Lluís Masmiquel

Recomendaciones y algoritmo de tratamiento del sobrepeso y la obesidad en personas adultas

Entre 1996 y 1999 se publicaron las primeras revisiones sistemáticas sobre la eficacia de diferentes intervenciones para el tratamiento del exceso de peso (sobrepeso y obesidad), momento en el que también se publicaron, en lengua inglesa, las 2 guías de práctica clínica (GPC) existentes para el abordaje clínico basado en la evidencia del sobrepeso y de la obesidad1,2. La GPC más reciente data de 1998, fue elaborada por el Panel de Expertos del Instituto Nacional del Corazón, el Pulmón y la Sangre de EE.UU. y alcanzó una gran difusión3. Desde entonces se ha acumulado gran cantidad de información científica, especialmente en aspectos relacionados con el tratamiento farmacológico y con el tratamiento quirúrgico para la reducción y el mantenimiento del peso corporal, información que posibilita la elaboración de una GPC actualizada sobre diagnóstico, valoración clínica y tratamiento del sobrepeso y de la obesidad en personas adultas.

Treatment of depression in type 2 diabetic patients: Effects on depressive symptoms, quality of life and metabolic control

BACKGROUND AND OBJECTIVES Type 2 diabetes (T2DM) almost doubles the risk of comorbid depression, with lifetime prevalence up to 29%. Recognition and treatment of depression in T2DM are important because of its association with hyperglycemia, diabetic complications and poor quality of life (QoL). However, although currently available medical therapy for depression is effective in reducing depressive symptoms, it does not consistently improve HbA1c levels. The aim of this study was to determine the effects of antidepressant therapy on depressive symptoms, health-related QoL and metabolic control in T2DM. METHODS 48 T2DM (47.8% males, age 59.8 ± 11.1, T2DM duration 9.5 ± 6.5 years) who had a major depressive disorder diagnosed with a Beck Depression Inventory (BDI) test score greater than 16 and confirmed with a structured interview, were prescribed citalopram 20mg once daily. 10 out of 48 refused the prescription and were used as controls. BDI score, BMI, HbA1c and the Spanish version of the SF-36 Health Survey were recorded baseline and after 6 months of treatment. Sociodemographic characteristics, complications related to T2DM and comorbidities were also recorded. RESULTS No differences in baseline characteristics were observed between the two groups. When compared with the untreated group (n=10), patients treated with citalopram (n=38) showed significant improvements in BDI score and in almost all areas of quality of life, except in general health and bodily pain. No differences in HbA1c, waist circumference or BMI were found. CONCLUSIONS Treating depressive symptoms with medical therapy in T2DM is associated with improvements in QoL and depression, but with no improvement in metabolic control or weight.

Postoperative grazing as a risk factor for negative outcomes after bariatric surgery.

INTRODUCTION/PURPOSE After bariatric surgery, de novo eating patterns can develop, such as grazing. Although grazing has been associated with poorer weight loss, it has received minimal attention. We aimed to assess the influence of grazing in clinical, biochemical and psychological outcomes in a bariatric surgery sample. MATERIALS AND METHODS Sixty patients (78.3%♀, age 46.35±9.89, months since BS 46.28±18.1) who underwent BS were evaluated cross-sectionally. Clinical, biochemical and psychological parameters were recorded. A pattern of grazing was assessed in this group of patients through interview. RESULTS 41.7% met criteria for grazing. Mean time since BS was greater in the group with grazing (57.64±23.7months vs 38.8±26.44months; p=0.008). Although there were no differences in initial and current BMI, the percentage of patients with weight regain was greater among patients with grazing (72% vs 11.7%; p<0.0001) and the percentage of excess weight loss was lower (28.15±6.96% vs 33.35±11.9%; p=0.05). There were more difficulties in following the standardized visits according to our hospitals protocol (17.6% vs 56%; p=0.009). No significant differences were found when assessing presurgical psychiatric comorbidity among patients with a grazing pattern and individuals without this condition (68% vs 55.9%; p=0.423). When assessing quality of life only mental health was lower among patients with grazing (49.6±22.7 vs 64.2±23.3; p=0.02). CONCLUSION Development of grazing is frequent after BS, especially when weight loss has reached a plateau. Due to its potential association with weight regain, systematic screening of grazing after BS is warranted.

