Barbara Zahorska-Markiewicz

Management of Obesity in Adults: European Clinical Practice Guidelines

The development of consensus guidelines for obesity is complex. It involves recommending both treatment interventions and interventions related to screening and prevention. With so many publications and claims, and with the awareness that success for the individual is short-lived, many find it difficult to know what action is appropriate in the management of obesity. Furthermore, the significant variation in existing service provision both within countries as well as across the regions of Europe makes a standardised approach, even if evidence-based, difficult to implement. In formulating these guidelines, we have attempted to use an evidence-based approach while allowing flexibility for the practicing clinician in domains where evidence is currently lacking and ensuring that in treatment there is recognition of clinical judgment and of regional diversity as well as the necessity of an agreed approach by the individual and family. We conclude that i) physicians have a responsibility to recognise obesity as a disease and help obese patients with appropriate prevention and treatment, ii) treatment should be based on good clinical care and evidence-based interventions and iii) obesity treatment should focus on realistic goals and lifelong management.

Prevalence, Pathophysiology, Health Consequences and Treatment Options of Obesity in the Elderly: A Guideline

The prevalence of obesity is rising progressively, even among older age groups. By the year 2030–2035 over 20% of the adult US population and over 25% of the Europeans will be aged 65 years and older. The predicted prevalence of obesity in Americans, 60 years and older was 37% in 2010. The predicted prevalence of obesity in Europe in 2015 varies between 20 and 30% dependent on the model used. This means 20.9 million obese 60+ people in the USA in 2010 and 32 million obese elders in 2015 in the EU. Although cut-off values of BMI, waist circumference and percentages of fat mass have not been defined for the elderly (nor for the elderly of different ethnicity), it is clear from several meta-analyses that mortality and morbidity associated with overweight and obesity only increases at a BMI above 30 kg/m2. Thus, treatment should only be offered to patients who are obese rather than overweight and who also have functional impairments, metabolic complications or obesity-related diseases, that can benefit from weight loss. The weight loss therapy should aim to minimize muscle and bone loss but also vigilance as regards the development of sarcopenic obesity – a combination of an unhealthy excess of body fat with a detrimental loss of muscle and fat-free mass including bone – is important in the elderly, who are vulnerable to this outcome. Life-style intervention should be the first step and consists of a diet with a 500 kcal (2.1 MJ) energy deficit and an adequate intake of protein of high biological quality together with calcium and vitamin D, behavioural therapy and multi-component exercise. Multi-component exercise includes flexibility training, balance training, aerobic exercise and resistance training. The adherence rate in most studies is around 75%. Knowledge of constraints and modulators of physical inactivity should be of help to engage the elderly in physical activity. The role of pharmacotherapy and bariatric surgery in the elderly is largely unknown as in most studies people aged 65 years and older have been excluded.

Joint statement of the European Association for the Study of Obesity and the European Society of Hypertension: obesity and difficult to treat arterial hypertension.

Obese patients are prone to arterial hypertension, require more antihypertensive medications, and have an increased risk of treatment-resistant arterial hypertension. Obesity-induced neurohumoral activation appears to be involved. The association between obesity and hypertension shows large inter-individual variability, likely through genetic mechanisms. Obesity affects overall cardiovascular and metabolic risk; yet, the relationship between obesity and cardiovascular risk is complex and not sufficiently addressed in clinical guidelines. The epidemiological observation that obesity may be protective in patients with established cardiovascular disease is difficult to translate into clinical experience and practice. Weight loss is often recommended as a means to lower blood pressure. However, current hypertension guidelines do not provide evidence-based guidance on how to institute weight loss. In fact, weight loss influences on blood pressure may be overestimated. Nevertheless, weight loss through bariatric surgery appears to decrease cardiovascular risk in severely obese patients. Eventually, most obese hypertensive patients will require antihypertensive medications. Data from large-scale studies with hard clinical endpoints on antihypertensive medications specifically addressing obese patients are lacking and the morbidity from the growing population of severely obese patients is poorly recognized or addressed. Because of their broad spectrum of beneficial effects, renin-angiotensin system inhibitors are considered to be the most appropriate drugs for antihypertensive treatment of obese patients. Most obese hypertensive patients require two or more antihypertensive drugs. Finally, how to combine weight loss strategies and antihypertensive treatment to achieve an optimal clinical outcome is unresolved.

