Maria de Fátima Haueisen Sander Diniz

Elevated Serum Parathormone after Roux-en-Y Gastric Bypass

BACKGROUND Abnormalities in calcium and vitamin D metabolism are observed early after gastric bypass, whereas clinical or biochemical evidence of metabolic bone disease might not be detected until many years after the procedure. The aim of the present study was to evaluate the impact of bariatric surgery on bone metabolism determined on the basis of postoperative laboratory changes in calcium, phosphorus, magnesium, alkaline phosphatase and parathormone (PTH) levels. METHODS 110 patients submitted to Roux-en-Y gastric bypass (RYGBP) were followed after surgery, and the following parameters were determined: intact PTH molecule (PTHi; chemiluminescence), alkaline phosphatase (colorimetric method), ionic calcium (selective electrode), phosphorus and magnesium (colorimetric method). RESULTS Elevated serum PTHi levels were observed in 29% of the patients and hypocalcemia in 0.9% from the 3rd postoperative month and afterwards (3 to 80 months after surgery). CONCLUSION There is a need for careful evaluation of bone metabolism and for routine calcium replacement after RYGBP.Background: Abnormalities in calcium and vitamin D metabolism are observed early after gastric bypass, whereas clinical or biochemical evidence of metabolic bone disease might not be detected until many years after the procedure. The aim of the present study was to evaluate the impact of bariatric surgery on bone metabolism determined on the basis of postoperative laboratory changes in calcium, phosphorus, magnesium, alkaline phosphatase and parathormone (PTH) levels. Methods: 110 patients submitted to Roux-en-Y gastric bypass (RYGBP) were followed after surgery, and the following parameters were determined: intact PTH molecule (PTHi; chemiluminescence), alkaline phosphatase (colorimetric method), ionic calcium (selective electrode), phosphorus and magnesium (colorimetric method). Results: Elevated serum PTHi levels were observed in 29% of the patients and hypocalcemia in 0.9% from the 3rd postoperative month and afterwards (3 to 80 months after surgery). Conclusion: There is a need for careful evaluation of bone metabolism and for routine calcium replacement after RYGBP.

Strain imaging in morbid obesity: insights into subclinical ventricular dysfunction.

Obesity has become an important health problem throughout the world. Early detection of cardiovascular abnormalities may be useful in the future for patient management. This study aimed to identify subclinical ventricular dysfunction in obese patients.

Glycemic Control in Diabetic Patients after Bariatric Surgery

Background: Morbid obesity is associated with a high prevalence of diabetes mellitus, and weight loss is fundamental to improve glycemic control. The aim of the present study was to evaluate the impact of weight reduction during the late postoperative period (≥ 12 months) after gastric bypass on the glycemic control of diabetic patients. Methods: Fasting glycemia (glucose oxidase) and glycohemoglobin A1c (enzymatic fluorescence, reference value: 4-6%) were determined before and after surgery. Results were compared by the Student t-test for paired samples (P <0.05). Results: 23 women and 8 men with diabetes, with a mean follow-up of 27.2 months and a mean age of 42.5 years (30-68), were studied. Before surgery, mean ± SD weight, BMI, excess weight, glycemia and glycohemoglobin were 135.9±11.6 kg, 51.8±6.4 kg/m2, 68.3±14.5kg, 173±71.2 mg/dl, and 7.4±1.9%, respectively. After surgery, mean weight, BMI, excess weight, percent weight loss, percent excess weight loss, glycemia and glycohemoglobin were 89.7±8.8 kg, 35±4.5 kg/m2, 24.6±11.6 kg, 32.6%±1.8 (12.6-46.5%), 64.7±18.3%, 98±17.3 mg/dl (P <0.01), and 5.4±1.0% (P <0.05), respectively. Oral anti-diabetic drug and/or insulin treatment was discontinued in 89.2% of the patients. After surgery, 90.3% of the patients maintained glycohemoglobin A1c levels <7.0%. Conclusion: Weight loss led to a significant and sustained improvement of glycemic control in these patients submitted to bariatric surgery.

