Helen Parretti

Clinical effectiveness of very-low-energy diets in the management of weight loss: a systematic review and meta-analysis of randomized controlled trials.

Guidelines suggest that very‐low‐energy diets (VLEDs) should be used to treat obesity only when rapid weight loss is clinically indicated because of concerns about rapid weight regain.

Guidelines for the follow‐up of patients undergoing bariatric surgery

Bariatric surgery can facilitate weight loss and improvement in medical comorbidities. It has a profound impact on nutrition, and patients need access to follow‐up and aftercare. NICE CG189 Obesity emphasized the importance of a minimum of 2 years follow‐up in the bariatric surgical service and recommended that following discharge from the surgical service, there should be annual monitoring as part of a shared care model of chronic disease management. NHS England Obesity Clinical Reference Group commissioned a multi‐professional subgroup, which included patient representatives, to develop bariatric surgery follow‐up guidelines. Terms of reference and scope were agreed upon. The group members took responsibility for different sections of the guidelines depending on their areas of expertise and experience. The quality of the evidence was rated and strength graded. Four different shared care models were proposed, taking into account the variation in access to bariatric surgical services and specialist teams across the country. The common features include annual review, ability for a GP to refer back to specialist centre, submission of follow‐up data to the national data base to NBSR. Clinical commissioning groups need to ensure that a shared care model is implemented as patient safety and long‐term follow‐up are important.

Efficacy of water preloading before main meals as a strategy for weight loss in primary care patients with obesity: RCT.

To investigate the efficacy of water preloading before meals as a weight loss strategy for adults with obesity.

Current recommendations in the management of hypothyroidism: developed from a statement by the British Thyroid Association Executive

Hypothyroidism is present in about 2–5% of the population and is routinely managed in general practice.1 Uncorrected disease carries significant morbidity and is associated with an increased risk of lipid disorders, cardiovascular disease, osteoporosis, and cognitive dysfunction.2 Most cases are due to chronic autoimmune thyroiditis, and are followed by destructive treatment of the thyroid gland with radioactive iodine or surgery.2 The prevalence of spontaneous hypothyroidism rises with age and is 10 times more common in women than in men.1 In primary hypothyroidism the earliest biochemical abnormality is an increase in serum thyrotropin (TSH) level with normal free T4 (FT4) and free T3 (FT3) concentrations (subclinical hypothyroidism).2 A proportion of individuals with subclinical hypothyroidism (approximately 2–4% per annum) will progress to overt hypothyroidism (decreased FT4 associated with increased serum TSH).1 Patients with overt disease typically manifest symptoms and usually benefit from thyroid hormone treatment. Synthetic levothyroxine (L-T4) remains the treatment of choice for hypothyroidism2–4 and is prescribed to an estimated 1.5 million people in the UK.2 It is simple to administer, and within weeks of initiation most patients achieve normal serum TSH levels, and enjoy restored health.2 However, a proportion of treated patients continue to suffer ill-health even after normalisation of their thyroid hormone levels.5 Most GPs will be familiar with the patient who is persistently dissatisfied with L-T4 therapy or those for whom a stable euthyroid state appears unachievable. The management of such individuals is challenging and sometimes frustrating for patients and clinicians alike. In addition recent community-based surveys have highlighted a series of pressing concerns including the indiscriminate use of thyroid tests,6 overdiagnosis, and excessive treatment of patients with mild hypothyroidism,7 and an …

Paradoxical fall in HDL cholesterol observed in a patient treated with rosiglitazone and pioglitazone