The Influence of Weight Loss on Serum Osteoprotegerin Concentration in Obese Perimenopausal Women

Objective: To assess the influence of weight reduction therapy on serum osteoprotegerin (OPG) concentration in obese patients and compare these results with normal‐weight controls.

The indexes of arterial structure and function in women with simple obesity: a preliminary study

Obesity is associated with an increased risk of cardiovascular disorders. The aim of the present study was to compare the indexes of arterial structure and function in women with simple obesity and healthy individuals. Twenty-two women with simple obesity (body mass index [BMI]: 33.6 ± 2.9 kg/m2, age: 29.7 ± 6.2 years), and 34 healthy women were included in the study. Healthy subjects were divided into two subgroups according to their age (<35 and >45 years): Control A-16 young women (age <35 years, BMI: 24.0 ± 3.0 kg/m2), and Control B-18 older women (age >45 years, BMI: 25.8 ± 2.9 kg/m2). Noninvasive, high-resolution, vascular ultrasound was used to evaluate the endothelial-dependent vasodilatation: flow-mediated dilatation of brachial artery (FMD); the arterial structure: intima-media thickness (IMT) of common carotid artery (CCA); and the compliance parameters corresponding to structural changes in large arteries (PWV: pulse wave velocity; PP: pulse pressure; TAC: total arterial compliance; Ao C: aorta compliance, CCA C: CCA compliance, stiffness indexes). Endothelial-dependent vasodilatation as represented by FMD was comparable in the obese group (16.8% ± 7.9%; median: 15.5%) and healthy subjects (Control A: 14.1% ± 4.7%; median: 13.6%; Control B: 13.9% ± 6.5%; median: 13.0%). The mean value of IMT was significantly increased (P < 0.05) in Control B group (0.67 ± 0.07 mm) in comparison to both obese patients (0.58 ± 0.09 mm) and Control A group (0.53 ± 0.05 mm). The compliance parameters (PWV, AoC, CCA C, stiffness indexes) were impaired in obese patients and Control B patients as compared to Control A individuals. PWV and stiffness indexes were significantly increased, and the AoC, CCA C-diameter, CCA C-area were significantly decreased. Simple obesity constitutes an important risk factor accelerating arterial stiffness in women.

Joint scientific statement of the European Association for the Study of Obesity and the European Society of Hypertension: Obesity and early vascular ageing.

Current cardiovascular risk scores do not include obesity or fat distribution as independent factors, and may underestimate risk in obese individuals. Assessment of early vascular ageing (EVA) biomarkers including arterial stiffness, central blood pressure, carotid intima–media thickness and flow-mediated vasodilation may help to refine risk assessment in obese individuals in whom traditional cardiovascular risk scores and factors suggest no need for specific medical attention. A number of issues need to be addressed before this approach is ready for translation into routine clinical practice. Methodologies for measurements of vascular markers need to be further standardized and less operator-dependent. The utility of these nontraditional risk factors will also need to be proven in sufficiently large and properly designed interventional studies. Indeed, published studies on vascular markers in obesity and weight loss vary in quality and study design, are sometimes conducted in small populations, use a variety of differing methodologies and study differing vascular beds. Finally, current vascular measurements are still crude and may not be sufficient to cover the different aspects of EVA in obesity.

Prognostic value of proangiogenic cytokines in children with lymphomas

Angiogenesis and proangiogenic cytokines are involved in neoplastic development. The role of these processes in lymphoma formation has not been established. The aim of the study was to assess angiogenesis on the basis of serum levels of vascular‐endothelial growth factor (VEGF) and basic fibroblast growth factor (bFGF) in childhood lymphomas. The prognostic value of these parameters was determined in the examined children.