C-Reactive Protein and B-Type Natriuretic Peptide Yield Either a Non-Significant or a Modest Incremental Value to Traditional Risk Factors in Predicting Long-Term Overall Mortality in Older Adults

Background New biomarkers may aid in preventive and end-of-life decisions in older adults if they enhance the prognostic ability of traditional risk factors. We investigated whether C-reactive protein (CRP) and/or B-type natriuretic peptide (BNP) improve the ability to predict overall mortality among the elderly of the Bambuí, Brazil Study of Aging when added to traditional risk factors. Methods From 1997 to 2007, 1,470 community-dwelling individuals (≥60 years) were followed-up. Death was ascertained by continuous verification of death certificates. We calculated hazard ratios per 1 standard deviation change (HR) of death for traditional risk factors only (old model), and traditional risk factors plus CRP and/or BNP (new models) and assessed calibration of the models. Subsequently, we compared c-statistic of each of the new models to the old one, and calculated integrated discriminative improvement (IDI) and net reclassification improvement (NRI). Results 544 (37.0%) participants died in a mean follow-up time of 9.0 years. CRP (HR 1.28, 95% CI 1.17-1.40), BNP (HR 1.31 95% CI 1.19-1.45), and CRP plus BNP (HR 1.26, 95% CI 1.15-1.38, and HR 1.29, 95% CI 1.16-1.42, respectively) were independent determinants of mortality. All models were well-calibrated. Discrimination was similar among the old (c-statistic 0.78 [0.78-0.81]) and new models (p=0.43 for CRP; p=0.57 for BNP; and p=0.31 for CRP plus BNP). Compared to the old model, CRP, BNP, and CRP plus BNP models led to an IDI of 0.009 (p<0.001), -0.005 (p<0.001) and -0.003 (p=0.84), and a NRI of 0.04 (p=0.24), 0.07 (p=0.08) and 0.06 (p=0.10), respectively. Conclusions Despite being independent predictors of long-term risk of death, compared to traditional risk factors CRP and/or BNP led to either a modest or non-significant improvement in the ability of predicting all-cause mortality in older adults.

Bariatric surgery and the gut-brain communication—The state of the art three years later

OBJECTIVE This review analyzes the literature concerning gut peptides and bariatric surgery, from 2005 to July 2009. In particular, we are interested in whether, and how, gastrointestinal peptide alterations following surgery interfere with appetite/satiety, and what role they might play in the resolution of comorbidities. RESEARCH METHODS AND PROCEDURE PubMed/MEDLINE and ISI Web of Knowledge were used to search for human studies concerning gut peptides profiles after any bariatric operation technique. RESULTS Most of the studies reviewed had longitudinal design, short follow-up, and low statistical power. The diversity of study results may be partially explained by methodological aspects. Glucagon-like peptide-1, gastric inhibitory peptide, and peptide YY alterations may contribute to the excellent results in glycemic control of diabetics. Results do vary depending on bariatric operation technique; this is particularly evident in the case of ghrelin, which has been much studied in recent years. Ghrelin suppression has been linked to increased satiety, alterations in energy homeostasis, and better glucose metabolism. CONCLUSIONS There is a lack of long-term data on gastrointestinal hormone profiles after bariatric surgery and the studies have many methodological pitfalls. We still need prospective, long-term, good methodological studies in this area.

Diet assessment in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil): Development of a food frequency questionnaire

OBJECTIVE: The objective of this article is to present the development of the Food Frequency Questionaire used in the Longitudinal Study of Adult Health-Brazil and analyze how diet exposes individuals to cardiovascular diseases and type 2 diabetes Mellitus. METHODS: The Longitudinal Study of Adult Health-Brazil dietary assessment instrument is based on a previously validated Food Frequency Questionaire and the final list of items took into consideration a study done in the six Longitudinal Study of Adult Health-Brazil investigation centers. RESULTS: New foods/preparations were included in the Food Frequency Questionaire with their respective portions, totaling 114 items. The perspectives of dietary analysis and cardiovascular diseases and diabetes are presented in Longitudinal Study of Adult Health-Brazil. CONCLUSION: A new instrument was developed to cover the regional particularities of the study population.

Overweight and Class I Obesity Are Associated with Lower 10-Year Risk of Mortality in Brazilian Older Adults: The Bambuí Cohort Study of Ageing