Weight-Related Quality of Life in Spanish Obese Subjects Suitable for Bariatric Surgery is Lower Than in Their North American Counterparts: a Case–Control Study

BackgroundObesity impairs quality of life, but the perception of the impairment could be different from one country to another. The purpose was to compare weight-related quality of life (QOL) between cohorts from Spain and North America.MethodsA cross-sectional case–control study was performed between two populations. Four hundred Spanish and 400 North American obese subjects suitable for bariatric surgery closely matched for race, gender, age, and body mass index (BMI) were included. Two non-obese control groups matched for gender, age, and BMI from each population were also evaluated (n = 400 in each group). The participants completed the Impact of Weight on Quality of Life—Lite (IWQOL—Lite) questionnaire, a measure of weight-related QOL.ResultsSpanish morbidly obese patients showed poorer QOL than their North American counterparts in physical function, sexual life, work, and total score. By contrast, Spanish non-obese control subjects reported better QOL in all domains than their North American counterparts. Women, both in Spain and North America, reported reduced QOL compared to men on the domain of self-esteem. In addition, North American women reported reduced QOL on the sexual life domain compared to men. BMI correlated negatively with all domains of QOL except for self-esteem in both national groups.ConclusionsSpanish obese subjects suitable for bariatric surgery report poorer weight-related quality of life than their North American counterparts, and obese women, regardless of nationality, perceive a reduced quality of life compared to men.

Serum laminin as a marker of diabetic retinopathy development: a 4-year follow-up study

PURPOSE The usefulness of laminin as a serum marker of diabetic retinopathy is a topic that generates conflicting views. The aim of the present study was to investigate the effect of diabetic retinopathy on serum laminin-P1, the larger pepsin resistant fragment of laminin, and to elucidate whether serum laminin-P1 could be an indicator of the risk for development of diabetic retinopathy. METHODS In a prospective study, 97 consecutive diabetic patients (35 type 1 and 62 type 2) without diabetic retinopathy and a urinary albumin excretion rate lower than 20 microg per minute were enrolled in a 4-year follow-up study. Patients who developed microalbuminuria during the study were excluded in order to avoid the influence of diabetic nephropathy on serum laminin-P1. At the end of follow-up, data from ophthalmologic studies and serum laminin-P1 were evaluated in the 66 normoalbuminuric diabetic patients who completed the study. RESULTS No statistical differences were observed in baseline laminin-P1 serum concentrations between patients who developed diabetic retinopathy (n = 15) and patients who remained without it during follow-up (n = 51). However, serum laminin-P1 levels obtained at the end of the study were significantly higher in patients who developed diabetic retinopathy (1.75 +/- 0.33 U/ml versus 1.47 +/- 0. 27 U/ml; P =.002). Furthermore, statistical difference was observed when initial and final values of serum laminin-P1 were compared in patients who developed diabetic retinopathy (1.56 +/- 0.27 U/ml versus 1.75 +/- 0.33 U/ml; P =.001). Remarkably, an increase in serum laminin-P1 concentration was detected in all but two of the patients who developed diabetic retinopathy. The relative risk of development of diabetic retinopathy in patients who showed an increase in serum laminin-P1 during follow-up was 5.4 (95% confidence interval, 1.32 to 22.13). CONCLUSIONS Serum laminin-P1 is a marker and a risk indicator of diabetic retinopathy but is not an early predictor of its development.

Are subjects with criteria for adult attention-deficit/ hyperactivity disorder doing worse after bariatric surgery? A case-control study.

INTRODUCTION There is an increasing awareness of the strong associations between obesity and adult attention- deficit/hyperactivity disorder (ADHD), with high rates of ADHD (26-61%) in patients seeking weight loss. AIMS To determine the frequency of ADHD in a bariatric surgery (BS) sample and investigate whether there were any differences among clinical, analytical and psychological parameters in individuals with criteria for ADHD. METHODS Sixty patients (78.3% female, age 46.3±9.8, months since BS 46.28±18.1) who underwent BS, with a minimum follow-up of 18 months, were evaluated cross-sectionally. Initial and current BMI, eating patterns, comorbidity, socio-demographic and biochemical parameters were recorded. For the screening of ADHD, ADHD self rating scale-v1.1 was administered. RESULTS Nineteen individuals (31.6%) had a positive screening for ADHD. This group had higher levels of HDL-cholesterol (62.8±17.3 mg/dl vs 53.5±9.9 mg/dl; p=0.011) and Apo-A (177.7±28.4 mg/dl vs 154.9±34.7 mg/ dl; p=0.015), and an increased consumption of lipids (42.2±7.1% vs 36.7±8.3%; p=0.019). Subjects with ADHD symptoms had more difficulties in following visits after BS (52.6% vs 24.3%; p= 0.011).We could not find any differences in achieved BMI, depressive symptoms or quality of life. CONCLUSIONS Patients who met criteria for ADHD face significant difficulties with compliance in follow-up, but we could not find differences in major clinical outcomes. Surprisingly, these patients could have a protective lipid profile.

Diabetes mellitus y trastorno depresivo, un mal binomio

Type 2 diabetes and depressive disorder are 2 chronic diseases highly prevalent in developed countries and with a negative impact on quality of life and life expectancy. In recent years, both conditions have been shown to be strongly associated. Thus, diabetics have an increased risk of suffering depressive disorder, as well as impaired glucose homeostasis, if they experience depression. In diabetic patients, concurrent depression is associated to greater difficulties in disease management and metabolic control, increased risk of developing chronic complications, decreased quality of life, and higher healthcare expenses. As a result, the interest of diabetic scientific societies in this association has increased, and they recommend regular mood assessment in diabetic patients. However, the limited clinical experience available and the conflicting results reported to date make it difficult to draw conclusions.