Long-term effects of lipase inhibition by orlistat on gastric emptying and orocecal transit time of a solid meal

BackgroundWe assessed the impact of a prolonged lipase inhibition upon gastric emptying (GE) and orocecal transit time (OCTT) of a 355-kcal low-fat solid meal.MethodsIn double-blind manner, 40 obese women BMI > 30 kg/m2, randomly allocated into two equal groups, took orally t.i.d. 120 mg orlistat or placebo during 8 weeks of a weight-reducing management. At randomization and after 2 months, GE was measured simultaneously with OCTT by means of a 13C-octanoic acid and a hydrogen breath test, respectively. Lipolytic activity was evaluated with a 13C-mixed triglyceride breath test (13C-MTGBT).ResultsA profound lipase inhibition by orlistat was confirmed by a 79.5% ± 16.9% reduction of the cumulative 6-h 13C recovery with 13CMTGBT. GE remained unchanged either in the orlistat (T1/2, 188 ± 35 min start versus 198 ± 36 min end) or the placebo (T1/2, 191 ± 35 min start versus 180 ± 39 min end) group. OCTT increased from 208 ± 54 min to 271 ± 64 min (P < 0.01) after orlistat treatment and did not change significantly (216 ± 76 vs. 234 ± 72 min) in the placebo group.ConclusionsNo adverse effect on the GE and a moderate prolongation of the OCTT of a low-fat solid meal is to be expected under a prolonged treatment with orlistat at a typical dosage regimen.

Serum ADMA concentration-- an independent factor determining FMD impairment in cardiac syndrome X.

Abstract Mechanisms of decreased endogenous vascular reactivity in individuals with cardiac syndrome X (CSX) are not fully understood. Aim. To evaluate the following serum markers: total nitric oxide (NO), asymmetric dimethylarginine (ADMA), platelet-derived growth factor (PDGF), and to establish their relation to ultrasound indexes of endothelial function and structural remodeling in CSX patients. Method. The study group consisted of 43 CSX patients (mean age: 56.3 ± 9 years), while the control group included 21 healthy subjects (mean age: 54.86 ± 6.9 years). The high-resolution ultrasound was performed to measure: flow-mediated vasodilatation (FMD), nitroglycerine-mediated vasodilatation (NMD) and intima-media thickness (IMT) of carotid arteries. Results. In CSX patients, significantly lower FMD (9.06 ± 3.2%) and significantly higher IMT (0.667 ± 0.14 mm) values were observed compared to healthy individuals (17.42 ± 8.4%, 0.571 ± 0.2 mm; P < 0.05). Mean total NO serum concentration was significantly higher in the CSX group (48.2 ± 18.2 μmol/L) as compared to controls (32.1 ± 1.4 μmol/L; P < 0.0001). There were no differences in serum ADMA and PDGF levels. In CSX patients, FMD values correlated with NO (r = 0.323; P = 0.039) and ADMA (r = -0.387; P = 0.012) serum levels; however, there were no significant correlations between NO and ADMA concentrations. Conclusion. Serum ADMA concentration is the only independent factor determining FMD impairment.

PROANGIOGENIC CYTOKINES VASCULAR-ENDOTHELIAL GROWTH FACTOR AND BASIC FIBROBLST GROWTH FACTOR IN CHILDHOOD LYMPHADENOPATHY

Increased angiogenesis is observed both in the inflammatory and in the neoplasmatic tissue. The aim of the study was to assess the diagnostic significance of serum concentration of vascular-endothelial growth factor (sVEGF) and basic fibroblast growth factor (sbFGF) in the various forms of lymphadenopathy in children. Ninety-four children with lymphadenopathy were studied: group A, 52 patients with lymphadenitis; group B, 42 patients with lymphomas. Group B was divided into subgroups: BP, children with lymphomas in peripheral lymph nodes and BM, children with lymphomas in peripheral lymph nodes and mediastinal tumor. The healthy control group was 20 children. Using enzyme-linked immunosorbent assays the authors quantified VEGF and bFGF in serum of healthy children and of children with lymphadenopathy. The sVEGF in group A was significantly higher than controls (313.8 versus 44.6 pg/mL; P <.05) and in group B was 633.4 pg/mL and was significantly higher than controls (P <.0001). The sVEGF and bFGF in group A versus subgroup BP were significantly lower (PVEGF <.05, PbFGF <.05), and sVEGF in subgroup BP versus BM was significantly lower (P <.05). These results show that the evaluation of serum VEGF concentration might be useful as noninvasive diagnosis of some chronic peripheral lymphadenopathies in children.