Background Prospective studies mostly with European and North-American populations have shown inconsistent results regarding the association of overweight/obesity and mortality in older adults. Our aim was to investigate the relationship between overweight/ obesity and mortality in an elderly Brazilian population. Methods and Findings Participants were 1,450 (90.2% from total) individuals aged 60 years and over from the community-based Bambuí (Brazil) Cohort Study of Ageing. From 1997 to 2007, 521 participants died and 89 were lost, leading to 12,905 person-years of observation. Body mass index (BMI) and waist circumference (WC) were assessed at baseline and at the 3rd and 5th years of follow-up. Multiple imputation was performed to deal with missing values. Hazard ratios (HR) of mortality for BMI or WC alone (continuous and categorical), and BMI and WC together (continuous) were estimated by extended Cox regression models, which were fitted for clinical, socioeconomic and behavioral confounders. Adjusted absolute rates of death at 10-year follow-up were estimated for the participants with complete data at baseline. Continuous BMI (HR 0.85; 95% CI 0.80–0.90) was inversely related to mortality, even after exclusion of smokers (HR 0.85; 0.80–0.90), and participants who had weight variation and died within the first 5 years of follow-up (HR 0.83; CI 95% 0.73–0.94). Overweight (BMI 25–30 kg/m2) was inversely (HR 0.76; 95%CI 0.61–0.93) and obesity (BMI ≥30 kg/m2; HR 0.85; 95% CI 0.64–1.14) not significantly associated with mortality. Subjects with BMI between 25–35 kg/m2 (23.8–25.9%) had the lowest absolute rates of death at 10-years follow-up. The association between WC and death was not significant, except after adjusting WC for BMI levels, when the relationship turned into marginally positive (HR 1.01; CI 95% 1.00–1.02). Conclusions The usual BMI and WC cut-off points should not be used to guide public health and clinical weight control interventions in elderly in Brazil.

Reduced brain natriuretic peptide levels in class III obesity: the role of metabolic and cardiovascular factors.

Objective: Brain natriuretic peptide (BNP) has potent lipolytic action and, probably, a role in the biological mechanisms of obesity. Clinically, high levels are found in subjects with heart failure (HF). Low levels and inverse relation to BMI lead to questioning of its clinical utility in obese subjects, but heterogeneous results are found in severe obesity. Methods: In order to describe BNP behavior and its metabolic and cardiovascular determinants in class III obesity, we performed BNP measurement as well as clinical and echocardiographic evaluation of 89 subjects from two public hospitals in Brazil. Multivariate logistic ordinal regression with BNP tertiles as the dependent variable was performed. Results: Mean (± SD) age and BMI (± SD) was 44 ± 11.5 years and 53.2 ± 7.9 kg/m2, respectively. 72 (81%) participants were women, and 18 (20%) had HF. Median BNP was 9.5 pg/ml(Q1 4.9; Q3 21.2 pg/ml). 30% of BNP values were below the detection limit of the method. In multivariate analysis, left atrial volume (LAV) was the only determinant of BNP levels (p 0.002) with odds-ratio of 1.1 (95% CI 1.03–1.16). Conclusion: BNP levels are low in severe obesity, even in subjects with HF. LAV, which marks diastolic dysfunction, determines BNP levels, but not BMI and metabolic abnormalities.

Estratégias de identificação, investigação e classificação de desfechos incidentes no ELSA-Brasil

OBJETIVO: O artigo descreve as estrategias do Estudo Longitudinal de Saude do Adulto (ELSA-Brasil) para a manutencao da adesao dos participantes ao longo do tempo e seu seguimento adequado. Isto e fundamental para garantir a validade interna de estudos longitudinais e identificar, investigar e classificar os desfechos incidentes de interesse. METODOS: A metodologia de seguimento da coorte combina contatos telefonicos anuais com re-exames e entrevistas a cada tres ou quatro anos. O objetivo e identificar desfechos incidentes de natureza transitoria, reversiveis ou nao; desfechos finais, de natureza irreversivel; bem como complicacoes relacionadas a evolucao das doencas cardiovasculares e diabetes, principais doencas estudadas. RESULTADOS: As entrevistas telefonicas visam monitorar a saude dos participantes e identificar possiveis eventos ocorridos, como internacoes hospitalares, exames ou procedimentos especializados definidos previamente. O participante tambem e incentivado a comunicar a ocorrencia de algum evento de saude ao Centro de Pesquisa. A partir da identificacao de um potencial evento, e iniciado um processo de investigacao, que inclui acesso a prontuarios medicos para verificacao de datas e informacoes detalhadas sobre aquele evento. Os documentos obtidos sao analisados sem identificacao do paciente, profissional ou servico de saude e classificados por um comite de especialistas medicos. A classificacao de desfechos incidentes adotada baseia-se em criterios internacionais consagrados, garantindo comparabilidade e reduzindo o erro de classificacao deles. Alem dessas estrategias, a ocorrencia de desfechos podera ser investigada por meio do relacionamento de dados com bases secundarias do Ministerio da Saude, como as de mortalidade e internacoes. CONCLUSOES: A correta identificacao de desfechos permitira estimar sua incidencia na coorte e investigar o efeito das exposicoes estudadas no ELSA-Brasil em sua linha de base e nas ondas posteriores.

The “obesity paradox” in an elderly population with a high prevalence of Chagas disease: The 10-year follow-up of the Bambuí (Brazil) Cohort Study of Aging

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