.

Fisiopatología de la retinopatía y nefropatía diabéticas / Pathophysiology of diabetic retinopathy and nephropathy

Despite the availability of multiple therapeutic approaches, diabetes mellitus with chronic hyperglycemia remains as the main cause of new cases of blindness and chronic renal failure in the western hemisphere. We herein review the molecular mechanisms by which chronic hyperglycemia causes retinopathy and nephropathy in type I and type 2 diabetic patients. Diabetic retinopathy develops silently along years or decades, producing symptoms only in its very ¡ate stages. Its slow development starts with the activation of aldose reducíase, shortly followed by the destruction of the retinal pericyte cells, and ends in sudden blindness when vitreous hemorrhage ensues. Nephropathy, on the other hand, centers its pathophysiology in the mesangial cell, that starts as a modified smooth-muscle cell, and turns itself into a myo-fibroblast, produces such amounts of cytoplasm and extracellular protein that strangulates the glomerular capillaries and causes renal failure. After a detailed review of the molecular mechanisms of the aforementioned complications, we conclude that, apart from directing our attention to the emerging medications that are being developed to block these molecular pathways, we should never abandon the struggle for improving the glycemic control of our diabetic patients.

[Ultrasound assessment of endothelial function in Chilean children and adults]. / Evaluación ultrasonográfica de la función endotelial en niños y adultos chilenos.

BACKGROUND: Endothelial dysfunction is an important pathogenetic mechanism in the development of atherosclerosis. AIM: To evaluate endothelial function in Chilean children and adult subjects and to provide normal values of flow mediated dilatation (FMD) in the Chilean population. SUBJECTS AND METHODS: Flow mediated dilation of the brachial artery was measured by high resolution ultrasonography in healthy children (n=32) and adults (n=69) of both gender, in a group of 8 healthy women during 4 periods of pregnancy and late postpartum, and in 22 men and women with a history of stroke or coronary heart disease. RESULTS: FMD in boys and girls was 9.9 +/- 3.6 and 10.0 +/- 4.2% respectively (NS). The figures for young women and young men were 11.3 +/- 3.8 and 8.6 +/- 3.9, respectively (p=0.02); for postmenopausal women and older men, 5.5 +/- 6.6 and 7.6 +/- 6.7 respectively (NS). During normal pregnancy and postpartum there were no significant changes in FMD. Patients with cardiovascular disease had a FMD of 0.3 +/- 5.2%, (p <0.001, with other groups). CONCLUSIONS: The present study provides values of FMD in healthy Chilean subjects of different ages, and in patients with coronary heart disease.

Evaluación de un programa piloto de intervención en adultos con sobrepeso u obesidad, en riesgo de diabetes / Evaluation of a pilot intervention program for overweight and obese adults at risk of type 2 diabetes

Background: The Ministry of Health of Chile and selected obesity specialized centers implemented an interdisciplinary pilot program for overweight adults at risk of diabetes to decrease the risk of type 2 diabetes (T2D) and cardiovascular risk factors (CVRF). Aim To assess the results of this program. Patients and methods: Beneficiaries of the public primary health system aged 18-45 years, with a body mass index (BMI) 25-38 kg/m² and fasting blood glucose 100-125 mg/dL or with any direct family member with T2D, were recruited. During the four months of the study, they were scheduled for three physician visits, four dietitian consultations, 14 physical activity sessions and four group workshops (two with a psychologist or therapist). In fasting blood samples, at the beginning and at the fourth month, glucose, insulin and lipids were determined. The Homeostasis model assessment (HOMA) index was calculated. Results: Two hundred-seventy-six patients were recruited and 160 (141 women), completed the four months of follow up. In this subgroup, at the start and end of the intervention, a BMI equal to or greater than 30 kg/m² was observed in 69 percent and 52 percent of subjects respectively, a systolic blood pressure equal to or greater than 140 mm Hg was observed in 24 percent and 6 percent respectively, a diastolic blood pressure equal to or greater than 90 mm Hg was observed in 28 percent and 9 percent respectively, a blood glucose equal to or greater than 100 mg/dL was observed in 61 percent and 19 percent respectively, a plasma insulin equal to or greater than 12,5 fi Ul/rnl was observed in 49 percent and 34 percent respectively and a HOMA equal to or greater than 2.5 was observed in 63 percent and 42 percent respectively (all these comparisons are significant with a p <0.05). Conclusions: In those patients that completed the follow up period, this intervention induced a significant decrease of some CVRF, such as BMI, fasting glucose levels...