Effects of depressive symptoms on clinical outcomes, inflammatory markers and quality of life after a significant weight loss in a bariatric surgery sample.

INTRODUCTION Obesity is linked to a low-grade chronic systemic inflammation that improves after weight loss. Depressive disorder has been suggested to be associated with systemic inflammation up regulation. OBJECTIVE We aimed to explore whether, after a significant weight loss, the presence of depressive symptoms was associated with differences in terms of inflammatory markers and quality of life. METHODS Sixty patients (78.3%♀, age 46.4 ± 9.9) who underwent bariatric surgery, with a minimum follow up of 18 months, were evaluated. For the screening of depression, the Beck Depression Inventory (BDI) was administered. RESULTS Ten subjects (16.6%) had a positive screening for depressive disorder. The percentage of patients with weight regain was greater among subjects with symptoms of depression (70% vs. 32%; p = 0.024), although no differences were seen regarding BMI prior to surgery and current BMI. Acute phase reactants were higher among subjects with symptoms of depression: platelets (319 ± 15 x 10^12/L vs. 232 ± 47 x 10 ^ 12/L; p = 0.001), erythrocyte sedimentation rate (24.7 ± 11.3 mm vs.17 ± 10 mm; p = 0.03), fibrinogen (486 ± 107 mg/dL vs. 406 ± 66 mg/dL; p = 0.003), ferritin (106 ± 180 ng/ml vs. 34 ± 44 ng/ml; p = 0.014) and ultrasensitive C-reactive protein (0.96 ± 1.84 mg/dL vs. 0.24 ± 0.26 mg/dL; p = 0.008). All domains of quality of life were significantly lower in the depressive group. CONCLUSIONS Despite a significant weight loss, inflammatory markers are greater and quality of life lower when associated with depressive symptoms.

Tratamiento quirúrgico de la obesidad: recomendaciones prácticas basadas en la evidencia

La obesidad morbida es, habitualmente, refractaria a los tratamientos convencionales, por lo que la modificacion de habitos dieteticos y de actividad fisica y/o el uso de farmacos consiguen perdidas de peso parciales con habitual recuperacion posterior. La cirugia bariatrica constituye una opcion terapeutica para los casos de obesidad con elevado indice de masa corporal (IMC) asociada a comorbilidades, con buenos resultados a corto y largo plazo. El Grupo de Trabajo sobre Obesidad de la Sociedad Espanola de Endocrinologia y Nutricion (GOSEEN) ha elaborado un documento con recomendaciones practicas basadas en la evidencia para el tratamiento quirurgico de la obesidad. La revision se estructura en 3 partes. En la primera se definen los conceptos de obesidad y comorbilidades asociadas, los tratamientos medicos y sus resultados, las indicaciones y contraindicaciones para el tratamiento quirurgico con los criterios de seleccion de los pacientes, el manejo pre y perioperatorio y la valoracion de grupos especiales, como adolescentes y personas de edad avanzada. En la segunda parte se describen las distintas tecnicas quirurgicas, las vias de acceso y los resultados comparativos, las complicaciones tanto a corto como a largo plazo, la repercusion de la perdida ponderal sobre las comorbilidades y los criterios para evaluar la efectividad de la cirugia. En la tercera parte se desarrolla el seguimiento postoperatorio, el control dietetico en fases tempranas y mas tardias tras la cirugia, y el calendario de control medico y analitico con la suplementacion de los distintos macro y micronutrientes en funcion de la tecnica quirurgica empleada. Se incluye un apartado final sobre gestacion y cirugia bariatrica, asi como tablas y graficos complementarios al texto desarrollado. La cirugia bariatrica sigue siendo un tratamiento discutido para la obesidad, pero los resultados en la correccion del exceso ponderal con mejoria en las patologias asociadas y en la calidad de vida confirman que puede ser el tratamiento de eleccion en pacientes seleccionados, con la tecnica quirurgica apropiada y con un correcto control pre y postoperatorio.

Estrategia terapéutica del exceso de peso en el adolescente y en su familia

In the natural history of type 2 diabetes, pancreatic insulin secretion is progressively depleted and metabolic control worsens. Treatment of these patients usually starts with diet and exercise, with subsequent use of oral glucose-lowering drugs, finally ending with insulin therapy to achieve good metabolic control. When there is still endogenous insulin secretion, the combination of insulin and oral glucose-lowering drugs is usually preferred, using a once-daily long-acting insulin analog, premixed insulin, or NPH insulin. When the patient no longer has any endogenous insulin secretion, or when good metabolic control cannot be achieved with a once-daily regimen, treatment with several insulin doses is required. This treatment consists of a basal-bolus regimen or several doses of premixed insulin. The choice between the 2 types of treatment should be based on the patient’s individual characteristics.