Introduction Glitazones (also known as thiazolidinediones) are a class of drugs used to treat type 2 diabetes mellitus. They bind to and activate PPARγ, a ligand-activated nuclear transcription factor expressed in adipose tissue, endothelial cells, skeletal muscle liver cells and other tissues. The activated PPARγ leads to changes in expression/transcription of several genes involved in glucose and lipid metabolism. The two currently available glitazones, rosiglitazone and pioglitazone, have been shown to raise HDL-C and lower TG levels in several clinical studies as well as increasing insulin sensitivity. Separate meta-analyses of the effects of rosiglitazone and pioglitazone on cardiovascular events were reported in 2007. It was seen that while rosiglitazone appeared to be associated with an increased risk of myocardial infarction pioglitazone showed a beneficial effect. Although no explanation for these disparate observations has been provided the possibility of significant differences between the two glitazones exists. We recently reported five case studies in which the addition of rosiglitazone in patients already on a fibrate led to unexpected reductions in HDL-C but with improvements in glycaemic control. Although the reasons for this were not clear we suggested that thiazolidinediones cross-reacted with PPAR-α and either decreased synthesis of ApoA1 or increased catabolism of ApoA1 leading to lower levels of HDL-C. Three of the patients were switched from rosiglitazone to pioglitazone and the HDL-C returned to normal levels. This pointed to differences between the two drugs in their actions on lipid metabolism. We now report a case which showed a paradoxical decrease in HDL-C when treated with rosiglitazone, but unlike the other patients reported by us also demonstrated a similar change when switched to pioglitazone.

Clinical effectiveness of very-low-energy diets in the management of weight loss

Guidelines suggest that very‐low‐energy diets (VLEDs) should be used to treat obesity only when rapid weight loss is clinically indicated because of concerns about rapid weight regain.

Clinical effectiveness of very-low-energy diets in the management of weight loss: a systematic review and meta-analysis of randomized controlled trials: Clinical effectiveness of very-low-energy diets H. M. Parretti et al.

Guidelines suggest that very‐low‐energy diets (VLEDs) should be used to treat obesity only when rapid weight loss is clinically indicated because of concerns about rapid weight regain.

Can drinking water before main meals help adults with obesity lose weight

A systematic review of randomized controlled trials studying the preventive effects of physical exercise, manual and behavioural treatments in acute low back pain and neck painIntroduction: The global financial crisis has left governments struggling to reduce their budget deficits. Loans and taxes are two important financial instruments for governments to close their budget gaps. According to models of temporal discounting and expected utility individuals should experience loans as a greater loss than taxes, depleting psychological resources and reducing individuals’ capacity to cope with stressors. The present research examined patterns of cardiovascular (CV) reactivity associated with exposure to loans or taxes. Methods: We randomised 73 students to one of three groups: loans, taxes, control (baseline). Participants in the experimental groups imagined finishing university with debts and having to repay the sums outstanding as a proportion of their salaried income over the next 30 years either via a loan repayment, or via taxes. Participants in the control group imagined finishing university, and then working in salaried employment over the next 30 years. All participants then performed a variant of the Trier Social Stress Test (TSST), whilst CV responses were monitored [BP (blood pressure), ECG (electrocardiogram), ICG (impedance cardiogram)]. Results: Compared to the control group, participants in the loan group exhibited maladaptive CV responses during the stress task (higher BP and higher total peripheral resistance [TPR]). Conversely, participants in the taxes group exhibited more adaptive CV responses and did not differ from the control group. Conclusions: Economic considerations have dominated debates surrounding macro-financial performance. The present research highlights the need to consider the psychological costs and benefits of tax-based and loan-based financial instruments.

Clinical effectiveness of very low calorie diets. Systematic review and meta-analysis of randomised controlled trials

Very low calorie diets (VLCDs) are an option for the management of obesity, but are not used in primary care. This abstract presents an ongoing review to examine whether VLCDs could be an effective option for GPs to manage obesity. Literature databases were searched from database inception to February 2013. Studies were included if they were randomised controlled trials that recruited overweight or obese adults, with or without comorbidities. The intervention needed to incorporate a VLCD and comparator could be a no intervention control or an intervention that could be given in primary care. The primary outcome was weight change at 12 months from baseline. Secondary outcomes were HbA1c, lipids, and blood pressure and we recorded adverse events. We included 11 studies in the analysis which randomised 425 participants to VLCD and 349 participants to a comparator. Compared with a behavioural weight loss programme, VLCDs achieved an additional −4.1 kg (−7.3 to −0.8) greater weight loss at 12 months. Using baseline observation carried forward (BOCF), the differencewas −3.4 kg (−6.7 to −0.05). The difference in weight loss using BOCF at 18–24 months was −1.6 kg (−3.3 to −0.01) and at 42–60 months was −1.5 kg (−4.0 to 1.0). Data on secondary outcomes, adverse events and subgroup analyses will be available for an updated abstract and be presented at the conference. We will conclude on whether VLCDs appear safe and effective and hence a useful option for achieving weight loss in primary care.